Every finding on record at Mcauley Residence

Based on observation, interview, and record review conducted during a Standard survey completed 1/8/25, the facility did not store all drugs and biologicals in locked compartments for one (Unit 2 East) of two medication storage rooms. Specifically, 16 medications for 7 residents were left unattended, unsecured on a shelf in the nurse's station. This involved Resident #s 17, 22, 68, 70, 72, 94, and 267. The findings are: The policy titled Ordering and Receiving Medications from the Dispensing Pharmacy dated 11/27/24 documented a licensed nurse receives medications delivered to the facility, immediately delivers the medications to the appropriate secure storage area (medication cart and/or narcotic cabinet) or to another licensed nursing staff member to place in their specific secure storage area on the appropriate unit. During an observation on 1/3/25 at 8:30 AM, the 2 East Nurses Station without a door or means to lock the area, located in the center of the unit near the common area where residents were sitting and no facility staff within visual view revealed the following medications on a shelf: - Resident #17 - 2 unopened bottles (473 milliliters in each) of Chlorhexidine 0.12% mouth rinse. - Resident #22 - 6 unopened bottles (473 milliliters each) of Lactulose (laxative) and 1 unopened bottle (473 milliliters) of Sorbitol 70% (laxative). - Resident #68 - 2 unopened boxes of Ipratropium Bromide 0.5 milligram and Albuterol Sulfate (medications used to open the airways) 3 milligram inhalation (30 vials in each). - Resident #70 - 1 unopened 30-ounce bottle of Citrucel Powder (laxative). - Resident #72 - 2 unopened bottles (355 milliliters in each) of Lanta liquid (antacid). - Resident #94 - 1 unopened box of Refresh tears (eye drops) (2 bottles, 15 milliliters in each). - Resident #267 - 1 opened bottle Betadine 10% (antiseptic used to clean minor cuts) solution (approximately 400 milliliters remaining). During an interview on 1/3/25 at 9:16 AM, Licensed Practical Nurse #2 observed the medications sitting on the shelf in the nurse's station and stated they should not be stored there because the nurse's station doesn't have a door and residents could freely enter the area, and there was not always an employee at the nurse's station to monitor the area. They stated they didn't know how long the medications had been on the shelf and they should be either in the medication cart, stored in a cabinet or given to the nursing supervisor if they were discontinued to be returned to the pharmacy. They stated they were not sure why or when they were put there and should be locked in a secure area. During an interview on 1/3/25 at 9:17 AM, Unit Manager Licensed Practical Nurse #4 stated they didn't know overflow medications could not be stored on the self in the nurse's station. They stated there were no doors at the nurse's station and there was not always staff at the nurse's station to prevent residents from wandering into the area to prevent them from having access to the medications. Unit Manager Licensed Practical Nurse #4 identified each medication and stated all the identified medications were recently delivered from the pharmacy, except Resident #267's betadine was discontinued and Resident #94's refresh tears were brought in by the resident and they should have been given to the Nursing Supervisor to be returned. They stated the facility's process for receiving medications from the pharmacy was the Nursing Supervisor received the medications from the pharmacy and they delivered the medication to the appropriate unit and gave the medication to the staff nurse. The staff nurse usually placed the medication into the appropriate medication cart unless there was no room in the drawer, then the medication was placed on the shelf in the nurse's station until there was room in the medication cart. They stated they didn't know how long the identified medications had been stored on the shelf. During an interview on 1/3/25 at 3:29 PM, Licensed Practical Nurse #3 stated they noticed several medication bottles on the shelf a few days ago but did not look at the medication bottle labels therefore were unable to describe the medications. They didn't know why they were on the shelf. They stated the nurse's station didn't have a door and the medications were not in a secure location and should have been placed in the medication cart. They sated they did not question why the medications were on the shelf and did not inform the Nursing Supervisor. They stated they left the medication bottles on the shelf and should not have. During an interview on 1/8/25 at 7:44 AM, Licensed Practical Nurse #5 stated they had been working at this facility for approximately a year and it had been the facility's process to store the overflow medications that could not fit into the medication cart on the shelf in the nurse's station. They stated there was not any doors at the nurse's station, the shelf was an unsecured location and there was not always an employee at the nurse's station to prevent a resident from access to the medications. They stated they didn't know they could not store medications on the shelf in the nurse's station. During an interview on 1/8/25 at 8:02 AM, Nursing Supervisor Registered Nurse #6 stated the process for receiving medications from the pharmacy, was the Nursing Supervisor received the medications from the pharmacy delivery driver and took the medications to the appropriate unit, gave the medications to the staff nurse, and expected the staff nurse to place the medications into a secure location such as a medication cart or locked cabinet. They stated medications left on a shelf in the nurse's station was not a secure location and should not have been stored on the shelf as wandering residents would have access. During an interview on 1/8/25 at 9:46 AM, the Director of Nursing stated medications should always be stored in a locked secure area and not on a shelf at the nurse's station because the nurse's station was not a locked area and there was not always an employee at the nurse's station to prevent a resident access. They stated there was a medication cabinet on the unit and the nurses should either place all medications into the medication cart or place the overflow medications into the locked medication cabinet. They stated they would have expected the nurses to ensure all medications were stored in a locked secure location. During an interview on 1/8/25 at 10:50 AM, Pharmacy Consultant stated they completed medication storage audits of medication carts and medication cabinets and had not looked at the shelves at the nurse's station because it was not a secure medication storage area, and medications should not be stored there. They stated medications stored on the shelves in the nurse's station potentially allowed a resident access to the medications and would consider this to be a safety issue for residents. 10 NYCRR 415.18(e)(1)

Based on observation, interview and record review conducted during the Standard survey completed on 1/8/25, the facility did not provide routine dental services to meet the needs of each resident for one (Resident #101) of one resident reviewed for dental services. Specifically, Resident #101 had complaints of tooth pain while chewing and was not evaluated by the dentist. The finding is: The policy titled Community Based Care: Dental Care effective date 11/18/21 documented that nursing staff will provide oral health care for each resident, assess resident's oral health upon admission, and obtain routine and 24-hour emergency dental care. Within 14 days of admission, the resident will have a comprehensive oral assessment completed by a dentist or dental hygienist unless refused by the resident. A dental service will perform an oral evaluation annually/as needed and make recommendations for an oral hygiene care plan as necessary for changes in oral/dental status. The physician/dentist will be informed of any changes noted in oral status (pain, swelling, redness, loose teeth, broken teeth, rash, etc.) and recorded in the plan of care and in the resident medical record. Resident #101 was admitted with diagnoses including dorsalgia (back pain), hemiplegia affecting the right dominant side (weakness on one side of the body), and hypertension (high blood pressure). The Minimum Data Set (a Resident Assessment Tool) dated 11/11/24 documented the resident was always understood, always understands, had moderate cognitive impairment, had mouth or facial pain, discomfort or difficulty with chewing, and did not receive routine or emergent dental care. The comprehensive care plan dated 11/6/24 documented Resident #101 had oral/dental health problems related to mouth or facial pain, discomfort, or difficulty with chewing. Interventions included to monitor, document, and report as needed an signs/symptoms of oral dental problems needing attention: pain (gums, toothache, palate), teeth missing loose, broken, eroded, decayed, and ulcers in mouth or lesions. On 11/18/24 the resident was alert and oriented to person, place and time and could participate in their plan of care. Interventions included to encourage the resident to make independent decisions and to participate in their plan of care as needed. Review of the nursing admission/readmission assessment dated [DATE] completed by Registered Nurse #4 documented Resident #101 had mouth or facial pain, discomfort, or difficulty with chewing. Review of the nursing Progress Notes dated 11/5/24-1/7/25 lacked documented evidence that Resident #101 was seen by the dentist or dental hygienist or that a medical provider was notified the resident had tooth pain. Review of Nurse Practitioner #1's progress note dated 11/8/24 and 11/11/24 documented Resident #101 had chronic back pain and received acetaminophen (Tylenol). There was no documentation that Nurse Practitioner #1 was notified of Resident #101's complaint of tooth pain. Review of the document titled Dental Services dated 12/5/24 documented Resident #101 consented for dental services at the facility. The Schedule of Residents to be Seen by the Dentist lists dated 11/18/24 and 12/16/24 did not include Resident #101. The Schedule of Residents to be Seen by the Dentist list dated 12/2/24 documented Resident #101 was to be seen by the dentist for the purpose of: New Admit. The Schedule of Residents to be Seen by the Dentist list dated 1/6/25 documented Resident #101 was to be seen by the dentist for the purpose of: New Admit (2nd attempt). The Dental Orders and Progress Notes dated 12/2/24 documented New Admission to sub-acute/short term rehab unit. Patient will be seen for acute issues/as needed/or when converted to long term care. Will follow up 30 days. There was a tooth chart at the top of the progress note form that was blank. Review of the Dental Orders and Progress Notes dated 1/6/25 documented new admission Covid-19 positive. There was a tooth chart at the top of the progress note form that was blank. During an observation and interview on 1/3/25 at 8:31 AM, Resident #101 stated they were supposed to be seen by the dentist at the facility, but they have not seen them. They began rubbing their left lower jaw and stated they had a problem with previous dental work that was done and there was a problem with the caps on their teeth. They stated they were having trouble describing the feeling, but then stated it was like a pain but not a pain; it was a sensitivity, and they felt like a dentist needed to look at it. During an interview on 1/7/25 at 12:02 PM, Licensed Practical Nurse #1 stated not all residents on the subacute unit were seen by the dentist. The residents were asked on admission if they would like to see the dentist; they would sign the consent form or sign that they declined to see the dentist. They stated if a resident had told them that they had mouth or tooth pain, they would look in their mouth and then report the resident's complaints to Registered Nurse #2. During an interview on 1/7/25 at 12:12 PM, Registered Nurse #2 stated when a resident was admitted to the facility, they were asked if they wanted to see the dentist and if they did then they would go on the dental list. They stated they had completed the Dental Services form for consent/declination with Resident #101 on 12/5/24 because they could not find the original consent form that was signed on 11/5/24. The Dental Services consent/declination form was not in the chart, and neither were the Dental Progress Notes. They stated after the consent form was signed, the Health Information Management Clerk #1 was notified and placed the resident on the list to be seen by the dentist. During an interview on 1/7/25 at 12:16 PM, Registered Nurse #3 stated they recalled when Resident #101 was admitted they were complaining about the crowns on their teeth hurting and they wanted to see the dentist. They stated they were unsure how often the dentist came into the facility, but they should have seen Resident #101 the month after they were admitted . During a telephone interview on 1/8/25 at 8:19 AM, the Quality Assurance Regional Manager, from the facility's dental contractor, stated the dentist who went to the facility was unavailable, but they would be able to answer questions regarding the process for residents to be seen by the dentist and some resident specific questions. They stated the dental team went to the facility twice a month to see residents, but if there was a more urgent dental problem, they were able to send a dentist sooner if needed. The Health Information Management Clerk #1 was responsible to give a list of any acute dental issues, the new admissions, and discharged residents. The Quality Assurance Regional Manager stated the facility had informed the contracted dental provider not to see any residents who were on the first floor unless there was an acute dental concern because they were subacute residents. Because of that, when there was a new admission on the subacute unit it would be documented on the Dental Orders and Progress Notes: New Admission to sub-acute/short term rehab unit. Patient will be seen for acute issues/as needed/or when converted to long term care. They stated the dental team wrote this as a reminder for themselves to follow up and see the resident within the next 30-60 days. It did not indicate that the resident was seen by the dentist. They expected the facility to let them know when a resident became long term care or had an acute complaint. Acute complaints included any pain or lost dentures; pain was something that would trump everything and the dentist would make sure to see the resident if they had any complaints of tooth or mouth pain. During a telephone interview on 1/8/25 at 8:53 AM, the Quality Assurance Regional Manager, from the facility's dental contractor, stated the dentist was not aware that Resident #101 had any pain or discomfort and if they were aware, it would have been documented on the Dental Orders and Progress Notes and it would have been documented on the Schedule of Residents to be Seen by the Dentist List at the facility. They stated the dentist was at the facility on 1/6/25 and saw there was a sign on Resident #101's door indicating they had a diagnosis of Covid-19, but the nursing staff at the facility did not tell the dentist that Resident #101 had complained of tooth or mouth pain. They stated if the dentist had known about the pain, they would have examined Resident #101 sooner. During an interview on 1/8/25 at 9:08 AM, Health Information Management Clerk #1 stated they provided the dentist with a list of any residents who were new admissions, discharges, and any residents who needed extra attention. They stated that when a resident had a specific complaint, the nursing staff would send a referral form that lists out the room number, resident name, reason for visit and last exam. After they received the referral, they gave that form to the dentist and they kept it. The referral form was how the dentist was aware of any resident who needed to be seen for any complaints. They didn't keep track of the referral forms or keep a copy of them. During an interview on 1/8/25 at 9:24 AM, Registered Nurse #3 stated when they were completing the Dental Services consent/declination with Resident #101 on their admission day, they told them that their tooth felt tender when they bit down and that it had something to do with their crowns on their teeth. They stated that they put in a referral for speech language pathology and because they signed the consent to be seen by the dentist, the dentist should have seen them. They stated they did not fill out a referral for the dentist only the Dental Services consent/declination form. During an interview on 1/8/25 at 9:33 AM, Registered Nurse #4 stated they completed Resident #101's Admission Assessment and Resident #101 was complaining of pain when they would chew and pain in their teeth. They stated because they were newer to the facility, they reported that information to a more senior nurse and that it might have been Registered Nurse #3. During an interview on 1/8/25 at 9:40 AM, Nurse Practitioner #1 stated they did not recall being informed by either the nursing staff or Resident #101 of any tooth pain or pain while chewing. They expected the staff to notify them or the dentist because as a medical provider they would have completed an assessment and may have been able to treat the problem. It was expected that the dentist should have been notified because they were a specialist in that area, and it could have been a problem that they would have been able to treat. During an interview on 1/8/25 at 10:29 AM, the Director of Nursing stated they expected the residents on the subacute units to be seen by the dentist based on the dentist's availability and if the resident consented to be seen. They stated they were unaware that subacute residents were not seen routinely by the dentist. They stated if Resident #101 was complaining of tooth pain on admission, it was expected that the Nurse Practitioner be notified in the event they were able to treat the problem and if the dentist was needed, it was expected Resident #101 be placed on the dental list with the reason they needed to be seen. Communication to the Nurse Practitioner and dentist were expected because it was for the comfort and care of Resident #101. During an interview on 1/8/25 at 10:52 AM, the Administrator stated they expected the dentist to see the residents on the subacute unit routinely and for the nursing staff to reach out to the Health Information Management Clerks to communicate any dental complaints by residents to the dentist. They stated Resident #101 should have been seen by the dentist because it was their request, and the facility should have followed through. 10 NYCRR 415.17(c)

