Every finding on record at Medina Memorial Hospital SNF

Based on interview and record review conducted during the survey, the facility failed to ensure there were services of a Registered Nurse for at least eight consecutive hours, seven days a week, unless waived. Specifically, the facility did not have eight consecutive hours of Registered Nurse coverage on 05/24/2026, 05/31/2026, 06/07/2026, and 06/20/2026, and the facility did not have a waiver.The findings include:The Facility Assessment Tool, last updated 2/21/2026, documented the facility was licensed to provide care for 30 residents, and the average daily census was 29-30. The attached document titled Nursing Department Staffing Guidelines, last updated March 15,2024, documented they required one Charge Registered Nurse for 30 residents.The facility policy and procedure titled RN Staffing for [NAME] Memorial Hospital SNF documented a Registered Nurse will be scheduled to be on the skilled nursing facility unit for eight consecutive hours per day, seven days a week.Review of the daily staffing sheets from 05/17/2026 through 06/20/2026, revealed there was no Registered Nurse scheduled to work on 05/24/2026, 05/31/2026, 06/07/2026, and 06/20/2026.During an interview on 06/22/2026 at 11:40 AM, the Director of Nursing stated they were responsible for staffing and making the nursing schedule for the skilled nursing facility. They stated there was not a Registered Nurse designated to the skilled nursing facility on 05/24/2026, 05/31/2026, 06/07/2026, and 06/20/2026. The Director of Nursing stated they thought the hospital Registered Nurse supervisor was able to cover for the skilled nursing unit on the dates that there was not a designated charge Registered Nurse.During an interview on 06/24/2026 at 10:15 AM, the Acting Administrator stated they had not been aware there was no Registered Nurse designated to the skilled nursing facility on 05/24/2026, 05/31/2026, 06/07/2026, and 06/20/2026. They stated there should have been a Registered Nurse on the schedule and going forward there would be.10 New York Codes, Rules, and Regulations 415.13 (b)(1)

Based on interviews and record review conducted during a survey, the facility failed to make prompt efforts to resolve grievances for one (Resident #2) of one resident reviewed. Specifically, there was no grievance form filed and there was lack of follow-through and resolution for Resident #2's reported missing property. The findings include: The policy titled Patient Complaint/Grievance Protocol, last reviewed on 4/1/2020 documented the facility was committed to providing the best care possible and recognizes patient satisfaction as an important indicator of quality outcome. Prompt investigation and remedy of complaints will occur. Investigation will occur in a fair and equitable manner to protect the rights and due process of patients. All patient complaints will be responded to orally or in writing. A complaint is a verbal or written concern that in most circumstances can be resolved at the time of the complaint. If a complaint cannot be resolved promptly (within one hour) by staff it is to be considered a grievance. The policy documented a grievance was considered resolved when the patient was satisfied with the actions taken on their behalf. The policy documented when an individual receives a verbal complaint/grievance he or she should explain that the complaint will be investigated and should be documented utilizing an Incident Report. Any response will be provided to complainant as soon as the investigation is completed. The policy titled Resident Rights dated 06/01/2024 documented the facility will ensure the residents are fully informed that the resident had the right to the safeguard of their property and money. Resident #2 had diagnoses which included chronic obstructive pulmonary disease (lung disease), major depressive disorder, and obesity. The Minimum Data Set (a residents assessment tool) dated 06/08/2026 documented the resident was cognitively intact, understood, and understands. The assessment tool documented that it was very important to them to take care of their personal belongings or things.During an interview on 06/17/2026 at 2:40 PM, Resident #2 stated they were missing a Buffalo Bills (a National Football League team) blanket and it was important to them. They stated everyone was aware and a missing property report was completed. Resident #2 stated they have not been given any follow-up to the missing blanket.Review of the monthly Resident Council Meeting Minutes from June 10, 2025-June 9, 2026, revealed staff did not document Resident #2's reporting that they were missing a Buffalo Bills blanket.The SNF (skilled nursing facility) Quality Assessment and Assurance Committee meeting minutes from July 11, 2025-March 13, 2026 did not contain any documentation of Resident #2 reporting they were missing a Buffalo Bills blanket.Resident #2's Progress Notes dated 04/20/2026 to 06/23/2026, did not contain any documentation of the resident reporting they were missing a Buffalo Bills blanket.During a further interview on 06/22/2026 at 11:03 AM, Resident #2 stated the blanket was still missing, it had been missing for about three months, but they could not remember specifically who they notified. They stated they would tell the certified aides and then the aides would tell the nurses. At 11:26 AM, Resident #2 approached the surveyor and stated they now remembered they notified Activity Leader #1 and Housekeeper #1 that the blanket was missing.During an interview on 06/23/2026 at 9:37 AM, the Director of Activities stated the process when a resident's property was missing is they would email the Director of Environmental Services, the Director of Nursing and the Administrator. The Director of Activities stated if missing property was reported at a resident council meeting, then it would be put into the resident council meeting minutes for that month. They stated when a resident reported missing property outside of the resident council meeting then the item would be reported at the Quality Assurance Meeting that meets every two months. The Director of Activities stated any follow up to the missing property would be put into the email chain. The Director of Activities stated they were not aware of any kind of missing property/grievance form that was to be filed at the time of a resident reporting missing property. They stated they were aware that Resident #2 reported a missing Buffalo Bills blanket. In a further interview at 10:50 AM, the Director of Activities stated they could not locate an email chain for Resident #2 missing property and therefore there was no documented follow up. They stated that there should be documented follow-up because residents have the right to have belongings and for psychosocial reasons it was important to have their personal belongings. During an interview on 06/23/2026 at 2:35 PM, the Director of Nursing stated that a missing item would be considered a grievance. They stated when a resident reports a missing item, it was to be brought to the attention of the staff at morning report, the Director of Environmental Services would be notified, and a note would be posted at the nursing station describing the missing item. They stated follow-up for the missing item would be discussed at the Quality Assurance Meeting. The Director of Nursing stated they did not have an official grievance form unless it was for high-cost items such as hearing aids or dentures. The Director of Nursing stated they had no documented follow-up for Resident #2's missing blanket but they should because it was their belongings and probably meant something to them. At 2:49 PM, The Director of Nursing provided the facility's policy for grievances/missing items. They stated after reviewing the policy there was a form to be filed that also had follow-up. They stated the form should have been used for Resident #2's blanket and it was not.During interviews on 06/24/2026 at 8:22 AM, Housekeeper #1 stated within the last month or two, Resident #2 mentioned to them that they were missing a Buffalo Bills blanket. They stated they told the Director of Environmental Service who would follow up on the missing item. They stated they believed the Director of Environmental Services files a form or emails everyone about the item. During an interview on 06/24/2026 at 9:21 AM, Activity Leader #1 stated within the last six months Resident #2 mentioned to them that they were missing a Buffalo Bills blanket. They stated that the process when a resident tells them they are missing personal property would be they would tell the certified nurse aides to keep an eye out for the item and they tell the Director of Environmental Services. Activity Leader #1 stated if a resident told them about a missing item in resident council meeting, then it goes into the minutes for that meeting. If they are told outside of the resident council meeting, then they would just notify the Director of Environmental Services. Activity Leader #1 stated they had been working at the facility for five years and had never filled out a grievance and/or missing property form. Activity Leader #1 stated they would consider Resident #2 missing blanket a grievance.During a telephone interview on 06/24/2026 at 11:01 AM, the Director of Environmental Services stated they recalled Resident #2 missing a Buffalo Bills blanket and it had been missing for a few months. They stated when they receive an email on a missing item they will print off the email and pin it to the cabinet to alert staff to look for the item. They stated they would also include any missing items in their Quality Assurance report and mention the items at the meeting every two months. They stated that it would be up to the Director of Nursing if missing items should be in a report or log, but it is very important for Resident #2 to have their personal belongings.During an interview on 06/24/2026 at 12:51 PM, Social Worker #1 stated they were revisiting the policy on who the grievance officer was, they were not officially the grievance officer, but complaints were usually directed through them. Social Worker #1 stated they were not aware Resident #2 was missing a blanket and there should be documented follow-up to the missing property. They stated documented follow up was important because the residents had a right to be aware of the steps taken to remedy their concern.During an interview on 06/24/2026 at 12:58 PM, the Acting Administrator stated they were the grievance officer through their risk management role at the facility. They stated they were not aware of Resident #2's missing blanket. They stated that they did not have an incident form for Resident #2 missing blanket, and they did not feel it rose the level of a grievance per the facility's policy. The Acting Administrator stated there should have been some sort of documentation for investigation, follow-up and closure for Resident #2's missing blanket.10 New York Codes, Rules and Regulations 415.3(d)(1)(i)(ii)

