Every finding on record at Margaret Tietz Center for Nursing Care Inc

Based on staff interview and record review conducted during the Recertification and Complaint Survey (NY00325508) from 05/21/2024 to 05/29/2024, the facility did not ensure each resident received adequate supervision and assistance devices consistent with a resident's needs, goals, and care plan to prevent accidents. This was evident for 1 (Resident #134) of 38 total sampled residents. Specifically, Resident #134 required 2 staff assistance using mechanical lift for transfers as documented in the Comprehensive Care Plan. On 10/04/2023 at 5:30 PM, Certified Nursing Assistants #6 and #3 transferred Resident #134 from wheelchair to bed without using the mechanical lift. During the transfer, Resident #134 felt weak while in a standing position, and their left leg scraped the wheelchair that caused a laceration that required emergency medical intervention. The Resident required 13 stitches to the wound. This resulted in actual harm to Resident #134 that was not Immediate Jeopardy. The findings include: The facility policy titled Care Planning Process with an effective date of 07/2022 documented that the purpose of the policy was to ensure each resident receives the necessary care and services to attain or maintain the highest practicable, physical, mental, and psychosocial well-being. The care plan shall address the individual resident's medical diagnoses and condition, activities of daily living functional ability, and strengths and needs. Resident #134 had diagnoses of Anemia (a condition in which there is a low level of healthy red blood cells to carry oxygen throughout the body), Cerebrovascular Accident (a condition in which there is loss of blood flow to a part of the brain which damages brain tissue), and Non-Alzheimer's Dementia (loss of memory and intellectual functions caused by other diseases). The Minimum Data Set assessment (an assessment tool that measures health status in nursing home residents) dated 09/05/2023 documented Resident #134 had severe impairment in cognition and was totally dependent on 2 staff members for transfer. A Comprehensive Care Plan for Activities of Daily Living Self Care Performance Deficit related to Activity Intolerance was initiated for Resident #134 on 08/30/2023. The care plan interventions included total dependence with 2 persons for assistance using mechanical lift for transfers. The Documentation Survey Report (overview of tasks and assignments completed by the Certified Nursing Assistants) for 10/2023 documented that Resident #134 required total dependence with 2 persons assist using mechanical lift for transfers. Certified Nursing Assistant #6 documented that the task was performed for 10/04/2023 3:00 PM to 11:00 PM shift. The Accident Report dated 10/04/2023 at 5:30 AM documented that the Registered Nurse was informed that Resident #134's leg was bleeding after transfer. Resident sustained a skin tear on the left lower shin. Resident #134 was confused and was unable to give a statement. The report documented the staff did not use a mechanical lift during transfer. The employee written statement dated 10/04/2024 by Certified Nursing Assistant #6, who was assigned to Resident #134, documented they saw blood coming from Resident #134's left leg when the Resident was placed in bed. Certified Nursing Assistant #6 documented Certified Nursing Assistant #3 assisted them in the care of the resident. The employee written statement dated 10/04/2023 by Certified Nursing Assistant #3 documented they helped transfer Resident #134 from chair to bed. The facility summary of investigation dated 10/06/2024 completed by the Director of Nursing documented Resident #134 was noted with a laceration that measured 8 x 1 x 0.2 centimeters on the left shin. During the investigation, the laceration was sustained when Resident #134 was transferred from wheelchair to bed by Certified Nursing Assistants #6 and #3. The summary of investigation documented as per Resident's care plan and Kardex (a document that contains resident care instructions for the Certified Nursing Assistants), Resident #143 required total assistance of 2 person using a mechanical lift for transfers. The Certified Nursing Assistants stated during the interview they transferred the Resident without using a mechanical lift, and as they were assisting the Resident into a standing position, the Resident felt weak, and their left leg scraped the wheelchair causing the laceration. Resident #134 was assessed by the attending physician and ordered to transfer the Resident to the hospital for sutures. The hospital patient discharge summary dated 10/04/2023 documented that Resident #134 was treated at the emergency department for left shin laceration that required 13 stitches. Several attempts to reach Certified Nursing Assistant #6 were unsuccessful. During an interview on 05/24/2024 at 3:38 PM, Certified Nursing Assistant #3 stated on the day of the incident, Certified Nursing Assistant #6 asked for help to transfer Resident #134 from the wheelchair to bed. At the end of the transfer, they noticed blood on the Resident's shin and notified the charge nurse. Certified Nursing Assistant #3 stated Resident #134 was not on their assignment, and they did not know the Resident needed a mechanical lift for transfer. During an interview on 05/24/2024 at 3:02 PM, Registered Nurse #4, who was the Registered Nurse Supervisor at the time of the incident, stated Resident #134 required total assist of 2 staff with the use of mechanical lift. They stated on the day of the incident, Certified Nursing Assistants #6 and #3 transferred Resident #134 from wheelchair to bed without using a mechanical lift, which was stated in the care plan and sustained an injury to their left leg. Registered Nurse #4 stated Certified Nursing Assistant #6 was not regularly assigned to the resident and did not know the Resident required the use of a mechanical lift for transfers. They stated they had a huddle (meeting) at the start of the shift and aides were notified of residents' status. Registered Nurse #4 stated they were not sure if Certified Nursing Assistants #6 and #3 participated in the huddle that day. During an interview on 05/29/2024 at 9:48 AM, Registered Nurse #2, who was the In-service Coordinator, stated Certified Nursing Assistants who were assigned to the Resident and those who were assisting were expected to check a resident's plan of care prior to providing care. During an interview on 05/29/2024 at 10:43 AM, the Director of Nursing stated they investigated the incident, and it was noted the Certified Nursing Assistants transferred Resident #134 without using a mechanical lift as documented in the Resident's plan of care. They stated Resident #134 sustained a skin tear on their left leg. They stated the Certified Nursing Assistants were trained on how to use Point of Care (an electronic medical record that provides resident care instructions for Certified Nursing Assistants) to find out what assistance a resident required and could have also verified a resident's transfer status from the charge nurse. During an interview on 05/29/2024 at 11:02 AM, the Administrator stated as per the facility's investigation, the staff did not use a mechanical lift during transfer and Resident sustained an injury. 10 NYCRR 415.12 (h) (2)

Based on record review and interview conducted during the Recertification Survey from 05/21/2024 to 05/29/2024, the facility did not ensure that a resident's comprehensive care plans were reviewed and revised to accurately reflect a resident's current status. This was evident in 1 of 38 sampled residents. Specifically, Resident #148's comprehensive care plan did not document Resident's urinary catheter was discontinued. The findings include: The facility policy titled Care Planning Process with effective date of 07/2022 documented the facility shall have a care planning process that is person centered which includes integrating assessment findings, developing an interdisciplinary care plan, regularly reviewing and revising the care plan, providing and documenting the care. Resident #148 was admitted to the facility with diagnoses of Atrial Fibrillation, Heart Failure, Benign Prostatic Hyperplasia, Renal insufficiency, and Obstructive Uropathy. On 05/21/2024 at 12:00 PM, Resident #148 was observed in the day room. Resident had no urinary catheter. The resident stated they had a urinary catheter inserted before admission to the nursing home and was removed 2 weeks ago. The Minimum Data Set assessment dated [DATE] documented Resident #148 had intact cognitive status. The Minimum Data Set further documented the Resident had indwelling catheter. A medical progress note dated 04/02/2024 documented Resident #148 was admitted from the hospital with chief complaint of acute on chronic congestive heart failure, complicated urinary tract infection, urinary retention, with indwelling urinary catheter. The nursing progress note dated 04/18/2024 at 7:19 AM documented Resident #148's urinary catheter was discontinued around 6:00 AM for trial voiding as ordered. A Comprehensive Care Plan for alteration in urinary elimination related to catheter usage for obstructive uropathy, acute kidney failure, and Benign Prostatic Hyperplasia was initiated on 04/02/2024. The care plan did not document that the urinary catheter was discontinued. During an interview on 05/28/2024 at 9:53 AM, Registered Nurse #1, who was the Registered Nurse Supervisor, stated Resident #148's urinary catheter was discontinued on 04/18/2024. They stated the Registered Nurse Supervisor on the floor should have reviewed and updated the care plan and should have documented that Resident #148's urinary catheter had been removed. They stated they did not know why the care plan had not been updated. During an interview on 05/28/2024 at 10:33 AM, the Assistant Director of Nursing stated the nurses' and nursing supervisors were responsible for updating the care plan. During an interview on 05/29/2024 at 10:38 AM, the Director of Nursing stated the nurses' and nursing supervisors were responsible for reviewing and updating the residents' care plans. They stated they have a lot of new nurses that were still learning which probably why Resident #148's care plan had been missed. 415.11(c)(2)(i-iii)