Based on observation, interview, and record conducted during an Abbreviated survey (Complaint #NY00323564) completed on 9/14/23, the facility failed to protect the residents' right to be free from physical abuse/corporal punishment for one (Resident #1) of three residents reviewed for abuse. Specifically, Licensed Practical Nurse (LPN) #1 placed their hand over Resident #1's mouth as a means to control the resident from yelling out. Additionally, Certified Nurse Aide (CNA) #1 did not report abuse immediately to facility Administration; and LPN #1 was not removed from resident access immediately and continued to care for residents in the facility. The finding is: The State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities revised 2/3/23 included the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Corporal punishment, which is physical punishment, is used as a means to correct or control behavior. 1. Resident #1 had diagnoses including dementia, anxiety, and depression. The Minimum Data Set (MDS - a resident assessment tool) dated 8/29/23 documented the resident had severe cognitive impairment. Additionally, Resident #1 exhibited behavioral symptoms (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) 1 to 3 days in the 7-day look back period. The comprehensive care plan (CCP) documented Resident #1 had a history of behaviors. The interventions included to approach/speak in a calm manner, divert attention, and if reasonable, discuss the behavior and explain/reinforce why the behavior is inappropriate/unacceptable. During an observation/interview on 9/14/23 at 9:06 AM, Resident #1 was well-kempt, pleasant, and had no obvious signs or symptoms of abuse. Resident #1 stated they have never been abused by anyone in the facility. The facility Resident/Patient Occurrence Report signed and dated 9/8/23 by the Director of Nursing (DON), documented on 9/8/23 at 2:30 PM the DON was notified by LPN #2 Unit Manager (UM) of an alleged abuse by LPN #1. LPN #2 UM reported that CNA #2 reported to them that CNA #1 witnessed LPN #1 cover the mouth of Resident #1 during morning care, when Resident #1 was yelling out. During an interview on 9/14/23 at 9:41 AM, CNA #1 stated on 9/8/23, between 7:00 AM and 8:00 AM, Resident #1 had refused morning care twice. CNA #1 stated they requested assistance from LPN #1. LPN #1 entered the room of Resident #1, the resident was sitting on the side of their bed, yelling out. LPN #1 placed their arm around the back of Resident #1's neck and placed their hand over Resident #1's mouth. CNA #1 left Resident #1's room, for one to two minutes, to retrieve a mechanical lift. When CNA #1 returned to Resident #1's room, LPN #1 still had their hand over Resident #1's mouth. CNA #1 stated they were aware they should have reported the incident immediately to the UM, but didn't want to be the cause of someone losing their job. During a telephone interview on 9/14/23 at 9:53 AM, CNA #2 stated on 9/8/23 CNA #1 reported to them Resident #1 was screaming and shouting during morning care, and that LPN #1 had placed their hand over Resident #1's mouth. CNA #2 stated they reported the incident to LPN #2 UM. During an interview on 9/14/23 at 10:23 AM, LPN #2 UM stated on 9/8/23 at approximately 1:55 PM, CNA #2 reported to them that CNA #1 witnessed LPN #1 cover the mouth of Resident #1 with their hand during morning care. LPN #2 UM stated CNA #1 should have reported the incident immediately for an investigation to be initiated and remove LPN #1 from caring for residents until the investigation was completed. During a telephone interview on 9/14/23 at 10:26 AM, LPN #1 stated CNA #1 requested assistance with Resident #1 on 9/8/23 with morning care. LPN #1 stated Resident #1 started screaming and LPN #1 placed their hand over the mouth of Resident #1 and told Resident #1 to be quiet. LPN #1 stated they would consider placing their hand over Resident #1's mouth abuse and would not consider placing their hand over the mouth of an agitated resident an effective method to calm the resident. During a telephone interview on 9/14/23 at 11:16 AM, the Behavioral Health Nurse Practitioner (NP) #1 stated Resident #1 had no recall of the incident. Additionally, NP #1 stated placing one's hand over the resident's mouth to control the resident's behavior of yelling would increase the resident's agitation. During an interview on 9/14/23 at 12:36 PM, the DON stated the facility determined LPN #1 abused Resident #1 by placing their hand over the resident's mouth. Additionally, the DON stated CNA #1 should have reported the abuse immediately to LPN #2 UM or Administration. During an interview on 9/14/23 at 2:10 PM, the Administrator stated they considered LPN #1's action abuse and CNA #1 should have notified a superior immediately. NYCRR 415.4(b)(1)(i)

Based on observation, record review, and interview conducted during a complaint investigation (Complaint #NY00316409) during the Standard survey completed on 5/15/23, the facility did not ensure residents had the right to be free from verbal and physical abuse for one (Resident # 74) of three residents reviewed for abuse. Specifically, on 5/11/23 CNA (Certified Nurse Aide) #1 was witnessed by other staff pointing their finger and yelling stop trying to hit me, grabbing Resident #74's right arm. In addition, CNA #1 pushed the wheelchair and proceeded to let go. The finding is: The facility policy and procedure titled Identification, Prevention, Investigation and Reporting of Victims Of Potential Abuse, Neglect or Exploitation revision date 11/2022, documented the facility prohibits any form of patient/resident abuse, neglect or exploitation while the patient/resident is under the supervision/care of the facility: assured that all patients/residents are treated with dignity and respect: report any suspected or actual victim of abuse, neglect, exploitation, injury of unknown origin, and/or misappropriation of patient/resident property when identified. Abuse was defined as inappropriate physical contact with a resident. Physical contact includes but is not limited to striking, pinching, kicking, shoving, bumping, and sexual molestation. Verbal abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents within their hearing distance, regardless of their age, ability to comprehend, or disability. Resident #74 had diagnoses that included unspecified dementia without behavioral disturbance, depression, and anxiety. The Minimum Data Set (MDS- a resident assessment tool) dated 4/1/23 documented Resident #74 was severely cognitively impaired, was sometimes understood, and sometimes understands. During an observation on 5/11/23 at 1:08 PM CNA #1 transported Resident #74 towards Unit 2 East nurse's station. Resident #74 reached their arm's out and attempted to touch other residents in the area. CNA #1 told Resident #74 to keep their hands to themselves. During a video surveillance observation from Unit 2 East on 5/11/23 at 3:25 PM, in the presence of the Director of Nursing (DON), the following was revealed. At 1:11 PM CNA #1 wheeled Resident #74 on to the unit after Resident #74 was wandering off the unit. CNA #1 transported Resident #74 to the nurse's station. CNA #1 was shaking their finger directly at Resident #74 and was seen saying stop hitting me, by the movements of CNA's lips. Resident #74 raised their right arm towards CNA #1. CNA #1 grabbed Resident #74's right arm when Resident #74 attempted to slap CNA #1. CNA #1 then grabbed Resident #74's wheelchair handles and shoved the wheelchair and let go of the handles, pushing Resident #74 5ft and out of the view of the video. At 3:35 PM after reviewing the video the DON stated grabbing of the arm was physical abuse and the pointing of the finger in Resident #74's face was verbal abuse as it was seen on the surveillance. CNA #1's demeaner was inappropriate and obviously yelled at Resident #74. Resident #74 had shown no signs of psychological, physical or emotional harm. The abuse was reported to the DON immediately by Licensed Practical Nurse (LPN) #3 Unit Manager (UM). CNA #1 was immediately removed from the unit, wrote a statement, interviewed, and sent home. The NYS (New York State) DOH (Department of Health) was notified and an investigation was initiated and still on-going. The DON stated CNA #1 did not have previous abuse allegations. Review of the NYS DOH Facility Incident Report documented the Director of Nursing (DON) submitted the Allegation type: Physical Abuse information on 5/11/23 at 3:30PM. Review of the Resident/Patient Occurrence Report dated 5/11/23 and completed by the DON revealed at 1:11 PM in the Unit 2 East common area staff to resident abuse occurred. LPN #1, LPN #2, and CNA # 5 had witnessed the abuse. At approximately 1:11 PM Resident #74 was attempting to hit or slap CNA #1. CNA #1 was witnessed by other staff pointing their finger at Resident #74 saying stop trying to hit me, I'm pregnant. CNA #1 grabbed Resident #74's right arm while Resident #74 was trying to hit CNA #1 and CNA #1 pushed Resident #74's arm away, then walked behind the wheelchair and pushed the wheelchair with Resident #74 away. No injuries were reported. Witness statements and employee accused of allegation were provided and signed by LPN #1, LPN #2, and CNA #1 on 5/11/23 and were as followed: -LPN #1 documented CNA #1 was yelling to stop hitting them. CNA #1 yelled I'm pregnant and was not going to get hit. LPN #1 documented they saw CNA #1 push the resident away in the wheelchair. -LPN #2 documented CNA #1 was arguing with Resident #74. Resident #74 was combative. CNA #1 called out I'm pregnant, I'm not going to get hit and lose my baby. CNA #1 then walked into the nurse's station. -CNA #1 documented they attempted to calm Resident #74. Instead of walking away, I pointed my finger telling Resident #74 to stop hitting me, and I pushed Resident #74's hand away from trying to hit me. During an observation and interview on 05/12/23 at 9:25 AM Resident #74's right arm revealed no injuries to the hand or forearm. During the time of the observation the resident stated they were feeling well, and their breakfast was wonderful, the resident was pleasant and cooperative. The resident also stated they had no pain or soreness to their right arm. When specifically asked if anything happened yesterday between the resident and staff or if anyone has ever hurt them the resident stated no and that they were fine. During a telephone interview on 5/12/23 at 10:25 AM CNA #1 stated on 5/11/23 Resident #74 attempted to hit CNA #1 and other residents in the area. CNA #1 pointed their finger at Resident #74 and stated Stop trying to hit me. I am pregnant. I was trying to get the resident away from me and grabbed the resident's right forearm to prevent them from hitting me and then gently pushed the wheelchair away. CNA #1 stated their actions were not rough and thought they were doing the right thing. CNA #1 was unaware that finger pointing was derogatory. I should have called for help or walked away. During an interview on 5/12/23 at 12:30 PM LPN #3 UM stated LPN #1 reported that CNA #1 was verbally and physically inappropriate with Resident #74 on 5/11/23 at 1:11PM. LPN #1 should have intervened when witnessing something like this. LPN #3 stated CNA #1 should have reapproached Resident #74 later. During a follow up interview at 3:47PM, LPN #3 UM stated CNA #1 had an inappropriate tone that was threatening toward Resident #74, therefore was verbal abuse. Grabbing Resident #74's arm and forcefully pushing the wheelchair was physical abuse. On 5/12/23 at 12:59 PM Resident #74 was engaged in conversation with another resident. Resident #74 did not show any physical, psychological, or emotional affects. During an interview on 5/12/23 at 1:00 PM, LPN #1 stated they overheard CNA #1 raising their voice at Resident #74 stating I'm pregnant. LPN #1 came out of the Unit 2 East charting area and saw CNA #1 hold up their arm to prevent Resident #74 from hitting them. LPN #1 observed CNA #1 pushing Resident #74 away from CNA #1 forcefully in their wheelchair. LPN #1 felt the push was inappropriate mistreatment, It was a hard push. LPN #1 reported the incident to LPN #3 UM. CNA #1 should have walked away. During a telephone interview on 5/12/23 at 2:52 PM LPN #2 stated CNA #1 yelled I'm pregnant and I'm not going to let anyone hit me, with a loud, nasty tone. LPN #2 stated CNA #1 grabbed Resident #74's right arm quickly to avoid being struck by Resident #74. LPN #2 reported the physical and verbal abuse to LPN #3 UM. CNA #1 should have left Resident #74 alone. During interview on 5/15/23 at 10:17AM, the Assistant Director of Nursing (ADON)/ Nurse Educator stated abuse education was provided annually and as needed. Physical contact including grabbing of the arm, scratching, pinching, kicking was physical abuse. CNA #1 was aggressive and displayed derogatory gestures such as pointing their finger. CNA #1's yelling, facial expressions, body language, and demeaner were inappropriate and considered verbal abuse. CNA #1 should have provided physical distance and let the situation deescalate. During a telephone interview on 5/15/23 at 11:06 AM, the Medical Provider was aware of the physical and verbal abuse on 5/11/23. Resident #74 showed no signs of physical, psychological, or emotional harm. During an interview on 5/15/23 at 12:27 PM, the Administrator stated there was a verbal altercation which led to a physical situation. CNA #1's actions were inappropriate. CNA #1 should not have engaged with Resident #74 and walked away. 10 NYCRR 415.4(b)(1)(i)