Based on observation, interview, and record review conducted during the Standard survey completed on [DATE], the facility did not ensure the system developed for advance directives was implemented in a manner that was consistent with residents' wishes for three (Resident #6, #21, and #24) of 16 residents reviewed for advance directives. Specifically, the facility did not ensure that all advance directive identifiers were consistent with the resident's advance directives. Facility staff were utilizing a process that was not consistent with the facilities current documented processes. The findings are: The policy and procedure titled Advanced Directives RHCF (Residential Health Care Facility) dated [DATE] documented the facility is committed to honoring the wishes of their patients' regarding their treatment. The Social Worker will inform the patient and/or health care agent and/or surrogate that the patient has a full code order. The Full Code status will be communicated through the application of a Blue Star sticker on the patient's wristband as well as a Blue Star placed at the head of the patient's bed. For any patient who is unable to or chooses not to wear a wristband and has a DNR order, a licensed nurse will provide education to patients and/or patient representatives that CPR will be initiated until code status is confirmed. 1. Resident #6 had diagnoses including dementia, chronic kidney disease stage 3, and osteoarthritis. The Minimum Data Set (Resident Assessment tool) dated [DATE] documented Resident #6 had moderate cognitive impairment, and advance directives that included do not resuscitate. The Kardex (guide used by staff to provide care) dated [DATE] documented Resident #6 had the advance directive of do not resuscitate. The Medical Orders for Life-Sustaining Treatment (MOLST) dated [DATE] documented a do not resuscitate order. The Order Summary Report dated [DATE] included a physician order for do not resuscitate. During an observation on [DATE] at 12:28 PM Resident #6 was observed in the main dining room, the name band on the resident's wrist did not include a red dot. 2. Resident #21 had diagnoses that included venous insufficiency (improper functioning of the vein values in the leg), heart failure and hypertension. The Minimum Data Set, dated dated dated [DATE] documented Resident #21 was cognitively intact. Review of the Comprehensive Care Plan with date initiated [DATE] documented that Resident #21 had Medical Orders for Life-Sustaining Treatment in place. Interventions include that Resident #21 was a do not resuscitate and do not intubate. Review of the Physician Orders dated [DATE] documented that Resident #21 had a medical provider order for do not resuscitate and do not intubate. Review of the Medical Orders for Life-Sustaining Treatment signed by Resident #21 documented on [DATE] documented that the resident's wishes were to have a do not attempt resuscitation-allow natural death medical providers order. During an observation and resident interview on [DATE] at 3:05 PM, Resident #21 had a red dot sticker on the spine of their medical record paper chart and a red dot sticker on their name placard outside of their door. There was no red dot sticker observed on their name tag that was attached to their wheelchair. Resident #21 stated that their advance directive wishes were to be a do not resuscitate. Resident #21 looked at their name band that was attached to their wheelchair and stated that it did not have a red dot sticker on it and added that it was an old name band. 3. Resident #24 had diagnoses that included dementia, Alzheimer's disease, and chronic obstructive pulmonary disease. The Minimum Data Set, dated dated dated [DATE] documented Resident #24 had severe cognitive impairment. Review of the Comprehensive Care Plan with date initiated [DATE] documented that Resident #24 had advance directives. Interventions include that Resident #24 was a do not resuscitate and do not intubate. Review of the Physician Orders dated [DATE] documented that Resident #24 had a medical provider order for do not resuscitate and do not intubate. Review of the Medical Orders for Life-Sustaining Treatment signed by Resident #24's health care proxy on [DATE] documented that the resident's wishes were to have a do not attempt resuscitation-allow natural death medical providers order. During on observation on [DATE] at 2:55 PM, Resident #24 had a red dot sticker located on their name band that was attached to their wheelchair and a red dot sticker on the name placard outside of their bedroom door. Resident #24 spine of their medical record paper chart did not have a red dot sticker. During an interview on [DATE] at 9:15 AM, Registered Nurse #2 stated resident code status identifiers were a red dot on the residents' name band, red dot on spine of chart, and a red dot on the door placard for residents with a do not resuscitate status/order. During an interview on [DATE] at 10:52 AM, Certified nursing assistant #1 stated residents wear bracelets with codes on them, red is do not resuscitate but was unsure what the red dot on the door placard meant. During an interview on [DATE] at 10:52 AM, Charge Nurse Registered Nurse #1 stated advance directive status can be found in the electronic medical record, the Medical Orders for Life-Sustaining Treatment. Additionally, for a resident with a do not resuscitate there were red dots on the spine of chart, name band, and door placard. During an interview on [DATE] at 12:36 PM, the Interim Director of Nursing stated they were unsure of the color codes without looking at a graph, but there would be an identifier on the resident's name band and spine of chart. If all identifiers were not accurate, there was the possibility a resident's code status wishes would not be honored. During an interview on [DATE] at 1:19 PM, the Administrator stated the advance directive policy and procedure dated [DATE] was the current advance directive policy. They stated they were aware of red dots on the resident name bands, door placards, and spines of chart signifying do not resuscitate but were unaware of where the red dot process originated. 10NYCRR 400.21

Based on observation, interview and record review conducted during a Standard survey completed on 5/24/24, the facility did not ensure residents were free from physical restraints imposed for purposes of discipline or convenience that were not required to treat the resident's medical symptoms, used for the least amount of time and document ongoing re-evaluation of the need for restraints for three (Resident #9,23, and 24) of three residents reviewed for physical restraints. Specifically, Residents #9, #23 and #24 had no assessments for the initiation or ongoing re-evaluation of the continued use of position change alarms. Additionally, there were no provider orders or notes to address the medical reason that warranted the use of the device. The findings are: The policy and procedure titled Alarm Use dated 11/1/2020 documented position change alarms are defined as chair and bed sensor pads, bedside alarmed mats, and alarms clipped to resident clothing. Position change alarms are never to be used as a restraint. Examples of negative potential or actual outcomes which may result from the use of position change alarms as a physical restraint include loss of dignity, bowel and bladder incontinence and sleep disturbance. The State Operational Manual issued 2/3/2023 defines position change alarms as alerting devices intended to monitor a resident's movements and emits an audible signal when a resident moved in certain ways. Additionally, a position alarm may limit a resident's movement when the resident was afraid to move to avoid setting off the alarm. 1.Resident #9 had diagnoses including depression, anxiety and atrial fibrillation (irregular heart rhythm). The Minimum Date set (resident assessment tool) dated 4/21/2024 documented the resident was understood, understands and was cognitively intact, an extensive assist of one person for ambulation and transfers and a bed/chair alarm was used daily. During an observation on 5/21/24 at 12:04 PM Resident #9 was observed in the main dining room in their wheelchair with an alarm on the seat of the wheelchair and the alarm box hanging from the wheelchair handle. During an observation on 5/22/24 at 2:05 PM Resident #9 was observed in their recliner in their room, feet were elevated with the alarm on the seat of the recliner and the alarm box was placed on the overbed table next to the recliner. During an observation on 5/23/24 8:38 AM Resident #9 was in their room in their wheelchair with the alarm box hanging from the wheelchair handle. During the observations, Resident #9 did not exhibit any unsafe movements or attempts to transfer self from the recliner or wheelchair. The comprehensive care plan dated 4/17/24 documented the resident was at risk for falls due to vision and hearing problems and adjustment to a new facility. Interventions included resident uses a pad alarm, and to ensure the device was in place at all times, initiated on 4/12/2024. Review of the interdisciplinary Progress Notes and provider notes dated 4/15/2024-5/23/2024 revealed no documented evidence that Resident #9 was assessed for, or consent was given for the use of the alarm. The current Physician Orders dated 4/15/2024 did not include documentation of an order for alarms. During an interview on 5/23/2024 at 8:43 AM, Resident #9 stated the blue box on the back of their wheelchair was an alarm, so they didn't get up and they thought it was in the seat of the wheelchair. Resident #9 stated they were getting used to the different sounds when it went off. Resident #9 stated it was on when they were in bed and if they moved around in bed too much it would go off and wake them up and they did not like that it woke them up. Resident #9 could not recall how long they have had the alarm and did not know why the alarm was being used. During an interview on 5/24/2024 at 8:49 AM, Certified Nursing Assistant #3 stated Resident #9 used the alarm because they were a fall risk. They were not sure why the resident had an alarm and did not believe the resident had fallen in the past and did not think the resident needed the alarm. During an interview on 5/24/2024 at 8:54 AM, Licensed Practical Nurse #3 stated Resident #9 used chair and bed alarms because they self-transferred a lot and was unsure if the resident had a history of falls. Licensed Practical Nurse #3 stated the resident has only been here a short time and I believe the alarm was initiated on admission. 2.Resident #23 had diagnoses including dementia, peripheral vascular disease (poor circulation of the lower extremities), and hypertension. The Minimum Data Set, dated dated dated [DATE] documented the resident had severe cognitive impairment, required substantial/maximal assistance (helper does more than half the effort) with sit to stand transfer, had not experienced any falls since the prior assessment, and a bed/chair alarm was used daily. During an observation on 5/20/2024 at 12:08 PM, Resident #23 was observed sitting in a recliner at the nurse's station. A chair alarm was observed clipped to the back of the resident's shirt. During an observation on 5/22/2024 at 10:41 AM, Resident #23 was observed sitting in a recliner at the nurse's station. A chair alarm was observed clipped to the back of the resident's shirt. During an observation on 5/23/2024 at 11:51 AM Resident #23 was observed sitting in a recliner at the nurse's station. A chair alarm was observed clipped to the back of the resident's shirt. An interview was attempted at that time, and Resident #23 was unable to verbalize their name or the reason for the alarm. During the observations, Resident #23 did not exhibit any unsafe movements or attempts to transfer self from the recliner. The comprehensive care plan initiated 3/31/22, documented the resident was at risk for falls due to confusion. Interventions included alarm on at all times was initiated on 2/20/2023. The Kardex (care guide) dated 5/24/2024 included alarm on at all times. The current Physician Orders dated 5/24/24 did not include documentation of an order for alarms. Review of the interdisciplinary Progress Notes, Assessments, and Provider Notes from 1/1/24 to 5/24/24 revealed there was no documented evidence of an assessment to determine the indication or need for the use of alarms or a consent for the use of alarms. During an interview on 5/22/2024 at 9:50 AM, the Activities Director stated Resident #23 used the alarm for safety, to alert staff if they have attempted to self-transfer. During an interview on 5/23/2024 at 11:58 AM, Certified Nursing Assistant #2 stated Resident #23 utilized the alarm to notify staff if they attempted to self-transfer. During an interview on 5/23/2024 at 1:27 PM, Certified Nursing Assistant #4 stated Resident #23 utilized the alarm to alert staff if they attempted to get up from the recliner because they were unsteady with ambulation. Certified Nursing Assistant #4 stated Resident #23 had an overall decline in their activities of daily living and they don't try to get up as much as they used to. 3.Resident #24 had diagnoses that included dementia, Alzheimer's disease, and fracture of the left pelvis. The Minimum Data Set, dated dated dated [DATE] documented the resident was usually understood, usually understands, and had severe cognitive impairment. Review of the Comprehensive Care Plan dated 3/4/2023, documented that Resident #24 was at risk for falls related to an unsteady gait and fall with fractured pelvis. Interventions included that Resident #24 was to have an alarm at all times. Review of the Order Summary Report with active orders as of 5/12/2024 revealed no documented evidence of a medical provider's order for Resident #24 to have an alarm. Review of Medical Doctor #1's progress notes from 3/4/2024-5/13/2024 revealed no documentation regarding Resident #24's use of an alarm. Review of the interdisciplinary Progress Notes dated 3/4/2024-5/23/2024 revealed no documented evidence that Resident #24 was assessed for, or consent was given for the use of the alarm. During intermittent observations on 5/21/2024 at 8:37 AM, 5/22/2024 at 9:43 AM, 5/22/2024 at 12:12 PM, 5/22/2024 at 1:31 PM, 5/23/2024 at 8:32 AM, 5/23/2024 at 10:17 AM, 5/23/2024 at 11:52 AM and 5/24/2024 at 8:19 AM, Resident #24 was either sitting in their wheelchair or a recliner chair with an alarm box that was clipped to the chair that had an attached magnet on a string attached to their top. During an observation and interview on 5/21/2024 at 3:39 PM, Resident #24 stood up from their wheelchair in the living space at the nursing station. The chair alarm was still attached to the resident with the alarm box still attached to the wheelchair. The alarm did not sound due to there being enough slack in the string that remained attached to the resident. Registered Nurse #1 approached Resident #24 and assisted them to sit back into the wheelchair. Registered Nurse #1 demonstrated how the alarm sounded by removing the magnetic piece from the alarm box. Registered Nurse #1 stated that Resident #24 had an alarm to alert staff when Resident #24 stood up and that there were many residents on the unit that utilized alarms. During a telephone interview on 5/24/2024 at 9:24 AM, Medical Doctor #1 stated they did not recall if they wrote an order for Resident #24's alarm. Medical Doctor #1 stated that Resident #24 had a fractured pelvis that was not completely healed and hoped the alarm would prevent Resident #24 from further hurting themselves by restricting their movement. During an interview on 5/24/2024 at 10:34 AM, the Administrator stated they could not locate documented evidence that Resident #24 had an order, was assessed for, or had a consent for the use of an alarm. The Administrator stated that Resident #24 alarm was the least restrictive safety intervention to prevent them from falling. During an interview on 5/24/2024 at 9:12 AM, Registered Charge Nurse #1 stated chair and bed alarms were used for residents #9, #23 and #24 because they were at risk for falls. Resident #24 fell and fractured their pelvis and Resident #9 and #23 self-transferred. The interdisciplinary team would discuss the resident's behaviors as a team at the residents quarterly meeting. There were no written assessments because the alarm was not a restraint as it's not restricting the residents for getting up. Families were notified by phone or when they come to visit and see the alarm on the resident. MD was made aware on rounds and there were no orders for the alarms. During an interview on 5/24/2024 at 9:44 AM, the Chief Nursing Officer stated they would expect there to be a reason for the use of the alarm, an assessment, get provider approval and family notification. During an additional interview on 5/24/2024 at 10:49 AM, the Administrator stated the interdisciplinary team would meet and would talk about the reason for the alarm other than that, the charge nurse would know more. 10 NYCRR 415.4(a)(2)(3)