Based on record review and interviews conducted during the Recertification Survey from 5/9/2022 to 5/13/2022, the facility did not ensure, to the extent practicable, that residents/resident representatives were involved in developing the comprehensive care plan and making decisions about their care. Specifically, the facility did not ensure that residents and resident representatives were afforded the opportunity to participate in the Comprehensive Care Plan (CCP) meeting. This was evident for 1 of 1 resident reviewed for Participation in Care Planning out of a sample of 38 residents. (Resident # 138) The findings are: The facility policy and procedure titled Care Planning Process with effective date 7/18 documented under section PROCEDURE 5. Resident and/or designated representative will be informed of scheduled CCP (Comprehensive Care Plan) meetings reflecting the date and time by the Social Services Department. A written invitation will be given to the resident and/or mailed to the family/designed representative. 6. Social Worker will document a plan of care note in the progress note section indicating that the letter was sent or additional communication with the family occurred regarding the invite to the care plan meeting. 11. The resident has the right to participate in establishing the expected goals and outcome of care, the type, amount, frequency and duration of care and any other factors related to the plan of care. Resident #138 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change MDS dated [DATE] documented Resident #138 rarely/never understood others or made self understood, had short and long-term memory problems, and cognitive skills for daily decision making was severely impaired. It further documented Resident #138 did not participate in assessment and the representative participated it. On 05/09/22 at 03:37 PM, family representative was interviewed and stated Resident #138 had been at the facility for more than 2 years. The family representative also stated the facility started inviting them to care plan meeting only in February or March 2022. Family representative further stated they made decisions for Resident # 138. The Social Service Progress note dated 3/17/2021 documented family representative was invited to participate in the care plan meeting scheduled on 3/17/2021 and family representative participated through conference call. The Social Services Progress notes dated 4/21/2022 documented family representative was invited to participate in the significant change care plan scheduled on 4/22/2022. SW Social Work Assessment - V 2 dated 3/2/2021, 6/1/2021 and 9/1/2021 documented it was for quarterly. It had no documented evidence that Resident #138 and/or family representative was invited to care plan meeting. SW Social Work Assessment - V 3 dated 11/30/2021 documented it was for quarterly. It had no documented evidence that Resident #138 and/or representative was invited to care plan meeting. SW Social Work Assessment - V 4 dated 2/28/2022 documented it was for Annual. It also documented Resident #138 and/or designated representative was invited to participate in the review and revision of the care plan. SW Social Work Assessment - V 4 dated 4/8/2022 documented it was for Hospital Readmit. It did not document Resident #138 and/or representative was invited to participate in the care plan meeting. The Comprehensive Care Plan Meeting sign in sheet for Resident #138 documented family representative attended the annual care plan meeting on 3/17/2021 and 3/18/2022, and significant change care plan meeting on 4/22/2022 but not the quarterly meetings on 6/16/2021, 9/15/2021, and 12/15/2021. It also documented Resident #138 did not attend any of the care plan meetings. There was no documented evidence that Resident # 138 or family representative had been invited to participate in the quarterly care plan meetings on 6/16/2021, 9/15/2021 and 12/15/2021. On 05/12/22 at 10:48 AM, Social Work Director (SWD) was interviewed and stated they had care plan meetings for initial, quarterly, significant change, annual, and as per resident/family representative request. SWD also stated Social Workers (SW) checked the electronic medical record and the list provided by MDS for coming care plan meeting to invite resident face to face on the unit and representative by phone call a few days before the care plan meeting. SWD further stated SW documented the invitation in the Social Services progress note or in Social Work Assessment. SWD stated they did not invite resident/representative to quarterly care plan meeting before 1/9/2022. SWD also stated the policy of care planning process was revised on 1/9/2022 to invite resident/representative to all care plan meetings including quarterly one. SWD further stated they started working at the facility on 12/15/2021 and did not know the reason there was a change in policy. On 05/12/22 at 11:15 AM, MDS Coordinator (MDSC) was interviewed and stated they sent the social work department a list of residents for coming week care plan meeting every Friday and SW invited residents and/or representative to the care plan meeting scheduled from Tue to Fri next week. MDSC also stated they invited resident/representative to initial, annual, and significant change but not quarterly care plan meeting before 1/9/2022. MDSC further stated they received the guideline and new policy for care plan meeting from the corporate around 1/9/2022 to invite resident and/or representative to all care plan meetings including quarterly one to better providing resident care by listening more frequently to the resident and/or representative. On 05/12/22 at 11:41 AM, Social Work Consultant (SWC) was interviewed and stated they recognized the importance of inviting resident and/or family representative to quarterly care plan meeting after their sister facility had the survey from the NYSDOH survey at the end of [DATE]. SWC also stated they revised the care plan meeting policy on 1/6/2022 after the plan of correction for the sister facility was accepted by NYSDOH in [DATE] and started inviting residents and/or representatives to all care plan meetings on 1/9/2022. SWC further stated they revised SW note to indicate if residents and/or family representatives were invited to care plan meeting and provided the in-service to SW on 1/10/2022 for Quarterly Care Planning process. SWC stated the resident and/or family representative were invited to care plan meeting by phone call, in-person, or written invitation. SWC also stated they made copy of the invitation letter and kept the copy in the file in SW department and SW documented in SW note for invitation through phone call or in-person. Based on the following corrective actions taken, there was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement prior to and during the time of this survey: 1. Residents/representatives were invited to quarterly care plan meeting starting 1/9/2022. 2. QA Department audited to ensure all the residents/representatives due for quarterly care meeting in [DATE] were invited and continue the audit in [DATE]. 3. Revised the facility policy & procedure titled Care Planning Process with effective date 1/2022 to include MDS will complete a Care Plan Review Meeting note to indicate the participation and/or attendance of the resident and/or designated representative for all meetings. 4. In-service for the topic Quarterly Care Planning Process was provided to all social workers, MDS Assessors, Registered Nurse Supervisors, department heads, and Administrator on 1/22/2022. 5. SW Social Work Assessment - V4 note was revised on 1/24/2022 to add the question for care plan invitation before the care plan meeting. 415.11(c)(2)(i-iii)

Based on observation, interview, and record review during the Recertification & Complaint Survey (NY 843) conducted from 5/9/22 - 5/13/22, the facility did not ensure the environment remained free of accident hazards as is possible, and that each resident received adequate supervision and assistance to prevent accidents. Specifically, 1) a resident sustained a blister to their right middle finger after using the unit microwave unsupervised and, 2) a resident was observed accessing the coffee dispensing machine in the unit pantry, without supervision and with a risk for injury. This was evident in 2 of 3 residents reviewed for Accidents out of a sample of 38 residents. (Resident #132 and #133) The findings are: 1. Resident #132 was admitted to the facility with diagnoses that included Dementia, [CONDITION(S)], and Arthritis. The Significant Change Minimum Data Set (MDS) assessment dated [DATE] documented resident was moderately cognitively impaired with a BIMS of 11 and required extensive assistance of 1 staff for transfer and walking in corridor/locomotion, and supervision and set-up for eating. The Facility Reported Incident (NY 843) dated 10/14/2021 documented Resident #132 accidentally burned their right middle finger while taking food out from the microwave. Upon initial assessment, no noted redness, no blister, no skin opening was observed. A cold pack was applied at that time. Resident did not require pain medication. Upon re-assessment the next morning, resident was noted with a red blister to the right middle finger. The Physician's Order dated 10/14/2021 documented [MEDICATION(S)] Cream 1 % Apply to Right Middle Finger topically two times a day for Blister. Nursing progress note dated 10/14/2021 documented that at approximately 9pm on 10/13/21, resident complained of pain and asked for Tylenol, PRN pain medication given as ordered. Nursing progress note dated 10/15/2021 at 15:44 documented that the nurse was informed of burn on resident's 3rd right finger which presents with 2 blisters currently, [MEDICATION(S)] applied. Resident denied any pain. On 10/14/21, a treatment order for [MEDICATION(S)] Cream 1 % Apply to Right Middle Finger topically two times a day for 14 days for Blister was placed. There was no documented evidence that outside referrals were necessary related to resident injury. On 05/10/22 at 09:27 AM, an interview was conducted with Resident #132. Resident #132 stated they never use the microwave and there is no longer a microwave here. Resident #132 also stated some time ago they used the microwave to heat food from outside that family had brought them and recalled a minor injury. 2. The facility policy and procedure titled Coffee Machine Dayroom Policy dated March 2017, documented The coffee machine will be turned on prior to meal service by the Rabbi/Designee. At the conclusion of each meal service, the machine will be turned off to ensure safety. Procedure: Rabbi/Designee will arrive on unit prior to meal service and turn on the coffee machine. Upon completion of meal service, will return to the units to turn off coffee machine. Resident #133 was admitted with diagnoses that included Polio and [CONDITION(S)]. The Quarterly MDS dated MDS dated [DATE] documented resident was moderately cognitively impaired and required limited assistance of one staff for most Activities of Daily Living and set-up and supervision for eating. The MDS also documented that the resident ambulated with a wheelchair and walker. On 5/11/22 at 10:41 AM, Resident #133 was observed wheeling themself into the dining room where they obtained a cup of hot water and a tea bag. There was no staff observed in the area at the time. Signage over the sink on an upper cabinet door documented coffee machine is to be locked at all times except during meals 7:45-9am/11:45-1pm/5:45pm - 7pm. please be sure to lock it after you are finished using it. On 5/11/22 at 10:43 AM, the surveyor pressed buttons on the machine and was able to dispense water and coffee as the machine was not locked. There was no barrier in place to prevent entry into the pantry area. On 5/11/22 at 10:46 AM, an interview was conducted with Registered Nurse (RN) #1. RN #1 stated that the Certified Nursing Assistant (CNA) and nurses monitor the day room/dining room area. RN #1 also stated that the staff reinforce with residents the importance of asking for help and the CNAs give out beverages only at mealtimes. RN #1 tested the machine and found it was unlocked as it dispensed coffee and stated they did not know how to lock the machine and would ask one of the CNAs how this is done. On 5/11/22 at 10:52 AM, an interview was conducted with CNA #1. CNA #1. stated that dietary is supposed to lock the machine. Between meals, residents are encouraged to ask staff rather than try to get something themselves. CNA #1 also stated residents should not be accessing the machine by themselves and if the resident needs coffee or tea between meals, they call the kitchen to unlock the machine. On 5/11/22 at 11:09 AM, Dietary Aide (DA) #1 was interviewed. DA #1 stated the dietary staff sets up the coffee machine, making sure coffee is in it. DA#1 also stated that they do not lock the machine as they do not have a key and the Rabbi is supposed to lock it. On 5/11/22 at 11:20 AM, an interview was conducted with the Food Service Director (FSD). The FSD stated that dietary staff clean the outside of the coffee machine and the drip tray and the coffee machine is locked between meals. The FSD also stated that when entering the pantry area, there is a ribbon type pull and latch to lock off the area. Once the steam table is broken down, the dietary aide is supposed to cordon off the area, however, any staff member can take down the ribbon to access the area, and they should close it off once done. The FSD further stated that the Rabbi locks and unlocks the coffee dispenser. On 5/11/22 at 11:49 AM, an interview was conducted with the Jewish Food Supervisor (JFS). The JFS stated that before meals, they go to each floor and turn on the coffee machine. The JFS further stated that they did not turn off the coffee machines today as it slipped their mind. 415.12(h)(1)

Based on record review and interviews conducted during the Recertification survey from 5/9/2022 to 5/13/2022, the facility did not ensure that an assessment accurately reflected the resident's status. Specifically, the Minimum Data Set (MDS) 3.0 assessment inaccurately documented that a resident did not have [CONDITION(S)] in last 30 days. This was evident for 1 out of 1 resident reviewed for Resident Assessment out of an investigative sample of 38 residents. (Resident #138) The findings are: The facility policy & procedure titled MDS Assessment Version 3.0 with effective date 10/20 documented under section Responsible Discipline that each individual completing a portion of the assessment signs and certifies the accuracy of that portion of the assessment. The policy also documented that Nursing/MDS is responsible for completion of the Infection ([CONDITION(S)], Pneumonia, +PPD) section of the MDS assessment. Resident #138 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Significant Change MDS dated [DATE] documented Resident # 138 had no Urinary Tract Infection ([CONDITION(S)]) in last 30 days in Section I. The Patient Review Instrument (PRI) dated 4/5/2022 documented in section titled Medical Conditions that Resident #138 had a Urinary Tract Infection during the past week The hospital discharge paper dated 4/7/2022 documented the admitted was 4/1/2022 and Resident #138 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MD Monthly Note dated 4/17/2022 documented Resident #138 had a recurrence of [CONDITION(S)] with [CONDITION(S)] Pneumoniae and was successfully treated with oral [MEDICATION(S)]. The note also documented that Resident #138 was hospitalized with [CONDITION(S)] and [CONDITION(S)] [CONDITION(S)] with [CONDITION(S)] was treated. The note documented recurrent [CONDITION(S)]'s, Urology consultation appreciated, hospitalized for urosepsis. On 05/12/22 at 02:57 PM, the MDS Assessor (MDSA) was interviewed. The MDSA stated they were responsible for completing section I and they reviewed the hospital discharge paper, PRI, and interviewed the staff on the unit before completing the Significant Change MDS assessment dated [DATE]. The MDSA also stated they did not read the question carefully and thought the question in section I Urinary Tract Infection ([CONDITION(S)]) (LAST 30 DAYS) was asking if a resident had an active [CONDITION(S)] upon re-admission to the facility. The MDSA further stated that Resident #138 did not have an active [CONDITION(S)] upon readmission on 4/7/2022 and therefore they did not code [CONDITION(S)]. The MDSA stated it was their error not reading the question carefully and coding [CONDITION(S)] incorrectly in the MDS assessment. On 05/12/22 at 03:15 PM, the MDS Coordinator (MDSC) was interviewed. The MDSC stated that the MDS assessor is supposed to review the hospital discharge paper, PRI and interviewed the unit staff to complete the MDS assessments. The MDSC reviewed the hospital discharge paper, PRI, and MD notes and stated Resident #138 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDSC also stated that MDS assessor should have coded Resident #138 as having had a [CONDITION(S)] for last 30 days in Section I of the MDS completed on 4/14/2022. 415.11(b)