Based on observation, interview, and record review conducted during a complaint investigation (NY00299176) during the Standard survey completed on 5/15/2023, the facility did not ensure that each resident receives adequate supervision for one (Resident #45) of two residents reviewed for accidents. Specifically, the facility did not ensure Resident #45 was adequately supervised to prevent an elopement from the facility on 7/16/22. The finding is: The policy and procedure (P&P) titled Community Based Care: Elopement/Unsafe Wandering/Missing Patient/Resident dated 3/9/21 documented the purpose is to ensure the safety and security of all patients and residents. To establish uniform guidelines for identifying patients/ residents who are at risk for elopement and/or unsafe wandering. The facility will attempt to ensure patient/ resident safety by limiting opportunities for patients/ residents to leave prior to discharge. Nursing has the responsibility to monitor patient/resident presence on the units. Resident #45 was admitted with diagnoses including dementia, type 2 diabetes mellitus, and Parkinson's disease (a disease that causes tremors and rigidity of movement). The Minimum Data Set (MDS- a resident assessment tool) dated 4/20/23 documented the resident was usually understood, usually understands and was severely cognitively impaired. Additionally, the MDS documented Resident #45 used a wander/elopement alarm daily. The comprehensive care plan (CCP) initiated on 5/20/21 documented Resident #45 had high elopement and wandering risk, was disoriented to place, had a history of attempts to leave the facility unattended and impaired safety awareness with exit seeking behavior. On 9/10/21 a wander guard (device to detect wandering) was placed to the left wrist of Resident #45. During observations on 5/9/23 at 9:59 AM and 5/10/23 at 3:27 PM, Resident #45 was sitting in the lounge area in front of the nurses' station. A wander guard bracelet was observed on the left wrist of Resident #45. During an observation on 5/9/23 at 9:59 AM revealed multiple posted signs dated 7/16/22, in the elevator and on the unit doors. The signs documented for the safety of resident please ensure when exiting a unit or the facility, that no other residents exit the unit at the same time. During an observation on 5/15/23 at 2:44 PM, the Director of Maintenance used a wander guard bracelet to activate a wander sensor alarm near the elevator and the front door. The wander guard system at both areas was functioning correctly. At that time the Director of Maintenance stated only staff should know the code to turn off the alarm because it was a safety concern. Review of the Elopement/Unsafe Wandering Risk Evaluation dated 5/28/22 revealed Resident #45 scored 16, indicating they were a high risk to wander. Review of the nursing progress notes from 7/2/22 through 7/16/22 revealed Resident #45 had a wander guard to the wrist and demonstrated exit seeking behaviors. Review of the HERDS (Health Electronic Response Data System): NH (Nursing Home) Incident Form dated 7/16/22 revealed Resident #45 was last seen at 3:30 PM and was noted missing at 3:38 PM. The visitor of another elopement risk resident turned the alarm off to the front entrance door. Resident #45 also exited the building, behind the visitor. Family members reported that Resident #45 had fallen out of a wheelchair and was on the ground in the back of the building. Resident #45 was brought back into the building with no injuries at 4:15 PM. The visitor who turned the alarm off also indicated they turned off the alarm upstairs by the elevators. All alarms were functioning properly. The Resident/Patient Occurrence Report dated 7/16/22 documented Resident #45 had a wander guard in place on the left wrist During an interview on 5/12/23 at 3:49 PM Licensed Practical Nurse (LPN) #5 stated they did not remember the alarm sounding on 7/16/22 when Resident #45 left the unit or facility. LPN #5 stated after Resident #45 was being brought back inside the building, the wander guard alarm sounded near the trigger points of the alarm system. LPN #5 stated, after the resident was returned to the unit, it was discovered that the wander alarm system did not initially sound because a family member from a different unit turned off the wander alarm. During an interview on 5/15/23 at 8:31 AM, Registered Nurse (RN) #2 stated, they were supervising the day Resident #45 was able to exit the building. RN #2 stated they were notified by a family member that someone was outside in a courtyard area and Resident #45 was on the ground. Resident #45 did not have any injury from the fall. At first it was unknown how Resident #45 got outside but it was determined that a visitor had taken another resident outside, and that resident also had a wander guard like Resident #45. The visitor was the one who disabled the alarm and Resident #45 followed them outside. During an interview on 5/15/23 at 10:03 AM, the Director of Nursing (DON) stated Resident #45 should not have been able to exit the facility doors on 7/16/22. DON stated they were unsure how the visitor was aware of the code, but they could have watched staff put the code into the keypad at some point. DON stated it was a safety concern and, potentially, the outcome could have been worse. DON stated it was expected that only staff disengage the alarm and staff should not give out the code to families. During an interview on 5/15/23 at 11:28 AM, the Administrator, stated on 7/16/22 it should have been staff who had entered the wander guard alarm code to turn off the alarm. It is not expected for the staff to give the code to visitors. The administrator stated only the staff were aware of the residents at risk for elopement and ultimately it was the staffs' responsibility to know whereabouts of the residents. The expectation was that the safeguard that was in place would work appropriately. The following corrective actions were implemented by the facility to correct the non-compliance as of 5/9/23 at 8:30 AM. The facility reported the incident accordingly, and an investigation was started by the facility. The code to the wander alarm system was changed by the facility staff. Based on incident documentation, the facility hung signs in the elevators and on the second-floor unit doors to remind all visitors to be aware of their surroundings and to ensure they are not being followed by residents who are high risk for elopement, immediately after the incident. The facility educated resident family members via robocall regarding the process for residents who were high risk for elopement and wander guard system post incident. During the Standard survey completed 5/15/23, the survey team verified through interviews and observations, both staff and families were knowledgeable of the process for residents who were high risk for elopement. 10 NYCRR 415.12(h)(2)

Based on interview and record review conducted during the Standard survey completed on 5/15/23, the facility did not ensure that the pharmacist reported irregularities to the attending physician, the facility's Medical Director and the Director of Nursing (DON), and these reports must be acted upon for three (Resident #31, #68 and #50) of five residents reviewed for drug regimen reviews. Specifically, Resident #31 had a consultant pharmacist recommendation dated 3/27/23 for a fasting lipid profile (FLP-a laboratory test to indicate the cholesterol level in the body) which the medical provider agreed and signed on 3/30/23, but the order was not implemented. Resident #68 had a consultant pharmacist recommendation dated 3/27/23 for Vitamin B12 lab level which the medical provider agreed and signed on 3/30/23, but the order was not implemented. In addition, Resident #68 had a consultant pharmacist recommendation dated 3/31/23 for changing Namenda (a medication used for memory) from 5 mg (milligrams), two tablets in the morning (AM) to one tablet two times a day (BID) which was left blank and unsigned by the medical provider with no follow-up. Resident #50 had a consultant pharmacist recommendation dated 3/30/23 to discontinue two medications Fleets enema and Milk of Magnesium (MOM)(both used to treat constipation), which the medical provider agreed and signed on 4/13/23, but was not implemented. The policy and procedure (P&P) title Community Based Care: Medication Regimen Review Recommendations and Reports dated 12/31/21 documented the purpose of the recommendation was to minimize or prevent adverse consequences or to prevent residents from receiving inappropriate medications. All recommendations made for a resident during review will be printed or emailed by the consultant pharmacist to the Director of Nursing (DON) and Nurse Manager. The Nurse Manager will provide the printed recommendation to the medical provider. The medical provider will document that the identified irregularity has been reviewed and what, if any action has been taken to address it. Medical Provider response must be completed within 30 days. Recommendations without a response after 30 days will be referred to the Medical Director. The P/P titled Receiving, Transcribing, and Implementing Physicians Orders dated 4/14/23 documented orders will be obtained from a medical provider including a licensed physician, physician assistant or nurse practitioner. Orders will be noted and confirmed by a licensed professional nurse. Licensed professional nurse will receive and implement medical provider orders. 1.) Resident #31 was admitted to the facility with diagnoses including diabetes mellitus (DM- high blood sugar), dementia, and hyperlipidemia- (elevated fat levels in the blood). The Minimum Data Set (MDS-a resident assessment tool) dated 2/9/23 documented the resident had severe cognitive impairment, sometimes understands and sometimes understood. Review of the Consultant Pharmacist Provider Recommendations dated 3/27/23 revealed recommendations for a lipid panel. The provider signed the recommendation on 3/30/23 and requested a FLP on the next lab day. Review of the Lab results from 3/30/23 through 5/11/23 revealed there was no FLP drawn. Review of the Order Summary Report dated 5/15/23 revealed a Physician's Order dated 3/30/23 to obtain a fasting lipid panel via lab draw on 3/31/23. There was no start or end date. Review of the Unit 2 East Specimen Log Sheets from 3/30/23 through 5/11/23 revealed there were no labs drawn for Resident #31 from 3/31/23 through 5/11/23. The Consultant Pharmacist Progress Notes documented Resident #31's medications and medical chart were reviewed by the Consultant Pharmacist on 4/25/23. There were no recommendations to the provider. During an interview on 5/11/23 at 1:26 PM, the Consultant Pharmacist stated Medication Regimen Reviews (MRR) were reviewed monthly. Irregularities and recommendations were documented and sent via email to the Unit Managers (UM), DON, Medical Director, and the Administrator. The Pharmacy Consultant stated recommendations were addressed, reviewed, and signed by the physician within 30 days. The Consultant Pharmacist assumed the provider didn't agree to the 3/30/23 recommendation as it was not done, therefore never followed up. During an interview on 5/12/23 at 4:42PM, Licensed Practical Nurse (LPN) #3 UM stated pharmacy recommendations were received through email. UMs printed the recommendations. The recommendations were reviewed the next day, discussed with the provider, and implemented. LPN #3 stated the provider signed the recommendation on 3/30/23 and the FLP should have been drawn on 3/31/23 and was not implemented. It's the responsibility of the UM to ensure recommendations were addressed. Once completed the signed recommendations were filed in the paper chart. During an interview on 5/15/23 at 11:19AM, the DON stated LPN #3 should have implemented the physician's order for the FLP. The Consultant Pharmacist should have identified the lab was missed during the 4/25/23 review. 2.) Resident #68 was admitted to the facility with diagnoses including dementia, anxiety, and DM. Review of the MDS dated [DATE] the resident is usually understood, usually understands and moderately cognitively impaired. Review of the Pharmacy Consultant report titled Consultant Pharmacist Provider Recommendations dated 3/27/23 revealed the resident is taking Metformin (medication that lowers blood sugar) and has not had a Vitamin B12 level in over 2 years. Metformin can cause Vitamin B 12 deficiency. The resident is scheduled for a lab draw on 4/7/23 consider adding a Vitamin B12 level. The form was signed by the provider on 3/30/23 and agreed with the recommendation. Review of the Order Audit Report dated 3/30/23 documented obtain B12 lab values on 4/7/23 one time only. Review of the residents Electronic Medical Record (EMR) and the residents medical record paper chart from 3/30/23 through 5/12/23 revealed there was no documented evidence the Vitamin B12 level was drawn. Review of the Pharmacy Consultant report titled Pharmacy Admission Medication Regimen Review (MRR) dated 3/31/23 and signed by the pharmacy consultant revealed recommendations to consider splitting Namenda from 5 mg, two tablets in the AM to one tablet BID. The form was not filled in or signed by the physician as of 5/12/23. There was no follow up documented by the Pharmacist Consultant. Review of the Pharmacy MRR for the months of April and May 2023 revealed there was no follow up from the Consultant Pharmacist regarding their Namenda recommendations. Review of the Order Summary Report dated as of 5/15/23 revealed Namenda 5mg take 2 tablets in the AM. During an interview on 5/12/23 at 2:56 PM LPN #3 UM stated LPN UM #3 stated they were not sure why the recommendation for the Namenda was not addressed with the physician. During an interview on 5/15/23 at 9:08 AM the DON stated there was a new UM on unit 2 East and they were taking care of the pharmacy recommendations at the time, printing the recommendations and giving them to the unit clerk. The DON was unaware the unit clerk was just filing them in the resident chart and the MD never saw them. During an interview on 5/15/23 at 12:25 PM the Consultant Pharmacist stated they follow up thru audits and does not go back and look at ever recommendation. If it's not done, I assume the MD did not agree. 3.) Resident #50 was admitted to the facility with diagnoses including diabetes mellitus, hypertension (high blood pressure), and chronic kidney disease (CKD) stage IV. The MDS dated [DATE] documented the resident understands, was understood and moderately cognitively impaired. Review of the Consultant Pharmacist Provider Recommendations dated 3/30/23 revealed to discontinue Fleets enema and MOM and to start Senokot S (a laxative medication used to treat constipation) due to Resident #50's decreased creatinine clearance level (a lab report that indicates renal function). On 4/13/23 Nurse Practitioner (NP) #1 accepted the recommendation to discontinue the enema and MOM. Review of the Medication Administration Record (MAR) dated 4/1/23-4/30/23 documented that Resident #50 was given MOM on 4/16/23 at 1:33 PM and a Fleet enema on 4/17/23 at 11:06 PM. Review of the Order Listing Report dated 5/15/23 documented the Physician's Order for MOM was discontinued on 5/12/23 and the order for Fleets enema was discontinued on 5/15/23. During an interview on 5/15/23 at 11:14 AM, Registered Nurse (RN) #2 UM stated Resident #50 had a recommendation made by the pharmacist on 3/30/23 and NP #1 agreed to discontinue the orders for MOM and Fleet enema on 4/13/23. RN #2 stated that the medications should have been discontinued on 4/13/23 when NP #1 signed the recommendation, and it was all of our responsibilities to make sure it was completed. During an interview on 5/15/23 at 11:32 AM, NP #1 stated that on 4/13/23 they signed and agreed with the 3/30/23 consultant pharmacists' recommendation to discontinue Resident #50's Fleet enema and MOM due to the resident's poor kidney function. The NP #1 stated their expectation would be the nursing staff discontinue the Fleet enema and MOM order on 4/13/23. During an interview on 5/15/23 at 12:21 PM, the Consultant Pharmacist stated that when they made a medication recommendation on 1 East unit, they would send a high priority email with attachments to RN #2 UM. The Consultant Pharmacist stated that if the recommendation was not followed upon, they would make the same recommendation the following month. The Consultant Pharmacist stated their expectation would be the nursing staff implement the recommendation when and if the medical provider agreed to the recommendation. During an interview on 5/15/23 at 1:48 PM, the DON stated it was the responsibility of the UM to review the pharmacy consultant recommendation with the medical provider and implement the response of the medical provider. The DON stated that Resident #50's recommendation from the pharmacist consultant on 3/30/23 signed by the medical provider on 4/13/23 should have been completed by RN #2 UM. 10 NYCRR 415.18(C)(2)

