Every finding on record at Luxor Nursing & Rehabilitation at Mills Pond

Based on observations, record review, and interviews during the Recertification Survey initiated on 1/7/2025 and completed on 1/14/2025, the facility did not distribute and serve food in accordance with professional standards for food service safety. This was identified during the dining facility task and for ten (Resident #186, Resident #197, Resident # 52, Resident # 16, Resident #142, Resident #200, Resident #50, Resident #12, Resident #128, and Resident #164) of ten residents during the Resident Council meeting. Specifically, on 1/13/2025 during the lunch meal service, three (Unit 1 North, Unit 2 North, Unit 3 South) of three units meals temperatures for the hot food items were below 135 degrees Fahrenheit. The finding is: The facility's policy titled Food Preparation and Service last revised March 2023, documented that potentially hazardous foods including meats, poultry, seafood, cut melon, eggs, milk, yogurt, and cottage cheese must be maintained below 41 degrees Fahrenheit and above 135 degrees Fahrenheit. Previously cooked food must be reheated to an internal temperature of 165 degrees Fahrenheit for at least 15 seconds. The temperature of foods held in steam tables will be monitored by food and nutrition service staff. The facility's policy titled Food Safety - Food Handling last revised in September 2021 documented that the facility recognized inadequate cooking and improper holding temperatures are critical factors implicated in foodborne illness. Potentially hazardous foods will be cooked to the appropriate internal temperatures and held at those temperatures for the appropriate length of time to destroy pathogenic microorganisms. Potential hazardous foods that were prepared from ingredients and were held in the danger zone (41 degrees Fahrenheit to 135 degrees Fahrenheit) for more than 4 hours will be discarded. The Resident Council meeting was conducted on 1/8/2025 at 11:55 AM. Ten of the ten residents in attendance unanimously complained of hot food being served at cold temperatures. On 1/13/2025 during the lunch meal service, three test trays were requested for three (Unit 3 South, Unit 1 North, Unit 2 North) of the three units. Two meal racks for Unit 3 South departed the kitchen at 12:39 PM and arrived at the unit at 12:40 PM. The racks were not covered. The last meal tray was served at 12:58 PM. The test tray temperatures were taken at 12:58 PM in the presence of the Assistant Director of Nursing Services. The temperature reading for the protein entree, the roasted chicken, was 128.5 degrees Fahrenheit. The temperature readings for the vegetables (diced potatoes and sliced carrot) were 124 degrees Fahrenheit and 108.1 degrees Fahrenheit respectively. Two meal racks for Unit 1 North departed the kitchen at 12:57 PM and arrived at the unit at 12:58 PM. The racks were not covered. The last meal tray was served at 1:03 PM. The test tray temperatures were taken at 1:03 PM in the presence of the Dietary Supervisor. The temperature readings for the vegetables (diced potatoes and sliced carrot) were 131 degrees Fahrenheit and 120 degrees Fahrenheit respectively. One meal rack for Unit 2 North departed the kitchen at 1:09 PM and arrived at the unit at 1:13 PM. The rack was not covered. The last meal tray was served at 1:25 PM. The test tray temperatures were taken at 1:25 PM in the presence of the Director of Finance. The temperature reading for the protein entree, the roasted chicken, was 120 degrees Fahrenheit. The temperature readings for the vegetables (diced potatoes and sliced carrot) were 100 degrees Fahrenheit and 110 degrees Fahrenheit respectively. During an interview on 1/13/2025 at 1:14 PM, the Food Service Director stated they knew there were concerns about hot meals being served cold from Resident Council and Food Committee meetings. The Food Service Director stated prior to the start of every meal, hot food temperatures were checked in the kitchen. The Food Service Director stated that the kitchen continued to utilize an old pellet heating system which was not distributing heat evenly to warm all the pellets at equal temperatures therefore, the food was not maintained to the desired temperature. The Food Service Director stated steamer used to cook vegetables is outdated and inefficient. They would also like to replace the open rack with an enclosed rack to maintain the food temperature during delivery. The Food Service Director stated that the administration was aware of the concerns and the facility continued to explore solutions such as a new steamer, enclosed racks, and a new pellet heating system; however, nothing has been finalized at this time. During a re-interview on 1/13/2025 at 3:54 PM, the Food Service Director stated the kitchen currently did not have enough metal pellets to maintain the temperature for each meal plate. There should ideally be 250 pellets; however, the facility currently has approximately 200 pellets on rotation. The Food Service Director stated meal trays prepared last, may not maintain appropriate food temperatures because the pellets would run out. The Food Service Director stated each resident who received a hot meal should have an insulated dome cover and a metal pellet to keep the hot food temperatures above 135 degrees Fahrenheit. During an interview on 1/14/2025 at 12:55 AM, the Administrator stated that they were aware of residents' complaints of food temperature since 2023. The Administrator believed timeliness was a responsible factor for low food temperatures. The Administrator stated that they implemented All Hands on Deck and expected non-nursing staff members to assist during meal services to improve the timeliness of meal delivery. The Administrator stated that they started looking into replacing kitchen equipment a few months ago and were aware that the Food Service Director addressed a mechanical issue with the pellet warmer system. The Administrator stated that there is an ongoing discussion of other purchases and no order had been made at this time. The Administrator stated that they were not aware that there were not enough metal pellets to circulate during mealtime. The Administrator stated that the Food Service Director should replace the damaged pellet and ensure that each resident has a pellet to keep their plate warm. The Administrator stated that The Administrator stated that all residents should receive a hot meal that was not cold. During an interview on 1/14/2025 at 12:55 AM, the Administrator stated they were aware of residents' complaints about food temperature since 2023. The Administrator stated they thought the issue was related to staff not distributing the meals timely and they implemented an all hands on deck approach and instructed all staff to take part in the meal distribution. The Administrator stated a few months ago they started looking into replacing kitchen equipment because the pellet warmer system was old and did not evenly heat all the pellets. The Administrator stated there is currently an ongoing discussion to purchase new equipment; however, no orders have been placed at this time. The Administrator stated they were not aware of the insufficient amount of metal pellets. 10 NYCRR 415.14(h)

Based on observations, record review, and interviews during the Recertification Survey initiated on 1/7/2025 and completed on 1/14/2025, the facility did not ensure each resident was served food and drinks that were palatable, attractive, and at a safe and appetizing temperature. This was identified for ten (Resident #186, Resident #197, Resident # 52, Resident # 16, Resident #142, Resident #200, Resident #50, Resident #12, Resident #128, and Resident #164) of ten residents during the Resident Council meeting. Specifically, during the Resident Council meeting held on 1/8/2025, ten of the ten residents in attendance complained of hot food being served at cold temperatures. On 1/13/2025, during the lunch meal service, three (Unit 1 North, Unit 2 North, and Unit 3 South) of three units' meals temperatures for the hot food items were recorded below 135 degrees Fahrenheit. The finding is: The facility's policy titled Food Preparation and Service last revised March 2023, documented that potentially hazardous foods including meats, poultry, seafood, cut melon, eggs, milk, yogurt, and cottage cheese must be maintained below 41 degrees Fahrenheit and above 135 degrees Fahrenheit. Previously cooked food must be reheated to an internal temperature of 165 degrees Fahrenheit for at least 15 seconds. The temperature of foods held in steam tables will be monitored by food and nutrition service staff. The Resident Council meeting was conducted on 1/8/2025 at 11:55 AM. Ten of the ten residents in attendance unanimously complained of hot food being served at cold temperatures. Resident #142, the Resident Council President, was admitted with diagnoses that included Diabetes Mellitus, Emphysema ( chronic lung disease that damages the air sacs in the lungs, making it difficult to breathe), and Hyperlipidemia (high cholesterol). The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident had intact cognition. Resident #200 was admitted with diagnoses that included Gout, Hypertension, and Depression. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. Resident #50 was admitted with diagnoses that included Acute Respiratory Failure and Obesity. The 5-day Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. Resident #164 was admitted with diagnoses that included Parkinson's Disease, Lymphoma, and Anemia. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 13, indicating the resident was cognitively intact. A review of the Resident Council minutes from 10/2024 to 12/2024 was conducted and no concerns were documented in the Resident Council minutes regarding hot foods that were served cold during meals. On 1/13/2025 during the lunch meal service, three test trays were requested for three (Unit 3 South, Unit 1 North, Unit 2 North) of the three units. Two meal racks for Unit 3 South departed the kitchen at 12:39 PM and arrived at the unit at 12:40 PM. The racks were not covered. The last meal tray was served at 12:58 PM. The test tray temperatures were taken at 12:58 PM in the presence of the Assistant Director of Nursing Services. The temperature reading for the protein entree, the roasted chicken, was 128.5 degrees Fahrenheit. The temperature readings for the vegetables (diced potatoes and sliced carrot) were 124 degrees Fahrenheit and 108.1 degrees Fahrenheit respectively. Two meal racks for Unit 1 North departed the kitchen at 12:57 PM and arrived at the unit at 12:58 PM. The racks were not covered. The last meal tray was served at 1:03 PM. The test tray temperatures were taken at 1:03 PM in the presence of the Dietary Supervisor. The temperature readings for the vegetables (diced potatoes and sliced carrot) were 131 degrees Fahrenheit and 120 degrees Fahrenheit respectively. One meal rack for Unit 2 North departed the kitchen at 1:09 PM and arrived at the unit at 1:13 PM. The rack was not covered. The last meal tray was served at 1:25 PM. The test tray temperatures were taken at 1:25 PM in the presence of the Director of Finance. The temperature reading for the protein entree, the roasted chicken, was 120 degrees Fahrenheit. The temperature readings for the vegetables (diced potatoes and sliced carrot) were 100 degrees Fahrenheit and 110 degrees Fahrenheit respectively. During an interview on 1/13/2025 at 1:14 PM, the Food Service Director stated they knew there were concerns about hot meals being served cold from Resident Council and Food Committee meetings. The Food Service Director stated that the kitchen continued to utilize an old pellet heating system which was not distributing heat evenly to warm all the pellets at equal temperatures therefore, the food was not preserved to the desired temperature. The Food Service Director stated an outdated steamer used to cook vegetables was also inefficient. The Food Service Director stated the administration was aware of the concerns and they continued to explore different solutions such as a new steamer, enclosed racks, and a new pellet heating system. The Food Service Director stated nothing had been finalized at this time. During an interview on 1/14/2025 at 12:55 AM, the Administrator stated they were aware of residents' complaints about food temperature since 2023. The Administrator stated they thought the issue was related to staff not distributing the meals timely and they implemented an all hands on deck approach and instructed all staff to take part in the meal distribution. The Administrator stated a few months ago they started looking into replacing kitchen equipment because the pellet warmer system was old and did not evenly heat all the pellets. The Administrator stated there is currently an ongoing discussion to purchase new equipment; however, no orders have been placed at this time. The Administrator stated they were not aware of the insufficient amount of metal pellets. 10 NYCRR415.14(d)(1)(2)