Based on observation, record review, and staff interviews during the re-certification survey, the facility did not ensure infection prevention control practices were followed to help prevent the spread, development, and transmission of communicable diseases and infections. Specifically, (1) A Registered Nurse (RN) was observed not preparing a sterile field prior to performing a wound treatment, and (2) the same RN did not perform proper hand hygiene during the wound treatment. This was evident in 1 of 3 residents reviewed for pressure ulcer injury care area out of a total sample of 38 residents (Resident #118). The finding is: The facility policy and procedure titled, Clean Dressing Change (Dated 04/2016) documented the following. .Prior to dressing change .washes hands using proper technique and at least for 20 seconds .cleans over bed table .bring supplies to bedside and all necessary equipment .establish a clean field by using disposable drape .ensures all items to be used are placed on clean field . The facility policy and procedure titled, Hand Hygiene Protocol (Dated 11/2017) documented the following. .the following procedure is to be used for hand hygiene using soap and water .turn on warm water .completely wet hands holding them lower than wrist .apply soap or hand hygiene agent and thoroughly distribute over hands and wrists . The Centers for Disease Control and Prevention (CDC) Guideline for Hand Hygiene in Healthcare Settings indicated the following. .When cleaning your hands with soap and water, wet your hands first with water, apply the amount of product recommended by the manufacturer to your hands, and rub your hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse your hands with water and use disposable towels to dry. Use towel to turn off the faucet. Avoid using hot water, to prevent drying of skin. Resident #118 was most recently admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) Annual assessment dated [DATE] documented resident with intact cognition. Resident also documented with one stage 3 pressure ulcer and is receiving wound care treatment. On 09/09/19 at 09:45 AM, Resident #118 was observed lying in bed on his back. RN #1 entered room to perform wound treatment. RN #1 had supplies in hand and placed the comfort foam, gauze packets, Dermaklenz spray, and drape on the bedside table next to the resident's breakfast tray. She then moved the tray to the resident's dresser table and moved supplies to where the tray was on the bedside table. The bedside table was visibly soiled with food debris. RN #1 proceeded to wash her hands, turning on faucet, getting soap prior to wetting hands, scrubbed, rinsed, and dried hands. She then used a paper towel to wipe the bedside table clean. RN #1 donned gloves and removed resident's left sock to remove the old dressing. The old dressing had a slight dried up red drainage color on it. RN #1 removed glove and proceeded to wash her hands by turning on faucet, getting soap prior to wetting hands, scrubbed, rinsed, dried hands and donned new gloves. RN #1 then sprayed Dermaklenz Spray on gauze and cleaned the wound twice. The wound was wiped dry with gauze. RN #1 removed gloves and washed hands by turning on faucet, getting soap prior to wetting hands, scrubbed, rinsed, and dried hands. RN #1 then placed Comfort Foam on wound and placed sock back on. resident's foot. RN #1 removed gloves and washed hand by turning on faucet, getting soap prior to wetting hands, scrubbed, rinsed, and dried hands. A Hand Hygiene Competency Criterion Checklist (Dated 09/06/19) was completed for RN #1 for hand washing with soap and water. Competency included wetting hands with water as first step before application of soap. A Clean Dressing Competency (Dated 09/06/19) was completed for RN #1. Competency included steps taken to perform wound treatment. Establishing a clean field by cleaning the over bed table and using a drape prior to placing all items on clean field is indicated. On 09/10/19 at 09:40 AM, RN #1 was interviewed. The RN stated prior to start of wound treatment, she has to make sure the bedside table is clear and cleaned with Clorox wipes prior to using. After it is cleaned, a drape is placed on top of it to place the wound supplies. RN #1 stated she was supposed to follow that protocol but didn't. She further stated the proper way to wash her hands is to wet hands first, get soap, scrub for 20 seconds, rinse, and dry with towel. RN #1 stated she did not follow that process because it is her habit to grab the soap first. RN #1 stated she is in-serviced monthly with infection control practices and hand washing. 09/13/19 at 11:28 AM, RN Infection Control Preventionist and In-Service Educator (RN #2) was interviewed. RN #2 stated prior to start of wound treatment, a sterile field should be established by using bleach wipes to wipe down the over bed table, wait for three minutes to air dry, and then place a drape on table for the wound supply placement. RN #2 also stated the proper way to wash hands are to turn on the faucet and wet hands first prior to getting soap. In-service educations on infection control and hand washing are completed frequently. 415.19(b)(4)

Based upon interviews and record review during an abbreviated survey (Complaint ID # NY 320), the facility did not ensure that medical records were maintained in accordance with accepted professional standards and practices in that they were complete and accurately documented. Specifically, two (Resident #1 and Resident #2), of three residents reviewed for elopement prevention had care plans that included 15 and 30 minute monitoring, respectively, as interventions to address unsafe wandering. The medical records lacked documented evidence that the staff monitored both residents as per their plan of care. Additionally, there was no documented evidence that Resident #1's elopement prevention device was checked for functionality. The findings are: The Policy and Procedure for Prevention of Wandering and Elopement dated 06/2013 documented if a resident is deemed at risk, an individualized care plan specific to the resident's needs will be developed and revised as needed. 1) Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-an assessment tool) dated 07/10/2017 documented the resident's cognitive skills for daily decision making as moderately impaired. He ambulated with supervision on the unit. The Comprehensive Care Plan (CCP) for wandering/elopement dated 07/09/2017 documented resident has episodes of wandering behavior and going in front of the elevator seeking exit. Resident has Dementia and able to ambulate around the unit. Interventions included 15-minutes visual check for 3 days. The Elopement Risk assessment dated [DATE] documented resident is at risk for elopement as evidenced by opening the alarm door and going off the unit. Intervention included frequent monitoring 15-30 minutes. The 15-minute monitoring sheet was initiated on 07/09/2017 and documented 15-minute visual checks. The 15-minute monitoring sheet lacked documented evidence that visual checks were performed on 7/16/2017 from 7 AM to 3 PM and on 7/17/2017 from 4 PM to 11 PM. The Wander Guard Check for Functioning Sheet (A wander guard is an elopement prevention device generally worn by the resident) lacked documented evidence that the wander guard checks for functioning were performed on 7/16/17 through 7/19/17. During an interview on 07/31/2017 at 1:17PM with the Director of Nursing (DON), he stated Resident #1 was started on 15 minutes monitoring on 07/10/2017. The DON stated he saw the 15-minute monitoring sheet on 07/19/2017 and noted there were omissions on documentation, but while the DON was doing his rounds, he observed the resident was always with a CNA (Certified Nurse Aide). The DON gave in-service training to staff to not only monitor the resident but also to document it. The DON stated that the 11:00 PM to 7:00 AM RNS (Registered Nurse Supervisor) checked the wander guard daily for functioning. The DON stated he was not able to locate the wander guard check sheets dated 07/16/2017 to 07/19/2017. During a telephone interview on 08/01/2017 at 10:23AM with 7:00 AM to 3:00 PM Certified Nursing Assistant (CNA #2), she stated Resident #1 was placed on 15-minute monitoring because he kept verbalizing that he wanted to go out. CNA #2 stated that she usually documented her observations on the 15-minute monitoring sheet. During a subsequent interview on 08/10/2017 at 3:28 PM, CNA #2 stated that, on 07/16/2017, she was responsible to document 15-minute monitoring for Resident #1 but she did not know why she did not document her observations. CNA #2 stated she was assigned to Resident #1 and watched him and took care of him that day. During a telephone interview on 08/01/2017 at 2:50PM with 11:00PM to 7:00 AM RNS #2, she stated on 07/16/2017 to 07/19/2017 she checked Resident #1's wander guard and it was always functioning. RNS #2 stated maybe the flowsheet for wander guard functionality checks were misplaced. During a telephone interview on 08/14/2017 at 3:18 PM with the 3:00 PM-11:00 PM CNA #6, she stated she was assigned to Resident #1 on 07/17/2017. CNA #6 stated she did not know why she did not document the resident's activity on 07/17/2017 from 4:00 PM to 11:00 PM on the 15-minute monitoring sheet however, she had monitored him every 15 minutes. 2) Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident's cognitive status as being severely impaired. She required extensive assistance of one person with walking and locomotion. The elopement risk evaluation dated 05/25/2015 documented the resident was at risk for elopement as evidenced by wandering and opening door. The CCP for Behavior Problem: Wandering/Elopement dated 07/20/2014 documented the resident with a [DIAGNOSES REDACTED]. Interventions included 30-minute visual check, apply wander guard to wheelchair. An update on the CCP dated 07/22/2014 documented the resident continued on 30-minute visual check. The Resident Care Instructions printed 08/01/2017 documented the resident had a behavior of wandering and noted, Resident with wander guard and on visual check every 30 minutes under safety instructions. The facility lacked documented evidence of every 30 minutes monitoring for Resident #2 as per plan of care and CNA care instructions. During an interview on 07/31/2017 at 1:17PM with the Director of Nursing (DON), he stated 30-minute monitoring sheets were not available for Resident #2. During a subsequent phone interview on 08/01/2017 at 2:02PM, the DON stated Resident #2 was originally placed on 30-minute monitoring on 07/20/2014 for 3 days. He stated that maybe at that time the 30-minute monitoring was not discontinued. During an interview on 07/31/2017 at 6:30PM with the 3:00PM to 11:00PM CNA #1, she stated she was assigned to Resident #2. CNA #1 stated Resident #2 was not on 15 or 30-minute monitoring and she did not document 30-minute visual check for Resident #2. During a phone interview on 08/11/2017 at 10:24AM with 7:0AM - 3:00PM CNA #5 she stated she was regularly assigned to Resident #2. She stated sometimes the resident was confused, agitated and wheeled herself around go to other residents' rooms. CNA #5 stated she watched Resident #2 but the resident was not on 30-minute monitoring and she was not documenting it. 415.22 (a) (1-4)

