Every finding on record at Mercy Hospital Skilled Nursing Facility

Based on observation, interview, and record review conducted during the Standard survey completed on 7/24/25, the facility did not ensure: they assessed all residents for risk of entrapment from bed rails prior to installation, they reviewed the risks and benefits of bed rails with the resident or resident representative, obtain informed consent prior to installation, or provide documentation that preventive maintenance was conducted for all bed rails for four (4) (Residents #7, 9, 27, and 50) of four (4) residents reviewed. Specifically, the U Rails were loose and not secure (Resident's #27 and #50); lacked evidence of consent and risks verses benefits; and there was no routine preventative maintenance (Resident #7, 9, 27, & 50). In addition, the U-Rails were installed in error (Resident #50) and not reflected on the care plan (Resident #7 and # 50).The findings are: The policy and procedure titled CBC: Use of U-Rails, dated 4/24/25 documented if a U-Rail is recommended, patient/resident representative will be educated on the risks and benefits of the U-Rail. Informed consent will be documented in the medical record. U-Rails will be documented as a device for aiding mobility. Maintenance/Designee will conduct entrapment zones utilizing the attached U-Rail Assessment Decision Tree. The procedure did not include who was responsible for obtaining consents or the risk benefit education. The Bed Lever (U-Rail) Instruction manual dated December 2018 documented the bed lever should be regularly checked by the carer/user to ensure the setup is correct and it is working as intended for the user. 1. Resident #50 had diagnoses including Alzheimer's, depression, and anxiety. The Minimum Data Set Assessment (a resident assessment tool), dated 5/7/25, documented Resident #50 had severe cognitive impairment, sometimes understood and sometimes understands. The Minimum Data Set documented that Resident #50 was independent for bed mobility and bed rails were not used. The Kardex Report (a guide used by staff to provide care) with the as of date of 7/22/25 did not reflect bilateral U-rails. The comprehensive care plan revised on 4/6/25 documented Resident #50 had repeated falls, poor safety awareness, and was independent with bed mobility. The comprehensive care plan did not document the use of the U Rails. The Physical Therapy Evaluation and Plan of Treatment provided by the facility on 7/22/25 and was dated 11/18/24 documented Resident #50 was independent for bed mobility. There were no recommendations for U-Rails. Review of the electronic medical record revealed there was no U-Rail Assessment Decision Tree for Resident #50. During observation on 7/17/25 at 11:57 AM, Resident #50's bed was positioned up against the wall in their bedroom. The bed had bilateral U-Rails. The right U-Rail moved two to three inches forward and backwards when pressed on and was not secure. During observation on 7/21/25 at 3:17 PM, Resident #50's right U-rail extended two to three inches from the mattress when moved back and forth. During observation and interview on 7/21/25 at 3:44 PM, Licensed Practical Nurse #3 stated Resident #50 used the U-Rail for bed mobility to maintain their independence. Licensed Practical Nurse #3 moved the U-Rail and stated it was crooked and wobbly while moving it back and forth. Licensed Practical Nurse # located the two black bolt knobs located on the inside of the bedframe and attempted to tighten the bolts but was unable to do so. Licensed Practical Nurse #3 stated the loose U-Rail could bust off if pressed on to hard and could cause an injury. Certified Nurse Aide #1 stated the U-Rail was extended outward from the mattress and was a safety hazard. During an interview on 7/21/25 at 4:00 PM, the Assistant Administrator stated U rails were side rails and they were responsible for tracking the U-Rails after Maintenance Staff #2 installed them. The Assistant Administrator measured for entrapment yearly, visually inspected the U-Rails quarterly, and did not know who was responsible for obtaining consent. Maintenance would be responsible to tighten loose U-Rails. There was no routine scheduled maintenance program. During observation and interview on 7/21/25 at 4:02 PM, Maintenance Staff #2 stated the U-Rail was loose and bowed and needed to be replaced. There was no scheduled routine preventative maintenance program for inspection of the U-Rails and there should be to prevent an accident. Resident #50 could have injured