Based on observation, record review, and interviews during the Recertification Survey initiated on 1/7/2025 and completed on 1/14/2025, the facility did not ensure that an infection prevention and control program designed to help prevent the development and transmission of communicable disease and infection was implemented. This was identified for one (Resident #208) of six residents reviewed for Infection Control. Specifically, Resident #208 had a physician's order for contact precautions secondary to Conjunctivitis (eye infection). On 1/13/2025, Occupational Therapist #1 and Physical Therapy Assistant #1 were observed ambulating the resident without proper Personal Protective Equipment. The finding is: The facility's Transmission Based Precautions policy and procedure last revised on 4/25/2024 documented contact precautions are implemented to prevent transmission of pathogens that are spread by direct or indirect contact with the resident or the environment. Upon entering the room of a resident on contact precautions, healthcare personnel and visitors should don (put on) a gown and gloves, and should doff (remove) Personal Protective Equipment prior to leaving the room. Resident #208 had diagnoses that included Hypertension and Conjunctivitis. The Admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, which indicated the resident had intact cognition. The Minimum Data Set assessment documented the resident's vision was adequate. The resident utilized a wheelchair for mobility and required supervision/touching assistance with wheeling. The resident was not ambulated during the assessment look-back period. A physician's order dated 1/12/2025 documented Tobramycin Ophthalmic Solution 0.3 % (antibiotic for eye infection). Instill 1 drop in each eye every 8 hours for Conjunctivitis for 5 days. A physician's order documented an order to place the resident on Contact precautions for Conjunctivitis until 1/16/2025. A Comprehensive Care Plan dated 1/12/2025 documented the resident had suspected/actual infection related to Conjunctivitis. Interventions included to administer antimicrobial medication as ordered, to administer medication and treatment as ordered, educate the resident/family/visitors on precautions, and Personal Protective Equipment to be worn by staff, providers, family, and visitors related to an active infection. During an observation on 1/13/2025 at 11:30 AM, Occupational Therapist #1 and Physical Therapy Assistant #1 were observed ambulating Resident #208 in the hallway towards the resident's room without the use of Personal Protective Equipment. A precautions sign was observed outside Resident #208 door that documented Contact Precautions, put on gloves and a gown before entry. Occupational Therapist #1 and Physical Therapy Assistant #1 ambulated the resident into the room and assisted the resident into a wheelchair. Occupational Therapist #1 and Physical Therapist Assistant #1 were interviewed immediately on 1/13/2025 at 11:38 AM. Occupational Therapist #1 stated they were walking the resident from the Rehabilitation Therapy gym to their room and were not allowed to wear gowns in the hallway. Physical Therapy Assistant #1 stated they knew to wear Personal Protective Equipment when entering a resident's room on Contact Precaution; however, they were only going into Resident #208's room to assist the resident back into their wheelchair. During a subsequent interview on 1/13/2025 at 11:57 AM, Occupational Therapist #1 stated Resident #208 wheeled themselves to the Rehabilitation Therapy gym and told them that something was wrong with their eyes. Occupational Therapist #1 stated soon after the resident came down, the nursing staff called them and told them to return the resident to their room because the resident was on Contact Precaution for Pink Eye. Occupational Therapist #1 stated they and Physical Therapist Assistant #1 decided to walk the resident to their room to get the ambulation session completed. Occupational Therapist #1 stated they thought they did not have to put on Personal Protective Equipment as they were only returning the resident back to their room. Occupational Therapist #1 stated they should have put on a gown and gloves before they entered the resident's room. During a subsequent interview on 1/13/2025 at 11:59 AM, Physical Therapist Assistant #1 stated they and Occupational Therapist #1 decided to walk the resident from the Rehabilitation Department gym to their room to get the ambulation session completed. Physical Therapist Assistant #1 stated they did not have to put on Personal Protective Equipment as they were only returning the resident to their room. During an interview on 1/14/2025 at 3:55 PM, the Director of Nursing Service stated that both Occupational Therapist #1 and Physical Therapy Assistant #1 should not have ambulated the resident in the hallway after they were notified of the resident's Contact Precautions status. During an interview on 1/13/2025 at 4:10 PM, the Infection Control Preventionist stated that Occupational Therapist #1 and Physical Therapy Assistant #1 should not have walked the resident in the hallway after being informed that the resident was on Contact Precaution and should have followed the facility's policy and utilized appropriate Personal Protective Equipment including a gown and gloves. 10 NYCRR 415.19(a)(1-3)

Based on observation, record review and interviews during the Recertification Survey initiated on 7/5/2023 and completed on 7/13/2023, the facility did not ensure that an infection prevention and control program (IPCP) designed to help prevent the development and transmission of communicable disease and infection was maintained. This was identified for one (Resident #95) of two residents reviewed for Pressure Ulcers. Specifically, during a wound care observation conducted on 7/12/2023 with Licensed Practical Nurse (LPN) #5, the LPN did not follow proper technique during cleansing of the wounds. LPN #5 did not clean each wound from the inner aspect towards the outer aspect of the wound and did not use new gauze for each cleansing of the wounds. The finding is: The facility's Pressure Injury policy revised 4/2017 documented to clean the area with normal saline (unless otherwise specified by the physician) and pat dry. The policy did not address the technique the staff should follow when cleansing a wound. Resident #95 was admitted with diagnoses that include Left Hip Stage IV Pressure Ulcer (PU) and Sacrum IV PU. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had short and long term memory problems. The resident was frequently incontinent of bowel and bladder. The resident was at risk for developing PU and had one or more unhealed Stage IV PU that were present on admission. A Physician order dated 6/14/2023 documented to treat the Sacral PU by applying Dakin's Cleanse (a wound cleanse) topically, followed by Iodoform strip packing to the wound bed and cover with a foam dressing everyday shift (7 AM - 3 PM). A Physician order dated 6/14/2023 documented to treat the Left Hip PU by applying Dakin's Cleanse topically, followed by Iodoform strip packing to the wound bed and cover with a foam dressing everyday shift (7 AM - 3 PM). A Comprehensive Care Plan (CCP) for PU Alteration in Skin Integrity dated 6/25/2021 and last updated 6/1/2023 documented the resident has an actual Stage IV Pressure Injury to the Left Hip. Interventions included but were not limited to refer to wound care specialist as needed; monitor wound daily for signs and symptoms of infection; and to report to the Physician as needed. A CCP for PU Alteration in Skin Integrity dated 6/25/2021 and last updated 6/1/2023 documented the resident had an actual Stage IV PU to the Sacrum. Interventions included but were not limited to refer to wound care specialist as needed; monitor wound daily for signs and symptoms of infection; and to report to the Physician as needed. A wound care observation was conducted on 7/12/2023 at 9:57 AM with LPN #5. LPN #5 was observed to remove the soiled dressing and packing from the left hip wound, then changed their gloves and washed their hands. After donning clean gloves, LPN #5 was observed to spray dermal wound cleanser to the left hip wound, then using a gauze LPN #5 cleansed the center of the wound using multiple circular motions. Without changing the gauze, LPN #5 used the same gauze to clean the center of the wound and the surrounding area of the wound a second time. LPN #5 was observed to use the same technique when cleansing the Sacrum Stage IV PU. LPN #5 was interviewed on 7/12/2023 at 10:45 AM regarding the cleansing of the wounds. LPN #5 stated that they receive frequent in-service education on wound care and that they were in-service to clean the wound using one single motion from the inner aspect of the wound to the outer aspect of the wound and to change the gauze with each cleanse. LPN #5 stated they were nervous and they should not have used the same gauze to cleanse the wound multiple times. LPN #5 further stated they should have performed a single motion each time they cleansed each wound and then used a new gauze each time they cleansed the wound. Wound Care Registered Nurse (RN) #2 was interviewed on 7/12/2023 at 12:01 PM. RN #2 stated they were responsible for yearly competency evaluations for each nurse who performs wound care. RN #2 stated that the nurses are taught to use one motion from the inner wound to the outer wound and to change the gauze each time they cleanse the wound. The Director of Nursing Services (DNS) was interviewed on 7/12/2023 at 1:12 PM. The DNS stated the nurses are educated to use one motion from the inner to the outer aspect of the wound using one gauze and to use a fresh gauze with each cleanse. The DNS stated LPN #5 should have changed the gauze each time they cleansed the wound. 10 NYCRR 415.19(a)(1-3)