Based on observation and interview, the facility did not ensure that infection control procedures were maintained. This was evident for 1 of 40 resident rooms observed during Stage 1. (Resident #255). This resulted in no actual harm with potential for more than minimal harm. The finding is: On 7/28/14 at 11:15 AM, the following was observed stored directly on the floor in the resident's room: One box of [MEDICATION NAME] wafers and two boxes of [MEDICATION NAME] bags. The RN (Registered Nurse) Neighborhood Manager was interviewed immediately and stated that the resident's care equipment was delivered directly from the company and to the resident's room. On 7/29/14 at 10:41am the CNA (Certified Nurse Assistant) was interviewed and stated that she intended to organize the resident care items in the resident's room and had forgotten about it. She further stated that the resident care items should not be on the floor. 415.19(a)(1-3)

Based on record review and staff interviews during the recertification survey, the facility did not ensure that Accident/Incident (A/I) Reports of an unknown origin were thoroughly investigated to rule out abuse and neglect. This was evident for three of ten residents reviewed for unnecessary medications in a total of 39 stage two sampled residents. Specifically, 1) Resident #225 was identified with discolorations to the arms without statements obtained from direct care staff as to how and when these injuries occurred, 2) Resident #275 was identified with a hematoma and ecchymotic area without statements obtained from direct care staff regarding circumstances that may have contributed to these injuries, and 3) Resident #65 was identified with a swollen right wrist without statements obtained from any direct care staff regarding circumstances that may have contributed to these injuries. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The findings are: 1) Resident #225 was readmitted to the facility on [DATE] status [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented that the resident's cognition was moderately impaired. The MDS also identified the resident as being an extensive assist of 2 persons for transfer. A Nurse's Note dated 5/31/13 at 10:59 PM documented that at 5:30 PM the resident was noted with a black/blue discoloration to the inner aspect of the left upper arm. An A/I Report dated 5/31/13 documented that the discoloration was first observed by a family member. A statement was obtained from the Certified Nursing Assistant (CNA) assigned to the resident on the 3:00 PM-11:00 PM shift. The statement documented that the resident was placed in bed at 4:45 PM with a two person assist. There were no additional statements obtained. On 6/8/13 at 5:00 PM, a skin discoloration to the right upper arm measuring 5.5 centimeters (cm) by 2 cm was identified by a family member. The A/I Report dated 6/8/13 documented that the assigned CNA had showered the resident that evening. There were no additional statements obtained from direct care staff. 2) Resident # 275 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented that the resident had moderately impaired cognition. The MDS also identified the resident as being an extensive assist of 2 persons for transfer. A Nurse's Note dated 6/15/13 at 10:35 PM documented that on rounds the resident was observed in their gerichair with an ecchymotic area measuring 2 cm by 2 cm to the resident's forearm. An A/I Report dated 6/15/13 at 9:00 PM documented the same. The assigned CNA stated that she had toileted the resident at 7:00 PM. There were no additional statements obtained from direct care staff on that shift or previous shifts. A Nurse's Note dated 6/26/13 at 9:30 AM documented that the resident's assigned CNA observed the resident in the dining room with a Hematoma to the dorsal area of the right hand. An A/I Report dated 6/26/13 at 9:30 AM documented that the assigned CNA stated that she had provided care at 7:00 AM to the resident and that no visible swelling was evident. There was no additional statement from the CNA who should have assisted in the transfer from bed to chair at that time. 3) Resident #65 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The resident was on comfort measures only. The MDS dated [DATE] documented that the resident had severely impaired cognition. The MDS also identified the resident as requiring extensive assist of 2 persons for transfer. A Nurse's Note dated 1/10/13 at 11:36 PM documented that the resident was complaining of pain in the right wrist. The area was noted to be swollen. An A/I Report dated 1/10/13 at 10:40 PM documented that the resident complained of pain to the right wrist. No statements were obtained from direct care staff assigned to the resident on the 3:00 PM -11:00 PM shift or previous shifts. The Director of Nursing (DON) was interviewed on 7/9/13 at 1:15 PM and stated that statements should have been obtained from the CNAs who had provided assistance with transfers for these residents. Additionally, the DON stated that she would have expected statements to have been obtained from the direct care staff on the previous shifts. 415.4(b)(1)(ii)

Based on record review and staff interview during the recertification survey, the facility did not ensure that a significant weight loss was addressed by the Registered Dietitian (RD) for one of three residents reviewed for Nutrition in a total sample of thirty-nine Stage 2 residents. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. (Resident #246) The finding is: Resident #246 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE] and discharged on [DATE]. The Admission 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was able to be understood and could understand and had a Brief Interview for Mental Status (BIMS) score of 9 which indicated moderately impaired cognitive skills for daily decision making. The New Admission Nutrition assessment dated [DATE] revealed that the resident had a Body Mass Index (BMI) of 21.09 which reflected an acceptable weight. A review of the electronic medical record revealed that the resident weighed 146.6 lbs (pounds) on 5/8/13 and 139.4 lbs on 6/15/13 which reflected a 5% significant weight loss in 5 weeks. The resident was also noted to weigh 136.6 lbs on 6/20/13 which reflected a 7% significant weight loss in 6 weeks. A review of all Dietary Assessments, Dietary Progress Notes, and Dietary related Comprehensive Care Plans (CCPs) revealed no documented evidence that the RD was aware of the resident's significant weight losses, nor were any nutritional interventions implemented to address the resident's weight loss. The RD was interviewed on 7/10/13 at 9:20 AM and stated that it was an oversight on her part that she did not document when the resident had a significant weight loss. The RD also stated that if she had known about the resident's significant weight loss, she would have reassessed the resident and written a note. 415.12(i)(l)

Based on record review and staff interviews during the recertification survey, the facility did not ensure that each resident's drug regimen is free from unnecessary drugs. This was evident for one of ten Stage 2 residents reviewed for unnecessary drugs in a total sample of 39 Stage 2 residents. Specifically, Resident #276 received an increased dosage of a [MEDICAL CONDITION] medication without adequate indications for the increase. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. This is a repeat deficiency. The finding is: Resident #276 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented that the resident was moderately impaired in cognition for daily decision making. The MDS further documented that the resident exhibited no behavioral problems. The Comprehensive Care Plan (CCP) dated 2/5/13 titled Behaviors documented that the resident had a behavior problem of yelling and screaming and exhibiting accusatory behaviors. The last entry to date on the Behavior CCP was dated 6/12/13 and documented the the resident continues to be critical of care and caregivers. A physician's orders [REDACTED]. A Psychiatric Consultation Report dated 6/25/13 documented to decrease the [MEDICATION NAME] to 0.5 mg by mouth twice a day and follow up in one month. The consult further documented that the resident had been taken off [MEDICATION NAME] (an antidepressant) and developed increased anxiety, was started on [MEDICATION NAME] (an antianxiety medication), but the resident became over sedated, and was now recommending to decrease the [MEDICATION NAME] to 0.5 mg twice a day and to avoid [MEDICATION NAME]. The consult documented that the resident is alert and mood and affect were within normal limits. A Nursing Progress Note dated 6/24/13 documented that the resident complained "I don't feel good" and a urine collection for analysis and culture and sensitivity was ordered. A Nursing Progress Note (N/N) dated 6/28/13 documented that [MEDICATION NAME] (ABT, an antibiotic) was ordered for a urinary tract infection [MEDICAL CONDITION]. N/Ns dated 6/29/13 through 7/2/13 documented that Resident #276 was alert and responsive, voiced no complaints and was on ABT for a UTI. There was no documented evidence in the N/Ns that Resident #276 exhibited any behavioral problems. The Certified Nursing Assistant (CNA) Documentation History Details for behavior dated 7/1/13 11:00 PM to 7/3/13 at 7:00 AM documented no behavioral problems. A physician's orders [REDACTED]. by mouth twice a day. A Nurse Practitioner (NP) Note dated 7/2/13 documented that Resident #276 was seen by the Psychiatrist on 6/25/13, [MEDICATION NAME] 0.5 mg BID (twice a day), UA showered >100,000 E. Coli (bacteria) and resident was very agitated. Started on [MEDICATION NAME] BID for 7 days. The NP's Note further documented that the [MEDICATION NAME] was increased, no tapering at this time. The NP was interviewed on 7/10/13 at 1:45 PM and stated that she increased the [MEDICATION NAME] because the resident was agitated, had a UTI and when the resident had previously been on that dosage her behavior had improved. The Registered Nurse (RN) responsible for Resident #276 was interviewed on 7/10/13 at 2:40 PM and stated that if a resident exhibited behaviors, she would expect the Nurse to document it in the N/Ns. The Licensed Practical Nurse (LPN) responsible for Resident #276 was interviewed on 7/10/13 at 3:00 PM and stated that she did not recall if the resident exhibited any behavioral problems on 7/2/13, but that the Resident did sometimes scream, but not continuously, and if the resident had behaviors that day, she would have documented it in the N/Ns. A facility document titled [MEDICAL CONDITION] Policy and Procedure dated May 2013 documented to limit orders for antipsychotic medications to specific conditions or situations for which they may be beneficial including agitated features as defined by ...continuous crying out, screaming, yelling or pacing that is frequent or severe enough to cause substantial personal distress or impair vital personal function. 415.12(l)(1)