Based on observation, interview, and record review during the Standard survey started on 5/9/23 and completed on 5/15/23, the facility did not operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes. Specifically, the facility was not in compliance with Section 915 of the 2020 Fire Code of New York State, which requires carbon monoxide detection in buildings with fuel-burning appliances and on-going preventative maintenance of carbon monoxide detectors. This affected one of one Basement. The finding is: Observations during the building tour on 5/9/23 from 8:40 AM until 2:20 PM revealed fuel-burning appliances were located in the Main Kitchen, Laundry Room, Boiler Room, and Generator Room, and all four locations were in the Basement. Further observation revealed single-station carbon monoxide detectors were located in the Basement in the Main Kitchen, in the Laundry Room, in the Boiler Room, and in the corridor outside of the Generator Room and the Boiler Room. Review of the carbon monoxide detector manufacturer's User Guide revealed to keep the alarm in good working order, test the alarm once a week by pressing the Test/ Reset button and vacuum the alarm cover once a month to remove accumulated dust. During an interview on 5/9/23 at 1:30 PM, the Director of Plant Operations stated all carbon monoxide detectors in the facility were located in the Basement, were single-station type, and were not tied into the fire alarm system. The Director of Plant Operations also stated there was no regular preventative maintenance done on the carbon monoxide detectors other than battery replacement. Additionally, on 5/12/23 at 1:55 PM, the Director of Plant Operations stated they did periodically check the carbon monoxide detectors during rounds, but did not document it. During an interview on 5/15/23 at 1:00 PM, the Administrator stated the facility did not have a policy and procedure about maintaining carbon monoxide detectors. 42 CFR 483.70(b) 10NYCRR: 415.29(a)(2), 711.2(a)(1) 2020 Fire Code of New York State, Section 915: 915.3.1, 915.6

Based on interview and record review conducted during the Recertification Survey completed on 12/15/21, the facility did not have the evidence that all alleged violations of misappropriation of resident property were thoroughly investigated for one (Resident #40) of four reviewed. Specifically, there was a lack of thorough investigations into an allegation of misappropriation of a missing ring. The findings are: The policy and procedure (P&P) titled Misappropriation of Patient/Resident Personal Property dated 1/2020 documented all appropriate measures are taken to ensure resident rights are protected pertaining to personal possessions. It is the policy that all losses and suspected misappropriations of resident property shall be promptly investigated, and appropriately recorded. The Supervisor notifies Dietary and Environmental Services immediately, in order that a search of these areas is initiated. The P&P titled Identification, Prevention, Investigation and Reporting of Victims of Potential Abuse, Neglect or Exploitation dated 6/30/21 documented all cases of suspected or actual abuse, neglect, exploitation, injury of unknown origin, and /or misappropriation of resident property will be reported to the immediate supervisor/manager and an investigation will begin immediately. Statements will be obtained from the resident, staff, family member, visitor and / or anyone involved. The Director of Nursing (DON) or designee will coordinate the investigation and is responsible for maintaining and ensuring completion of all investigative documentation. Resident #40 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - a resident assessment tool) dated 10/12/21 documented Resident #40 was alert and oriented and had intact cognitive response. The MDS documented Resident #40 required extensive assistance of one person for personal hygiene. During an interview on 12/9/21 at 3:26 PM Resident #40 stated the police came in because they reported a ring was missing and does not know the outcome. During another interview on 12/13/21 at 11:26 AM the resident stated the ring was worth $350.00 and wants the ring back. Review of facility's Resident Jewelry Inventory Check List dated 9/7/21 through 9/9/21 revealed Resident #40 had a purple stone ring. Review of the Progress Notes from 9/1/21 through 12/15/21 revealed there is no documentation related to the missing ring. Review of the Report of Concern dated 9/13/21 and signed by the Grievance Officer / Social Work Department Director (SW #2) on 9/14/21, the DON on 9/14/21 and the Administrator on 9/14/21 revealed Licensed Practical Nurse (LPN) #1 documented, Resident #40 stated the Certified Nursing Assistant (CNA) with the short blonde hair and long eyelashes took my [MEDICATION(S)] diamond ring off of my finger. In addition, the Management Investigation Report documented resident reported CNA removed her ring and did not return it, resident wants her ring returned. Investigator's proposed options / response to the Concern/Grievance documented, Unable to return ring because CNA reports the ring was messy (bowel movement on hand and ring) CNA states they removed ring, washed it, and placed it in a white washcloth. Ring was probably placed in dirty laundry bin and lost related to laundry is sent out of facility. Review of facility document signed by SW #1 dated 9/14/21 revealed Resident #40 describes the ring as oval with a purple stone and small diamonds surrounding the purple stone. Resident #40 stated it went missing 4 - 5 days ago on second shift while 2 CNAs were providing care, the CNA standing on the left side was washing her hands, removed the ring and was told the CNA would put the ring back on but never did. The resident stated the ring came off easily because their hands were wet and soapy. Resident #40 described the appearance of the CNA who took the ring off their finger. Review of the Occurrence Report Statement Form dated 9/14/21 documented CNA #1 and another employee were cleaning the resident when they noticed the resident's hands were messy, therefore they (CNA #1) took the resident's ring off to clean it. All dirty linen went to laundry the ring was probably wrapped in a washcloth and sent to laundry. CNA #1 described the ring as gold, oval shaped with a purple stone in the middle. Review of the undated Occurrence Report Statement Form documented CNA #2 helped CNA #1 with Resident #40's care and did not see a ring. Review of the Occurrence Report Statement Form dated 9/14/21 by the DON, documented on 9/14/21 at approximately 1:30 PM, they took the agency CNA #1 to Resident #40's room for identification and upon entering the room the resident verified CNA #1 removed their ring and Resident #40 stated they want their ring back. DON informed Resident #40 they were in the process of locating it. Review of the Town Complaint Information the police report dated 9/14/21 documented, Resident #40 stated that ring was taken by an employee. Employee gave a written statement to the Director at the facility stating that CNA #1 removed the ring to clean the resident because the resident was soiled and that the ring was placed inside a washcloth and believes the ring could have been placed in the wash. The Director stated they were doing an internal investigation but do not have any poof of a theft occurring. Review of the Investigation Summary - Conclusion dated 9/14/21 the DON documented, the facts of this investigation have not given reasonable cause to believe that misappropriation occurred because of the findings. The CNA did not intentionally destruct or take the resident's ring (theft). The CNA did remove the ring, washed it, and placed it in a washcloth. The washcloth appears to have been placed into the dirty linen bin and removed from the facility. Therefore, based upon the facts of this investigation, does not meet reporting criteria for misappropriation. During an interview on 12/14/21 at 10:07 AM Laundry Aide #1 stated sometimes towels and washcloths are mixed with the resident's personal laundry from the units, therefore it is sorted and washcloths and towels are placed in a separate laundry bag and taken to the soiled storage room near the loading dock for pick up from the contracted laundry company. Laundry Aide #1 stated the contracted laundry company is responsible to wash all facility bed linens, towels and washcloths. Laundry Aide #1 stated they are unaware of a missing ring and were not working in the laundry department in September 2021. During an interview on 12/15/21 at 9:15 AM SW #1 stated they had not asked the resident what the worth of the ring was and was aware the investigation concluded the ring may have been placed inside a washcloth and sent to laundry. SW #1 stated they do not recall informing the Environmental Department Director and had not contacted contracted laundry company of the ring and should have. SW #1 stated the facility does not typically replace jewelry, unfortunately the ring is gone and the Administrator would determine if the ring would be replaced. SW #1 stated the investigation was concluded by the DON. During an interview on 12/15/21 at 9:34 AM the Director of SW #2 Grievance Officer stated they had been informed a CNA was washing the resident's hands and the ring came off with the soapy washcloth, and assumed it went to laundry. The Director of SW #2 stated they had not ask the resident the worth of the ring and doesn't know if the Environmental Department Director and contracted laundry company was informed of the missing ring. Director of SW #2 stated SW #1 or the DON should have informed the Environmental Department Director. Director of SW #2 stated upon conclusion of the investigation if the facility or employees of the facility are known to be responsible for the loss, the Administrator would make the decision if the item is to be replaced or reimbursed, and there was no direction from the Administrator for value or replacement of the ring. During an interview on 12/15/21 at 9:48 AM the DON stated the investigation is completed and file is closed and there is no replacement or monetary value provided to the resident because that is the facility's policy. The DON stated they had not inquired the value of the ring and doesn't know the worth. The DON stated they believe the ring was placed in a washcloth and sent out to the contracted laundry company. They had not informed the Environment Department Director, interviewed any facility laundry personnel or contacted the contracted laundry company concerning the missing ring. The DON stated the Administrator would make the decision if the item is to be replaced or reimbursed. During an interview on 12/15/21 at 10:04 AM the Administrator stated the investigation is completed and file is closed and there is no replacement or monetary value provided to the resident because that is the facility's policy. The Administrator stated they do not know the value of the ring and would need to contact the Resident's daughter and would need to ask SW #1 if they had contacted the contracted laundry company of the missing ring. During another interview on 12/15/21 at 1:02 PM the Administrator stated Resident #40's daughter deferred the question of the value of the ring to Resident #40. Therefore SW #1 questioned the resident and Resident #40 stated the rings worth was $350.00. The Administrator stated Resident #40 should have been asked the value of the ring, the facility's laundry personnel should have been interviewed and the contract laundry company should have been notified and questioned of the missing ring. The Administrator stated they were ultimately responsible for the employee's actions and this was not a thorough investigation. During an interview on12/15/21 at 1:49 PM the Environmental Department Director stated they were not aware there was a missing ring for Resident #40. They stated when a resident's personal item is lost and potentially in the laundry department, they should have received a Concern Report, interviewed the facility's laundry personnel and contacted the contracted laundry company of the missing ring. 415.4(b)(3)