Based on interview and record review conducted during a Standard survey conducted 7/28/22 through 8/2/22, the facility did not use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. Specifically, one of one resident care unit (skilled nursing facility (SNF) independent of the hospital) reviewed for staffing revealed an RN was not scheduled for eight consecutive hours per day on the weekends and holidays for the past four months. The finding is: Review of a facility Policy and Procedure (P&P) titled RN Staffing for [NAME] Memorial Hospital SNF dated 9/1/2020 documented an RN will be scheduled to be on the SNF unit for eight consecutive hours/day, seven days a week. The P&P documented in the event that a RN is not available on the unit for eight consecutive hours/day, seven days a week the SNF will seek a Centers for Medicare and Medicaid Services (CMS) RN staffing waiver. Regardless of the waiver status the hospital RN nursing supervisor will continue to provide care, as needed to the SNF unit, when the SNF RN is not on the unit. 1. Review of the facility Daily Staffing Sheet dated 3/6/22 through 8/2/22 revealed there was no documented evidence that an RN was scheduled for eight consecutive hours, seven days a week in the hospital-based nursing home. The Daily Staffing Sheet revealed that an RN was not scheduled on the unit for eight consecutive hours on the weekends and holidays. During an interview on 8/1/22 at 10:27 AM, RN #1 stated they worked Monday through Friday as the RN Charge Nurse for the SNF. RN #1 stated they did not work on weekends, and they did not have any on-call responsibilities after their working hours. During an interview on 8/2/22 at 10:36 AM, Licensed Practical Nurse (LPN) #1 Nursing Supervisor stated they were responsible for staffing the SNF. LPN #1 stated there was not an RN scheduled on the weekends for the SNF, and the hospital nursing supervisor was responsible for rounding in the SNF. During an interview on 8/2/22 at 11:22 AM, the Director of Nursing (DON) stated there were no SNF RNs scheduled on weekends or holidays. The DON stated the RN building (hospital) supervisors to cover both the hospital and the SNF off-shifts, weekends and holidays. The DON stated their expectation was for the RN building nursing (hospital) supervisors was to round hourly, respond to any emergency situations, and assist on the SNF units as needed. The DON stated that the RN building (hospital) nursing supervisors were not stationed on the SNF unit and would have responsibilities to attend to on the hospital side of the building. During an interview on 8/2/22 at 11:32 AM, the Administrator stated they did not renew the RN 7 days a week for 8 hours a day waiver yearly because they thought the waiver was good from recertification survey to recertification survey. During an interview on 8/2/22 at 12:43 PM, RN #2 stated they were the hospital RN Nursing Supervisor and would were responsible for overseeing the hospital and the SNF on weekends. RN #2 stated they would spend about one to three hours of their workday on SNF duties but were not required to sit on the SNF unit. RN #2 stated they would carry a cellular telephone and the LPN medication nurses would call them when needed. RN #2 stated some of their SNF responsibilities on the weekends would be rounding hourly, ensuring the SNF was staffed, co-signing for insulins, resident assessments, and assisting the staff with resident care when needed. 415.13 (b)(1)