Based on observations, interviews and record review during an abbreviated survey, the facility did not ensure that services were provided that meet professional standards of quality. Resident #1 was treated with a Continuous Passive Motion (CPM) device without a Physician ' s order for the treatment. This was evident for 1 of 3 sampled residents (Resident #1). This resulted in no harm with the potential for more than minimal harm that is not Immediate Jeopardy. Complaint # NY 642 The findings include: Resident # 1 was a [AGE] year old female admitted to the facility on [DATE] at 5:00PM. Her [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 dated 8/1/12 identified the resident with intact cognition. On 8/15/12 at 3:30PM Resident #1 was observed in her bed. The resident was observed with a Continuous Passive Motion device applied to her right knee. A review of the hospital Patient Review Instrument (PRI) dated 7/25/12 documented Right Knee CPM 0-50 degrees twice daily progress by 10 degrees as tolerated. A review of the Initial Physical Therapy (PT) Evaluation, dated 7/26/12 documented right lower extremity Range of Motion (ROM) including active knee flexion limited to 60 degrees by pain. The knee was noted in a removable immobilizer. The note did not identify that the resident had an order from the hospital for a CPM device. A review of the Comprehensive Care Plan for Physical Therapy effective 7/27/12 documented Physical Therapy 5 times per week for a minimum of 150 minutes per week for 4 weeks. The Comprehensive Care Plan did not include an intervention for CPM daily. A review of the Physician ' s Orders from 7/26/12 - 8/15/12 did not reveal that there was an order for [REDACTED]. A review of the facility policy and procedure titled " Continuous Passive Motion, " undated revealed that upon admission the resident will either present with hospital discharge orders and occasionally recommended parameters from surgeon who performed the surgery. If there are no formal physician orders or recommended parameters present, nursing or the physical therapist should contact the MD immediately for this information. Resident # 1 was interviewed on 8/15/12 at 1:05PM. She stated that she has CPM therapy with the therapist for 2 hours daily. She was instructed by the therapist on how to stop the CPM if she was in pain, needed to go to the bathroom and when the treatment was completed. The resident stated she would call the nurse to remove the CPM from her leg. On 8/15/12 at 3:00PM the Certified Nursing Aide (CNA) # 1, who worked on the 3:00PM-11:00PM shift was interviewed. She stated that the physical therapist applied the CPM machine to the resident daily. On 8/15/12 3:15PM an interview was conducted with CNA # 2, who worked the 3:00PM- 11:00PM shift. She stated that the resident received therapy with the CPM device. She stated that the physical therapist set the range and then she would plug in the CPM machine and apply it to the resident for 2 hours daily. On 8/15/12 at 10:45AM an interview was conducted with the Physical Therapist. He stated that if a resident is admitted with a CPM order from the hospital then the facility continues the treatment with a Physician ' s order. The Physical Therapist noted the CPM order on Resident #1 ' s Hospital PRI. The Physical Therapist stated that after he evaluated Resident #1, he notified the Director of Rehabilitation regarding the hospital order for CPM. The Physical Therapist stated that the Director of Rehabilitation is responsible for providing the resident with the CPM machine and obtaining the order for the CPM. He stated that Resident #1 did not have a Physician ' s order for a CPM device. He stated that he set the range of motion for the CPM daily. The resident was instructed regarding how to stop the machine when needed. He stated that the nurse could take off the device after completion of treatment and as needed. On 8/22/12 at 12:35PM a telephone interview was conducted with the Director of Rehabilitation. He stated that the hospital PRI was received on 7/26/12 when the resident was admitted and that the PRI documented that the resident received CPM treatment. The Director of Rehabilitation stated that the facility rents CPM devices and it takes 2-3 days to arrive. The PT initial evaluation was done on 7/27/12 and the CPM was started on 7/30/12. The Director of Rehabilitation stated that it was an oversight that the CPM was initiated without a Physician ' s order. He stated that the Physical Therapist applied the CPM and the CNA and the resident were in-serviced on how to stop the CPM. The CPM treatment was applied for 2 hours daily. On 8/15/12 at 2:45PM the Medical Director was interviewed, she stated that the physical therapist is responsible for the assessment, recommendation and writing the order for the CPM machine. The Medical Director stated that she approves and signs the order. 415.11(c)(3)(i)

Based on record review and interviews the facility did not ensure adequate supervision for a resident who has a history of falls. This was evidenced by a resident who was high risk for falls not being supervised as per her care plan at 30 minute intervals and provided with a safe environment.As a result the resident had a fall with subsequent injuries including a hip fracture. This was evident for 1 of 30 sampled residents, Resident # 2. This resulted in actual harm that is not immediate jeopardy. The findings are: Resident #2 is a [AGE] year old female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. On 7/26/12 at 12:15pm the resident was observed in the dining room while lunch was served. She was sitting in a wheelchair, with the chair alarm visible. The resident's room was also observed on the same date at approximately 12:45 PM, the bed was with in the standard position (not lowered). The resident was not observed in the bed at this time. The MDS (minimal data set) 3.0 dated 8/8/11 on admission documents the residents BIMS (brief interview for mental status) score as 12 , (cognition is moderately impaired). The resident requires extensive assistance of 2 people to transfer and for toileting. The resident is frequently incontinent of bowel and bladder. The resident was identified as having a fall with a fracture within the last 30 days prior to admission. The "Falls Risk Assessment" dated 8/25/11, 10/22/11, 10/24/11, 1/15/12 and 2/27/12 documents that the resident is high risk for falls. The "Care Plan Activity Report" for "Falls" effective 8/2/11 documents interventions: Provide safe, clutter free, well-lit environment, assist transfers, bed alarm/chair alarm, bed low and locked. call bell in reach, , ....Toilet at every 2 hours or upon request, ....Hourly rounds. The Nursing Notes dated 8/2/11 document that the resident is attempting to act independently trying to get out of bed to bathroom. On 8/9/11 , 8/11/11, 8/13/11 the resident is assisted to a commode at her bedside. On 8/14/11 the resident was requesting to go to the bathroom several times during the night. On 8/15/11 , 8/17/11 the resident slept on and off during the night and the resident requested to use the commode several times. On 8/24/11 the resident was noted using a commode intermittently during the night. On 8/24/11 the resident was moved from the 6th floor to the 2nd floor. There was no reason documented in the medical chart for the move. On 8/25/11 at 1:10 am the resident was found on the floor in her room. The "Resident CNA Documentation Record" dated 8/2/11 - 8/31/11 documents in the "Safety" "Protective Measures" section that the resident was not provided a bed in the low position 24 days of the month on the 3-11pm shift and 22 days during 11-7 am shift including and on 8/25/11 both shifts. Additionally, there is no documented evidence that the resident was toileted every 2 hours and that she was monitored every hour as per the plan of care dated 8/2/11. The Accident/Incident Form dated 8/25/11 documents that the resident will be toileted at 12 am and 4 am to prevent recurrence and a commode will be at bedside. The "Care Plan Activity Report" for falls dated 8/25/11 documents to toilet resident at 12 am and 4 am and commode at bedside. The Physicians notes dated 8/31/11 document that the resident was evaluated for restlessness and unable to sleep at night. The resident was started on Ambien for Insomnia. On 9/9/11 the residents room was changed from the 2nd floor to the 5 th floor. The Nursing notes dated 10/21/11 at 9:21pm documents that the resident was found on the floor in front of her bed. The resident sustained [REDACTED]. The "Accident/Incident Form" dated 10/21/11 documents that the resident attempted to get out of her wheelchair unassisted . The resident will be placed on 30 minute checks and will be put to bed at 8pm as per resident preference to prevent a recurrence. The "Resident CNA Documentation Record" dated 10/1/11-10/31/11 in the "Safety" "Protective Measures" section documents that the resident was not provided a bed in the low position 18 days of the month during the 3-11pm and 11-7am shifts. Additionally, there is no documented evidence that the resident was toileted as per the plan of care and that a commode was offered to the resident since her move to the 5th floor on 9/9/11. The Nursing Notes dated 11/3/11 at 4:35pm document that the resident was toileted by the LPN (Licensed Practical Nurse) , the resident got up from the toilet unassisted and fell . The resident was sent to the hospital. The resident was readmitted to the facility on [DATE] with a right nasal fracture. The "Accident/Incident Form" dated 11/3/11 documents that the LPN heard a bang at the door, and found the resident on the floor . The follow-up measures are for a staff member to stay with the resident in the bathroom during toileting secondary to resident impaired judgement. The Nursing Notes dated 1/15/12 at 7:07am document that the resident was observed by the CNA (Certified Nursing Assistant) at 2 am on the floor next to her bed. The resident complained of pain to the back , lower spine and hip region. Resident was noted with difficulty standing with 2 assist. The resident was admitted to the hospital on [DATE] and returned to the facility on [DATE] s/p (status [REDACTED]. Rib fracture of 9 th and 10 the rib. The "Accident/Incident Form dated 1/15/12 documents that the resident will be on 1 hour visual checks and continue safety rounds. The "Care Plan Activity Report" dated 1/15/12 documents that the resident will be on 1 hour visual checks. The "Care Plan" dated 1/25/12 documents that the resident will be toileted by staff when making rounds if she is awake while in bed. The "Resident CNA Documentation Record" dated 1/1/12-1/31/12 documents in the "Safety" "Protective Measures" section that the resident was not provided a bed in the low position 21 days on the 3-11pm shift and 13 days on the 11-7am shift. Additionally there is no documentation regarding monitoring of the resident and toilet schedule. The Nursing Notes dated 2/27/12 at 4:39am documents that the resident was found at 3:45am on the floor in front of the bathroom in her room. The resident sustained [REDACTED]. The "Resident CNA Documentation Record" dated 2/1/12-2/29/12 documents in the "Safety" "Protective Measures" section that the resident was not provided a bed in the low position 7 days on the 3-11pm shift and 19 days on the 11-7am shift including 2/27/12. Additionally, there is no documented evidence that the resident was monitored as per the plan of care every 30 minutes and no documentation regarding a toilet schedule. On 7/26/12 at 2:30pm and 3:45pm the RN (Registered Nurse) Manager (7-3p) was interviewed and stated that the resident displays behavior where she feels she is more independent than she is capable. She stated that the resident wheels herself to the bathroom and try's to get up unassisted. She stated the resident would wake up in the middle of the night and yell. She stated that the resident was assessed as a high risk for falls. She stated that the protocol for high risk residents are to provide bed and chair alarms, floor mats, observing and alerting the staff. She added that there was no visual checks documented, and that when the staff monitor the resident it means , keeping an eye on them. There is no specific staff person to monitor the resident but when the CNA and Nurse make rounds they monitor. Lastly, she stated that the resident was never given a bedside commode since on the 5 th floor. She is put on the toilet and needs to be supervised at all times. On 7/26/12 at 3:30pm the Director of Nursing was interviewed and stated that the resident is a high risk for falls. She stated that there should be documentation in reference to the residents where abouts, when monitoring. She further stated that the resident should have never been left alone in a bathroom because of her known behavior of trying to get up and thinking she is more independent than capable. On 7/26/12 at 3:50pm the CNA 3-11pm shift was interviewed. She stated that she works on the 5th floor and knows the resident approximately 1 year. She stated that the resident is toileted and she never leaves the bathroom as long as she remembers. She added that she never saw a bedside commode for the resident. She stated that the resident is put to bed around 9:30pm. On 7/26/12 at 4pm the LPN (3-11pm shift) was interviewed and stated that the resident is total care. As long as he can remember the resident has been trying to be independent, getting up from her wheel chair and bed. He stated that on 11/3/11 he had taken the resident to the bathroom to help the staff. He closed the door for privacy and waited outside. He heard a noise and the resident was already on the bathroom floor. He stated that he should have called a female CNA to help the resident while she was in the bathroom considering her behavior of trying to be independent. He added that he never observed the using a bedside commode. On 7/26/12 at 5pm the ADON (Assistant Director of Nursing) was interviewed and stated that she reviews all the Accident and Incident reports but is not responsible for follow up regarding the interventions implemented, that would be the Nurse Manager in Charge. 415.12(h)(1)