themselves with the unsecured U-Rail. The 2025 Resident Room Inspection documentation provided by the facility on 7/22/25 at 8:45 AM documented Resident #50's bed make was by (name of manufacture) and was in new/good condition. There was no evidence the U-Rails had been inspected. During an interview on 7/22/25 at 9:42 AM, Physical Therapist #1 stated U-Rails enhanced independence with bed mobility and assist with getting in and out of bed. They recommended and assessed residents for U-Rails. They verbally discussed consent along with the risks versus benefits for the use of the U-Rails with the resident or representative without specifically documenting their discussions. Unsecured U-Rails would be a concern for entrapment and falls. Physical Therapist #1 could not locate a U-Rail assessment decision tree for Resident #50. They stated therapy did not recommend the U-Rails according to their physical therapy evaluation dated 11/18/24. They stated the U-Rails must have been installed in error on Resident #50's bed. Physical Therapist #1 did not know how long the U-Rails were on Resident #50's bed. During an interview on 7/23/25 at 9:42 AM, the Director of Nursing stated administration kept a record and checked for entrapment yearly. They were unsure if maintenance did routine preventative inspections and would expect staff to report if a U-Rail was loose. They stated there was no documentation in electronic medical record that consent, or education was provided prior to the installation of the U Rails for Resident #50. The U-rails may have been on from a previous resident in Resident 50's room and should have been removed when Resident #50 was admitted into that room. Resident #50 should have never had the U-Rails. During a telephone interview on 7/23/25 at 2:20 PM, the Director of Operations for the U rail company stated the instruction manual was not specific with safety inspections and would expect inspection of the U-Rails at least quarterly to make sure they were secured to the frame and had no loose bolts to prevent injury. During an interview on 7/24/25 at 9:21 AM, Registered Nurse #1 Clinical Nurse Manager stated maintenance was responsible to ensure the U-Rails were secured but anyone could visibly inspect the U-Rails and should tighten them when they were loose. Maintenance should be checking the U-Rails monthly to ensure they were secured and to prevent a potential accident. Registered Nurse #1 did not inspect Resident #50's bed and was unaware Resident #50 should not have had the U-Rails. 2. Resident #27 had diagnoses that included anoxic (without oxygen) brain damage, hemiplegia (paralysis on one side of body), and major depressive disorder. The Minimum Data Set, dated [DATE] documented Resident #27 had moderately cognitively impaired, was usually understood and usually understands. Resident #27 required partial/moderate assist by staff rolling left and right in bed. The Kardex Report with an as of 7/21/25 documented Resident #27 utilized bilateral assistive U-Rails for positioning. Bed mobility: dependent x2 (two staff) for sit to supine, partial/moderate for rolling with use of assistive U-Rails. Provide verbal cues and assist for safety. The comprehensive care plan revised 3/1/2022 documented Resident #27 had limited functional mobility related to traumatic brain injury with left hemiparesis. Interventions revised on 7/21/25 documented Resident #27 was dependent x2 (two staff) for sit supine, partial/moderate assist for rolling with use of assistive U-Rails. Provide verbal cues and assist for safety. Additionally, the comprehensive care plan revised 6/13/25, documented Resident #27 was at risk for falls. Intervention initiated 5/23/24 documented use of bilateral assistive U-Rails for positioning. The Physical Therapy evaluation dated 12/16/24 documented use of assistive U-Rails for rolling with bed mobility. Review of U-Rail Assessment Decision Tree forms dated 8/4/22 - 6/17/25 for Resident #27 revealed there was no evidence that informed consent was obtained and that education was provided on the risks and benefits of the U-Rails. During observations on 7/18/25 at 10:40 AM and 2:16 PM, 7/21/25 at 9:52 AM and 3:05 PM, Resident #27's bed had bilateral U-Rails at the head of the bed. The U-Rail on the left side, was loose, wobbled 2-3 inches, and the 2 screws securing the U-Rail to the bed frame were not secure. During an interview on 7/21/25 at 9:52 AM, Resident #27's was out of bed sitting in wheelchair in room and stated the U-Rail kind of gives because it was