Based on observation, interview, and record review conducted during a Standard survey started 7/28/22 and completed 8/2/22 the facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails. Assess the resident for risk of entrapment from bed rails prior to installation. Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. Specifically, one (Resident #3) of one resident observed for side rail use the facility did not ensure the resident was assessed for the risk of entrapment prior to installation, and ensure risks versus benefits of the bed rails were reviewed with the resident or if applicable the resident's representative on an ongoing basis. The finding is: The policy and procedure (P&P) entitled Bed Entrapment dated 8/29/17 documented to provide a safe environment for all patients and residents within the facility to reduce life- threatening entrapments. On an annual basis the Maintenance Department will complete a bed survey for entrapment on all beds. There was no policy provided by the facility regarding side rail assessments, consents, and risk versus benefits. 1. Resident #3 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- a resident assessment tool) dated 7/28/22 documented Resident #3 cognitively intact, was understood and understands. The MDS under Section P documented the resident did not use side rails. The comprehensive Care Plan (CCP) documented under Limited Physical Mobility- Bed Positioning with a revision date of 6/9/22 Resident #3 prefers bilateral upper handrails. The Certified Nurse Assistant (CNA) Careplan (guide used by staff to provide care) undated documented Resident #3 prefers bilateral upper handrails. During an observation on 7/28/22 at 11:02 AM revealed Resident #3 was asleep in bed with two upper half bed rails in the up position. During an observation on 7/28/22 at 2:03 PM revealed Resident #3 was asleep in bed with two upper half bed rails in the up position. During an observation on 7/29/22 at 11:06 AM revealed Resident #3 was asleep in bed with two upper half bed rails in the up position. During an observation on 8/1/22 at 1:37 PM revealed Resident #3 was asleep in bed with two upper half bed rails in the up position. During an interview on 8/1/22 at 1:40 PM, Certified Nursing Aide (CNA) #1 stated they were not sure why Resident #3 had the two upper half rails up. CNA #1 stated the resident was independent with ambulation and transfers, but will ask for assist assistance if needed. The resident may use then to stand up from the bed. During an interview on 8/1/22 at 2:53 PM, Licensed Practical Nurse Supervisor (LPN) #1 stated they were unaware Resident #3 used two upper half bed rails and did not know what the resident used them for. LPN #1 further stated the bed rails could be considered a restraint and there should be an assessment for the use of the bed rails. During an interview on 8/1/22 at 2:57 PM, Registered Nurse (RN) #1 stated Resident #3 uses the bed rails to get up and to position self in bed. Therapy was responsible for the assessment of the bed rails and an assessment should be completed with every CCP review. During an interview on 8/2/22 at 9:33 AM, the Director of Therapy (Registered Occupational Therapist, OTR) stated we assess for use of functional mobility and the residents need for bed rails, but we don't approve the use for the bed rails, the administrator has to approve the use because it would be considered a restraint. The Director of Therapy further stated Resident #3 has not been assessed for the use of the bed rails and was not aware the resident was using bed rails. During an observation on 8/2/22 at 10:32 AM, the Director of Nursing (DON) stated Resident #3 uses the bed rails to reposition in bed. The resident requested bed rails a long time ago but could not recall why. Nursing would be responsible for assessing for the use of the bed rails and an assessment has not been done. During an observation on 8/2/22 at 11:59 AM revealed Resident #3 was asleep in bed with two upper half bed rails in the up position. 415.12(h)(1)

Based on interview and record review during the Standard survey from conducted from 7/28/22 through 8/2/22, the facility did not provide the appropriate liability and appeal notices to Medicare beneficiaries at the termination of Medicare coverage for three (Residents #11, 17, and 20) of three residents reviewed. Specifically, the facility did not provide responsible party (RP) with a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) and a Notice of Medicare Non-Coverage (NOMNC) (#11), the facility did not provide the resident or RP with a SNF ABN and there was no documented evidence the NOMNC was mailed to RP after telephone contact (#17) and there was no documented evidence the NOMNC was mailed to the RP after telephone contact (#20). The findings are: The Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN Form CMS (Centers for Medicare & Medicaid Services)- (2018) documents Medicare requires skilled nursing facilities (SNFs) to issue the SNFABN to beneficiaries prior to providing care that Medicare usually covers but may not pay for in this instance because the care is considered not medically reasonable and necessary; or considered custodial. The Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS- documents CMS requires that notification of changes in coverage for an institutionalized beneficiary/enrollee who is not competent be made to a representative. If the provider is personally unable to deliver a NOMNC to a person acting on behalf of a beneficiary/enrollee, then the provider should telephone the representative to advise him or her when the enrollee's services are no longer covered. The date of the conversation is the date of the receipt of this notice. Confirm the telephone contact by written notice mailed on that same date. 1. Resident #11 was admitted to the facility under Medicare Part A services with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, a resident assessment tool) dated 2/7/22 documented Resident #11 had moderate cognitive impairment. The facility Health Care Proxy - Decision-Making Capacity Determination signed and dated by the Social Worker 2/14/22, documented the resident lacks capacity. The Facility Beneficiary Protection Notification Review worksheet documented Medicare Part A Skilled Services Episode Start Date: 2/1/22 and Last covered day of Part A Service: 2/26/22. The SNF ABN and NOMNC were signed and dated 2/24/22 by Resident #11. During an interview on 8/3/22 at 8:53 AM the Social Worker (SW) stated Resident #11 lacked capacity when they signed and dated the SNF ABN and NOMNC making the notification invalid. The notices should have been signed and sent to the RP. 2. Resident #17 was admitted to the facility under Medicare Part A services with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident #17 had severe cognitive impairment. The Facility Beneficiary Protection Notification Review worksheet documented Medicare Part A Skilled Services Episode Start Date: 3/2/22 and Last covered day of Part A Service: 3/19/22. The facility was unable to provide evidence the SNF ABN was provided to the RP upon the termination of Medicare Part A services and unable to provide evidence the NOMNC was mailed to the RP the date telephone contact was made to the RP. During an interview on 7/29/22 at 10:52 AM, the Administrator stated the facility did not have a SNF ABN for Resident #17. During an interview on 8/1/22 the SW and Director of Care Management stated a SNF ABN was not issued for Resident #17. The SW stated they were on vacation at the time the notification was required, and the Director of Care Management stated they were unaware a SNF ABN was required. Additionally, the SW stated they reviewed the NOMNC with the RP via telephone and the NOMNC was mailed to the RP. There was no documentation in the electronic medical record (EMR) the NOMNC was mailed to the RP on the date of telephone contact nor was there a certified return receipt of the mailing. 3. Resident #20 was admitted to the facility under Medicare Part A services with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident #20 had severe cognitive impairment. The Facility Beneficiary Protection Notification Review worksheet documented Medicare Part A Skilled Services Episode Start Date: 6/13/22 and Last covered day of Part A Service: 7/1/22. There was no documentation in the electronic medical record (EMR) the SNF ABN and NOMNC were mailed to the RP on the date of telephone contact nor was there a certified return receipt of the mailing. During an interview on 8/3/22 at 8:53 AM, the SW stated they contacted Resident #20's RP via telephone regarding the SNF ABN and NOMNC. Additionally, the SW stated the notices were mailed to the RP. 415.3(h)(2)(iv)

Based on interiew and record review conducted during an Standard survey completed on 1/6/20, the facility did not ensure that all alleged violations including abuse, neglect, exploitation or mistreatment including injuries of unknown origin source, are reported immediately, but not later than two hours later after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury to the Administrator and other officials (including to the State Survey Agency and the Adult Protective Services where state law provides for jurisdiction in long-term care facilities) in accordance with State Law through established procedures. Specifically, one (Residents #26) of one resident reviewed for reporting of alleged violations of abuse were involved in a resident to resident altercation. The incident was not reported timely to the New York State Department of Health (NYSDOH) as required. Resident #11 involved. The finding is: Review of the facility policy and procedure (P&P) titled Policy and Procedure for Reporting Patient/Resident Abuse/Neglect dated 12/27/16 documented any professional or non-professional of the Residential Health Care Facility (RHCF) will ensure that all alleged violations including abuse, neglect, exploitation or mistreatment including injuries of unknown origin source, are reported immediately, but not later than two hours later after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator of the facility and to other officials (including to the State Survey Agency and the Adult Protective Services where state law provides for jurisdiction in long-term care facilities) in accordance with State Law through established procedures. The P&P further documented the term physical abuse shall mean inappropriate physical contact with a nursing home resident which harms or is likely to harm the resident to include but not limited to striking, pinching, kicking and shoving. The term verbal abuse shall mean use of oral, written or gestured language that willfully includes disparaging or derogatory terms that harm or is likely to cause harm to the resident. 1. Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-a resident assessment tool) dated 11/26/19 documented the resident was severely cognitively impaired was understood and understands. Review of the comprehensive Care Plan dated 12/11/19 revealed the resident had potential to be physically aggressive. On 12/10/19 the resident put his hand over another resident's mouth and told her to shut up. Interventions included to keep in eye sight of staff when out of bedroom and check on when in bed every half hour. Review of an Incident Investigation report for Resident #11 dated 12/10/19 at 6:30 PM revealed under Occurrence Category: aggression towards another resident. The resident (#11) was in the dining room after dinner yelling out, a peer (#26) stood and put their hand over Resident #11's mouth and said shut up. Staff immediately intervened and there were no injuries. Review of a Progress Note for Resident #11 dated 12/10/19 at 9:20 PM revealed the resident was in the dining room after the meal yelling out, when peer (Resident #26) stood, leaned over placed their hand on resident's (#11) mouth and stated, shut up. Staff immediately intervened and removed peers' hand (#26) from resident's face (#11). There was no redness, ecchymosis (bruising), or abrasion observed. The nurse removed the peer's hand (#26) and at this time the peer clenched their fist and pulled their arm back indicating they were going to strike the resident (#11) with a closed fist. The nurse intervened again preventing further contact. Review of the untitled physician progress notes [REDACTED].#26 was seen for an acute visit. Resident #26 grabbed another resident (#11) who was yelling on the unit. Resident #26 was was annoyed by the resident (#11). The behavior can be construed as annoying and the response aggravated but not inappropriate with his general disinhibition. Staff have reviewed his care plan and will try to keep them separated. The resident was pleasant during the visit and had no recollection of the incident. During an interview on 1/6/20 at 12:20 PM, the Administrator stated she was aware of the resident to resident incident but unaware that Resident #26 put a hand over Resident #11's mouth. The staff intervened, there was no injury to the resident and that's why it was not reported to the NYSDOH. 415.4(6)(2,4)