Based on observation, record review, and interviews during the Recertification Survey initiated on [DATE] and completed on [DATE], the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. This was identified during the initial tour of the kitchen on [DATE]. Specifically, emergency dry food and food products delivered to the facility without expiration dates were not tracked. The safety of consumption and discard dates of these food products were not determined as per the manufacturer's recommendations. The finding is: The facility's policy titled Food Safety - Food Handling dated ,d+[DATE] documented that the facility only accepts prepared foods from suppliers subject to federal, state, or local food service inspections and who remain in good standing with such agencies. All kitchen staff will be in-serviced on labeling procedures. All prepared items stored in cooling units will be labeled and dated. The facility's policy titled Food Storage last revised [DATE] documented that all stock must be rotated with each new order received. Rotating stock is essential to assure the freshness and highest quality of all foods. Old stock is always used first (first in- first out method). The policy documented to supervise the person designated to put stock away to make sure it is rotated properly. Food should be dated as it is placed on the shelves if required by state regulation. Date marking to indicate the date or day by which a ready-to-eat, Time/Temperature Control for Safety Food (formerly known as PHF) should be consumed, sold, or discarded will be visible on all high-risk food. Canned goods should be used and rotated within 6 months. The policy did not specify what date the 6-month perimeter was determined from. During an initial tour of the kitchen on [DATE] at 11:42 AM, an inspection of the emergency dry storage room was conducted. Three cases of canned chili con carne with beans were observed with hand-written expiration dates dated ,d+[DATE] while the best by dates printed on the cans indicated ,d+[DATE]. Six loose cans of three bean salad were observed sitting on top of a sealed case of canned chili. All six cans of three bean salad did not have delivery dates nor comprehensible expiration dates printed on the cans. The Food Services Director (FSD) was interviewed on [DATE] immediately following the observation and stated that they (Food Service Director) had a tracking system to remind them when the emergency food stock must be rotated or discarded. The FSD stated that the identified items were ordered before they were employed. The FSD stated that they did not know why the expiration dates of the canned chili con carne with beans were written as ,d+[DATE] instead of ,d+[DATE]. The FSD stated that the best by date should have been ,d+[DATE], and the items should have been discarded. The FSD stated that they did not know when the cans of three bean salad were delivered and how long the cans were stored in the emergency room . The FSD stated that they did not know how to interpret the expiration date of the canned three bean salad and there was no way to determine the expiration date at this time. The FSD stated that they do not retain invoices for more than a few days after shipment. The FSD was re-interviewed on [DATE] at 12:37 PM and stated that the three bean salad cans were discarded after the observation. The FSD stated that the facility currently has no system of checking expiration dates of canned food upon delivery. The FSD stated that they did not educate nor expect kitchen staff to check for expiration dates of any canned foods at the time of delivery. The FSD stated that they trusted food vendors to deliver non-perishable food items that were not expired. The FSD stated that they only expect the stock person to use a date gun to label all canned items with the delivery date. The FSD stated that they will reach out to the manufacturer to obtain the manufacturer's recommendations for foods with best by date to determine how long those foods will be safe to consume beyond best by date. The FSD further stated that they will in-service all kitchen staff on reading the dates on the food packaging and reporting any concerns related to expiration dates of the foods to the FSD. Dietary Aide (DA) #1 was interviewed on [DATE] at 12:37 PM and stated they (DA#1) were responsible for receiving and stocking the food delivery. DA #1 stated that when they stock new items, they rotate the old items in the front and place the new items in the back. DA#1 stated that they dated all items on the day they were delivered. DA#1 stated that the expired chili was in the emergency supply section and the FSD was responsible for ensuring the expiration dates of the emergency supplies and rotating out expired items. DA #1 stated that the expired chili should have been pulled from the shelf. The Administrator was interviewed on [DATE] at 4:41 PM and stated that there was a clerical error where an incorrect expiration date was indicated on the outside of the box of the canned chili con carne with beans. The Administrator stated that the expired items were removed and replaced. The Administrator stated that the facility should not have expired food items and they (Administrator) would conduct an audit to ensure the facility did not keep other expired food items. 10 NYCRR 415.14(h)

Based on observation, record review, and interviews during the Recertification Survey initiated on 7/05/2023 and completed on 7/13/2023, the facility did not develop and implement a Comprehensive Person- Centered Care Plan (CCP) for each resident that includes measurable objectives and time frames to meet a resident's nursing needs. This was identified for one (Resident #136) of two residents reviewed for Accident Hazards. Specifically, Resident #136 had no CCP developed for the independent use and storage of large nail clippers. The finding is: The Care Plans-Comprehensive Policy, revised 10/2019 documented that a comprehensive, person-centered care plan (CCP) is developed within seven days of the completion of the required comprehensive assessment. Assessment of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. The Activities of Daily Living (ADL)- Personal Hygiene Policy, revised 10/2021 documented that residents deemed appropriate by the Interdisciplinary Team (IDT) will be encouraged and permitted to perform their own nail care and maintain personal hygiene products. The resident's care plan and Kardex (a document that is utilized for resident care instructions provided to Certified Nursing Assistants) for any special care or needs of the individual are to be reviewed. Resident #136 was admitted with diagnoses including Anxiety Disorder, Schizophrenia, and Psychotic Disorder. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. The resident required supervision and set up help for personal hygiene. Resident #136, who resides on the Dementia Care Unit 3 South, was observed on 7/05/2023 at 3:53 PM with large nail clippers in their opened dresser drawer. Resident # 136 was interviewed immediately after the observation on 7/05/2023. Resident # 136 stated that they cut their own nails and have kept the nail chippers in their drawer since admission in March of 2021. Resident # 136's entire CCP was reviewed on 7/10/2023. There was no CCP developed for the resident's independent use and storage of the nail clippers. The Director of Social Services (DSS) #1 was interviewed on 7/11/2023 at 1:04 PM and stated that Resident# 136 informed the DSS #1 that they clip their own nails. The DSS #1 stated that the resident having the nail clippers in their room was not a concern. The care plan entitled Resident is Competent to Safely Use a Nail Clipper and Clip his Nails Independently was developed and implemented on 7/11/2023 by Nursing. Licensed Practical Nurse (LPN) #6 was interviewed on 7/12/2023 at 9:55 AM and stated that a CCP dated 7/11/2023 was implemented for the resident on their use of nail clippers. Resident #136 was interviewed on 7/12/2023 at 10:00 AM and stated that they keep their nail clippers in their room and leave them in their top dresser drawer. The resident stated that they are allowed to clip their own nails. Resident # 136 stated DSS #1 spoke to the resident about their nail clippers on 7/11/2023 and DSS#1 observed them in the top dresser drawer. The resident's Kardex was reviewed on 7/12/2023 and documented the use of nail clippers initiated on 7/11/2023. The Physician's order dated 7/12/2023 documented that the resident may keep their own nail clippers. The Director of Nursing (DNS) #1 was interviewed on 7/12/2023 at 1:20 PM and stated that the permission to possess personal hygiene items like nail clippers are dependent on the type of resident. The IDT will look at the resident's cognitive status, will assess the resident for safe use of nail clippers, and a care plan will be implemented if the resident is assessed as safe for independent use and storage of nail clippers. The DNS stated that a CCP relating to the use of nail clippers was initiated on 7/11/2023 and a Physician's order was placed on 7/12/2023. The CCP and Physician's order should have been implemented upon admission. 10 NYCRR 415.11(c)(1)

Based on observation, record review and interviews during the Recertification Survey initiated on 7/5/2023 and completed on 7/13/2023 the facility did not ensure that each resident is treated with respect and dignity and is cared for in a manner that promotes maintenance or enhancement of his or her quality of life. This was identified for two (Resident #129 and Resident #95) of two residents reviewed for dignity. Specifically, 1) Certified Nursing Assistant (CNA) #3 was observed abruptly wheeling Resident #129 into the bathroom without informing the resident before moving their wheelchair. Resident #129 was startled. 2) CNA #3 was again observed to abruptly move another resident (Resident #95) in bed onto their left side to position the resident for wound care. CNA #3 did not explain or alert the resident before moving the resident. The sudden movement surprised and startled the resident. The findings are: The facility's Quality of Life/Dignity policy revised 10/2021 documented that residents shall be treated with dignity and respect at all times. The policy documented, Treat with Dignity means the resident will be assisted with maintaining and enhancing his or her self-esteem and self-worth. 1)Resident #129 was admitted with diagnoses that include Non-Alzheimer's Dementia and Depression. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 4 which indicated the resident had severely impaired cognition. The resident required extensive assistance of one staff for transfers, toileting, and dressing, and required supervision with one-person physical assistance for locomotion on and off the unit. Prior to the start of a wound care observation conducted on 7/12/2023 at 9:57 AM, Resident #129 was seated in a wheelchair at the foot of the bed. The resident was holding their pants over their knees. CNA #3 was already in the resident's room and abruptly wheeled Resident #129's wheelchair without saying anything to the resident. The resident was startled. CNA #3 then continued to wheel the resident into the bathroom and did not explain to the resident why they (CNA #3) were taking them (Resident #129) into the bathroom. CNA #3 was interviewed on 7/12/2023 at 10:45 AM and stated they received in-service education to explain all tasks to the resident prior to performing the task. CNA #3 stated that they should have explained that they (CNA#3) were going to transport the resident into the bathroom to perform morning care before moving the wheelchair. The Director of Nursing Services (DNS) was interviewed on 7/12/2023 at 1:22 PM. The DNS stated CNA #3 should have explained that they were going to transport the resident into the bathroom prior to moving the wheelchair. The DNS stated all staff were educated to explain all tasks to be completed prior to performing the task. 2) Resident #95 was admitted with diagnoses that include Dementia without Behavioral Disturbance and Anxiety Disorder. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had both short and long term memory problems. The resident had no behavior problems and did not reject care. The resident required extensive assistance of one staff member for bed mobility and was frequently incontinent of bowel and bladder. The resident was at risk for developing pressure ulcers and had one or more unhealed two Stage IV pressure ulcers that were present on admission. During a wound care observation conducted on 7/12/2023 at 10:30 AM Licensed Practical Nurse (LPN) #5 was observed preparing for the sacral wound dressing change at the treatment cart in the hallway at the entrance of the resident's room. Resident # 95 was observed lying in bed on their back. CNA #3 was in the room and was observed to abruptly turn the resident onto their left side, facing the wall, causing the resident to be startled. The resident was observed to outstretch both arms and placed their right hand against the wall. Prior to turning the resident to their left side, CNA #3 did not inform the resident that they were going to turn them (Resident #95). CNA #3 was interviewed on 7/12/23 at 10:45 AM and stated they received in-service education to explain all tasks to the resident before performing the tasks. CNA #3 stated that they should have explained they were going to turn the resident onto their left side before performing the task. The Assistant Director of Nursing Services (ADNS)/Staff Educator was interviewed on 7/12/2023 at 1:10 PM. The ADNS stated that staff receive in-service education to explain any tasks that have to be completed prior to performing the task. The ADNS stated in July 2023 they (ADNS) initiated in-service education with all staff including CNA #3, regarding quality of life, dignity, and effective communication. The ADNS stated CNA #3 should have explained to the resident that they (CNA #3) were going to turn the resident before moving or turning the resident. The Director of Nursing Services (DNS) was interviewed on 7/12/2023 at 1:22 PM. The DNS stated that CNA #3 should have explained that they (CNA #3) were going to turn the resident prior to turning the resident on their left side. The DNS stated all staff were educated to explain all tasks to be completed prior to performing the task. 10 NYCRR 415.3(d)(1)(i)