Based on observation, record review and interview the facility did not review and revise a resident's CCP (comprehensive care plan in a timely manner after the resident developed an nosocomial (developed while in the facility) pressure ulcer. This was evident for 1 of 30 sampled residents (Resident #12) This resulted in no harm with potential for more than minimal harm. The findings are: Resident # 12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During the initial tour conducted on 7/23/12, the nurse reported that the the resident was developed a nosocomial pressure ulcer. The resident was observed during wound care on 7/25/12 at 10:30 AM. She had a granulating stage 3 pressure ulcer to the right ischium. The MDS (minimum data set) 3.0 assessment dated [DATE] documented the presence of 1 stage 3 pressure ulcer. A CCP ( comprehensive care plan) for Pressure ulcer risk updated 1/23/12 documented that the resident was free of pressure ulcers. A late entry nursing note dated 3/23/12 documented that on 3/9/12,the writer had been informed that the resident developed a stage 3 pressure ulcer. The physician's orders [REDACTED]. A CCP dated 3/23/12 documented that the resident was "at risk for pressure ulcer" with the goal that the resident would be free of pressure ulcer development for 90 days. There was no update to the resident's CCP to reflect the development of an actual pressure ulcer identified by nursing staff on 3/9/12. There were new goals set indicated or interventions to address the plan of care for the newly identified pressure ulcer. On 7/27/12 at 10:10 AM an interview was conducted with the unit RNM (registered nurse manager). The RNM stated that the the nurse on the 3 PM -11 PM shift first noted the pressure ulcer on 3/9/12 by . This nurse informed the physician on the evening of 3/9/12. The physician ordered a treatment for [REDACTED]. She stated that she did not remember to revise the CCP to address the wound care until 2 weeks later on 3/23/12. 415.11(c)(2)(i)

Based on observation, record review and interview, facility staff did not ensure that the resident's plan of care was followed for: stool collection (Resident #1), a chair alarm (Resident #3), medication administration (Resident # 11), elevation of a resident's legs (Resident # 21). This was evident for 4 of 30 sampled residents This resulted in no harm with potential for more than minimal harm. Findings are: 1) Resident # 1 is an [AGE] year old female with [DIAGNOSES REDACTED]. Nursing notes documented the following: 6/29/12 - " Resident had 1 large LBM (large bowel movement). " 7/2/12 - Resident noted with LBM. " 7/3/12 - Resident continues with loose mucosy bowel movements. MD (medical doctor) made aware and ordered Stool for C- Diff test. " 7/4/12 - at 2:21 PM " Resident noted with LBM. " At 11:16 PM - " LBM x1 during tour. " 7/10/12 - " Resident noted with 1 large loose bowel movement this morning. " 7/11/12 - " Resident noted with 1 large loose bowel movement this morning. " 7/14/12 - " LBM x1 during shift. " The physician's order [REDACTED]. " Review of laboratory reports dated 7/1/12 to 7/23/12 revealed no documented evidence that the physician's orders [REDACTED]. On 7/24/12 the charge nurse and Assistant Director of Nursing were interviewed. Both stated that there was no indication that the stool ordered by the physician on 7/3/12 and 7/19/12 was collected. 2) Resident # 3 is a [AGE] year old female with [DIAGNOSES REDACTED]. On 7/26/12 at 11 am the resident was observed in her room , she was sitting in her wheelchair, there was no chair alarm observed. The MDS (minimum data set) 3.0 dated 7/15/12 (Annual Review) documented the resident's BIMS (brief interview for mental status) score as 1/15 severe cognitive impairment. The MDS also documented that the resident has a history of falls with injury. The Comprehensive Care Plan dated 6/7/12 for "Falls" documented under interventions: w/c (wheelchair) alarm. The "Resident Nursing Instructions" dated 7/26/12 documented: "chair alarm". On 7/26/12 at 11am the CNA (Certified Nursing Assistant) was interviewed and stated that she had taken the resident out of bed that morning and that the battery to the chair alarm needed to be replaced. She stated that she informed the LPN (Licensed Practical Nurse) at 7:45 am. On 7/26/12 at 11:15 am the LPN was interviewed and stated that she did not recall anything about the need for batteries for the chair alarm. She added that she just found out. The resident was observed sitting in her wheelchair without the chair alarm for over 3 hours. 3) Resident # 11 is an [AGE] year old with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score as 2 (severely impaired cognition). The MDS also documented a mood score of 12 (moderate depression) evident by trouble concentrating daily, having little energy, poor appetite, trouble falling asleep, or staying asleep, or sleeping too much, little interest in doing things, and feeling down, depressed, or hopeless. The Comprehensive care plan for [MEDICAL CONDITION] drug use dated 4/8/2012 includes interventions as "administer medications as ordered, observe for changes in behavior and mental status, observe for signs and symptoms of adverse reactions to medications and report to MD (Medical Doctor), provide emotional support and reassurance as needed" The physician's order [REDACTED]. " The Medication Administration Record (MAR) dated 7/1/12- 7/25/12 documents administration of [MEDICATION NAME] on 7/15/12 at 5:30 AM and at 8:46 AM (approximately 3 hours apart). The Controlled substances medication record documents on 7/15/2012 one tablet of [MEDICATION NAME] administered at 5:30 AM and at 2 PM. Review of the MAR and the Nursing progress notes revealed no documentation regarding the following: Evidence of appropriate physician's order [REDACTED]. The LPN #2 medication nurse was interviewed on 7/25/2012 at 4:10 PM and stated that on 7/15/12 in the morning she observed the resident aggressive, cursing and screaming when she came to work. "I intended to give him (resident) [MEDICATION NAME] and then I realized he already got it, so I gave it at 2:45 PM." She was unable to explain, why the MAR documented 8:45 AM as the time of administration of [MEDICATION NAME] and stated "I must have clicked something." Review of the 24 report for 7/15/12 did not reveal any documentation regarding [MEDICATION NAME] administration after 5:32 AM. LPN #3 was interviewed on 7/26/2012 at 3:45 PM and stated she was the medication nurse on 7/15/12 3-11 shift and could not recall any verbal or written communication from the previous shift regarding administration of [MEDICATION NAME]. The Registered Nurse Manager (RNM) was interviewed on 7/25/12 at 1:30 PM and stated she was not aware of any irregularities related to medication administration until reviewing documentation with the surveyor. The Director of Nursing was interviewed on 7/27/12 at 12:31 PM and stated that the medication nurse should have called the Medical Doctor (MD) in the morning of 7/15/12 to obtain an appropriate order if all non-pharmacological interventions were ineffective in managing the resident's behavior. If [MEDICATION NAME] was given in error at 8:45 AM, this should have been immediately communicated to the RNM or Supervisor on duty and to the MD, so that the resident could be assessed, monitored, and appropriate medication error report completed. If medication was given at 2:45 PM as per LPN statement, this should have been documented on the MAR, in the medical record, and communicated to the oncoming shift. 4) Resident #21 is [AGE] year old female with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] documented that the resident needs extensive assist in transfer. The integrated notes documented the following: 4/8/12 Dietary - " Resident has 2+ leg [MEDICAL CONDITION]. " 4/23/12 Nursing - Residents right shin was noted swelling. " 4/24/12 Medical - " Note: was informed by nurse that pt has an area of swelling over right leg.. " 4/24/12 Nursing - " New leg rest requested from OT (Occupational Therapist) for elevation of right to reduce [MEDICAL CONDITION]. " 4/27/12 Medical - " Pt examined at bedside for swelling of the lower extremity. Resident c/o (complain) Rt (right) leg pain associated with swelling ....Extremities: Rt leg 2+ [MEDICAL CONDITION] ...mild fluctuant swelling ....Lt (left) leg [MEDICAL CONDITION]+.. " 4/28/12 Medical - " Follow up for swelling of the right leg .....unclear of its origin pedal [MEDICAL CONDITION] of right leg ...5/1/12 Nursing - " Redness and swelling continues to right leg. " physician's orders [REDACTED]. " On 7/27/12 at 10:30 to 12:30, the resident was observed in the dining area during activities and at lunch time, with both legs not elevated. On 7/27/12 at 12:35 PM, the Certified Nursing Assistant was interviewed and stated that she was not aware that the resident's legs needed to be elevated. She further stated that it is not recorded in the accountability record. On 7/27/12 at 12:40 PM, the charge nurse was interviewed and stated she could not answer why the nursing aide was unaware that the resident's legs needed to be elevated. 415.11 (c) (3) (ii)

Based on record review and interview, the facility did not ensure that the attending physician followed up on an order for [REDACTED].#1) This resulted in no harm with potential for more than minimal harm The finding is: Resident #1 is an [AGE] year old female with [DIAGNOSES REDACTED]. The MDS (minimum data set) initial assessment documents the resident as being cognitively intact with a BIMS (brief interview for mental status) score of 14. It further documents that the resident does not exhibit problems with her long and short term memory. The resident was assessed as being totally dependent on staff for toileting and is at times incontinent of bowel and bladder. Infectious Disease Consult notes dated 7/3/12 documented the following: " Resident with unresolved [MEDICAL CONDITION] .....Recommendations: Check stool for[DIAGNOSES REDACTED] ... " The physician's order [REDACTED]. " Review of laboratory reports dated 7/1/12 to 7/23/12 revealed no documented evidence that the physician's order [REDACTED]. The integrated notes written by members of the nursing staff and maintained in the resident's medical record documented the following: On 6/29/12 - " Resident had 1 large LBM (large bowel movement). "; 7/2/12 - Resident noted with LBM. "; 7/3/12 - Resident continues with loose mucosy bowel movements. MD (medical doctor) made aware and ordered Stool for C- Diff test. " 7/4/12 - at 2:21pm Nursing - " Resident noted with LBM. " At 11:16pm Nursing - " LBM x1 during tour. " 7/10/12 Nursing - " Resident noted with 1 large loose bowel movement this morning. " 7/11/12 Nursing - " Resident noted with 1 large loose bowel movement this morning. " 7/14/12 - " LBM x1 during shift. " There was no documented evidence that a stool specimen was collected and sent to the laboratory for testing as per doctor's orders. On 7/24/12 at 11 AM, the Infectious Disease Consultant was interviewed and stated that she does not follow up on consult unless being called to do so. She added that all her recommendations were discussed with the attending physician. On 7/26/12 at 8:15 AM , the attending Physician was interviewed and stated that " the stool specimen was not obtained because the resident kept flushing after bowel movements. She would forget to call the CNA (certified nurse's assistant) for collection of stool after moving bowels. He added that resident made him aware that the test was not done. The physician further stated that the resident was receiving he was waiting to see if the symptoms would subside before further addressing the issue. On 7/19/12 at 8:00 AM the physician ordered 250 mg [MEDICATION NAME] to be given to the resident by mouth twice a day for 30 days secondary to a [DIAGNOSES REDACTED]. The nursing staff was not able to obtain a stool sample and notified the physician. The physician did not document this in the resident's medical record nor did he give nursing staff any further instructions in regards to the collection of stool. The facility's policy on " Medical Staff Responsibilities, " dated March 2012 documented: " The Attending Physician shall be the primary physician responsible for providing medical services and coordination the healthcare of each resident/patient in the facility ....All Medical Staff document all resident/patient other important clinical information in the medical record". 415.15(b)(2)(iii)