Based on interview and record review conducted during an Abbreviated survey (Complaint # NY 423) completed on [DATE], the facility did not honor the resident's right to formulate an advance directive for one (Resident #1) of six residents reviewed. Specifically, Resident #1 had a Medical Orders for Life Sustaining Treatment (MOLST, a set of medical orders for advance directive status) for Do Not Resuscitate (DNR-allow for natural death) and the facility initiated cardiopulmonary resuscitation (CPR, an emergency procedure with chest compressions and often artificial ventilation for someone in cardiac arrest) when the resident went unresponsive and was absent of breath and pulse. The finding is: The facility policy and procedure (P&P) titled Cardiopulmonary Resuscitation Process, reviewed ,d+[DATE], included that emergency basic life support will be provided in accordance with related physicians orders, such as Do Not Resuscitate (DNR-allow for natural death), and the patient's/resident's Advanced Directive/Medical Orders for life Sustaining Treatment (MOLST). Cardiopulmonary Resuscitation (CPR) will be initiated on all patients/residents without an identified Do Not Resuscitate (DNR) order or without an identified Advance Directive. Patients/residents requiring Cardiopulmonary Resuscitation (CPR) will be identified by a blue wrist band. DNR status will be listed in the medical record under the Advance Directive tab by nursing personnel. A white wrist band will identify patients/residents with a DNR order who reside at the facility. The electronic medical record will contain documentation regarding the patient's/resident's choices regarding CPR and/or any other advance directives, (this also includes any patient/resident wishes expressed through a resident representative). Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The patient's/resident's wishes should be verified by referring to the pink MOLST form in the paper chart located on the unit (this would reflect the most current information regarding patient's/resident's wishes as a reference). The facility P&P titled, Advance Directives dated [DATE], included the clinician shall document in the patient's/resident's medical record if an advance directive has been made. A copy of the advance directive shall be place in the patient's medical record. Advance directives shall be honored, in accordance with Federal, State, and local laws and regulations. The facility P&P titled, Medical Orders for Life Sustaining Treatment (MOLST) Completion and Use, dated [DATE] documented that the MOLST form is a medical order form that converts an individual's wishes regarding life-sustaining treatment into medical orders. A completed, fully executed MOLST is a valid medical order, and is immediately actionable. Resident #1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission History and Physical dated [DATE], documented that Resident #1 lacked capacity for medical decision making. Review of the Medical Orders for Life Sustaining Treatment (MOLST) document dated [DATE] and [DATE], documented Resident #1 was a DNR: Do not attempt resuscitation (allow natural death). Review of the Order Summary Report dated [DATE], revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A Progress Note dated [DATE] at 12:29 PM, written by Registered Nurse (RN) #2, documented that she spoke with Resident #1's Health Care Proxy (HPC) who wanted the MOLST to be updated to reflect a DNR for Resident #1. The MOLST was changed, verified by two nurses, and the MD was updated. A Progress Note dated [DATE] at 9:45 AM, written by the Director of Nursing (DON), revealed that at approximately 9:10 AM an overhead page announced a medical emergency in Resident #1's room. Upon immediate arrival the RN (RN #5) and Nurse Practitioner (NP) were providing chest compressions and breaths to Resident #1. The automated external defibrillator (AED, a medical device that can analyze the hearts rhythm and deliver an electrical shock) indicated no shock was advised. The paramedics arrived at 9:19 AM. CPR ceased, and the paramedics called the time of death at 9:21 AM. A Progress Note dated [DATE] at 12:44 PM, written by RN #1, revealed Resident #1 was rapidly declining, talking with a gurgling voice and was sweating profusely at 9:10 AM. The NP was called into the room and at that time Resident #1 became unresponsive-not responding to any voice commands and no palpable pulse was found. An Acute Note dated [DATE], written by the NP, revealed that Resident #1 was seen for altered mental status and audible gurgling. Upon entering the room, Resident #1 room was unresponsive and staring at the wall. The NP was told that Resident #1's advance directives directed CPR. Resident #1 went into witnessed cardiac/respiratory arrest and the NP and clinical nurse manager (RN #5) began CPR immediately. After approximately 15 minutes of CPR, paramedics arrived. Within minutes of the paramedic's arrival it was brought to their attention that Resident #1's MOLST form, signed by attending physician, directed a DNR order. CPR was immediately ceased, and time of death was 9:21 AM. Review of an Employee Statement signed and dated [DATE] revealed RN # 2 spoke with Resident #1's HCP who verbalized for the resident to be a DNR. RN #2 documented that she completed the MOLST with a second staff member, clipped it to the chart for the provider to verify upon their assessment. RN #2 documented she had no further knowledge of the verified, updated MOLST as she had no continuation of transcribing new admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of an employee statement (handwritten on a Progress Note) signed and dated [DATE], revealed RN #1 documented the resident was wearing a white name tag and that she checked the electronic medical record and the order indicated CPR. RN #1 wrote that she checked the paper chart and there was no MOLST present in the advance directives section. During an interview on [DATE] at 11:28 AM, the NP stated that on [DATE] she was as alerted by RN #1 that Resident's #1 condition has changed. She stated when she entered the room, the resident was not responding, staring out in space and was gurgling. She stated RN #1 told her the resident was a full code. She stated the resident lost pulse, respirations and CPR was started. She stated the AED was applied but no shock was advised. She stated after the paramedics arrived the DON came into room, stated the resident was a DNR, and chest compressions were stopped. She stated the resident did not respond at any point in during the compressions and had CPR for about 15 minutes in total. She stated she would expect staff to update the provider with a MOLST change and a phone order to be done in the chart. During an interview on [DATE] at 11:51 AM, RN #5 (Clinical Nurse Manager) stated on [DATE] RN #1 was in the room with Resident #1 who was in distress. She stated they applied a rebreather mask and put oxygen on Resident #1 and when the NP entered the room, Resident #1's respirations ceased. RN #5 stated that RN #1 told the NP that Resident #1 was a full code, CPR was started and continued until Resident #1 was pronounced dead by the paramedics. She stated a resident's code status is identified by the MOLST in the chart and by the resident's arm band. RN #5 stated a white arm band indicated a DNR and a blue arm band indicated CPR. She stated the admission nurse is to obtain the MOLST, they are to call the MD, immediately transcribe the new order and change the name band. She stated the reason for a MOLST is to honor the resident's wishes. During an interview on [DATE] at 12:02 PM, the MD stated the purpose of a MOLST is so there was no confusion about a resident's wishes. The MD stated if there was a change in a MOLST, he expected the document to be left in his folder to be signed, he would not expect a phone call, but would expect an updated order to be put in the EMR that he could sign remotely. The MD stated he couldn't remember if he signed Resident #1's MOLST on [DATE] or [DATE], however he did an admission history and physical on [DATE]. During a telephone interview on [DATE] at 12:29 PM, RN #1 stated on [DATE] she went into Resident #1's room and the resident was profusely sweating, gurgling and weak. She stated the NP entered the room and the resident became unresponsive. RN #1 stated she went to check the resident's code status in the EMR, it said the resident was CPR and CPR was started on Resident #1. She stated the AED was placed but no shock was advised. She stated CPR was stopped when the MOLST was found in the filing section. She stated she does not know who found the MOLST. RN #1 stated Resident #1 was wearing a white wristband, however when RN #1 check the EMR it indicated CPR. During an interview on [DATE] at 12:41 PM, the Director of Nursing (DON) stated RN #2 updated Resident #1's MOLST on [DATE] and clipped it the front of the resident's chart. She stated that RN #2 knew the MD was coming in that day to see Resident #1 and he would sign the MOLST when he came in. The DON stated the MD signed the MOLST and put it into the to be filed bin. She stated RN #2 did not change the order in the EMR. The DON stated at some point Resident #1's name band was changed to a white band but could not identify who changed the name band. She stated it seemed there was not a clear documentation process in place for a MOLST change. She stated the advanced directives order needs to go into the EMR so it reflects the resident's wishes. She stated the nurse that makes a change to the MOLST should call the provider, put an order into the EMR, put the MOLST in the MD folder to sign, and change the resident's name band. During an interview on [DATE] at 12:53 PM, the Administrator stated the staff member that initiated a change in the MOLST should have put the change into the EMR. The order was written but it did not get put into the paper chart. He stated the importance of the MOLST is to honor the person's wishes or expectations on advance directives. 415.3(f)(2)(iii)

Based on observation, interview and record review conducted during a Standard survey completed on 5/20/19, it was determined that the facility did not implement an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. Specifically, one (Resident #49) of one resident reviewed for antibiotic stewardship program revealed that the resident was receiving Bactrim (an antibiotic) as a urinary tract infection [MEDICATION NAME] (prevention) without appropriate indications for its use and monitoring. The finding is: Review of the facility policy and procedure (P&P) titled Antibiotic Stewardship Program dated (MONTH) (YEAR) revealed that the facility will educate medical providers, nursing staff, and the public about the use of antibiotics; produce a report that monitors and audits antibiotic usage; use the McGeer Criteria guidelines and standard procedures aimed at optimizing antibiotic use; and that the Consultant Pharmacist will complete a monthly antibiotic regimen review. Review of an undated information pamphlet from the facility titled Antibiotic Use For Urinary Tract Infections (UTI's) - Information for Residents and Families revealed that the facility will only test for an infection if the resident has symptoms like back pain; foul smelling or cloudy urine; or blood in their urine (McGeer criteria). If there are no symptoms, the resident will be monitored and observed for any urinary issues. 1. Resident #49 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated 3/15/19 documented the resident was cognitively impaired, sometimes understands, and sometimes understood. Further review of the MDS revealed that under Section I, the resident did not have a urinary tract infection in the last 30 days. Additional review of MDS assessments dated 1/11/18, 4/19/18, 7/11/18, 9/12/18, and 12/13/18 revealed the resident did not have a urinary tract infection in the last 30 days. Review of the chronological medical record from (MONTH) (YEAR) to (MONTH) 2019 revealed the following: - Comprehensive Care Plan (CCP) revealed that the resident had a history of [REDACTED]. - Physician's orders dated 5/2/19 revealed that the resident has been taking Bactrim 400 milligram (mg)/ 80mg. The medication was ordered on [DATE]. Review of the order revealed that the order status is active. Further review of the orders revealed that there was an as needed order for a Urology consult that was active from 7/20/17. There were no active orders for a urinalysis. There were no active orders for [MEDICATION NAME] (good bacteria) to preserve good bacteria. - Medication Administration Record [REDACTED]. - Recorded body temperatures ranged from 96 degrees Fahrenheit (F) to 98.5 degrees F. A fever is clinically indicated with the body temperature is 100.4 F or higher. - Outside consults for the resident did not contain a consultation from a Urologist. - Pharmacist Consultant Monthly Medication Review did not have recommendations to review antibiotic use for prevention of a urinary tract infection. - Physician's Progress Notes for the assessment and plan for the resident there was no orders for urinalysis lab work. During an observation of the resident on 5/15/19 at 12:32 PM revealed the resident had a Foley catheter (insertion of tube into the bladder to drain urine) that was draining clear, light yellow urine and there was no odor noted. An additional observation on 5/17/19 at 8:35 AM revealed the resident's Foley catheter was draining clear colored urine and there was no odor noted. During an interview on 5/17/19 at 9:31 AM, the Pharmacist Consultant stated she was aware that the resident was on the antibiotics. She thought that the resident was seeing a Neurologist for her [MEDICAL CONDITION] bladder and that is why she didn't give any recommendations to the physician. Going forward she would recommend to the physician to have the resident see a urologist and that the resident was a good candidate to trial off the antibiotics. During an interview on 5/17/19 at 10:46 AM, Registered Nurse (RN) #3 Infection Control Nurse stated they were aware of the resident receiving a daily dose of an antibiotic as she monitors antibiotic use in the facility. She had not approached the physician about it and the physician is aware of the antibiotic stewardship program. RN #3 stated she was aware the resident does not meet McGeer criteria for using antibiotics for a urinary tract infection. RN #3 further stated going forward, she will discuss the rationale with the physician concerning antibiotic use and the catheter. During an interview on 5/17/19 at 11:45 AM, the Physician stated he was using the antibiotics as a prevention for urinary tract infections. He was aware that the resident did not meet the McGeer criteria for antibiotics. He was not aware that the resident had not seen a urologist stating, that's an oversight on my part. Nothing more, nothing less. During an interview on 5/20/19 at 9:37 AM, the Director of Nursing (DON) stated she would expect the Physician and the Pharmacist Consultant to review the resident's medication monthly to see if there were any irregularities and to monitor antibiotic use. 415.12(l)(1)