Based on observation, interview, and record review during the recertification survey completed on 05/13/2021, the facility failed to establish and maintain an Infection Control Program to ensure the health and safety of residents to help prevent the transmission of COVID-19 for 1 out of 5 residents. Specifically, the facility did not have appropriate signage for a resident (#406) who was on Transmission-Based Precautions. Additionally, the facility staff did not wear required Personal Protective Equipment (PPE) while applying a pain patch to Resident #406's back. The finding is: The Centers for Disease Control and Prevention (CDC) guidance titled Transmission-Based Precautions (undated), provides: Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning Personal Protective Equipment (PPE) upon room entry and properly discarding before exiting the patient room is done to contain pathogens. The Centers for Disease Control and Prevention (CDC) guidance entitled Preparing for COVID-19 in Nursing Homes dated 11/20/20 documented that universal use of all recommended PPE for the care of all residents on the affected unit (or facility-wide depending on the situation) is recommended when even a single case among residents or HCP is newly identified in the facility; this could also be considered when there is sustained transmission in the community. The Health Advisory: COVID-19 Cases in Nursing Homes (NH) and Adult Care Facilities, dated 3/13/20 and revised 7/10/2020, documented there are confirmed cases of COVID-19 in a NH, all residents on affected units should be placed on droplet and contact precautions, regardless of the presence of symptoms and regardless of COVID-19 status. Health Care Providers (HCPs) and other direct care providers should wear gown, gloves, eye protection (goggles or a face shield), and N95 respirators (or equivalent) if the facility has a respiratory program with fit tested staff and N95. Otherwise, HCP and other direct care providers should wear gown, gloves, eye protection, and face masks. Facilities may implement extended use of eye protection and facemasks/N95s when moving from resident to resident (i.e. do not change between residents) unless other medical conditions which necessitate droplet precautions are present. However, gloves and gowns must be changed, and hand hygiene must be performed. The facility's policy titled Isolation-Room Placement, last revised 11/5/2020, documented that employees and other direct care providers should wear gown, gloves, eye protection (goggles or a face shield) and an N95 mask when caring for new admissions in the isolation period. The policy also documented that a Yellow Sign indicates a resident identified as exposed or potentially exposed to an active positive COVID-19 person and full Personal Protective Equipment (PPE) should be worn-mask, gown, goggles or face shield, and gloves. During an interview on 5/06/2021 at 10:52 AM the Director of Nursing Services (DNS) stated there were no positive COVID-19 residents in the facility, however there was a housekeeper currently on [NAME] who tested positive for COVID-19 with the results received by the facility on 5/3/2021. The DNS stated the housekeeper worked exclusively on unit 1 South. This unit is designated for new admissions and residents receiving sub-acute care who are on Transmission Based Precautions. Resident #406 was admitted to the facility on Unit 1 South with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5/7/2021 Admission Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation made on 5/7/2021 at 8:13 AM on Unit 1 South, the Licensed Practical Nurse medication nurse (LPN) was observed administering a [MEDICATION(S)] Patch (pain patch) to resident #406. The LPN was wearing gloves, a face shield and an N95 mask, but no gown. The LPN leaned over and came in contact with the resident's bed. The LPN applied the [MEDICATION(S)] patch to the resident's lower back. During an interview on 5/7/2021 at 8:13 am and 8:20AM, the LPN medication nurse stated that the yellow stop signs outside the rooms were for COVID-19 precautions. There was no stop sign outside Resident #406's room, but the nurse stated there is supposed to be. Additionally, the LPN stated that they were not sure if a gown was needed for placing a patch on the resident's back and would have to check. The DNS was interviewed on 5/7/2021 at 10:00 AM. The DNS stated that the nurse should have had a gown on when applying the patch to Resident #406's lower back. On 5/7/2021 at 12:00 PM a yellow stop sign was observed outside Resident #406's room. The Registered Nurse (RN) Infection Preventionist (IP) was interviewed on 5/11/2021 at 2:35 PM. The IP stated that if contact with the resident is expected then a gown should be worn when a resident is on Transmission-Based Precautions on unit 1 South. The RN Staff Educator was interviewed on 5/12/2021 at 10:18 AM. The Staff Educator stated that the yellow stop sign is for COVID-19 precautions and suspicion of COVID-19 for a newly admitted resident. The Staff Educator stated that the staff has been verbally told that full PPE must be worn when entering a resident room, which means wearing a gown, eye protection, gloves and an N95 mask for residents who are on Transmission Based Precaution. 415.19(a)(1-2); 400.2

Based on record review and staff interviews during the Recertification Survey completed on 05/13/2021 the facility did not ensure that medication irregularities reported by the Consultant Pharmacist were reviewed and acted upon by the Physician for 2 (Resident #47 and #163) of 5 residents reviewed for unnecessary medications. Specifically, the Consultant Pharmacist made recommendations to the Physician and a decision to agree or disagree to the recommendation was not documented by the Physician. The findings are: 1) Resident #47 was admitted with diagnoses that include Diabetes Mellitus (DM), Depression and Hypertension ([CONDITION(S)]). The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score of 14 that indicated the resident was cognitively intact. The resident had no behaviors and was on antidepressant and antipsychotic medications. On 4/9/2021, the Pharmacy Consultant Note documented: 1. Caution: [MEDICATION(S)] and [MEDICATION(S)] use with [MEDICATION(S)] 5 mg twice daily (bid) may have potential risk of bleed/bruise risk. Benefit>Risk. 2. Caution: [MEDICATION(S)] and [MEDICATION(S)] use with diagnosis of DM may increase glucose levels. Benefit>Risk. 3. Can [MEDICATION(S)] 50 mg HS (at bed time) be Gradual Dose Reduction (G.D.R.) attempted? The Physician's orders dated 5/12/2021 included: 1- [MEDICATION(S)] ([MEDICATION(S)]-an antihypertensive medication) ER (extended release) Tablet 60 milligrams (mg) 1 tablet by mouth one time a day for [CONDITION(S)] 2- [MEDICATION(S)] (an anticoagulant) 5 mg Tablet for [CONDITION(S)] bid. 3- [MEDICATION(S)] ([MEDICATION(S)]-an Antidepressant medication) HCl 75 mg Tablet by mouth one time a day for Depression. 4- [MEDICATION(S)] ([MEDICATION(S)]-Antipsychotic medication) 50 mg Tablet by mouth at bedtime for MDD (Major Depressive Disorder). 5- [MEDICATION(S)] ([MEDICATION(S)]-Antipsychotic medication) 0.5 mg Tablet by mouth every 12 hours for MDD The physician did not address any of the Pharmacist consult recommendations dated 4/9/2021. The Director of Nursing Services (DNS) was interviewed on 5/12/2021 at 11:45 AM and stated there was an oversight and the Physician was not notified of the Pharmacist's recommendations until yesterday (5/11/2021). The Physician should have been notified on 4/9/2021 when the Pharmacy Consultant completed the Medication Regimen Review (MRR). The Physician was interviewed on 5/12/2021 at 12:53 PM and stated this Pharmacy consult was just brought to the Physician's attention on 5/11/2021. The Physician stated that the Pharmacist's recommendations should have been brought to the Physician's attention within 2-3 days of the consult. The Physician stated that the physician used to check the Electronic Medical Record (EMR) for Pharmacy consult recommendations, however, it was too time consuming. I may have to check the EMR for consult recommendations and address them in a more timely manner. 2) Resident #163 was admitted with diagnoses that include Basel Cell [CONDITION(S)], Major Depressive Disorder (MDD) and [CONDITION(S)] (GERD). The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score as 9 which indicated the resident had moderately impaired cognition. The resident had no documented behaviors and was on antidepressant medications. The resident's face sheet documented allergies to [MEDICATION(S)] (pain medication) and [MEDICATION(S)] (pain medication). On 3/29/2021, the Pharmacy Consultant note documented: 1. Resident has allergy to [MEDICATION(S)] but can tolerate Tylenol component? 2. Proton Pump Inhibitors is Beer's list drug secondary to potential risk of bone loss, fracture or [CONDITION(S)] with chronic use. Still necessary? 3. Caution [MEDICATION(S)] may increase International Normalized Ratio (INR)- of [MEDICATION(S)]. Benefit greater than risk? An undated response to the Pharmacist's review was documented by the Director of Nursing Services (DNS) as follows: 1- Despite allergy, tolerating. 2- Yes 3. The word Benefit was circled. The words Reviewed with MD A review of the medical record from March 2021through May 2021 revealed no documentation by the attending Physician regarding the 3/29/2021 Pharmacy Consultant note. The Physician's orders dated 5/12/21 included: 1. 3/16/21 Tylenol 325 milligrams (mg), Give 2 tablets by mouth every 6 hours as needed (PRN) for Pain until 04/10/2021. 2. [MEDICATION(S)] (antiacid) 40 mg Tablet delayed release. Give 1 tablet by mouth one time a day for GERD. 3. [MEDICATION(S)] HCl ([MEDICATION(S)]- an Antidepressant medication) Tablet 25 mg. Give 1 tablet by mouth, one time a day for Depression. 4. [MEDICATION(S)] Tablet 3 MG (Warfarin Sodium- Anticoagulant) Give 3 mg by mouth at bedtime. The DNS was interviewed on 05/12/2021 at 11:55 AM and stated that the Pharmacy consultant reviews were discussed with the attending Physician via telephone with responses documented on behalf of the Physician. The DNS stated that the attending Physician was expected to sign the consult once in the building, however the consult dated 3/29/2021 was never signed. The DNS stated that the attending Physician reviewed the Pharmacy consultant recommendations prior to COVID-19 outbreak but has not done so since that time. The resident's attending Physician was interviewed on 05/12/2021 at 12:55 PM and stated that the discussions with the DNS of the pharmacy consultant's recommendations were not documented in the medical records. The attending Physician stated that the doctors usually signed the Pharmacy Consultant recommendations following discussion with the DNS, but did not recall signing the Pharmacy Consultant note dated 3/29/2021. 415.18(c)(2)