Based on observation, record review, and interview completed during the Standard survey completed 1/6/20, the facility did not ensure that a resident with limited range of motion receives appropriate treatment and equipment to prevent further decrease in range of motion. Specifically, one (Resident #5) of one resident reviewed for range of motion (ROM) services was not provided with a palm guard (assistive device that positions the fingers away from the palm) to their right hand as recommended by Occupational Therapy (OT). The finding is: 1. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- a resident assessment tool) dated 11/6/19 documented the resident was severely cognitively impaired, and was rarely/never understood, sometimes understands. Review of the comprehensive Care Plan dated 10/19/18 revealed the resident had an activities of daily living (ADL) self-care performance deficit related to Alzheimer's with periods of agitation, limited mobility and limited ROM with interventions including the resident has contractures of right shoulder with the potential for loss of upper extremity (UE) motion, recommend passive range of motion (PROM) both shoulders and active range of motion (AROM) to elbow, wrist and hands twice a day (BID), right palm guard apply after PROM apply to right UE and throughout the day. The Therapy Evaluation and Treat Order form dated 10/28/19 documented the reason for the evaluation was because the resident holds their right hand in a tight fist and included a [DIAGNOSES REDACTED]. Review PT/OT/ST (Physical Therapy/OT/ Speech Therapy) Recommendations to Caregivers dated 11/12/19 revealed right palm guard was issued to prevent skin breakdown due to resident holds hand/digits in flexed, clenched fist, wear throughout the day. Review or the Order Summary Report dated 12/23/19 revealed no documented evidence for the use of the resident's right hand palm guard. Intermittent observations revealed the following: 1/2/20 7:26 AM the resident's right hand with all five digits pressed against the resident's palm, no palm guard in place. Resident was unable to to open fingers on command. 1/2/20 12:04 PM the resident was in thr dining room for lunch, staff was assisting with the meal, all five digits were pressed against the resident's palm and there was no palm guard in place. 1/3/20 8:46 AM the resident was out of bed to dining room, fully dressed and sleeping in the wheel chair. There was no palm guard to the right hand and the right thumb nail was a half inch long. 1/3/20 12:07 PM the resident was in the dining room for lunch, there was no palm guard in place on the right hand. 1/3/20 1:37 PM the resident was in bed, no palm guard in right hand. During an interview on 1/3/20 at 12:54 PM, Certified Nursing Assistant (CNA) #1 stated she was the resident's aide and was responsible for ROM and applying the resident's splint. The resident refuses PROM and is resistive. The CNA stated she was told the palm guard was discontinued and had not seen it in over a week. During an interview on 1/3/20 at 1:00 PM, Registered Nurse (RN) #1 stated she was unsure if the palm guard was discontinued and would look into it. She was also unsure if an MD order was needed for the palm guard. During an interview on 1/3/20 at 1:07 PM, the Certified Occupational Therapy Assistant (COTA) stated the resident was issued the palm guard when he was discharged from OT recently. The palm guard should be worn all the time accept at night. During an interview on 1/3/20 at 1:10 PM, the Occupational Therapist stated the resident was on therapy from 11/6/19 through 11/27/19. The resident should still be wearing the palm guard, it was not discontinued. If the staff can't find it, they should them know. During an interview on 1/3/20 at 1:17 PM, the Director of Nursing (DON) stated there should be a physician's orders [REDACTED]. During an interview on 1/6/20 at 8:01 AM, the Administrator stated palm guard application was not on the CNA tasks in the electronic medical record (EMR) to be completed, but it is on there now. During an interview on 1/6/20 at 2:01 PM, the Administrator revealed the facility did not have a policy and procedure in place for splint application. 415.12(e)(2)

Based on interview and record review conducted during the Standard survey completed on 1/6/20, the facility did not use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. Specifically, one of one resident care unit (skilled nursing facility independent of the hospital) reviewed for staffing revealed an RN was not scheduled for eight consecutive hours per day on the weekends and holidays for the past four months. Specifically, one of one resident care unit (skilled nursing facility (SNF) independent of the hospital) reviewed for staffing revealed an RN was not scheduled for eight consecutive hours per day on the weekends and holidays for the past three months. The finding is: Review of a facility policy and procedure (P&P) titled RN Staffing for Hospital SNF dated 3/1/19 revealed an RN will be scheduled to be on the SNF for eight consecutive hours/ day, seven days a week. The acute care (hospital) RN Nursing Supervisor will continue to provide care, as needed, when the SNF RN is not on the unit. Review of the facility Daily Staffing Sheet dated 9/1/19 through 12/31/19 revealed there was no documented evidence that an RN was scheduled for eight consecutive hours on weekends and holidays. During an interview on 1/3/20 at 8:55 AM, the RN Unit Manager stated she works Monday through Friday as the RN Unit Manager. The RN Supervisor from the hospital covers Saturday, Sunday, and holidays at the SNF. The hospital Supervisor covers both the hospital and the SNF on those days. During an interview on 1/3/20 at 12:45 PM, the Director of Nursing (DON) stated there are RN building supervisors that cover both the hospital and SNF weekends and holidays. Her expectation was for the supervisors to primarily be present on the SNF Unit as there are more residents on that SNF unit than patients in the other 2 Units (emergency room (ER) and hospital unit). The RN Supervisor would be expected to round those units every 1 to 2 hours, respond to any emergency situations in the building, and assist on the units if needed. In addition, while it is the expectation for the RN Supervisor to focus their time on the SNF Unit, if there was something emergent on the other two units they would of course go there. 415.13(b)(1)

Based on interview and record review conducted during an Abbreviated survey (Complaint #NY 651) completed on 8/29/19, the facility did not use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. Specifically, one of one resident care unit (skilled nursing facility (SNF) independent of the hospital) reviewed for staffing revealed an RN was not scheduled for eight consecutive hours per day on the weekends and holidays for the past five months. The finding is: Review of a facility Policy and Procedure (P&P) titled RN Staffing for Hospital SNF dated 3/1/19 revealed an RN will be scheduled to be on the SNF for eight consecutive hours/ day, seven days a week. The acute care RN Nursing supervisor will continue to provide care, as needed, when the SNF RN is not on the unit. 1. Review of the facility Daily Staffing Sheet dated 3/23/19 through 8/25/19 revealed there was no documented evidence that an RN was scheduled for eight consecutive hours, seven days a week in the hospital-based nursing home. The Daily Staffing Sheet revealed that an RN was not scheduled on the unit for eight consecutive hours on the weekends and holidays. During an interview on 8/29/19 at 8:31 AM, the RN Director of Nursing (DON) stated there are RN building supervisors that cover the hospital and SNF weekends, holidays, and off-shifts. The supervisors' round to all the units (emergency room (ER), SNF, hospital unit) every 1 -2 hours, respond to any emergency situations in the building, and assist on the units if needed. In addition, the DON stated that while it is the expectation the RN supervisor focus their time to the SNF, there are occasions when the supervisor would possibly be pulled away from the SNF. During an interview on 8/29/19 at 10:35 AM, the Administrator stated the expectation of the building supervisor is to dedicate 3:00 AM through 11:00 AM on weekends and holidays to the SNF unit with the exception of a code (an emergency situation in which a patient has an unexpected loss of heart function, breathing and consciousness, requiring a team of providers to begin immediate resuscitative efforts). During an interview on 8/29/19 at 11:26 AM, RN #4 (building supervisor) stated, Administration would like to see us on the SNF unit 3:00 AM through 7:00 AM but that's just not realistic. The ER might be full, there may be admits to the hospital, and we round to all the units every hour. It's just not realistic. During an interview on 8/29/19 at 11:49 AM, RN #5 (building supervisor) stated, I make sure there is adequate staffing, round all the time, I try to spend as much time on each unit as I can. There are no specific times for any unit, I'm all over the building, wherever they need help. 415.13(b)(1)

Based on interview and record review conducted during an Abbreviated survey (Complaint #NY 651), completed on 8/29/19, the facility did not ensure PRN (as needed) orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for appropriateness of that medication for one (Resident #2) of three residents reviewed for unnecessary antipsychotic medications. Specifically, the issues involved the lack of limiting a PRN order for anti-psychotic medication to 14 days and the lack of the attending physician or prescribing practitioner directly examining the resident and assessing the resident ' s current condition and progress to determine if the PRN antipsychotic medication is still needed. The finding is: The policy and procedure (P&P) entitled [MEDICAL CONDITION] Medications RHCF (Residential Health Care Facility) dated 4/1/19 documented a [MEDICAL CONDITION] drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: anti-psychotic; anti-depressant; anti-anxiety; and hypnotic. PRN orders for antipsychotic medications are discontinued automatically after fourteen days unless a shorter duration is specified in the order. PRN orders for antipsychotic medications may not be renewed or reordered unless a prescriber directly [MEDICATION NAME] the resident and documents the effectiveness, benefit, and continued need of the medication. 1. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a resident assessment tool) dated 7/27/19 documented the resident was severely cognitively impaired, was understood, usually understands, and received antipsychotic medication. The MDS documented physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) occurred daily; verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) occurred daily; and other behavioral symptoms not directed toward others (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) occurred daily. Review of a physician's order [REDACTED]. Review of the Medication Administration Record [REDACTED] - [MEDICATION NAME] solution. Inject 1 mg intramuscularly every 8 hours as needed for severe agitation. Start date - 5/10/19. D/C (discontinue) date - 5/29/19. - [MEDICATION NAME] 1mg IM was administered on 5/11/19, 5/14/19, 5/15/19, 5/21/19, 5/25/19, 5/26/19, and 5/27/19. The prn antipsychotic physician order [REDACTED]. Review of a physician's order [REDACTED]. Review of the 5/1/19 - 5/31/19 MAR indicated [REDACTED]. Review of the 6/1/19 - 6/30/19 MAR indicated [REDACTED]. Review of Progress Note dated 5/29/19, authored by Registered Nurse (RN) #1 included, Spoke with primary physician this am regarding residents ' status and medication regime. See new order to continue prn IM [MEDICATION NAME] x 14 days for severe agitation. Review of Multidisciplinary Progress Notes 5/29/19 revealed a lack of evidence of the attending physician or prescribing practitioner directly examining the resident and assessing the resident ' s current condition and progress to determine if the PRN antipsychotic medication is still needed. During an interview on 5/29/19 at 9:42 AM RN #1 stated, I spoke with the physician on the phone about extending the prn [MEDICATION NAME] another fourteen days, he (physician) wasn ' t in that day. During an interview on 8/29/19 at 2:27 PM the Medical Director stated, a prn antipsychotic order cannot be for more than 2 weeks, then would need to evaluate the resident if an antipsychotic is still needed. 415.12(I)(2)(i)