Based on interview and record review conducted during the Standard survey completed on 5/20/19, the facility did not ensure that pharmaceutical services (including procedures that assure the accurate acquiring, receiving , dispensing and administering of all drugs and biologicals) met the needs of each resident. One (Resident #3) of four residents reviewed for pharmaceutical services had issues. The facility did not ensure medications were admisinstered in accordance with the the physician's orders [REDACTED]. After the staff identified each pill, it was determined that an extra dose of [MEDICATION NAME] (cardiac medication) was in the medication cup. The finding is: The facility's policy and procedure (P&P) entitled Medication Administration Guidelines dated (MONTH) 26, (YEAR) documented medications are administered following the system known as the Six Rights: right name, right drug, right dose, right route, right time and frequency and the right documentation. In addition; the policy documented, remain with the resident until medication has been taken/ verify all oral medications have been swallowed. At no time are medications to be left at the bedside, except in areas approved for self-administration. A medication error is defined as the wrong patient, wrong drug, wrong dose, wrong time, wrong route, or omission of a prescribed drug. The facility's P&P entitled Medication Variance Reporting dated 12/1/12 documented Medication Variance Form will be completed for all transcription, dispensing and prescribing variances. Medication variances will be categorized according to the severity index. Type of Error/ Category lists Category A thorough H. Category A description documented, circumstances or events that have the capacity to cause harm, but the medication did not reach the resident (potential prescription, transcription, dispensing). 1. Resident #3 was initially admitted to the facility on [DATE] and readmitted on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS, a resident assessment tool) dated 4/28/19 revealed the resident was understood and understands. Review of the undated comprehensive care plan revealed dated 5/14/19 the resident had cognitive loss, was moderately impaired for decision making, was alert and oriented to surroundings, but demonstrated confusion and forgetfulness at times. Review of the Physician order [REDACTED]. - Aspirin 81 milligram (mg) by mouth one time a day, - [MEDICATION NAME] (diuretic, medication that promotes excreation of urine) 0.5 mg give two tablets by mouth in the morning to equal 1 mg, - [MEDICATION NAME] (iron supplement) 325 mg by mouth one time a day, - [MEDICATION NAME] (medication to improve digestion) one tablet by mouth one time a day, - Folic Acid (supplement) 1 mg give 0.5 tablet by mouth one time a day, - [MEDICATION NAME] (potassium supplement) 10 milliequivalents (MEQ) give 2 tablets by mouth one time a day, - [MEDICATION NAME] (anti-depressant) 10 mg give one tablet by mouth one time a day, - [MEDICATION NAME] (used to improve muscle strength in patients with certain muscle diseases) 60 mg one tablet by mouth three times a day, - [MEDICATION NAME] (beta blocker used to treat [MEDICAL CONDITION], lowers blood pressure) give 12.5 mg by mouth every 8 hours, - [MEDICATION NAME] HCL (used to treat low blood pressure when standing) 2.5 mg give one tablet by mouth one time a day, - [MEDICATION NAME] (corticosteroid, prevents the release of substances in the body that cause inflammation) 20 mg one tablet by mouth one time a day, - [MEDICATION NAME] delayed release (used to treat [MEDICAL CONDITION] reflux disease) 40 mg by mouth one time a day, - Sprionolactone (diuretic) 25 mg one tablet by mouth one time a day, - Thera (multi-vitamin) 400 microgram (mcg) one time a day, and - Vitamin B12 (supplement) give 1,000 mcg by mouth one time a day. Review of the Medication Administration Record (MAR) dated 5/1/19 through 5/31/19 revealed the Licensced Practical Nurse (LPN) #2 documented the resident was administered all medications on 5/15/19 at 8:00 AM and 9:00 AM as ordered. During an observation on 5/15/19 at 9:43 AM a medication cup was on the resident's bedside table containing: two green tablets, one orange tablet, one white tablet, two ½ (one half) white tablets, one ½ yellow tablet, and one oval white tablet. During an interview on 5/15/19 at the time of the observation, the resident stated he did not know a cup with medications was on his bedside table and that he does not take his medications alone. The resident further stated, even at home his wife would stand near him to ensure he took his medications. There were no staff members in the room during the observation. During an interview and observation on 5/15/19 at 9:47 AM, Registered Nurse (RN) Clinical Nurse Manager (CNM) #4 identified there were eight pills in the medication cup on the resident's bed side table and stated the resident does not self-medicate. RN #4 removed the medication cup from the resident's room, and stated that nurses should not be leaving medications at the bedside. The nurse administering the medications were to observe the resident take the medications and document appropriately after the medications have been taken by the resident. Additionally, the resident was complex and receives a lot of medications therefore there should be more caution taken when pouring and administering his medications. During an interview on 5/15/19 at 9:48 AM LPN #2 stated the resident was taking his medications when he left the bedside to attend to the roommate, and thought the resident took all of the medications. During an observation on 5/15/19 at 9:50 AM RN #4 CNM and LPN #2 reviewed the resident's MAR (medication administration record) with each blister pack for the resident to identify each medication tablet in the cup that was removed from the resident's bedside. The medications were identified as follows: - two green tablets = [MEDICATION NAME] 0.5 mg - one orange tablet = [MEDICATION NAME] 25 mg - one white tablet = [MEDICATION NAME] 60 mg - two ½ white tablets = [MEDICATION NAME] 25 mg - one ½ yellow tablet = Folic Acid 0.5 mg, and - one oval white tablet = [MEDICATION NAME] 40 mg. At the time of the observation, LPN #2 stated, there were two [MEDICATION NAME] ½ tablets in the medication cup in error. There should have been only one ½ [MEDICATION NAME] tablet in the cup. During an interview on 5/15/19 at 9:59 AM LPN #2 stated he would not normally leave medications at the resident's bedside, and makes sure the resident takes his medications but he got distracted. Additionally, he doesn't know how he poured an extra [MEDICATION NAME] in the cup and stated he must have been distracted. During an interview on 5/15/19 at 10:00 AM , the Director of Nursing (DON) stated every nurse passing medications should ensure the resident takes the medication. Medications are not to be left at a resident's bedside. She was aware there was an extra dose of [MEDICATION NAME] in the cup, and this was a medication error. During further interview on 5/15/19 at 1:26 PM, LPN #2 stated he observed the resident take some medications, but was called away, got distracted and didn't go back to ensure the resident took all of the medications. LPN #2 stated the medication administration process was to match the blister pack with the order, put the medication into the medication cup, administer the medication to the resident, after the medications are administered to the resident document on the MAR each medication that was administered. If the medication was refused or not taken then it should be documented on the MAR to match what the resident actually took. During an interview on 5/20/19 at 12:50 PM, the DON stated medication administration should follow the 5 rights; right name, right dose, right route, right time and frequency and right documentation. The process of medication administration is to pour each medication into the medication cup according to the MAR, identify the resident, give the resident the medications and make sure they are all taken (swallowed) before leaving the room, and if the nurse must leave before all medications are taken by the resident because of an emergency; then the nurse should take the medications with them, not leave them at bed side and return when they are available to complete the medication administration and the documentation on the MAR should reflect the accuracy of the administration, i.e. if the resident refuses or can't swallow the medication, it should be documented on the MAR. The facility's Performance and Behavior Corrective Action Report dated 5/15/19 documented an incident of Endangering Patient. The report documented on the morning of 5/15/19 the Department of Health brought to the attention of the clinical manager that medication was left on the bedside table of a patient. The medication was removed by the clinical manager and identified per MAR. Medications to which were supposed to be administered were: [MEDICATION NAME], Folic Acid, Spirolactone, [MEDICATION NAME] and Mestonin. During a medication pass the associate (nurse) who prepared the medication is personally responsible for the administration and charting of the same. You are to remain with the patient until medication has been taken, verify all oral medications have been swallowed. At no time are medications to be left at the bedside, except in area approved for self-administration. The form was signed by LPN #2, the DON and the Assistant Director of Nurising (ADON) RN #3. Review of the facility's Medication Variance Form dated 5/15/19 revealed LPN #2 had an additional ½ tablet of [MEDICATION NAME] placed in the medication cup, the description revealed a dispensing error Category A - circumstances or events that have the potential to cause harm, but the medication did not reach the resident. The form also documented; How could variance have been avoided? Remain with patient until medication all consumed., form signed by LPN #2, RN #4 CNM, and DON. 415.12(m)(2)

Based on observation, interview, and record review conducted during a Standard survey completed on 5/20/19, it was determined that the facility did not ensure that the facility establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. One (Resident #107) of four residents reviewed for infection control during care had issues with the lack of proper infection control practices. Specifically, staff (Certified Nurse Aide (CNA) and Registered Nurse (RN)) touched multiple services after touching the resident's Foley drainage bag without hand washing or changing gloves; emptied used bed bath water into a shared sink; and placed toothpaste that had fallen off the toothbrush onto the countertop of the sink back onto the toothbrush. The finding is: The facility policies and procedures (P&P) entitled Handing Washing/ Hand Hygiene for Community Based Care dated 1/4/18 and Urinary Catheter dated 10/28/15 documented handwashing was mandatory before and after contact with the patient/ resident, catheter, drainage system, or urinal. Further review of the P&P's documented staff must decontaminate their hands before and after handling resident/ patient care devices such as urinary catheters. 1. Resident #107 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated 4/19/19 documented the resident was severely cognitively impaired, sometimes understands, sometimes understood, and requires an extensive assist of two people for bed mobility and total assist of one for personal hygiene. The undated Comprehensive Care Plan (CCP) documented the resident required a total assist of one person for personal hygiene and oral care. The Visual/Bedside Kardex Report (guide used by staff to provide care) dated 5/3/19 documented the resident required total assist of one person for personal hygiene and oral care. During a morning care observation on 5/17/19 at 7:17 AM, CNA #1 placed a basin with water on a barrier covered over the bed table. She proceeded to wash the resident's face and upper body. She emptied the used water into the sink that was shared by the resident and his roommate. CNA #1 went into the bathroom and replaced the water in the basin. She washed her hands, put on new gloves, and placed the basin on the barrier. She proceeded to wash the resident's catheter, genitals, perineal area, and anal area. The CNA again emptied the used water into the shared sink and the countertop was observed to have water on it. She went to the bathroom, washed her hands, and put on new gloves. The resident was partially dressed and was being prepared for transfer from his bed to his chair. CNA #1 placed with her gloved hand the resident's urine collection bag that contained approximately 100 milliliters of yellow urine onto the resident's bed. She finished dressing the resident and placed the sling to transport the resident under him. She brought over the mechanical lift and put the sling straps on the lift. The resident was lifted, and Registered Nurse (RN) #2 Clinical Nurse Manager put the resident's urine collection bag onto his lap. She was not wearing gloves. CNA #1 and RN #2 maneuvered the resident into his chair. They both washed their hands after the resident was positioned in his chair. CNA #1 moved him over to the shared sink and placed a towel around the resident's neck. She prepared to brush his teeth. She applied toothpaste on the toothbrush. The toothpaste fell off the toothbrush. The CNA proceeded to wipe the toothpaste off the counter with the toothbrush and placed into the resident's mouth. Interview on 5/17/19 at 7:49 AM with CNA #1 revealed that she normally empties the used water into the sink stating, am I not supposed to?. She said she should have washed her hands and put on new gloves after touching the urine collection bag before touching the resident's clothes and chair, the sling, and the mechanical lift. She said she shouldn't have put the toothpaste from the sink countertop back onto the resident's toothbrush. Interview on 5/17/19 at 7:59 AM with RN #2 revealed she should have worn gloves before touching the urine collection bag and that she shouldn't have put the bag on the resident's lap during the transfer. RN #2 stated that CNA #1 should not have emptied the used water into the shared sink and should have emptied into the toilet. Additionally, CNA #1 should have put new toothpaste on the toothbrush. Interview on 5/20/19 at 9:37 AM with the Director of Nursing (DON) revealed she expected her staff to perform hand hygiene after handling a resident's urinary collection bag and before touching anything else. The DON stated she would expect her staff to wear gloves when touching any of the resident's care equipment. She would expect her staff to get more toothpaste and not wipe it off the sink counter. She would expect her staff to empty used water from a bed bath into the toilet and not the shared sink. 415.19(b)(4)

Based on observation, interview, and record review conducted during the Standard survey completed on 5/20/19, the facility did not ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for one (Resident #31) of three residents reviewed for respiratory care. Specifically, the oxygen (O2) humidifier bottle and oxygen tubing was not changed. The finding is: The policy and procedure (P&P) entitled Oxygen Therapy dated 6/29/15 documented the tubing should be changed bi-monthly. The P&P did not address changing the oxygen humidification bottle. 1. Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- a resident assessment tool) dated 3/2/19 documented the resident was cognitively intact, usually understands and was usually understood. The MDS documented the resident required the use of oxygen therapy. The comprehensive care plan (CCP) last reviewed 3/14/19 documented the resident had sleep apnea with interventions that included oxygen at night and as needed (PRN). Review of the Order Summary Report dated 4/29/19 documented an order for [REDACTED]. Further review revealed an order for [REDACTED]. Intermittent observations from 5/15/19 to 5/20/19 revealed the following: - 5/15/19 at 7:58 AM - Resident was in bed watching television (TV) and O2 was not in use. The humidifier bottle was labeled with a piece of white tape dated 3/14/19, with a nurse signature, and timed 3:00 PM to 11:00 PM shift. The oxygen tubing was labeled 3/15/19. - 5/16/19 at 7:45 AM - Resident was in bed and O2 was not in use. The humidifier bottle was labeled with a piece of white tape dated 3/14/19, with a nurse signature, and timed 3:00 PM to 11:00 PM shift. The oxygen tubing was labeled 3/15/19. - 5/16/19 at 11:50 AM - Resident was out of bed sitting in his wheelchair watching TV and O2 was not in use. The humidifier bottle was labeled with a piece of white tape dated 3/14/19, with a nurse signature, and timed 3:00 PM to 11:00 PM shift. The oxygen tubing was labeled 3/15/19. - 5/17/19 at 7:42 AM - Resident was in bed, awake with the HOB elevated wearing O2 at 2L via NC. The humidifier bottle was labeled with a piece of white tape dated 3/14/19, with a nurse signature, and timed 3:00 PM to 11:00 PM shift. The oxygen tubing was labeled 3/15/19. - 5/20/19 at 8:00 AM - Resident was in bed and O2 was on at 2L via NC. The humidifier bottle was labeled with a piece of white tape dated 3/14/19, with a nurse signature, and 3:00 PM to 11:00 PM shift. The oxygen tubing was not dated. Review of the Medication Administration Record [REDACTED]. Review of the Treatment Administration Record (TAR) dated 4/1/19 to 4/30/19 and 5/1/19 to 5/31/19 revealed the tubing and mask/ canual were signed off as being changed per the MD order. Further review revealed an order entry for Oxygen Concentrator and to monitor the level of sterile water in humidifier bottle every shift and to fill as needed. During an interview on 5/20/19 at 8:44 AM, Licensed Practical Nurse (LPN) #4 stated O2 tubing and humidifier bottles are changed on the 1st and 15th of every month. LPN #4 observed the resident's O2 set up and stated the tubing should be labeled, and she would change it right now. LPN #4 stated the humidifier bottle was dated 5/14/19. She removed the humidifier bottle from the O2 concentrator and held it to the light of the window at eye level. She then stated Oh, wait, that is a three, 3/14/19, I do this every day, I thought it was a five, I will change it right now. During an interview on 5/20/19 at 8:54 AM, Registered Nurse (RN) #5 Clinical Nurse Manager (CNM) stated the process was to change the O2 tubing and humidifier bottle on the 1st and 15th of every month and they should be labeled. She stated Resident #31 wears O2 at bedtime and takes it off in the morning. During an interview on 5/20/19 at 2:31 PM, LPN #4 stated we change the humidifier bottle with the tubing two times a month, that's what I do. During an interview on 5/20/19 at 2:32 PM, RN #5 CNM stated changing the humidifier bottle was not in the policy but it should be changed with the tubing. During an interview on 5/20/19 at 2:37 PM, the Director of Nursing (DON) stated she would expect the O2 humidifier bottle to be changed with the tubing/ NC which is done two times per month. 415.12(k)(6)