Based on record review, and staff interviews during the Recertification Survey completed on 5/13/2021, the facility did not ensure that each residents' Comprehensive Care Plan was updated to reflect the residents' current status for one (Resident #193) of two residents reviewed for Activities of Daily Living (ADL). Specifically, Resident #193 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Comprehensive Care Plan (CCP) and the Certified Nursing Assistant (CNA) Task record (directions for the CNAs to provide care to the resident) were not updated with the resident's current Physician orders. The finding is: Resident #193 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) Score of 9 which indicated the resident had moderate cognitive impairment. The resident had no behavioral symptoms and required total assistance of two staff members for transfer. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Nursing may provide more assistance if necessary. A CCP dated 10/21/2020 and last updated 4/7/21 documented the resident required assistance with ADLs related to Fatigue, Impaired Balance, Limited Mobility, and Limited Range of Motion. The CCP documented the resident required limited assistance of one staff member for transfer. There was no documented evidence the CCP was updated with the current transfer order for Hoyer Lift and two staff assistance. A Rehabilitation Intervention Note dated 4/7/2021 documented the resident was evaluated and treated as per the Physician's (MD) orders, status post [MEDICAL RECORD OR PHYSICIAN ORDER] . A Nurse's note dated 4/7/2021 documented the resident was presently receiving Occupational Therapy and transfers with a Hoyer Lift. An ADL Change in Status Form dated 4/7/2021 documented a Hoyer Lift with assistance of two staff members for transfer. A Review of the CNA task record documented the resident required limited assistance of one staff member for transfer. The 7:00 AM - 3:00 PM CNA #6 was interviewed on 5/13/21 at 11:36 AM and stated that prior to hospitalization the resident required supervision to extensive assistance of one to two staff members for ADLs. CNA #6 stated after the resident was readmitted from the hospital the resident required Hoyer Lift for transfer for a short time, and was then upgraded back to two persons assistance for transfer. CNA #7 was interviewed on 5/13/2021 at 11:42 AM and stated that the resident required assistance of one staff member for transfers. CNA #7 stated during toileting in the bathroom the resident would stand up and sit on the toilet when cued. The Physical Therapy Assistant (PTA) and the Certified Occupational Therapy Assistant (COTA) were interviewed concurrently on 5/13/2021 at 12:20 PM with. Both the PTA and the COTA stated when the resident first came back from the hospital the resident was not motivated, was resistant, and was not safe which led to the resident being assessed for a Hoyer Lift transfer. The COTA stated that since this recent readmission the resident was made a Hoyer lift for transfer for safety because of the resident's behavior. The PTA and the COTA stated during therapy sessions when an attempt was made to work with the resident, the resident did not follow directions. The resident should remain a Hoyer transfer because of the resident's fluctuating behaviors. Additionally, both the PTA and COTA stated the expectation is that the staff transfer the resident with a Hoyer Lift as ordered. The Physical Therapist (PT) was interviewed on 5/13/2021 at 1:35 PM and stated the PT assessed the resident upon readmission on 4/7/2021. The PT stated the resident was unable to perform sit to stand transfer and was unable to get into the chair. The PT stated because the resident was not able to transfer into the chair the safest transfer for the resident was a Hoyer Lift transfer. The Director of Nursing Services (DNS) was interviewed on 5/13/2021 at 4:25 PM and stated that the CCP and the CNA Task records should have been updated to reflect the current transfer order for the resident. 415.11(c)(2)(i-iii)

Based on observation, record review, and staff interviews during the Recertification Survey completed on 5/13/2021, the facility did not ensure that residents were receiving care and services in accordance with each resident's plan of care. This was identified for one (Resident #158) of two residents reviewed for Quality of Care concerns. Specifically, Resident #158 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . However, on two separate observations the ACE wraps were not in place to the resident lower extremities, and The finding is: Resident #158 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) Score as 9, which indicated moderate cognitive impairment. The resident had no behavioral symptoms and required extensive of one staff members for all Activities of Daily Living (ADL)s A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order included making sure to use two ACE wraps on each lower extremity and to remove at hour of sleep (HS) for diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Treatment Administration Record (TAR) dated 5/1/2021 to 5/31/2021 documented ACE wraps to be applied from the toes to below the knees. Apply on the 11:00 PM- 7:00 AM and remove on the 3:00 PM-11:00 PM. A Comprehensive Care Plan (CCP) dated 3/23/21 for Fluid Deficit documented the resident had actual and potential for fluid deficit related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident has a history of [CONDITION(S)] and use of Diuretics. Interventions included monitoring laboratory work, weight, and [CONDITION(S)]. There was no documentation for the use of the ACE wraps for the resident's lower extremities. During an observation on 5/7/2021 at 11:40 AM Resident #158 was observed sitting in the bedroom in a wheelchair. The resident was observed with bilateral lower extremity [CONDITION(S)] (swelling) and was wearing gray non-skid socks. During a subsequent observation on 5/7/2021 at 1:30 PM, the resident was in the bedroom sitting in a wheelchair being fed by the assigned Certified Nursing Assistant (CNA #1). There were no ACE wraps observed on the resident's lower extremities. The assigned 7:00 AM-3:00 PM shift CNA#1 was interviewed on 5/7/2021 at 1:35 PM. CNA#1 stated that CNA#1 was floated to the resident's Unit and was not aware of the resident's need for the ACE wraps. CNA #1 further stated the ACE wraps were not on the resident's legs at the start of the 7:00 AM-3:00 PM shift. The 7:00 AM-3:00 PM Licensed Practical Nurse (LPN#2) was interviewed on 5/7/2021 at 1:40 PM and stated that only the treatments that are ordered for the 7:00 AM-3:00 PM shift appear on the computer screen and that the ACE wrap was to be applied to the resident's legs on the night shift. LPN #2 further stated if the ACE wrap treatment order had appeared on the computer screen then LPN #2 would have applied the ACE wraps to the resident's lower extremities. In a subsequent interview with the 7:00 AM-3:00 PM LPN #2 on 5/7/21 at 2:15 PM, LPN #2 stated at the start of the 7:00 AM-3:00 PM shift, the ACE wraps were on the nightstand because they were soiled. The resident did not have the ACE wraps on. An interview was conducted on 5/7/21 at 2:30 PM with the 11:00 PM - 7:00 AM LPN#3, who worked on 5/6/2021-5/7/2021 night shift, stated that the ACE wraps were applied by the LPN #3 at 5:00 AM. When the LPN went to administer the morning medications, the juice spilled on the ACE wraps. LPN #3 took the ACE wrap off and placed them on the resident's dresser. LPN#3 further stated an emergency occurred and LPN #3 had to leave at 7:00 AM and did not inform the day shift nurse. the Director of Nursing Service (DNS) was interviewed on 5/12/2021 at 4:23 PM and stated that the ACE wraps should have been in place on the resident's lower extremities as per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 415.11(c)(1)