loose. Resident #27 did not know if anyone was aware of the U-Rail being loose. During an observation and interview on 7/21/25 at 3:07 PM, Certified Nurse Aide #8 stated they were responsible to ensure residents who had U-Rails were able to use them and to assist them with the use of the U-Rails. They stated they were not responsible for putting the U-Rails on the bed but if they were loose, wobble or anything was out of place they would notify the nursing supervisor. They stated it was important to report concerns with the U-Rails to prevent falls, potential serious injuries to the residents or someone else. Certified Nurse Aide #8 observed the U-Rail in Resident #27's room and stated the left U-Rail was very wobbly. They attempted to tighten the screws attaching the U-Rail to the bed frame and were unable to. During an observation and interview on 7/21/25 at 3:21 PM, Licensed Practical Nurse #3 stated U-Rails were utilized by residents to assist with mobility, turning and positioning while in bed. Licensed Practical Nurse #3 stated if a U-Rail were ever loose, they would notify therapy, and/or maintenance to check them. They stated if a resident relied on U-Rails for mobility and they were loose there could be risk of injury with their use. Licensed Practical Nurse #3 stated they were not aware of any loose U-Rails on Unit 3. Upon observation on Resident #27's left U-Rail in room, Licensed Practical Nurse #3 stated the U-Rail did not seem secured, very loose. Resident #27 stated Yes, it is. During an interview on 7/22/25 at 9:42 AM, Physical Therapist #1 stated residents were assessed for the use of U-Rails based on nursing, family request or an observed resident need. They stated U-Rails were utilized to enhance mobility, assist with turning and positioning and getting out of bed. They stated either nursing or they explained to residents' families that the U-Rail bed rail does not prevent falls. Physical Therapist #1 stated the use of U-Rails were reviewed quarterly to determine if use is still appropriate for residents. They stated U-Rail use was discontinued if determined they were no longer appropriate. Physical Therapist #1 stated maintenance installed the U-Rails based on therapy recommendations and that therapy did not maintain the U-Rails. They stated there was nothing documented in the resident's records regarding consent for use and/or on education regarding the risks/benefits of the use of U-Rails. They stated it would be important that education was provided because there were risks with the use of U-Rails, like entrapment, and that they were being utilized for the right reasons. During an interview on 7/24/25 at 9:35 AM, Registered Nurse #1, Clinical Nurse Manager stated they were not aware of any loose, unsecured U-Rails. They stated they would expect staff to report any U-Rail concerns to them so maintenance could be notified. They stated loose U-Rails were a risk for falls, injuries. Additionally, they stated maintenance should be checking U-Rails at least monthly to ensure everything was in working order. 3. Resident #7 had diagnoses that included spinal stenosis (narrowing of one or more areas in your spine most often in upper or lower back), history of falls, and transient cerebral ischemic attack (mini stroke). The Minimum Data Set, dated [DATE] documented Resident #7 was cognitively intact, was understood and understands. Resident #7's bed mobility was documented as supervision. The Kardex Report with an as of date 7/21/25 documented for staff to assist Resident #7 to turn/reposition every two hours, more often as needed or as requested. Bed mobility documented the use of a bed wedge on the left side for positioning per resident request. Ensure resident was lying in the middle of bed. Increase assist as needed. Requires supervision assist with rolling left to right; from a sitting to a lying position and from lying to sitting position. The Kardex Report did not document the use of U-Rails. The comprehensive care plan revised 1/11/2023 documented Resident #7 had limited functional mobility related to weakness and spinal stenosis. Interventions revised on 1/31/25 documented the use of a bed wedge on the left side for positioning per the resident's request. Ensure resident was lying in the middle of bed. Increase assist as needed. On 7/22/25 interventions were revised and included use of assistive U-Rails for bed mobility. The Physical Therapy evaluation dated 11/27/24 documented the use of U-Rails with supervision for lying to sit position and rolling with