Based on record review and staff interviews, the facility did not ensure that each resident ' s drug regimen was free from unnecessary drugs. Specifically: 1) Resident # 11 received an excessive dose of an antianxiety medication ([MEDICATION NAME]) and this PRN (as needed medication) was administered without consistent documented evidence of behaviors indicating use of medication, effects of medication, and non-pharmacological interventions attempted prior to the administration; 2) Resident # 24 received PRN (as needed) pain medication ([MEDICATION NAME]) without consistent monitoring of pain level prior and post administration of medication. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. The findings are: 1) Resident # 11 is an [AGE] year old with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score as 2 (severely impaired cognition). The MDS also documented a mood score of 12 (moderate depression) evident by trouble concentrating daily, having little energy, poor appetite, trouble falling asleep, or staying asleep, or sleeping too much, little interest in doing things, and feeling down, depressed, or hopeless. The Monthly physician's orders [REDACTED]. The physician' s order dated 7/13/2012 documents: " [MEDICATION NAME] 1 mg tab (tablet) ...give 1 tablet (1 mg) by oral route per day as needed Q (every) 8 hours for Anxiety state, unspecified. " The Medication Administration Record (MAR) dated 7/1/12- 7/25/12 documents administration of all [MEDICAL CONDITION] medications and administration of [MEDICATION NAME] on 7/13/12, 7/14/12, 7/15/12 at 5:30 AM and at 8:46 AM (approximately 3 hours apart), and at 7/21/12. The "Monitoring " section of the MAR was noted blank. The Comprehensive care plan for [MEDICAL CONDITION] drug use dated 4/8/2012 includes interventions as "administer medications as ordered, observe for changes in behavior and mental status, observe for signs and symptoms of adverse reactions to medications and report to MD (Medical Doctor), provide emotional support and reassurance as needed" The Comprehensive care plan for behavior dated 3/27/2012 documents use of [MEDICAL CONDITION] medications related to psychosocial well-being, mood, and disruptive behavior. It includes interventions as "monitor changes in behavior and mental status, encourage participation in recreational activities of choice, re-approach when resident is agitated. " Review of the MAR and the Nursing progress notes do not document evidence of behaviors precipitating administration of PRN [MEDICATION NAME] on 7/13/2012 at 8:25 PM or non-pharmacological interventions attempted prior to administration. There is no evidence of non-pharmacological interventions attempted prior to administration of [MEDICATION NAME] on 7/14/12 at 4:30 AM; 7/15/2012 at 5:30 AM. Further there is no evidence of a physician' s order to administer PRN [MEDICATION NAME] 7/15/12 at 8:46 AM (3 hours after administration of previous dose) . There is no documentation of behaviors precipitating administration, non-pharmacological interventions attempted prior to administration and effects of medication in the medical record. There is no evidence of non-pharmacological interventions attempted prior to administration of [MEDICATION NAME] on 7/21/2012 at 1:06 AM. On 7/25/2012 at 1:30 PM the Licensed Practical Nurse (LPN #1 ) who is the regular medication nurse on the dayshift was interviewed. She stated that per the facility's protocol staff is required to document behaviors of the resident prior to administration of PRN medication and any non-pharmacological interventions attempted prior to administration of PRN medication. The LPN further stated that if the resident continues to display problem behavior the nurse would administer PRN medication, then observe and document how effective the medication was. On 7/25/2012 at 4:10 PM the LPN #2 medication nurse was interviewed. She stated that on the morning of 7/15/12 she observed the resident exhibiting aggressive behavior such as, cursing and screaming. LPN # 2 stated, "I intended to give him [MEDICATION NAME] and then I realized he already got it, so I gave it at 2:45 PM." LPN #2 further stated she always signs the MAR after she administers the medication and was unable to explain, why the MAR documents 8:45 AM as the time of administration of [MEDICATION NAME]. "I must have clicked something." The LPN #2 further stated she endorsed to the next shift verbally and via 24-hour report that [MEDICATION NAME] was administered at approximately 2:45 PM "Also, I should have written a progress note." LPN #2 also stated that she verbally communicated to the Registered Nurse Manager (RNM) on duty that day that she gave medication at 2:45 PM, but could not recall his/her name. Review of the 24 report for 7/15/12 does not reveal any documentation regarding [MEDICATION NAME] administration after 5:32 AM. LPN #3 was interviewed on 7/26/2012 at 3:45 PM and stated she was the assigned medication nurse on duty during the evening shift on 7/15/12. She could not recall any verbal or written communication from previous shift regarding administration of [MEDICATION NAME]. The Registered Nurse Manager (RNM) was interviewed on 7/25/12 at 1:30 PM and stated she was not aware of any irregularities related to medication administration until reviewing documentation with the surveyor. The Director of Nursing was interviewed on 7/27/12 at 12:31 PM and stated that the medication nurse should have called the Medical Doctor (MD) in the morning of 7/15/12 to obtain appropriate order if all non-pharmacological interventions were ineffective in managing resident's behavior. If [MEDICATION NAME] was given in error at 8:45 AM, this should have been immediately communicated to the RNM or Supervisor on duty and to the MD, so that the resident could be assessed, monitored, and appropriate medication error report completed. If medication was given at 2:45 PM as per LPN statement, this should have been documented on the MAR, in the medical record, and communicated to the oncoming shift. The DON stated that the electronic MARs are being spot checked by the night shift supervisors. 2) Resident # 24 is [AGE] year old with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score as 14 (cognitively intact) and frequent presence of pain at level 5/10 in the 5 days period prior to the MDS completion date. On 7/27/2012 at 10:20 AM the resident was interviewed in his room. The resident stated he is having pain daily in his back and abdomen. The resident stated his pain is sometimes mild (2-3) and sometimes stronger (about 8). Usually he experiences the strongest pain at evenings before he goes to sleep. The resident stated that the nurses give him pain medication per request and that most of them ask him to describe and to quantify his pain level prior and after he receives his medication. The Comprehensive care plan (CCP) for pain management dated 12/27/2012 documents " alteration in comfort secondary to Dx: CA (cancer), Arthritis and includes goal " resident will maintain optimal level of comfort daily. " The following interventions are included in the CCP: " administer pain medication as ordered and assess for presence of pain or discomfort. " The CCP for [MEDICAL CONDITION] dated 12/27/2012 includes interventions as " monitor effectiveness of meds given and observe for any adverse reactions. " The CCP for polypharmacy includes interventions as " drug regimen to be monitored on a continuum and tapered or discontinued as appropriate. " The Monthly physician order [REDACTED]. " Medication Administration Record for month of June, 2012 documents that [MEDICATION NAME] was administered 69 times for pain on level 1-8 mostly to his back and hip, with exception of 12 times (on evening shift), 2 times (day shift) and 1 time (night shift), when level of pain prior to and post administration was documented as 0. Medication Administration record for month of July, 2012 documents that [MEDICATION NAME] was administered 58 times for pain on level 1-8 located mostly in back and bone, with exception of 13 times (on evening shift), and 3 times (day shift), when level of pain prior to and post administration was documented as 0. The evening medication nurse was not available for the interview. The Registered Nurse Manager (RNM) was interviewed on 7/25/2012 at 11:45 PM and stated that in order to monitor effectiveness of pain medication, alert and oriented residents are asked by the medication nurse to describe pain, its location and intensity. Resident ' s responses should be documented on the MAR with each administration. After administration, the electronic MAR will automatically remind the nurse to check effectiveness, the RNM stated. In addition, the RNM stated, if the resident demanded pain medication, but reported no pain, the medication nurse should have documented that and notified the RNM and the MD, so that appropriate care plan could be developed. 415.12 (1) (1)

Based on record review and interview the facility did not ensure that quarterly MDS (minimum data set ) assessements accurately reflected residents' status for behavior and falls This was evident for 2 of 30 sampled residents (#10 and # 11). This resulted in no harm with potential for more than minimal harm. The findings are: 1) Resident # 10 is an [AGE] year old with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score as 10 (moderately impaired cognition). The MDS also documented a mood score of 11 (moderate depression) evident by trouble concentrating daily, having little energy, poor appetite, trouble falling asleep, or staying asleep, or sleeping too much, little interest in doing things, and feeling down, depressed, or hopelessness. The medication section documented no: antipsychotic, antianxiety, antidepressant, and hypnotic medications. Review of the Monthly physician' s orders from 4/1-7/27/2012 documents " [MEDICATION NAME] 0.25 mg Tab (tablet) ...give 1 tablet (0.25mg) by oral route once per day at bedtime for [MEDICAL CONDITION] and [MEDICATION NAME] 20 mg Cap (capsule) ...give 1 capsule (20 mg) by oral route once daily for [MEDICAL CONDITION]. " The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. 2) Resident # 11 is an [AGE] year old with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score as 2 (severely impaired cognition). The MDS documents no behavioral symptoms and no falls since last assessment. Review of the Review of the Nursing progress notes reveal that the resident was observed with periods of verbal disruption on 6/22/12, 6/26, 6/27, "verbally disruptive towards the staff, yells and curses at staff and other residents " on 6/30, "screams and uses profanity " on 7/1, "periods of agitation, yelling @ (at) intervals " on 7/2, "yelling and screaming, periods of agitation" on 7/5, 7/6, and 7/7/2012. The Certified Nursing Assistant Documentation History Detail for behavior monitoring in July of 2012 documents that the resident displayed yelling and screaming behavior daily on 7/1-7/7/2012 (except on 7/2/2012). Review of the nursing progress note and Comprehensive care plan for falls dated 3/27/12 reveals that the resident sustained [REDACTED]. The Registered Nurse Manager was interviewed on 7/25/2012 at 1:30 PM and stated she completes the MDS assessments based on observation, review of the resident's record (progress notes, MD orders, MAR, hospitalization records, etc) and on basis of communication with other disciplines. The RNM stated that the she completed MDS assessments for both residents and that the inaccuracy was an oversight. The MDS Coordinator was interviewed on 7/25/12 at 4:20 PM and stated she reviews the MDS assessment to assure that all appropriate sections were completed by the appropriate disciplines. If she notices something grossly irregular in the assessment, she would notify the responsible staf. However, every discipline is responsible for accurately completing their assigned MDS section. 415.11 (b)