Based on observation, record review, and staff interviews during the recertification survey, the facility did not ensure that each resident's drug regimen was free from unnecessary medications. This was evident for for two of eight residents reviewed for [MEDICAL CONDITION] medication use. Specifically, 1) Resident # 186 received a [MEDICAL CONDITION] medication Quetiapine ([MEDICATION NAME]), an antipsychotic medication, without documented evidence of a clinical indication or medical assessment for the use of Quetiapine; and 2) Resident # 152 received an antipsychotic medication for an excessive duration without an attempt at a Gradual Dose Reduction (GDR) and in the absence of clinical symptoms. The findings are: 1) Resident #186 is [AGE] years old and was admitted to the facility for short term rehabilitation on 1/10/19 with diagnosed including: [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 5 indicating severely impaired cognition. The MDS documented the resident had no symptoms of [MEDICAL CONDITION], Hallucinations or Delusions. The MDS also documented the resident received 7 days of antipsychotic medication during the look back period. A Medical Diagnoses Record dated 1/10/19 documented Dementia, Muscle weakness and Hypertension. The Medical Diagnoses Record was updated on 1/23/19 and documented a [DIAGNOSES REDACTED]. A Physician order [REDACTED]. A Pharmacy review dated 1/10/19 documented that Quetiapine is not approved by the Food and Drug Administration (FDA) to treat Dementia, and there was a black box warning for geriatric residents that may increase the mortality rate. The pharmacy review documented there is no [DIAGNOSES REDACTED]. The Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. A Psychiatric evaluation dated 1/14/19 documented that the resident was [AGE] years old with Dementia and was admitted on [DATE]. The Psychiatric evaluation documented no reports of mood lability and that the resident's insight and judgement were impaired. The Psychiatric evaluation documented that a GDR was not completed due to possible decompensation of the resident's behavior and to continue the current medications. The Psychiatric evaluation also documented that the Physician agreed with the evaluation. physician progress notes [REDACTED]. All of these physician progress notes [REDACTED]. There is no documented evidence of an assessment or medical indication for the continued use of Quetiapine. Behavior Notes dated 1/20/19, 1/28/19, 2/4/19, and 2/11/19 had no documented evidence of [MEDICAL CONDITION], Hallucinations or Delusions. The physician's orders [REDACTED]. Observations on 2/8/19 at 8:05 AM and 1:15 PM revealed the resident was sleeping in her bed. An interview was held with the resident's Certified Nursing Assistant (CNA) on 2/13/19 at 8:24 AM. The CNA stated the resident is calm, cooperative, never exhibits any behaviors. The resident answers questions, can inform you of what she needs, wheels herself around in the wheelchair and attends activities. An interview was held with the Licensed Practical Nurse (LPN) on 2/14/19 at 10:00 AM. The LPN stated the resident is pleasant and cooperative, exhibits no [MEDICAL CONDITION] or behavior concerns. An interview was held with the Psychiatric Nurse Practitioner (NP) on 2/14/19 at 10:12 AM. The NP stated that Resident #186's son reported the resident lived alone prior to admission and reported the resident stated to him she was hallucinating, reporting that she thought someone might break into her home. The NP stated that is why she did not decrease the Quetiapine. The NP stated the [DIAGNOSES REDACTED]. An interview was held with the Pharmacy consultant on 2/14/19 at 1:10 PM. The Pharmacist stated that the resident should not be receiving Quetiapine with a [DIAGNOSES REDACTED]. An interview was held with the Registered Nurse (RN) Assistant Director of Nursing (ADON) on 2/15/19 at 8:00 AM. The ADON stated that when the resident was admitted to the facility the Physician was informed of the admission medications and determines the need and diagnoses for all the admission medications. An interview was held with the Director of Nursing Services (DNS) on 2/15/19 at 8:32 AM. The DNS stated that the resident should not be on Quetiapine and that the Physician should have addressed the [MEDICAL CONDITION] medication Quetiapine. An interview was held with the Physician on 2/15/19 at 8:45 AM. The Physician stated that he did not document on the use of Quetiapine for Resident #186. The Physician stated that residents with Dementia sometimes have [MEDICAL CONDITION] but that during his visits with the resident she was calm, pleasant and did not show any signs of [MEDICAL CONDITION]. The Physician stated that he was not aware that Dementia related [MEDICAL CONDITION] is not an indication for the use of the [MEDICAL CONDITION] medication Quetiapine. 2) Resident # 52 is [AGE] years old and was admitted on [DATE] with diagnosed including: [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] documented the resident had modified independence in cognitive skills for daily decision making. The resident's Mood Score was 13, indicating the resident has moderate depressive symptoms. The MDS documented the resident was receiving Antipsychotic and Antidepressant medications daily and that Antipsychotic medication was administered on a routine basis without an attempt of a GDR. The physician's orders [REDACTED]. The original order, documented in the electronic medical record, was dated 8/31/13. A Comprehensive Care Plan (CCP) titled, The Potential to Demonstrate Physical Behaviors, initiated 8/9/16, was updated on 12/27/18 and documented the resident has [MEDICAL CONDITION] and may think the food is poisoned. There were no updates to the CCP documenting these behaviors being exhibited by the resident. The [MEDICAL CONDITION] Medication Care Plan CCP, initiated on 1/2/13 and updated on 12/27/18 documented that no GDR will be attempted as per history or past decompensation. A Psychiatric Consultation dated 3/5/18 documented the resident had diagnoses of Dementia, [MEDICAL CONDITION] and Depression and that [MEDICATION NAME] was to be continued. The consultation documented that the dose reduction in the past had resulted in decompensation, weight loss, and delusions. There was no significant weight loss as documented on the most recent MDS dated [DATE]. Subsequent Psychiatric Evaluations dated 6/11/18, 9/10/18 and 12/10/18 all documented that the resident was not a candidate for a GDR of [MEDICATION NAME] related to long history of Paranoia and Delusional thinking. A Pharmacist Consultation note dated 9/29/18 recommended to consider if a GDR could be attempted. The response documented from the Physician was that GDR was contraindicated secondary to targeted symptoms worsened. Behavior Monitoring Weekly reports dated of 5/2/18, 5/16/18, 5/23/18, 6/6/18, and 6/20/18 documented that there had been no change in the resident's behavior from baseline. Behavior Monitoring notes dated 11/14/18, 11/21/18, 12/5/18, 12/12/18, 12/19/18, 12/24/18 and weekly through 2/11/19 documented no behaviors and no behavioral interventions were required by staff. The Pharmacy Consultant documented a recommendation for a GDR on 1/26/19. The response from the Physician was that the recommendation was reviewed with the Psychiatric Nurse Practitioner/NP, who had prescribed the [MEDICATION NAME], and a GDR would be contraindicated secondary to worsening behavior. The resident was observed sleeping in bed on 2/08/19 at 12:01 PM, with her head covered with a towel. The Registered Nurse (RN)/Unit Manager was interviewed on 2/15/19 at 9:31 AM. The RN stated that there have been no recent episodes of agitation or aggression and that she had never heard the resident exhibit any paranoia. The RN stated that the resident feeds herself with supervision, without any paranoid verbalizations noted by the RN. A subsequent observation of the resident was made on 2/15/19 at 9:32 AM. The resident was observed sleeping in bed. The resident's CNA was interviewed on 2/15/19 at 9:56 AM. The CNA stated that she has cared for the resident since the resident's admission. The CNA stated that the resident has never been aggressive, often prefers to stay in the bed and can be resistive to getting out of bed. The CNA stated that the resident has some odd behaviors but they are not dangerous to the resident or to others. The CNA further stated that the resident will attend some short term activities. The CNA described the resident as generally pleasant and quiet, who will eat in the dining room most times, does not voice any complaints and prefers to stay in her room. The resident's Attending Physician/MD was interviewed on 2/15/19 at 11:04 AM. The MD stated that a GDR was not attempted because the resident has had significant behaviors in the past. The Psychiatric Nurse Practitioner/ NP was interviewed on 2/15/19 at 12:27 PM. The NP stated that [MEDICATION NAME] was the only medication that was successful for the resident. The NP stated that prior attempts at a GDR were unsuccessful per the resident's history and that the resident had decompensated and the behaviors had returned. 415.12(l)(2)(i)(ii)

Based on record review and staff interview during the Recertification Survey the facility did not ensure that the resident's Admission Minimum Data Set (MDS) Assessment was completed within the 14 day time frame after admission. This was evident for one of five residents reviewed for Unnecessary Medications in a total of 27 Stage 2 sampled residents. Specifically, on 8/4/17, review of the Admission MDS for Resident # 190 revealed that the MDS was not completed within the 14 day time frame requirement for completion of Admission MDS assessments. The finding is: Resident #190 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 8/4/17 review of the Admission MDS due to be completed by 7/31/17 revealed that it was not completed within the 14 day required time frame. An interview was held with the Registered Nurse (RN) MDS Coordinator on 8/4/17 at 12:15 PM. The RN stated that the MDS should have been completed, but it was missed. 415.11(a)(3)(i)