Based on record review and interviews conducted during an Abbreviated survey (Complaint #NY 651) completed on 8/29/19, the facility did not ensure that the Quality Assessment and Assurance (QAA) Committee developed and implemented appropriate plans of action to correct identified quality deficiencies and regularly reviewed, analyzed and acted on available data to make improvements. Specifically, the QAA committee did not ensure that the approved Plan of Correction (P[NAME]) for F727 - RN (Registered Nurse) 8 Hrs (hours)/ 7 days/ Wk (week), Full Time DON (Director of Nursing), cited during the Standard survey completed on 1/22/19 was implemented. The findings are: Refer to F 727 - RN 8 Hrs/7 days/ Wk, Full Time DON - Scope and Severity D. 1. Review of the approved Plan of Correction (P[NAME]) for the Standard survey completed on 1/22/19 revealed the facility identified a correction date of 3/23/19 related to the deficient practices cited under F727 - RN 8 Hrs/ 7 days/ Wk, Full Time DON. The following corrective actions were identified: Review RN staffing policy - policy follows regulatory requirements under F727 stating there will be an RN designated to the SNF (skilled nursing facility) for 8 consecutive hours a day 7 days a week. Education will be provided by DON to staffing scheduler, secretary, Payroll, and RN's who work on the unit regarding RN staffing policy and that a RN will be schedule exclusively for the SNF for 8 consecutive hours per day, including weekend and holidays. The Daily Staffing Sheet will be reviewed for compliance daily during morning report by the Charge Nurse and DON for 1 month and then once a month at administrator/ DON 1:1 meeting. Audit will review that there are 8 consecutive hours of RN coverage 7 days a week including weekends and holidays specific to the SNF unit, results will be reported to the QA Committee who will make further recommendations where needed. The person responsible for compliance was the DON and the alleged completion date was 3/23/19. During an interview on 8/29/19 at 10:35 AM, the Administrator stated, It was communicated to staff that there were designated times the building supervisor was to dedicate to the SNF on weekends and holidays, 3:00 AM through 11:00 AM, with the exception of a code (an emergency situation in which a patient has an unexpected loss of heart function, breathing and consciousness, requiring a team of providers to begin immediate resuscitative efforts). That's the expectation, I would expect that they would be doing it. During an interview on 8/29/19 at 1:57 PM, the Administrator stated, It's in our policy, that's the expectation the RN Supervisor will cover the SNF from 3:00 AM to 11:00 AM on weekends and holidays. We have done audits that review the schedule, payroll, and posted nurse staffing. The DON for the hospital did the in-servicing for the RN supervisors, as they are hospital employees. In addition, the Administrator stated the facility had not conducted any audits as to whether the RN supervisors actually spent eight consecutive hours on the SNF unit weekends and holidays. 415.27(c)(3)(iv,v)

Based on interview and record review conducted during the Standard survey completed on 1/22/19, the facility did not use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. Specifically, one of one resident care unit (skilled nursing facility independent of the hospital) reviewed for staffing revealed an RN was not scheduled for eight consecutive hours per day on the weekends and holidays for the past six months. The finding is: Review of a facility policy and procedure (P&P) entitled RN Staffing dated 9/2015 revealed the Director of Nursing (DON) provides eight hours of administrative and clinical care five days per week. Additional RN nursing hours are provided by the hospital RN supervisory staff on weekends and as needed. 1. Review of the facility Daily Staffing forms dated 7/1/18 through 1/19/19 revealed there was no documented evidence that an RN was scheduled for eight consecutive hours, seven days a week in the hospital based nursing home. The Daily Staffing forms revealed that an RN was not scheduled on the unit for eight consecutive hours on the weekends and holidays. During an interview on 1/15/19 at 12:06 PM, the DON stated she works at least eight hours per day, Monday through Friday. During an interview on 1/16/19 at 12:35 PM, the RN Charge Nurse stated she works Monday through Friday, 7:00 AM to 3:00 PM. During an interview on 1/18/19 at 2:57 PM, the Administrator stated the RN scheduled on weekends and holidays is a house supervisor and splits their time between the nursing home and the hospital. Additionally, the weekend supervisors know this (nursing home) is their primary spot for patients on weekends. During an interview on 1/22/19 at 9:35 AM, RN #3 stated she works as a supervisor on weekends. In addition, she stated, I oversee the function in the hospital, the ER (emergency room ), SNF (skilled nursing facility), and units. I accommodate everyone. RN #3 stated it varies by night as to how much time is dedicated specifically to the nursing home, over there multiple times a shift, at least a couple hours in a twelve hour shift. During an interview on 1/22/19 at 10:12 AM, RN #4 stated, I round all the units, I try to get to North (SNF) for the dinner meal to assist with feeding. I'm over there intermittently during the course of my twelve-hour shift. 415.13 (b)(1)