Based on record review and interview, the facility nursing staff did not ensure that professional standards were followed for reporting irregularities in medication administration - specifically a [MEDICAL CONDITION] medication being given outside of the prescribed timeframe. This was evident for 1 of 30 sampled residents (#11). This resulted in no harm with potential for greater than minimal harm. Findings are as follows: Resident # 11 is an [AGE] year old with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score as 2 (severely impaired cognition). The MDS also documented a mood score of 12 (moderate depression) evident by trouble concentrating daily, having little energy, poor appetite, trouble falling asleep, or staying asleep, or sleeping too much, little interest in doing things, and feeling down, depressed, or hopeless. The Comprehensive care plan for [MEDICAL CONDITION] drug use dated 4/8/2012 includes interventions as "administer medications as ordered, observe for changes in behavior and mental status, observe for signs and symptoms of adverse reactions to medications and report to MD (Medical Doctor), provide emotional support and reassurance as needed" The physician's order [REDACTED]. " The Medication Administration Record (MAR) dated 7/1/12- 7/25/12 documents administration of [MEDICATION NAME] on 7/15/12 at 5:30 AM and at 8:46 AM (approximately 3 hours apart). The Controlled substances medication record documents on 7/15/2012 one tablet of [MEDICATION NAME] administered at 5:30AM and at 2PM. Review of the MAR and the Nursing progress notes reveals lack of documentation regarding following: 7/15/2012- evidence of appropriate physician's order [REDACTED]. The medical record did not reveal documentation regarding discrepancy between the MAR and the Controlled substances record. The LPN #2 medication nurse was interviewed on 7/25/2012 at 4:10 PM and stated that on 7/15/12 in the morning she observed the resident aggressive, cursing and screaming when she came to work. "I intended to give him [MEDICATION NAME] and then I realized he already got it, so I gave it at 2:45PM." The LPN #2 further stated she always signs the MAR after she administers the medication and was unable to explain, why the MAR documented 8:45 AM as the time of administration of [MEDICATION NAME]. "I must have clicked something." The LPN #2 further stated she endorsed to the next shift verbally and via 24-hour report that [MEDICATION NAME] was administered at approximately 2:45 PM. "Also, I should have written a progress note. It must be there." The LPN #2 also stated she verbally communicated to the Registered Nurse Manager (RNM) that she gave medication at 2:45 PM, but could not recall his/her name. Review of the 24 report for 7/15/12 did not reveal any documentation regarding [MEDICATION NAME] administration after 5:32AM. The LPN #3 was interviewed on 7/26/2012 at 3:45 PM and stated she was medication nurse on 7/15/12 at afternoon and could not recall any verbal or written communication from the previous shift regarding administration of [MEDICATION NAME]. The Registered Nurse Manager (RNM) was interviewed on 7/25/12 at 1:30 PM and stated she was not aware of any irregularities related to medication administration until reviewing documentation with the surveyor. The Director of Nursing was interviewed on 7/27/12 at 12:31PM and stated that the medication nurse should have called the Medical Doctor (MD) in the morning of 7/15/12 to obtain appropriate order if all non-pharmacological interventions were ineffective in managing resident's behavior. If [MEDICATION NAME] was given in error at 8:45AM, this should have been immediately communicated to the RNM or Supervisor on duty and to the MD, so that the resident could be assessed, monitored, and appropriate medication error report completed. If medication was given at 2:45PM as per LPN statement, this should have been documented on the MAR, in the medical record, and communicated to the oncoming shift. 415.11 (c) (3) (i)

Based on record review and interview the facility did not ensure that the comprehensive MDS (minimum data set ) assessment accurately reflected residents' status for behavior, falls history, and [MEDICAL CONDITION] drug use. This was evident for 2 of 30 sampled residents (#11, #12). This resulted in no harm with potential for more than minimal harm. The findings are: 1) Resident # 11 is an [AGE] year old with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 annual assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score as 2 (severely impaired cognition). The MDS documented no behavioral symptoms and no falls since admission or prior assessment. Nursing Annual assessment dated [DATE] documents "Resident is alert with confusion, easily agitated with verbal abuse and disruption, " "Number of Falls in past Quarter: 4." Review of the Nursing progress notes reveal that the resident was observed "yelling and screaming ...with increased agitation, verbal abuse..periods of outbursts " on 3/20, "easily agitated, yelling for no apparent reason " on 3/21/12, "continuous yelling " help,help " , very agitated on 3/22 and 3/23/12, "continues to yell and scream for no apparent reason " on 3/27, 3/28, 3/29, 3/30, 4/1, 4/3, 4/4, 4/5, and 4/6/2012. The Certified Nursing Assistant Documentation History Detail for behavior monitoring in April of 2012 documents that the resident displayed yelling and screaming behavior on 4/1/12, 4/2/2012, and 4/4/2012. The nursing progress note dated 2/13/2012 documents that the resident was observed sitting on the floor next to left side of bed ...no visible injury." The Registered Nurse Manager was interviewed on 7/25/2012 at 1:30 PM and stated she completes the MDS assessments based on observation, review of the resident ' s record (progress notes, MD orders, MAR, hospitalization records, etc) and on basis of communication with other disciplines. The RNM stated that the MDS did not accurately reflect the resident ' s behavioral status and the number of falls. "It was an oversight." The MDS Coordinator was interviewed on 7/25/12 at 4:20 PM and stated she reviews the MDS assessment to assure that all appropriate sections were completed by appropriate disciplines. If she notices something grossly irregular in the assessment, she would notify the responsible staff, the MDS Coordinator stated, but otherwise, every discipline is responsible to accurately complete assigned MDS section. 2) Resident # 12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS 3.0 assessment dated [DATE] documented no [MEDICAL CONDITION] drug use. physician's orders [REDACTED]. The unit RN (registered nurse) was interviewed on 7/27//12 at 2:40 PM and stated she completed the MDS assessment. She further stated that data reviewed included the medication record and the [MEDICAL CONDITION] medications should have been accurately recorded on the MDS. 415.11 (a) (2)

Based on observation, interview and record review during an abbreviated survey, the facility did not ensure that the resident ' s environment remained free of accident hazards and did not provide supervision to prevent accidents. This was evident for 1 out of 4 sampled residents (Resident #1). Resident #1 who was at risk for falls and wandering was not monitored. Additionally, the facility did not ensure that a stairway exit door was alarmed. Subsequently, the resident exited the unit via an unalarmed exit door, fell down the stairway in his wheelchair and was observed by staff on the stairway landing with a large amount of bleeding from his head. Emergency Medical Services (EMS) responded and the resident was pronounced dead by EMS. This resulted in actual harm that is not Immediate Jeopardy. Complaint # NY 487 The findings include: Resident#1 is a [AGE] year old male who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 dated [DATE] noted that the resident had severely impaired cognition. A Comprehensive Care Plan for falls, initiated on [DATE] documented that the resident had a history of [REDACTED]. The interventions included keeping needed items within reach, providing bed and chair alarm, toileting every 2 hours or upon request, conducting hourly rounds and providing a wander guard. The Accident/Incident Form dated [DATE] documented that at approximately 10:03 PM the resident was found sitting on the floor next to his bed. The immediate follow-up intervention to prevent a recurrence that was put into place was 30 minute visual checks. The Accident/Incident Form dated [DATE] documented that at approximately 11:10 PM the resident was observed sitting on the floor. The immediate follow-up intervention to prevent a recurrence that was put into place was 1:1 by the Certified Nurses Aide (CNA) for 1 hour until the resident calms down. The Accident/Incident Form dated [DATE] documented that at approximately 12:45 AM, the resident was found was on the floor. The immediate follow-up intervention to prevent a recurrence was to take resident out of bed when awake to prevent getting falls from bed and to place the resident in a supervised area. The Accident/Incident Form dated [DATE] documented that at approximately 1:00 AM, the resident was found was on the floor. There were no new interventions were put into place. The nurse ' s notes dated [DATE] - [DATE] was reviewed. The nursing notes revealed that the resident exhibited behaviors including exit seeking, wandering and restlessness. On [DATE] the resident was noted to be very restless and confused. On [DATE], the resident was wandering during the night, attempting to open the exit door and trying to get in the elevator. On [DATE] on the 11:00PM -7:00AM shift, the resident was restless at night and unable to sleep. On [DATE] at 2:40 AM, the resident was noted as confused and restless during the night. He was also noted as ambulating in his wheelchair, calling out his wife ' s name and making several attempts to stand from wheelchair. On [DATE] the resident was confused and trying to go out the exit door. On [DATE], the resident was restless and attempted to get out of wheelchair. On [DATE] the nursing notes documented that the resident required continuous monitoring and was very confused. A review of the nurse ' s notes dated [DATE] revealed that on [DATE] at 5:45 AM, the Licensed Practical Nurse (LPN) responded to the resident ' s wheelchair alarm and found the resident lying on his right side at the bottom of the staircase landing with a large amount of blood around his head. He was assessed by the Registered Nursing Supervisor and found to have weak vital signs. At 5:50 AM there were no vital signs present, at which time Cardiopulmonary Resuscitation (CPR) was initiated until 911 responded. The resident was then pronounced dead by EMS at 6:05 AM. A review of the " Visual Check Record " dated [DATE] - [DATE] revealed numerous omissions throughout the month of November. There were a total of 6 omissions on the 7:00AM- 3:00PM shifts, 12 omissions on the 3:00PM- 11:00PM shifts and 12 omissions on the 11:00PM-7:00AM shifts. The staff was not able to locate the " Visual Check Record " for the Month of [DATE]. On [DATE] at 11:15AM an interview was conducted with LPN Charge Nurse who worked on [DATE] 3:00PM -11:00PM. She stated that the resident would wander on the unit and say he was looking for his wife, and staff would re-direct him back to his room or to the dining room. Upon inquiry, she stated that she was not aware that the resident was on 30 minute visual checks. On [DATE] at 9:30AM an interview was conducted with the LPN Charge Nurse who worked on [DATE] from 11:00PM-7:00AM. She stated that when she came on the unit that day, the 3:00PM-11:00PM nurse from the previous shift informed her that the resident was on 30 minute visual monitoring. She stated that on [DATE] at approximately 5:45AM, she heard an alarm. She stated that it was the resident ' s wheelchair alarm. She then observed the resident lying on his right side at the bottom of the staircase landing with a large amount of blood around his head. He was assessed by the Registered Nursing Supervisor and found to have weak vital signs and shortly thereafter, there were no vital signs at which time CPR was initiated until 911 responded. The resident was then pronounced dead by EMS. Upon further inquiry, she stated that the north side exit door alarm did not go off because it was not switched on. The 11:00PM-7:00AM Certified Nurse ' s Aide (CNA) who worked on [DATE] was interviewed on [DATE] at 10:00AM. He stated that on [DATE] the resident was awake at 5:00 AM, so he got him dressed and brought him to the dining room area at approximately 5:20 AM and left the resident in the dining room watching television. Upon inquiry, he stated that no one else was in the dining room area because it was very early. However, the dining room must be supervised when there are residents in the dining room. The Director of Nursing was interviewed on [DATE] at 2:00 PM. She stated that the dining room is always supervised by the staff on the 7:00AM-3:0PM and 3:00PM-11:00AM shifts. However, the residents are rarely in the dining room on the 11:00PM -7:00AM shift so no one would be in the dining room to supervise them. An observation of the third floor north side exit door on [DATE] at 11:00AM revealed that there is an emergency box on the upper right side of the door. The box indicates that the alarm should be in the " ON " Position, with the cylinder in the vertical position. The Director of Plant Operations was interviewed on [DATE] at 2:30 PM. He stated that all exit doors are checked daily by maintenance to ensure that the alarms are functioning properly. He was not able to provide any documentation indicating that the stairwell exit door alarms were checked and working properly. The Maintenance employee was interviewed on [DATE] at 2:00 PM. He stated that he checked the stairway exit door the day before the incident and the alarm was functioning and the cylinder was in the " ON " position for the alarm to be activated. A review of the Policy and Procedure titled " Security Protocols " implemented on ,[DATE] documents that all nursing exit stairwell doors are checked once daily for proper closure and alarms by the Building Service Department. 415.12(h)(2)