Based on record review and staff interviews during the Recertification Survey, the facility did not ensure that for one of five residents reviewed for Unnecessary Medications in a total Stage 2 sample of 27 residents, who was receiving an antipsychotic medication, that a Gradual Dose Reduction (GDR) was attempted during the past year. Specifically, for Resident # 302 with a [DIAGNOSES REDACTED]. The finding is: Resident # 302, an [AGE] year old female with a [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented that the resident's cognition was moderately impaired with a Brief Interview for Mental Status (BIMS) score of 10. No behavioral symptoms were identified on the MDS. The MDS also documented that the resident was receiving an antipsychotic medication daily. The current physician's orders [REDACTED]. The following is the Black Box Warning for the medication [MEDICATION NAME]: Elderly patients with Dementia-related [MEDICAL CONDITION] treated with antipsychotic drugs are at an increased risk of death. [MEDICATION NAME] ([MEDICATION NAME]) is not approved for the treatment of [REDACTED]. The Medical Progress Note dated 10/10/16 documented Dementia with Mood Disorder and weight loss. There were no noted behavioral issues. A Medication Regimen Review (MRR) dated 10/15/16 documented a request for a GDR for [MEDICATION NAME], 0.25 mg at hour of sleep (HS), which was started on 7/18/16. A hand written response on the MRR documented, Psychiatric Consultation. The Medical Progress Note dated 10/18/16 documented mood was stable and without physical or verbal aggression. There were no behavioral issues noted. The Medical Progress Note dated 10/24/16 documented MRR appreciated and addressed; GDR for [MEDICATION NAME]. No behavioral issues were documented on the progress note dated 10/24/16. A Psychiatric Consultation was completed on 10/31/16 and documented a plan to discontinue the [MEDICATION NAME]. The same psychiatric consult documented there were no hallucinations, delusions, or behavioral problems. The Medical Progress note dated and signed 11/3/16 documented that the resident's mood was stable and the resident was without any physical or verbal aggression. The plan was documented as follows: Dementia, [MEDICAL CONDITION]. On [MEDICATION NAME] and [MEDICATION NAME] without reported Adverse Drug Reactions (ADR). Psych meds benefits greater than the risks. Continue with meds. There was no other rationale documented on the Physician's Progress note for not having attempted a GDR. The nursing note dated 12/2/16 at 14:28 documented the following: Resident continues to show fluctuating moods, crying, and anger. Even with much TLC, is difficult to direct. Self propelling on the unit hallucinating, reorienting frequently then resumes a calmer behavior for a time. Spoke with Physician's Assistant to restart, [MEDICATION NAME] 0.5 mg every (q) HS and to see Psych on Monday. There was no documented evidence that a medical work up was completed when hallucinations reappeared prior to the increase of the antipsychotic medication [MEDICATION NAME] in December 2017. A recent MRR dated 5/13/17 requests a GDR for [MEDICATION NAME] and noted the the dose was increased to 0.50 mg on 12/2/16. The hand written response documented Psych Consult. The Psychiatric Consults completed by a Nurse Practitioner (NP) dated 5/22/17 and 7/24/17 documented in error that a GDR had been attempted and resulted in hallucinations; however, review of the MARs from July 2016 through July 2017 revealed that there was not a GDR attempted. The Licensed Practical Nurse (LPN) was interviewed on 8/4/17 at 9:35 AM. The LPN stated that there had not been a GDR for [MEDICATION NAME] and that in December 2016 the dosage of the [MEDICATION NAME] was increased. During an interview with the Director of Nursing Services (DNS) on 8/04/2017 at 11:15 AM, she explained that the primary care Physician taking care of the resident in October 2017 is no longer working in the facility. An interview was conducted with the Psychiatrist Nurse Practitioner (NP) on 8/04/2017 at 11:30 AM. She stated that she had made a recommendation to discontinue [MEDICATION NAME] on the 10/31/16 Consult and that [MEDICATION NAME] had been discontinued for a week and then restarted when behaviors escalated. An interview was conducted with the Charge Licensed Practical Nurse (LPN) on 8/04/2017 at 11:32 AM. The Charge Nurse stated that she cannot explain why the recommended GDR was never attempted. A second interview was held with the Psychiatrist NP on 8/4/17 at 12:00 PM. She explained that she places the Consult report on the nurses desk. She further stated that usually the Physician orders [REDACTED]. In addition, the NP stated that she probably did not speak with the physician because normally they (the primary care physician) do what ever she has asked. She also acknowledged that the [MEDICATION NAME] had not been discontinued (as she had recommended). An interview was held with the Medical Director on 8/04/2017 at 1:30 PM. He stated that the Physician can disagree with the Consultation recommendation to discontinue the antipsychotic medication. He also stated that the Physician's Medical Progress Note dated 11/3/16 was initiated based on the Psych Consult (10/31/16). He further stated that it would have been a benefit if the physician had documented more clarification regarding the benefit outweighing the risk of the [MEDICATION NAME]. Despite the documented plan to discontinue the antipsychotic medication, there was no documented evidence that a GDR had ever been attempted in the past year since 7/18/16. 415.12(l)(1)

Based on record review and staff interviews during the Recertification Survey, the facility did not ensure that each resident's medical record was accurately documented. This was evident for one of five residents reviewed for Unnecessary Medication in a total of 27 Stage 2 sampled residents. Specifically, the Medication Administration Record [REDACTED]. The finding is: Resident #190 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A facility Intravenous Therapy Policy dated 4/2016 documented that the Licensed Practical Nurse (LPN) is not permitted to administer Intravenous (IV) medications through a Peripherally Inserted Central Catheter (PICC) line. A Nursing Admission assessment dated [DATE] documented the resident was admitted from the hospital with a [DIAGNOSES REDACTED]. The resident had a PICC line in the right upper extremity and was to be administered the IV antibiotic [MEDICATION NAME] via the PICC line for 19 days. A Physician order [REDACTED]. A Medication Administration Record [REDACTED]. An interview was held on 8/3/17 at 12:30 PM with the LPN who signed the MAR indicated [REDACTED]. The LPN was interviewed again on 8/3/17 at 1:00 PM. The LPN stated that she did not give the IV [MEDICATION NAME], that the RN supervisor administered the medication. An interview was held with the Director of Nursing Services (DNS) on 8/4/17 at 8:15 AM. The DNS stated that the RN Supervisor stated that he administered the medication on 8/2/17. The DNS also stated that the RN should have ensured that the MAR indicated [REDACTED]. The RN who worked on 8/2/17 on the 3:00 PM to 11:00 PM shift was interviewed on 8/4/17 at 11:15 AM. The RN stated that he administered the IV [MEDICATION NAME] on 8/2/17 at 10:00 PM. He did not document that he administered the medication because there was a signature already there. The RN also stated that he should have ensured that the MAR indicated [REDACTED]. 415.22(a)(1-4)

Based on medical record review and staff interview during an abbreviated survey (Complaint ID #: NY 682) the facility did not ensure that each residents drug regimen was free of any significant medication error. Specifically, one (Resident #1) of three residents reviewed for accuracy of prescribed medications was discharged home with prescriptions intended for a different resident. Resident #1 after discharge collected the medication from a community pharmacy (where the prescriptions were called in by the facility) and consumed those medications. Subsequently Resident #1 was transferred to the hospital emergency room (ER) for evaluation due to her complaints of not feeling well, where she was observed in the critical care ER. She had a discharge [DIAGNOSES REDACTED]. Findings Include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) (assessment tool) dated 12/24/2016 documented Resident #1's cognitive status as; cognitively intact. The Facility Discharge Planning Process Policy dated 07/2014 documented; an interdisciplinary discharge summary and instruction shall be completed by the different clinical disciplines to ensure that appropriate information about the resident shall be communicated to the organization and provider to which the resident is referred or discharged . The Facility Interdisciplinary Discharge Summary and Instructions Policy dated 11/2016 documented the discharge summary will include a reconciliation of all discharge medications with pre-admission prescribed and over the counter medications; clarification was requested and (per the facility Administrator that included review of the hospital record prior to admission, medication while at nursing home, including over the counter and discontinued medications). The Order Summary Report dated December 27, 2016 for Resident #1 documented the active medications that Resident #1 was receiving while at the facility were as follows: [MEDICATION NAME] Nebulization Solution for wheezing; [MEDICATION NAME] for arrhythmia; [MEDICATION NAME] for chest pain; Calcium [MEDICATION NAME]-Vitamin D for supplement; Eliquis, a blood thinner; [MEDICATION NAME] for immunosuppressant; [MEDICATION NAME] for diuresis; [MEDICATION NAME] Sodium for [MEDICAL CONDITION]; Losartan Potassium for hypertension; [MEDICATION NAME] HCL for dizziness; [MEDICATION NAME] for antiplatelet; [MEDICATION NAME] Reflux Disease (GERD). The discharged Medications for Resident #1 documented on the Discharge and Care Plan Summary Guide (discharge instructions and summary) effective date 12/26/2016 for Resident #1 included the following discharge medications: [REDACTED]. The Discharge Summary dated 12/27/2016 by RN #1 documented the resident was medically cleared by the Nurse Practitioner (NP) and is stable for discharge. Documentation included vital signs, medication was reviewed with the resident's family member and were electronically faxed to the resident's pharmacy. Opportunity was given to ask questions and all questions were answered. The resident was discharged via wheelchair with her family member at 11:45 AM. The emergency room (ER) Progress Notes dated 12/27/2016 -12/28/2016 documented Resident #1 presented to theER on [DATE] with a throbbing headache and lightheadedness after taking [MEDICATION NAME], Aspirin and [MEDICATION NAME]. Resident #1 was discharged to home from a Sub-Acute Rehabilitation (SAR) on 12/27/2016 with incorrect medications. This was reviewed by the medicine team/pharmacy team when compared to previous discharge summary from the hospital on [DATE], Resident #1's pharmacy, the resident's rehabilitation facility (the NP). Specifically, Resident #1 was in a good state of health when she developed a headache for which she took [MEDICATION NAME] as prescribed on discharge from the SAR, leading to dizziness. Resident #1 was observed closely in the critical care ER. Cardiology was consulted and recommended a follow up in the clinic and strongly recommended clarification of her listed SAR medications. The medications were corrected/simplified. She was discharged to home with cardiology follow up. The Rehabilitation facility was contacted and made aware of the prescribing error. The ER Discharge Instructions dated 12/28/2017 documentation included; [DIAGNOSES REDACTED]. The Facility Investigation Summary dated 12/27/2016 documented Resident #1 was prescribed the wrong medications on her discharge. On 12/28/2016 a pharmacist from the hospital notified the NP that (Resident #1) was readmitted to the hospital at approximately 2:00 AM on 12/28/2016. The pharmacist from the hospital identified the medication discrepancies while reconciling the hospital medications from the patient's prior hospital stay to the medications prescribed by NP upon discharge from the nursing home. It was determined the NP electronically prescribed the wrong discharge medication regimen for Resident #1. The orders were entered in the electronic medical record by the NP and sent to the pharmacy. The Nursing Home immediately notified the resident's family member of the medication discrepancy on the same date. During an interview on 01/18/2017 at 10:30 AM with the Administrator he stated that he received a voicemail on 12/28/2016 from Resident #1's family member who informed him that Resident #1 was transferred to the hospital for low blood pressure. During an interview on 01/18/2017 at 10:41 AM with the 7:00 AM - 3:00 PM Unit Manager Registered Nurse (RN), she stated once the discharged medications are completed the charge nurse writes the discharge summary including documenting medications ordered by the physician in the discharge summary. Discharge instructions are reviewed by the Unit Manager then it's brought to the charge nurse. She stated when she discharged a person and she had documented medications in the discharge summary she checks it against the physician's orders [REDACTED]. The RN stated that she did not review the medications. During an interview on 02/01/2017 at 8:45 AM with Licensed Practical Nurse (LPN) #1, LPN #1 stated that normally when the resident and family is ready for discharge she reviews the medications. On the date of the incident she was in a care plan meeting and was told that RN #1 reviewed the medications/treatments with Resident #1 and the family. LPN #1 stated that she documented the wrong medications on the discharge summary. LPN #1 stated that she was never orientated how to discharge a resident. LPN #1 asked the nurses around her on what she was supposed to document the medications on the discharge summary from the physician's orders [REDACTED]. During an interview on 02/01/2017 at 11:30 AM with the prescribing NP, he stated it was brought to his attention that Resident #1 was discharged on the wrong medications. He did confirm based on the record that he did send the wrong medication order to the pharmacy. While entering the medications into the computer for the pharmacy he used the medication profile for a different resident. During an interview on 02/02/17 at 7:50 AM with 7:00 AM - 3:00 PM RN #1, she stated on 12/27/2016 she was not assigned to Resident #1. The Unit Manager asked her to discharge Resident #1 and review the medications with Resident #1. She stated she took the summary (discharge instructions) with her to Resident 's #1 room and reviewed the medications documented on the discharge summary. 415.12 (m)(2)