Based on observation, interview, and record review conducted during the Standard survey completed on [DATE], the facility did not ensure residents who use [MEDICAL CONDITION] drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for one (Resident #22) of three residents reviewed for unnecessary antipsychotic medications. Specifically, the issues involved the lack of implementation of non-pharmacological interventions at the time of a gradual dose reduction (GDR). In addition, the lack of behavior documentation to support the determination of a failed GDR of [MEDICATION NAME] (antipsychotic medication). The finding is: The policy and procedure entitled [MEDICAL CONDITION] Medications RHCF (Residential Health Care Facility dated [DATE] documented a [MEDICAL CONDITION] drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: anti-psychotic; anti-depressant; anti-anxiety; and hypnotic. After every order to start, increase, decrease, or stop a [MEDICAL CONDITION] medication, a nurse will document the resident's status, including the presence or absence of symptoms and side effects, once per shift for two weeks, then once per day for two weeks, reporting any significant change in the resident's condition to the medical staff. The interdisciplinary care team will discuss all residents receiving [MEDICAL CONDITION] medications no less often than every 90 days. These discussions should include: Severity and frequency of target symptom behaviors: [MEDICAL CONDITION] (a mental disorder characterized by a disconnection from reality) delusions (a fixed false belief not shared by others that the resident holds even in the face of evidence to the contrary), hallucinations (the perception of the presence of something that is not actually there. It may be auditory or visual or involve smells, tastes or touch), sadness, loss of interest, anxiety, irritability, apathy, disinhibition, intrusiveness, [MEDICAL CONDITION], impulsivity, care refusal, verbal or physical aggression; Circumstances or signs that lead to the symptoms worsening (triggers), including environmental factors; Current pharmacological and non-pharmacological interventions; Evidence of symptoms or behaviors getting worse; The reasons a drug dose should be changed (increase or decrease) at this time, including a regulatory requirement for a gradual dose reduction. 1. Resident #22 was admitted to the facility [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a resident assessment tool) dated [DATE] documented the resident was cognitively intact, was understood, understands, and received antipsychotic medication. The MDS documented physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) occurred one to three days in the past seven days that did not put the resident or others at significant risk for physical illness or injury, significantly interfere with care, nor interfere with living environment. Review of the physician's orders [REDACTED]. Review of Progress Notes included the following: - [DATE] authored by Activities Director. Assisted resident with cleaning room. Room noted to be full of clutter. Resident not very accepting of help. - [DATE] authored by a Registered Nurse (RN). Resident upset that staff requested to change bedding d/t (due to) soiling. Bed was washed and fresh linens applied. Also, staff attempted to declutter room as much as resident would allow. Review of pharmacist note dated [DATE] revealed the following: BMARC (behavior modification assessment record committee) review of psychoactive medications completed on ,[DATE] by healthcare team. Reviewed resident's use of [MEDICATION NAME] (0.25 mg daily) and [MEDICATION NAME] (anti-depressant) (150 mg daily) for [DIAGNOSES REDACTED]. Resident was on [MEDICATION NAME] (anti-depressant). This was discontinued after her last BMARC review. Per dietician, weights have remained stable. Mood also relatively stable. She has been in pain, mostly due to her recent fall. This is relieved with prn (as needed) [MEDICATION NAME] (medication used to treat moderate to severe pain) (usually used about twice per day). Team discussed resident history. She has been on [MEDICATION NAME] for over ten years. Last GDR of this was one year ago. Resident appears to be stable on current regimen. Since GDR of [MEDICATION NAME] is overdue will request but note that current use, along with use during entirety of stay in RHCF (Residential Health Care Facility), has stabilized mood. Will suggest 0.125 mg daily as an option for GDR and re-evaluate in (MONTH) as a result. Review of the Physician Telephone Orders dated [DATE] revealed an order to decrease [MEDICATION NAME] to 0.125 mg daily. Review of a Progress Notes dated [DATE] authored by the Administrator revealed, this writer approached resident and explained the need for items to be off the floor in the room. Resident with long history of hoarding behaviors and consistent need for staff assistance to manage. Discussed safe environment and regulations that require clear pathways in resident rooms. Asked resident to assist/direct cleaning of items off the floor at this time. Resident upset but stating do what you want - writer explained many of the items on the floor had been dropped, were expired food, napkins used tissues etc. Resident increasingly upset demanding that nothing be thrown out - writer suggested that only true garbage be thrown out - showing resident each item retrieved from the floor. During cleaning efforts writer threw out used Kleenex from the floor at which point resident became irate - grabbed writer by neck and began yelling. Review of the Progress Notes [DATE] through [DATE] revealed there was no documentation of adverse mood/ behaviors by the resident before or after the [DATE] note. Review of the Behavior Summary Report for the weeks ending [DATE], [DATE], [DATE], and [DATE] revealed there was no documented evidence of the following behaviors: abusive language; biting; frequent crying; grabbing; kicking/ hitting; pinching/ scratching/ spitting; pushing; rejection of care; repeats movement; repeats verbalization; sexually inappropriate; threatening behavior; wandering; yelling/ screaming. Review of the 24 Hour Report Sheet Long Term Care revealed there was no documented mood/behaviors by the resident. During an interview on [DATE] at 11:18 AM, RN #1 stated, there weren't any intervention changes at the time of the GDR, we basically just monitored her for any behaviors. She did very well other than her hoarding, she's pretty much been the same. She had the one issue when she grabbed at Administrator, with room cleaning, but had no physical aggression prior to that and no physical aggression since then. We determined the GDR failed through a pharmacy BMARC recommendation. During interviews with the following CNA's (Certified Nurse Aide) revealed: - [DATE] at 11:33 AM, CNA #1 stated, no changes in behavior in the past few months, she did have a change in ambulation after she fell ([DATE]). - [DATE] at 11:35 AM, CNA #2 stated, no real changes in behavior, when I first came here she had just fallen and stayed in her room, she's coming out more getting coffee and socializing. Review of the Physician Telephone Orders dated [DATE] revealed an order to increase [MEDICATION NAME] to 0.25 mg po qd (every day). During an interview on [DATE] at 12:05 PM, the Physician stated, my expectation is when a GDR is attempted the staff is monitoring and documenting the resident behaviors and that the MD is updated to reassess. I don't exactly recall how I was notified of the resident behaviors, I'm assuming on routine rounds but don't specifically recall, my guess would be an informal discussion with staff, and my supposition is behaviors would be documented. During an interview [DATE] at 8:22 AM, the Pharmacist stated, when we do BMARC medications are reviewed, an increase in severity of mood symptoms was described. The failed GDR was determined based on the choking incident and increased behaviors and the physician was hesitant to even attempt the GDR. Interview with the Director of Nursing (DON) RN on [DATE] at 9:25 AM revealed, the [MEDICATION NAME] was changed back to the original dose because the GDR was not a good change ultimately, obviously the behaviors and agitation increased during the GDR. She was very argumentative. 415.12 (1)(I)

Based on interview and record review conducted during the Standard survey completed on 1/22/19, the facility did not electronically submit to CMS (Centers for Medicare and Medicaid Services) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS. One of one facility reviewed for payroll based journal revealed the facility submitted inaccurate information to CMS 7/1/18 through 12/31/18. Specifically, the facility submitted eight hours of Registered Nurse (RN) staffing for weekends and holidays that could not be verified. The finding is: The facility did not provide a policy and procedure (P&P) regarding payroll based journal. Refer to F727 - RN 8 hours/ 7 days a week - Scope and Severity (S&S) = D 1. Review of the facility Daily Staffing forms dated 7/1/18 through 1/19/19 revealed there was no documented evidence that an RN was scheduled for the skilled nursing facility on weekends and holidays. Review of the CASPER Report 1702D for the facility entitled Individual Daily Staffing Report dated 07/01/18 through 12/31/18 revealed the facility reported Registered Nurse with Administrative Duties worked a total of 8 hours on weekends and holidays. During an interview on 1/18/19 at 2:57 PM, the Administrator stated the RN scheduled on weekends and holidays is a house supervisor and splits their time between the nursing home and the hospital. The Administrator also stated the facility claims eight RN hours per twenty-four hours on the payroll based journal for weekends and holidays. During an interview on 1/22/19 at 9:35 AM, RN #3 stated she works as a supervisor on the weekends. I oversee the function in the hospital, the ER (emergency room ), SNF (skilled nursing facility), and the units. I accommodate everyone. RN #3 stated it varies by night as to how much time is dedicated specifically to the nursing home, over there multiple times a shift, at least a couple hours in a twelve-hour shift. During an interview on 1/22/19 at 10:12 AM, RN #4 stated, I round all the units, I try to get to North (SNF) for the dinner meal to assist with feeding. I'm over there intermittently during my twelve-hour shift. RN #4 was unable to give a specific amount of time spent on the SNF weekends and holidays. During an interview on 1/22/19 at 8:17 AM, the Account responsible for submitting the payroll based journal stated all time and attendance information generated from the payroll is manually entered to CMS. An administrative secretary sends the RN supervision schedule so that four hours per twelve-hour supervisory shift can be allocated to the correct employee on weekends and holidays. I take direction from the Administrator, four hours per each twelve-hour supervision shift is reported on PBJ (payroll based journal). I cannot say which four hours, I input the four hours based on the direction of the Administrator. 400.2

Based on interview and record review conducted during the Standard survey completed on 1/22/19, the facility did not ensure that a written summary of the baseline care plan, that included initial goals, a list of current medications, dietary instructions, and services/ treatments to be administered by facility and personnel acting on behalf of the facility, was provided to the resident or the resident's representative. Specifically, three (Residents # 6, 7, 21) of four newly admitted residents reviewed for baseline care plans had no documented evidence that a written summary of the baseline care plan was provided to the resident and/ or the resident's representative by completion of the comprehensive care plan. The findings are: Review of a policy and procedure (P&P) entitled Admission Care Plan Policy for Long Term Care dated 9/1/18 revealed the resident or designated representative will be provided a written summary of the resident's plan of care in a language that is easily understood by the facility Social Worker/ Designee. There will be documentation in the resident's clinical record that the baseline care plan was given to the resident and/or designated representative. 1. Resident #6 was admitted into the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated 11/1/18 documented the resident was severely cognitively impaired, and was sometimes understood and sometimes understands. Review of the Progress Notes dated 4/18/18 through 5/18/18 revealed there was no documented evidence that a copy of the resident's baseline care plan was provided to the resident or the resident's representative. Review of the untitled care plan signature sheet dated 5/9/18 revealed there was no documented evidence that a copy of the resident's baseline care plan was provided to the resident or the resident's representative. During an interview on 1/18/19 at 10:27 AM, Registered Nurse (RN) #1 stated she does not give the resident or the resident's representative a copy of the care plan. She further stated that she thinks it was either the secretary or the Social Worker who provides it. During an interview on 1/22/19 at 8:27 AM, the Unit Secretary stated the nurse provides all the paperwork to the resident or families. I do not do anything like that because I am not here every day on this unit. During an interview on 1/22/19 at 8:30 AM, the Social Worker stated, I put the Kardex care guide on the closet it in the residents' room upon admission. I do not provide the resident or the family with a copy of a care plan. During an interview on 1/22/19 at 8:37 AM, the Director of Nursing (DON) stated, Everyone gets a copy of the care plan. The family gets a copy if they (the resident) are demented. They receive a copy of it yearly and if there was a significant change. It probably is not being done upon admission. The Social Worker is to be providing these copies. During an interview on 1/22/19 at 8:44 AM, the Administrator stated, The Social Worker is to be providing this at the first Care plan meeting either to the representative or the resident. If no one comes to the meeting, it is then mailed out. During an interview on 1/22/19 at 9:47 AM, the DON stated, the Social Worker does not document it anywhere that she provides a copy of the care plan to the resident or the resident's representative. I cannot find it being documented that they received the care plan. 2. Resident #7 was admitted into the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed that the resident is moderately impaired cognitively and is understood and understands. Review of the progress notes dated 5/7/18 through 6/7/18 revealed there was no documented evidence that a copy of the resident's baseline care plan was provided to the resident or the resident representative. Review of the untitled/ undated care plan signature sheet revealed there was no documented evidence that a copy of the resident's baseline care plan was provided to the resident or the resident representative. During an interview on 1/22/19 at 9:47 AM the DON stated, I cannot find it being documented anywhere in the medical record that the resident/ representative received a copy of the care plan. 3. Resident #21 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed the resident was cognitively intact. Review of a comprehensive care plan with a print date of 6/19/18 revealed there was no documented evidence the care plan was reviewed and provided to the resident or resident's representative. Review of the Nursing Progress Notes dated 6/1/18 through 6/30/18 revealed there was no documented evidence the care plan was reviewed or provided to the resident or the resident's representative. Review of the Social Service Progress Notes dated 6/5/18 through 6/30/18 revealed there was no documented evidence the care plan was reviewed or provided to the resident or resident's representative. Review of the Social Services/ CM Initial Interview dated 6/14/18 revealed there was no documented evidence the care plan was reviewed or provided to the resident or resident's representative. During an interview on 1/22/19 at 8:37 AM, the Director of Nursing (DON) stated, Everyone gets a copy of the care plan. The family gets a copy if they (the resident) are demented. They receive a copy of it yearly and if there was a significant change. It probably is not being done upon admission. The Social Worker is to be providing these copies. 415.11(c)(1)