Based on observation, interview and record review conducted during the Standard survey completed on 1/9/18, the facility did not ensure that a resident receives appropriate care and services for use of an indwelling catheter (Foley - a tube inserted into the bladder to drain urine). One (Resident #17) of three residents observed for catheter use had issues. Specifically, a resident had a different size catheter in place than was ordered by the Physician and specified on the Comprehensive Care Plan (CCP). The finding is: 1. Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - resident assessment tool) dated 10/6/17 revealed the resident has moderately impaired cognition and uses an indwelling catheter. Review of the Medication Review Report dated 1/8/18 revealed an order for [REDACTED]. Review of the CCP (identified as current by Registered Nurse Unit Manager (RN #1) revealed the resident has an indwelling catheter; last changed 12/13/17 (16 French with 10cc balloon). The care plan was revised on 1/8/18 to include the catheter was last changed on 12/18/17 (18 French silicone with 10cc balloon). Review of a Progress Note dated 12/13/17 at 7:28 PM revealed the Foley was replaced as per MD (Medical Doctors) orders, the procedure was tolerated well. Review of a Progress Note dated 12/18/17 at 10:44 PM revealed a new order from the MD to reinsert a Foley catheter. Upon removal of old catheter, the tip was found to be occluded (plugged) with mucous. During an observation and interview on 1/8/18 at 11:25 AM, the RN Unit Manager #1 checked what size indwelling catheter the resident currently had in place and stated he had an 18 in right now. The RN further stated, it was changed December 18th, that's probably why it's different, so they had an order to reinsert it. When asked what should the order include the RN stated, probably put a reason why they had to reinsert it and the size they would like to put in as well. During an interview on 1/9/18 at 12:00 PM, the Director of Nursing (DON) stated she would expect the nurse to get a physician's orders [REDACTED]. The care plan should be updated to match appropriately. Review of the policy entitled Urinary Catheter dated 10/28/15 revealed for insertion of an indwelling urethral catheter includes to obtain physician's orders [REDACTED]. 415.12(d)(2)

Based on interview and record review conducted during a complaint investigation (Complaint #NY 378) conducted during the Standard survey completed on 10/20/16, the services provided or arranged by the facility did not meet professional standards of quality. One (Resident #6) of four residents reviewed for professional standards related to pressure sores had issues involving the lack of a Professional Registered Nurse (RN) assessments of open areas/pressure sores. The finding is: 1. Resident #6 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 8/26/16 revealed the resident has severe cognitive impairment and is usually understood and sometimes understands. Review of a Progress Note - Health Status Note dated 6/9/16, written by a Licensed Practical Nurse (LPN#1), revealed the resident had a small open area on left buttock that looks like a broken blister. Review of a Progress Note - Skin/Wound Note dated 6/14/16 written by LPN #3 revealed two open areas remain on inner left buttock. #1 outer most area is approximately 2.5 x 1.5 cm (centimeter). Round shaped with flat irregular edges. #2 inner most area is long oval shape, edges flat. The tissue surrounding both areas was described as pink and blanchable. Additional review of the Progress Notes revealed that there was no documentation of a RN assessment of the left buttock that was as noted on 6/9/16 until 6/14/16. Review of a Progress Note - Skin/Wound Note dated 7/24/16 written by LPN #3 revealed documentation of a new oval shaped reddened area on right outer heel measuring 2 cm x 3 cm. Review of the Medication Review Report dated 7/24/16 revealed the following orders: heel booties every shift when in bed - right outer heel Stage I and Skin Prep (protective barrier) to both heels every shift - right outer heel Stage I. Review of Progress Notes dated 7/24/16 through 9/22/16 revealed no further documentation of measurements of the Stage 1 area on the right outer heel and no assessment by a Registered Nurse (RN). Review of the Treatment Administration Records (TARs) dated 7/24/16 through 7/30/16 and 8/1/16 through 8/24/16 revealed Skin Prep was applied to both heels every shift right outer heel Stage 1 pressure sore measuring 2 cm x 3 cm. Interview with the Director of Nursing (DON) on 10/19/16 at 10:50 AM revealed she would expect weekly measurements of the Stage I pressure area and an RN assessment. 415.11(c)(3)(i)

Based on interview and record review conducted during a complaint investigation (Complaint #NY 378) conducted during the Standard survey completed on 10/20/16, the facility did not ensure that a resident having pressure sores receives the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. One (Resident #6) of four residents reviewed for pressures sores had issues involving a five day delay of a Registered Professional Nurse (RN) assessment of an open area on the resident's left buttock. In addition, there was a lack of an initial and ongoing weekly RN assessments of a Stage I pressure sore on the resident's right heel. The finding is: 1. Resident #6 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 8/26/16 revealed the resident has severe cognitive impairment and is usually understood and sometimes understands. a) Review of a Health Status Note Progress Note, written by a Licensed Practical Nurse (LPN#1), dated 6/9/16 revealed the resident had a small open area on left buttock that looks like a broken blister. Review of a Skin/Wound Note Progress Note dated 6/13/16, written by LPN #3, revealed the resident had two open areas noted on inner left buttocks. Wound bed is pink, zero drainage or odor. Surrounding skin is pink and blanchable. The note further revealed that a new order was obtained from the Physician to apply [MEDICATION NAME] Extra Protective cream to the left inner buttock every shift and after incontinent care as needed. Note left for CNM (Clinical Nurse Manager) to assess. Review of a Progress Note - Skin/Wound Note dated 6/14/16, written by LPN #3, revealed the two open areas remain on inner left buttocks. #1 outer most area is approximately 2.5 x 1.5 cm (centimeter). Round shaped with flat irregular edges. #2 inner most area is long oval shape, edges flat. The tissue surrounding both areas was pink and blanchable. CNM notified 6/13/16. Review of a Progress Note - Skin Assessment Note dated 6/14/16, written by RN#1, revealed documentation that the resident was identified to have an area of shearing located on the her left buttock that measured 2.3 cm x 2.4 cm, there was no drainage and the periwound (area surrounding a wound) was described as pink and blanchable. There was a 5 day delay in the assessment of the open area by an RN. Interview with the RN (#1) Unit Manager on 10/19/16 at 9:20 AM revealed she didn't stage the area on the left buttock because there wasn't any depth to it. The RN Unit Manager stated It was just like a scratch and in her opinion Shearing is not a Stage 2 and she does not feel a blister would be a Stage 2. It's just a blister. Interview with the RN (#1) Unit Manager on 10/19/16 at 2:15 PM revealed she was on vacation the week the area developed. The RN Unit Manager stated that Either (RN #3) the Two East Unit Manager or (RN #4) the Wound Care Coordinator (WCC), should have assessed the area sooner. b) Review of a Progress Note - Skin/Wound Note, written by LPN #3, dated 7/24/16 revealed a new oval shaped reddened area noted on right outer heel measuring 2 cm x 3 cm. Review of the Medication Review Report dated 7/24/16 revealed the following orders: heel booties every shift when in bed - right outer heel Stage I and Skin Prep (protective barrier) to both heels every shift - right outer heel Stage I. Review of Progress Notes dated 7/24/16 through 9/22/16 revealed no documented evidence of measurements for the Stage I pressure sore on the resident's right outer heel and there was no documented evidence of an assessment by an RN. Review of the Treatment Administration Records (TARs) dated 7/24/16 through 7/30/16 and 8/1/16 through 8/24/16 revealed Skin Prep was applied to both heels every shift - right outer heel Stage I pressure sore measuring 2 cm x 3 cm. During an interview on 10/19/16 at 9:20 AM, the RN (#1) Unit Manager stated she didn't have documentation of the Stage I pressure sore on the heel. Interview with the Director of Nursing (DON) on 10/19/16 at 10:50 AM revealed she would expect weekly measurements for the Stage 1 pressure area. Additionally, the DON stated she would not call a fluid filled blister a Stage 2 pressure sore and added shearing is not necessarily a Stage 2 as it's not pressure. The previous WCC would say a broken blister would be a Stage 2 but not a fluid filled blister. Review of the Wound and Treatment Policy dated 6/09 revealed the definition for a pressure ulcer is any lesion caused by unrelieved pressure that results in damage to the underlying tissue. Although friction and shearing are not primary causes of pressure ulcers, they are important contributing factors to the development of pressure sores. The definition of a Stage 2 pressure ulcer is a partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. 415.12(c)(2)

Based on interview and record review, conducted during the Standard survey completed on 10/20/16, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. One (Resident #62) of five residents reviewed for unnecessary medications had an issue involving the lack of documented monitoring of the resident's behavior to support the ongoing use of Klonopin (anti-anxiety medication). The finding is: 1. Resident #62 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS- a resident assessment tool) dated 8/6/16 revealed the resident has moderate cognitive impairment, usually understands and is usually understood. Further review of the MDS revealed documentation that the resident had a poor appetite or over-ate for several days of the look-back period. There were no episodes of [MEDICAL CONDITION] or behavioral symptoms documented. Review of the Medication Review Report for the date range: 10/3/16 to 11/3/16, signed by the Physician on 10/5/16 revealed orders for the following [MEDICAL CONDITION] medications (medication used to manage behaviors, stabilize mood or treat psychiatric conditions): - [MEDICATION NAME] Capsule Delayed Release Particles (antidepressant) 60 milligrams (mg) give 1 capsule by mouth one time a day (QD) - Klonopin ([MEDICATION NAME]) Tablet (anti-anxiety medication) 0.5 mg Give 0.5 mg by mouth three times a day (TID) Also listed on the Medication Review Report for the date range: 10/3/16 to 11/3/16 was an order to monitor mood and behavior q (every) shift. Review of the current untitled comprehensive care plan, revised on 8/28/15, revealed a focus area entitled The resident uses [MEDICAL CONDITION] medication r/t (related to) Depression, Anxiety with a goal that the resident Will receive lowest dose necessary for desired effect. Review of the Consultant Pharmacist's Medication Regimen Review (MRR) form revealed the following recommendation made by the Consultant Pharmacist on 5/31/16: According to the manufacturer of [MEDICATION NAME], the recommended frequency of dosing is q12h (every 12 hours). Please consult with medical (Physician) to reduce the number of doses per day or document rationale for q8h (every 8 hour) dosing. Review of the Annual History and Physical, completed by the Nurse Practitioner (NP), dated on 9/2/16 revealed the resident had no documented behaviors of sadness, weeping, anxiety or hallucinations. The NP documented the following in the Assess and Plan section: continues on Klonopin which does seem to have positive effect. Has occasional episodes still but overall improved. No GDR (gradual dose reduction) at this time as benefit outweighs risk. Review of the electronic medical record (eMR) Progress Notes from 1/1/16 to current (10/2016) revealed there was one Behavioral Note written by a Licensed Practical Nurse (LPN) on 3/10/16 at 4:35 AM. The LPN documented that the resident was yelling, and throwing pillows and blankets on the floor. Additional review of the eMR Progress Notes revealed one Psychosocial Note written by the Social Worker on 8/22/16 at 7:48 AM that documented the resident made a statement about having acid thrown at her. There was no further documented evidence in the computerized Progress Notes that the resident was having behaviors related to anxiety. Review of Nurse Report Sheets from January 2016 to current, provided by the Administrator as evidence of the resident's behaviors, revealed the following: - 1/4/16 between 7:00 AM to 3:00 PM - Increased confusion this morning, refused to get out of bed - 1/9/16 between 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM - Anxious and restless - 3/9/16 between 11:00 PM to 7:00 AM - Awake, confused, restless all shift - 4/21/16 between 7:00 AM to 3:00 PM - Refused to get out of bed During an interview with the Registered Nurse (RN #3) Clinical Nurse Manager (CNM) and the Social Worker (SW) on 10/18/16 at 1:41 PM, the SW stated that the BMARC (Behavior Modifying Agent and Review Committee) meets monthly and discusses the resident's behaviors. The SW stated that the committee did not maintain documentation of the discussions and decision making regarding resident's [MEDICAL CONDITION] medications. The SW stated that the 11/27/15 BMARC/Psych Med Change Note, found in the eMR, was the most current documented evidence of the committee's discussion regarding the resident's use of anti-anxiety medication. Further review of the eMR on 10/19/16 at approximately 11:00 AM revealed a Health Status Note written by the RN (#3) CNM on 10/19/16 at 8:41 AM that documented the NP was contacted to review the resident's medications and recent mood state. The RN CNM documented that new orders were obtained for Klonopin 0.5 mg by mouth every 12 hours. Review of an undated facility policy BMARC Review revealed the purpose is to ensure that our residents and patients are receiving the most appropriate medication and/or dosage related to a specific [DIAGNOSES REDACTED]. - Each resident/ patient receiving an antidepressant, antipsychotic, hypnotic, anxiolitics (anti-anxiety), memory enhancing medication is reviewed for appropriateness, dosage and/ or need for GDR. 415.12(l)(1)