Based on record review and staff interviews conducted during the recertification survey, it was determined the facility did not provide or arrange services that met professional standards of quality for 1 of 3 residents (#248) reviewed for Pressure Ulcers. Specifically, the facility did not ensure that a Braden Scale Skin Assessment (BSSA) was completed by qualified professional staff (Registered Nurse). The BSSA was completed by a Licensed Practical Nurse (LPN) and was an inaccurate assessment. The finding is: Resident #248 had [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had long and short term memory loss and that the resident had moderately impaired decision making. The MDS documented that the resident was always incontinent of bladder and was extensive assistance with two staff members for bed mobility. A BSSA dated 1/5/16 was incorrectly assessed under the category of moisture, mobility and sensory perception. The BSSA documented under the category moisture that the resident's skin was only occasionally moist. The BSSA also documented under the category mobility that the resident's mobility was slightly limited and under the category for sensory perception that the resident was slightly limited in the ability to respond to verbal commands. Review of the MDS in the medical record revealed that the BSSA was incorrect under the category for moisture. For mobility, the MDS revealed that the resident required extensive assistance of two staff members for bed mobility. The Certified Nursing Assistant Accountability Record (CNAAR) documented that the resident was always incontinent of urine so the resident's skin was very moist. An observation on 6/21/16 at 11:45 AM revealed that the resident was not responsive to questions and was totally dependant on the staff for mobility. An interview was held with the resident's Certified Nursing Assistant (CNA) on 6/21/16 at 10:15 AM. The CNA stated that the resident is totally incontinent of urine and dependent with all care and that the resident rarely responds to questions. An interview was held with the LPN on 6/21/16 at 11:45 AM. The LPN stated that she completed the BSSA dated 1/5/16 and could not explain how she assessed the resident to determined the answers she documented under the category for sensory perception, moisture and mobility. An interview was held with the MDS Nurse on 6/21/16 at 11:55 AM. The MDS Nurse stated that she initiates the BSSA but does not complete the form, the LPN on the unit completes it. The MDS Nurse also stated that it should be co-signed by an RN but could not explain why this assessment was not co-signed. 415.11(c)(3)(i)

Based on residents, Ombudsperson and staff interviews during a Recertification survey, the facility did not ensure provision of clean bed and bath linens that are in good condition. Specifically, facility did not address long standing frequent shortage of linen supplies including towels, sheets, pillow cases and night gowns. This was noted from interviews with one Resident (#113) out of a total of 12 census resident interviews conducted, the Resident Council President (#48), the Ombudsperson and review of the monthly Resident Council minutes from February, April and May 2016. The finding is: A) Resident #48 is the Resident Council President. The Resident Council President's Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. The Resident Council President was interviewed on 6/16/16 at 11:10 AM and stated that residents have been complaining about shortage of sheets, towels, pillow cases and night gowns in the Resident Council meetings on and off through the year. She stated that many times when there is shortage of night gowns, people have had to sleep in the same clothes that they wore all day. She stated that bed linens are supposed to be changed every Monday, and some times pillows are without cases for 2-3 days and beds might be without a sheet for a whole day until supplies are available. She stated that the Administrator has informed the Resident Council that he is trying his best. B) The Facility Ombudsperson was interviewed on 6/16/16 at 10:15 AM. She stated that the residents have been complaining in the Resident Council for the past year about shortage of towels, sheets and gowns to wear. She stated that some residents do not get showers because towels are not available. C) Resident #113's MDS dated [DATE] documented a BIMS score of 15 indicating intact cognition. Resident #113 was interviewed on 6/15/16 at 11:00 AM and stated that she is unhappy because the staff often run out of sheets, blankets, towels and night gowns. Monthly Resident Council meeting minutes were reviewed from January to June 2016. The following was documented regarding linen supplies shortage including, sheets, pillow cases, night gowns and towels: - February 2016 meeting, documented,Administrator has placed an order for [REDACTED]. - April 2016 meeting documented, Administrator informed the residents that if they need additional towels, sheets or night gowns ask a staff member for assistance because they are available. - May 2016 meeting documented, Administrator has ordered additional pillow cases, towels and sheets. The Administrator was interviewed on 06/16/2016 at 1:25 PM and stated that the facility always has 3 days emergency supplies of linen (sheets, pillow cases, night gowns and towels). He stated that the outside vendor for Laundry service has its ups and downs in terms of short delivery. The Administrator stated sometimes 1000 items may have been sent out and only 800 might be returned and the difference has to be made up from back up supplies. The Administrator also stated that he knew there was a linen shortage problem so he had placed a large purchase order 2 months ago. The Administrator added that corrections have been made to Laundry service issues and there are very few complaints in the Resident Council for the last couple of months. The Environmental Director was interviewed on 6/16/16 at 2:00 PM. He stated that he over sees the Laundry Service. He stated that, we do have issues here and there regarding inadequate linen numbers. I have never heard of any major issues. He stated that the porters deliver linen to the units. He stated that the Laundry delivers linen daily, sometimes it more and at other times it is less. He delivers what is available and then if he gets paged for more, he goes to the back up storage and delivers. He stated he was not aware of any par levels to be delivered to the specific units. He stated he thought that the Certified Nurses Assistants (CNA's) hoarded the linen away in their assigned Resident rooms and other CNA's were unable to find them. A 7:00 AM -3:00 PM Porter 1 was interviewed on 06/16/2016 at 1:47 PM and stated he delivers supplies to the unit twice a day and is not aware of any shortage. A 7:00 AM - 3 PM Porter 2 was interviewed on 06/16/2016 at 1:48 PM and stated that they distribute the supplies that they have received from Laundry and if the units call in a shortage they retrieve from storage and supply. He was not sure if Par levels of supplies were required to be delivered for every shift. A 7:00 AM to 3:00 PM shift CNA was interviewed on 06/17/2016 at 11:22 AM and stated that at times the linen has not been delivered to the units at the start of her shift and the wait is sometimes 10 minutes to 30 minutes. She stated that if there are additional shortages, she tell the Nurses, who call for supplies. 415.5(h)(3)

Based on record review and staff interviews during the recertification survey, the facility did not ensure that comprehensive assessments of a resident were completed not less than once every 12 months. This was evident for 1 of 2 Stage 2 residents reviewed for Participation in Care Planning in a total sample of 28. Specifically, the Annual Minimum Data Sets (MDS) Assessment for Resident #204 was not completed timely. The finding is: Resident #204 has [DIAGNOSES REDACTED]. An Annual MDS was completed on 6/2/15. Quarterly MDSs were completed on 7/29/15, 10/29/15, 1/29/16 and 4/29/16. There was no documented evidence that an Annual MDS was completed within 12 months, as required. The Registered Nurse (RN) MDS Coordinator was interviewed on 6/20/16 at 11:44 AM and stated there was an error. Four quarterly MDSs were completed, without the completion of an annual MDS assessment. 415.11(a)(3)(iii)

Based on observation and staff interviews during the recertification survey, the facility did not ensure that housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior were provided. Specifically, during the initial tour of the general environment on 2 of 7 Nursing Units (3 North and 3 South), individual room observations and Environmental Facility Rounds, there were multiple housekeeping and maintenance issues observed, including uneven cracked floor tiles, and walls and furniture in disrepair. The findings are: During the Initial tour of the facility on 6/15/16 during the hours of 8:30 AM and 10:00 AM, and throughout the survey process from 6/15/16 through 6/21/16 the following observations were made: 3 South Unit: Room 302- wall in disrepair, cove molding in disrepair adjacent to bathroom and behind bathroom door. Room 311- chipped 3 drawer nightstand, wall and cove molding near closet in disrepair and floor tiles cracked adjacent to bathroom door. Room 317- floor tiles cracked adjacent to bathroom door. Room 321- floor tiles cracked at entrance to bathroom and encrusted with glue-like gray substance and tiles are uneven. Room 387- frame of overbed table is rusted and 6 drawer dresser is chipped. 3 North Unit: Room 336- wooden frame of padded chair has scuffed varnish, chair seat padding is ripped, bedside table is chipped and overbed table has dirty rusted frame. Room 338- scuffed, detached wallpaper on walls near window, and wall is bubbled. Cove molding on wall under window is in disrepair. The Director of Environmental Services was interviewed on 6/21/16 at 12:40 PM and stated that he was aware of the needed repairs on the 3rd Floor Nursing Units, as rounds are made every week. The Director further stated that the areas brought to his attention will be repaired and a complete renovation of the 3rd Floor is planned to include removal of all wallpaper, spackle and painting of walls and replacement of all floor tiles. The Administrator was interviewed on 6/21/16 at 12:45 PM and stated that some furniture has already been ordered and a proposal was received for the work to be done on the 3rd Floor, but was unable to provide a date for the work to begin. 415.5(h)(2)