Based on observation, interview, and record review conducted during the Standard survey completed on 1/22/19 the facility did not post accurate and complete nurse staffing information on a daily basis. Specifically, the Daily Staffing sheets did not include the facility name, current date, resident census, the total number and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift. The finding is: 1. Intermittent observations from 1/15/19 to 1/18/19 revealed the Daily Staffing sheet was displayed on a bulletin board across from the nurses' station on the skilled nursing unit. Observations of the Daily Staffing sheets provided by the facility for the dates 1/15/19 through 1/18/19 revealed the following: - Facility name was not on the daily staffing sheet. - The year was missing on the [DATE]th through [DATE]th daily staffing sheets. - The total number and actual hours worked by registered nurse (RN), licensed practical nurse (LPN), certified nurse aide (CNA) was not on daily staffing sheet. - Resident census was not on the daily staffing sheet. Review of Daily Staffing sheets dated 7/1/18 through 1/18/19 revealed facility name, total number and actual hours worked by RN's, LPN's, and CNA's, and resident census are not documented on the sheets. Some of the Daily Staffing sheets document a complete date including the year, while others did not. During an interview on 1/22/19 at 8:56 AM, the Administrator stated, I see what you're saying, I know it's for this facility but how would someone else? It's sloppy without the year. I guess we will be revamping these sheets. The facility did not provide a policy and procedure regarding the posting of nurse staffing information.

Based on interview and record review conducted during the Standard survey, completed on [DATE], the facility did not ensure that SCREEN forms DOH (Department of Health)-695 were completed as required. Five (Residents #9, 15, 20, 30, 31) of nineteen residents reviewed for preadmission SCREENS had issues. Residents #9, 15, and 31 did not have a SCREEN completed prior to admission. Additionally, the SCREEN form was completed by an employee of the facility (#20, 30) and the SCREEN was not signed by the resident or the legal resident representative (#30). The findings include but are not limited to: 1. Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - resident assessment tool) dated [DATE] revealed the resident has moderately impaired cognition. Review of the resident's medical record, including the electronic and paper record, revealed there was no documented evidence that a SCREEN Form DOH-695 was completed prior to the resident's admission to the facility. During an interview on [DATE] at 3:30 PM, RN #3 stated she couldn't find the PASARR (Pre-Admission Screening and Resident Review) and that the Social Worker is working on finding the form. During an interview on [DATE] at 8:00 AM, the LMSW (Licensed Master Social Worker) stated she could not find the resident's SCREEN form, the resident was admitted prior to the Social Worker working in the facility. The Social Worker stated she was calling the county Department of Health to see if they have them. Further interview at 11:28 AM, the Social Worker stated that she didn't have the SCREEN form and that residents do have to come with the SCREEN when they are admitted to the facility. The SCREENs are supposed to go in the chart (paper chart) and when the resident is discharged or deceased the SCREEN's are then scanned into medical records. The Social Worker further stated, I'm thinking of having them scanned into the medical record right away. During an interview on [DATE] at approximately 11:50 AM, the Director of Nursing (DON) stated that new admissions should have them before they come in, we're obviously having issues with this when asked about the SCREEN Form DOH-695. 2. Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has severely impaired for decision making. Review of SCREEN Form DOH-695 dated [DATE] revealed Item 37 of the SCREEN was undated and unsigned by the Patient, Resident, Person and or Legal Representative or Health Care Agent acknowledgement. Interview with the facility LMSW on [DATE] at 12:06 PM revealed, Item 37 should be signed either by the resident themselves or the residents responsible party prior to admission. If unable to obtain a signature, the Qualified Screener should place an explanation for the lack of a signature at Item 37. Further review of the SCREEN form dated [DATE] revealed the facility LMSW signed and dated the form as the Qualified Screener. During the interview with the LMSW on [DATE] at 12:06 PM revealed the LMSW received her Screening Certificate in [DATE]. The LMSW stated she completes the SCREENs at the hospital for residents going to another facility or the facility attached to the hospital with whom she is employed. The LMSW stated her job duties include discharge planning for the hospital and that she completed the SCREEN for Resident #30 as part of her discharge planning duties. The LMSW was unaware whether nursing home personnel should be completing the SCREENs for residents being admitted to the facility with whom they are employed. Review of the state regulation 415.26 included the following: For residents in general hospitals and residing in the community, the SCREEN, as specified in section 400.12 of this Title, performed prior to admission to the nursing home shall not be completed by personnel of a residential health care facility, except where a certified home health agency or other appropriate community-based assessor has been contacted by the resident or the resident's designated representative, for the purpose of completing the SCREEN, and has not completed the SCREEN within 48 hours. 3. Resident #20 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is cognitively intact, is understood and understands. Review of the SCREEN Form DOH-695 dated [DATE] revealed the form was completed by the facility LMSW. During interview on [DATE] at 12:05 PM, the LMSW stated she was trained to complete SCREENs and has a Screening Certificate. The LMSW stated she screens the patients in the hospital for Long Term Care. 400.11 415.26

Based on interview and record review conducted during the Standard survey completed [DATE] the facility did not develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident's rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Three (Residents #6, 20, 31) of 19 residents reviewed for care plan development had issues that involved the lack of care plan development for the use of antipsychotic medications (#6, 20), and Advanced Directives (#31). The findings are: Review of the policy and procedure entitled Care Plans and Procedure for Completing dated ,[DATE] revealed the RN (Registered Nurse) will initiate a plan of care using the nursing process framework and integrate information from various assessments to identify and assign priorities to patient care needs. The plan takes into consideration the total physiologic, psychosocial, and cognitive needs and medical plan of care. Any discipline may identify a problem, but primarily responsibility for review and prioritization rests with the RN in collaboration with the physician. 1. Resident #6 was admitted to the facility [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - resident assessment tool) dated [DATE] revealed the resident has severe cognitive impairment and was administered an antipsychotic medication. Review of a Medication Administration Record [REDACTED]. Review of a [MEDICAL CONDITION] Medication/ BMARC (Behavior Management Review Committee) Note dated [DATE] revealed the use of [MEDICATION NAME] for anxiety with [MEDICAL CONDITION]. Review of the Comprehensive Care Plan (CCP) revised [DATE] revealed the resident uses anti-anxiety medication [MEDICATION NAME]. The care plan was not developed to include the use of [MEDICATION NAME]. During interview on [DATE] at 11:08 AM, RN #3 stated she is part time, but will occasionally do care plan revisions. RN #3 stated that she did not notice the antipsychotic medication was not on the care plan. The RN then stated she does not participate in the care plan meetings or the BMARC review. 2. Resident #20 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is cognitively intact, is understood and understands. Additionally, the resident received antipsychotic medication. Review of the MAR indicated [REDACTED]. Review of the CCP revised [DATE] identified as current revealed there was no care plan developed for the use of [MEDICATION NAME]. During interview on [DATE] at 11:47 AM, the Social Worker stated she is not exactly sure where on the care plan the medication would be documented. Typically, medications are discussed in care plan meetings and then in the BMARC meeting right which is after the care plan meeting. The Social Worker stated she was unsure why the [MEDICATION NAME] did not appear on the CCP. During interview on [DATE] at 12:50 PM, the Director of Nursing (DON) stated she expected the nurses to address [MEDICAL CONDITION] medications and should be on the CCP. The Interdisciplinary Team (IDT) is responsible for care plan development and she expected specific behaviors be addressed and person centered. The DON also stated anyone on the IDT can revise a care plan. 3. Resident #31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident expired in the facility on [DATE]. Review of the MDS dated [DATE] revealed the resident was cognitively intact. Review of the Medical Orders for Life-Sustaining Treatment (MOLST) form signed by the Physician [DATE] included the following: - DNR Order: Do Not Attempt Resuscitation (Allow Natural Death). This means do not begin CPR (Cardio-Pulmonary Resuscitation, artificial ventilation and chest compressions). Review of the care plan, with the closed date of [DATE], revealed the care plan did not address the residents DNR status. Interview with the DON on [DATE] at 1:04 PM revealed it is the responsibility of the nurse or the Social Worker completing the MOLST to ensure the residents Advance Directive status is included on the care plan. 415.11(c)(1)