Based on interview and record review conducted during the Standard survey completed on 10/20/16, the facility did not maintain clinical records on each resident in accordance with acceptable professional standards and practices that are complete; accurately documented; readily accessible; and systematically organized. Two (Residents #62, 219) of 21 residents' medical records reviewed for complete and accurate documentation had issues involving the lack of a physician's orders [REDACTED].#219) and the lack of documentation of Monthly Medication Regime (MRR) reviews completed by the Consultant Pharmacist (Resident #62). The findings are: 1. Resident #219 has [DIAGNOSES REDACTED]. Review of the Minimal Data Set (MDS- an assessment tool) completed on 10/7/16 revealed the resident has severe cognitive impairment, sometimes understands ,and is sometimes understood. Further review of the MDS revealed the resident receives Hospice Services from a local Medicare certified Hospice provider. Review of the electronic medical record (EMR) revealed the Care Plan Detail dated 7/11/16 documented that the resident is followed by Hospice. Review of the Medication Review Report with the date range: 9/26/16 to 10/26/16, signed by the Physician on 10/5/16 did not include a physician's orders [REDACTED]. Review of the Physician's Interval Visit note for 9/26/16 did not document the Physician's review of the need for Hospice Services. During interview on 10/18/16 at 2:13 PM, the Hospice Registered Nurse (RN) stated that the resident moved into the facility in February 2016 with Hospice services already being provided. The Hospice RN stated that the resident currently receives skilled nursing, social work, music therapy, massage therapy and pastoral services from the Hospice provider. During an interview on 10/19/16 at 10:54 AM, the Registered Nurse (RN #3) Clinical Nurse Manager stated that the medical record should have a signed physician's orders [REDACTED]. 2. Resident #62 has [DIAGNOSES REDACTED]. Review of the MDS completed on 8/6/16 revealed the resident has moderate cognitive impairment, usually understands, and is usually understood. Review of the Admission Record the resident was admitted to the facility on [DATE]. Review of the Medication Review Report with the date range 10/3/16 to 11/3/16, signed by the Physician on 10/5/16 revealed orders for the following medications: [REDACTED] - APAP ([MEDICATION NAME]- a pain reliever/ fever reducer) 325 mg (milligram), give 650 mg by mouth every 4 hours as needed for pain/ elevated temperature - Artificial Tears Solution 1.4% (percent) Instill 1 drop in both eyes every 2 hours as needed for dry eyes - Artificial Tears Solution 1.4% Instill 1 drop in both eyes three times a day (TID) - [MEDICATION NAME] Tablet (blood pressure medication) 100 mg, give 1 tablet by mouth in the morning - Bactrim Tablet (antibiotic) 400-80 mg, give 1 tablet by mouth at bedtime - [MEDICATION NAME] Suppository Insert 10 mg rectally every 24 hour as needed for constipation - [MEDICATION NAME] Tablet (blood thinner) 1 mg, give 0.5 mg tablet at bedtime - [MEDICATION NAME] Tablet 3 mg, give 3 mg by mouth at bedtime. Give along with 0.5 mg to make total dose 3.5 mg - [MEDICATION NAME] Capsule Delayed Release Particles (antidepressant) 60 mg give 1 capsule by mouth one time a day - Fleet Enema 7-19 GM (gram)/118 ml (milliliter), Insert 4.5 ounce rectally every 24 hours as needed for constipation - [MEDICATION NAME] tablet (diuretic - medication used to promote the excretion of urine) 40 mg, give 1 tablet by mouth two times a day - Gas Relief Tablet Chewable, give 125 mg by mouth three times a day for gas pain - Klonopin Tablet (anti-anxiety) 0.5 mg, give 0.5 mg by mouth three times a day - [MEDICATION NAME] Solution (treat constipation) 10 GM/15 ml, give 45 ml by mouth two times a day - [MEDICATION NAME] Tablet (anti-hypertensive) 20 mg, give 20 mg by mouth one time a day - Milk of Magnesia Suspension 1200 mg/15 ml, give 30 ml by mouth as needed for constipation - [MEDICATION NAME] Tablet 5-325 mg (narcotic pain medication), give 1 tablet by mouth four times a day - [MEDICATION NAME] Cream (antifungal) Unit/GM, apply to abdominal fold, groin topically (on the skin) two times a day for excoriated blistered area abdominal fold and groin - Potassium Chloride ER Tablet Extend Release 20 mEq (miliequivalent), give 1 tablet by mouth one time a day - [MEDICATION NAME] S tablet (treat constipation) 8.6-50 mg, give 1 tablet by mouth two times a day - [MEDICATION NAME] Tablet ([MEDICAL CONDITION] hormone replacement) 112 mcg (microgram), give 1 tablet by mouth one time a day - Vitamin C Tablet give 500 mg by mouth two times a day - Vitamin D3 Capsule Unit, give 1 capsule by mouth in the morning starting on the 13th and ending on the 13th every month Further review of the medical record revealed a Pharmacy Consultant Medication Regimen Review (MRR) form with documented MRRs completed on 9/7/16 and 10/6/16. There was no documented evidence of MRRs completed prior to September 2016. During an interview with the Consultant Pharmacist on 11/17/16 at approximately 11:45 AM, the Consultant Pharmacist showed the surveyor his computerized monthly medication review records for Resident #62 from January 2016 through September 2016. The Consultant Pharmacist stated his computerized record are not readily accessible to facility staff. The Consultant Pharmacist stated he did not know where the Pharmacy Consultant MRR form was prior to September 2016 and that is why a new form was started. Interview with the Registered Nurse (RN #3) Clinical Nurse Manager and the Social Worker on 10/18/16 at 1:41 PM revealed no additional documentation of MRRs were available for review. Review of a facility policy and procedure entitled Medication Regimen Review Recommendation and Reports revised August 2008 revealed the report of the Medication Regimen Review should be readily available to the surveyors when requested. Additionally, the report should be kept in a consistent location to facilitate communication of the Pharmacist's findings and recommendation to other members of the interdisciplinary team. 415.22 (a)(1,2,3)

Based on interview and record review conducted during a Standard survey completed on 12/15/15, the facility did not inform the resident's physician or the resident's responsible party when there was a significant change in the resident's physical condition and a need to alter treatment significantly. Two (Residents #106, 346) of 15 residents reviewed for notification of change had issues involving the lack of physician notification of abnormal blood glucose results with symptomatic [DIAGNOSES REDACTED] (low blood glucose/sugar level) according to physician orders [REDACTED].#106). The findings are: 1. Resident #346 has [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED].<) 70 or greater than (>) 250. Review of the Medication Administration Report (MAR) dated 12/2015 revealed accurate transcription of the 12/3/15 order to monitor blood glucose levels before meals and at bedtime and to notify the physician of a blood glucose <70 or of the 12/3/15 physician Review of a Physician's Telephone Order dated 12/3/15 at 8:45 PM revealed an order to administer a one time dose of 12 units of Humalog (fast acting) insulin subcutaneously (under the skin) one time for a blood glucose of 357. A Physician's Telephone Order dated 12/3/15 at 8:43 PM directed to administer a one time dose of 6 units of [MEDICATION NAME] (slow acting) insulin subcutaneously and to recheck the blood glucose at 2:00 AM Review of a Nursing Progress Note dated 12/4/15 at 6:17 AM revealed that the resident's blood glucose was 64 at 2:00 AM and the resident was cool and clammy. The resident was given juice and a sandwich. There was no documentation that the Physician was contacted regarding the blood glucose of 64. Additional review of the MAR indicated [REDACTED]. Review of Nursing Progress Notes dated of 12/4/15 revealed there was no documentation that the Physician was notified of the blood glucose of 259. Interview with RN #5 on 12/14/15 at approximately 9:00 AM revealed if it wasn't documented that she contacted the Physician regarding the blood glucose of 64, then she didn't do it, and she would have documented in the Progress Notes. Interview with LPN #1 on 12/14/15 at approximately 10:15 AM revealed if she called the Physician or the Nurse Practitioner (NP) regarding the resident's blood sugar of 259, she would have documented it in the Progress Notes. Interview with the RN Resident Care Coordinator (RN #3) on 12/14/15 at approximately 10:30 AM revealed she expects her staff to call the Physician if blood glucose levels are not within the parameters. Interview with the Director of Nursing (DON) on 12/15/15 at approximately 9:00 AM revealed she expects staff to follow the parameters, notify the Physician, and it should be documented in the Progress Notes. Review of a policy and procedure entitled Notification of a Significant Change in Condition dated 6/26/15 revealed the patient's/ resident's provider will be notified promptly when the resident experiences a significant change in condition. 2. Resident #106 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS -a resident assessment tool) dated 10/17/15 revealed the resident has severe memory impairment, usually understands, and is understood. Review of a Nursing Progress Note dated 11/13/15 revealed the resident had bright red blood in the urine and the Physician was notified. There was no documentation that the resident's family was notified. Review of a Physician's Telephone Order dated 11/13/15 revealed an order to obtain a urine culture. Review of a Urine Culture and Sensitivity Report dated 11/13/15 revealed the urine culture was positive for > (more than) 100,000 cfu/ml of Proteus Mirabilis (bacteria). Review of a Physician's Telephone Order dated 11/16/15 revealed an order for [REDACTED]. Review of a Physician's Telephone Order dated 11/18/15 revealed an order to discontinue the [MEDICATION NAME] Capsule 250 mg by mouth three times a day and start Keflex (antibiotic) 250 mg by mouth three times a day for five days for a UTI. Review of the 24 Hour Nurse Report Sheets dated 11/11/15 to 11/25/15 revealed no documented evidence that the family was notified of the change in the resident's condition and the plan to begin antibiotic therapy. Further review of Nursing Progress Notes dated 10/26/15 to 11/22/15 revealed on 11/18/15 the Physician was in to see, orders reviewed and renewed, N.O. (new order) to D/C (discontinue) [MEDICATION NAME] and start Keflex 250 mg one by mouth three times a day for 5 days (15 doses) for UTI, pharmacy notified, daughter notified of the change in antibiotic. During an interview on 12/9/15 at 2:25 PM, the resident's daughter stated I was notified of a change in antibiotic, but was never informed about my Mom's change in condition resulting in a urinary tract infection. The resident's daughter stated she was not aware that the resident had blood in her urine (on 11/13/15), was diagnosed with [REDACTED]. During an interview on 12/14/15 at 10:56 AM, RN #2 stated I would expect the family to be notified if someone had a urinary tract infection. I believe the family needs to be updated when there is a change in behavior or a change in diagnosis. Interview with the DON on 12/15/15 at 8:38 AM revealed When changes in a resident's condition occur such as a fall, illness or significant change, I expect the nurses to update the Kardex and the family. 415.3(e)(2)(ii)(b)(c)

Based on observation, interview and record review conducted during the Standard survey completed on 12/15/15 the facility did not ensure that services provided or arranged by the facility were provided by qualified persons in accordance with each resident's written plan of care. One (Resident #106) of 13 residents observed for care plan implementation was not provided geri gloves (white cloth gloves) and proper footwear as planned. The finding is: 1. Resident #106 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 10/17/15 revealed the resident has severe memory impairment, usually understands, and is understood. Review of the comprehensive care plan (CCP) revised 11/15/15 revealed the resident has focus problems related to bruising easily, high risk for falls, and a history of skin tears. CCP interventions include plans to apply geri gloves at all times to both arms, provide padded boots in bed, and ensure that the resident is wearing appropriate footwear - shoes. Review of the CNA (Certified Nurse Aide) Kardex (guide used by staff to deliver care) dated 12/11/15 revealed instructions for the resident to wear geri gloves at all times to both arms; provide padded boots in bed, and ensure that the resident is wearing appropriate footwear - shoes. Observation of morning care, in the presence of the Registered Nurse (RN#2) Unit Manager on 12/14/15 at 11:17 AM, revealed the resident was in bed, lying in a supine position (on her back), with large blue padded boots on both feet and not wearing geri gloves as per the plan of care. During an observation of a bed to wheel chair transfer using a Sara Lift (standing lift) on 12/14/15 at 11:50 AM, two CNAs (#2 and 3) positioned the resident on the left side of the bed, positioned the yellow transfer sling around the resident, and attached the sling to the lift. The CNAs began to transfer the resident into the wheelchair and requested that the resident hold onto the steering hand grips with both arms exposed and place her feet wearing the large blue padded booties on the foot support of the Sara Lift. The CNAs proceeded to raise the controls on the lift. During the observation, the RN Unit Manager interrupted the transfer to stop the CNAs from proceeding any further. During an interview on 12/14/15 at 11:51 AM, the RN Unit Manager stated I would not want her to wear the booties to transfer because her feet would slip, it would be unsafe for her to transfer with those booties on. Further observation on 12/14/15 at 11:56 AM revealed that CNA #2 checked the Kardex provided to her by the RN Unit Manager, she replaced the large blue padded booties with the resident's shoes, and attempted to place the resident's feet on the foot support of the lift. The CNAs then transferred the resident to the wheelchair with the resident holding onto the steering hand grips, with no geri gloves on her arms. Interview with CNA #1 on 12/14/15 at 12:06 PM revealed I do not normally get this resident up, I usually check the Kardex before I start doing care. I should have made sure the geri gloves were on as they protect the skin. Interview with the RN Unit Manager on 12/14/15 at 12:16 PM revealed I was concerned with the transfer with the booties on, that's why I stopped them. CNA #1 should have read the Kardex prior to starting. I would expect someone with frail skin to have their geri gloves on prior to a transfer. Interview with the Manager of Rehab (rehabilitation) Services on 12/15/15 at 8:37 AM revealed I know the resident has shoes. The Kardex indicates that the blue padded booties are to be worn in bed. I would interpret that this would not include for transfers. Interview with the Manager of Rehab on 12/15/15 at approximately 11:00 AM revealed she moved the intervention for proper footware - shoes to the Transfer section of the Kardex. Interview with the Inservice Coordinator on 12/15/15 at 10:28 AM revealed I would expect someone to have geri gloves on prior to a transfer as per the plan of care. 415.11(c)(3)(ii)