bed mobility. Physical Therapy evaluation was completed on 1/27/25 at the request of nursing secondary to right sided weakness. Prior level of function for bed mobility was partial/moderate assist with U-Rails. Resident #7's safety awareness was impaired. The evaluation dated 1/27/25 did not document the use of U-Rails for bed mobility. Review of Physical Therapy progress note dated 1/31/25 Physical Therapist #1 documented they re-assessed Resident #7 and they were back to their baseline level of function. Bed Mobility recommendations were documented as supervision with U-Rails. Review of U-Rail Assessment Decision Tree form for Resident #7 dated 2/1/23 - 5/27/25 revealed there was no evidence that informed consent was obtained and that education was provided on the risks and benefits of the U-Rails. During intermittent observations on 7/18/25 at 2:11 PM, 7/21/25 at 9:07 AM and 7/22/25 at 11:13 AM Resident #7's bed had two bilateral bedrails (U-rails) to head of bed that were secure to the bed frame. During an interview and observation on 7/22/25 at 10:19 AM, Physical Therapist #1 stated Resident #7 utilizes U-Rails for bed mobility. Review of Resident #7's comprehensive care plan Physical Therapist #1 stated they had not cared planned for the use of the U-Rails for Resident #7 and should have been. Physical Therapist #1 stated there was no evidence regarding consent for use and/or on education regarding the risks/benefits of the use of the U-Rails for Resident #7. Additionally, they stated a referral was made by nursing requesting U-Rails on 2/1/23. During an interview on 7/22/25 at 10:44 AM, Assistant Administrator/Director of Environmental Services stated bed assessments were completed annually or as needed if a mattress was changed out or if U-Rails were applied to measure for risk of entrapment. They stated there was no routine, preventative maintenance that was completed related to the U-Rails. During an interview on 7/22/25 at 2:59 PM, the Director of Nursing stated they were not sure how often routine maintenance was completed on U-Rails attached to resident's beds. They stated they would expect nursing staff to report any broken items of equipment to the nursing supervisor immediately for resident safety. They stated if a U-Rail was not secured properly, was loose, the U-Rail would not be able to be utilized as indicated and could come off. The Director of Nursing stated that verbal consent was given by resident families, for the use of U-Rails but there was no documented evidence. Additionally, they stated there needed to be a more formal process, uniform way of completing U-Rail assessments to assure risks, benefits and consent for use of U-Rails was completed and documented. 4. Resident #9 had diagnoses including rheumatoid arthritis (a disorder in which the body's immune system attacks itself, primarily in the joints, causing inflammation, swelling, pain and immobility), joint contractures (joints become stiff and unable to move through their normal range of motion) and chronic pain syndrome. The Minimum Data Set, dated [DATE] documented Resident #9 was moderately cognitively impaired, was sometimes understood and sometimes understands. The resident was dependent on staff for bed mobility and bed rail use was not documented on the assessment The Kardex Report with an as of date 7/23/25 documented Resident #9 used bilateral assist U-Rails for positioning. The comprehensive care plan initiated 12/16/24 documented Resident #9 had limited functional mobility related to contractures, weakness and rheumatoid arthritis. The resident utilized U-Rails to roll to the side. The Physical Therapy Evaluation and Plan of Treatment dated 12/16/24 documented rolling left to right with substantial/max assist with U-Rails. Their prior level of functioning was max assist for bed mobility. Review of the U-Rail Decision Tree revealed Physical Therapist #1 assessed Resident #9 for U-Rail safety on 12/18/24. They were requested by a Health Care Agent for a resident who lacks capacity. Physical therapy assessment for ability to use marked with an X resident can use and exit around U-Rail, and marked with an X U-Rail is not a restraint. Resident #9 was reevaluated for safety on 12/31/24, 3/18/24 and 6/17/25. The forms did not include consent or risk benefit education. Review of Resident #9's medical record revealed there was no evidence that informed consent was obtained and that education was provided on the risks and benefits for the use of the U-Rails. During observations from 7/18/25 at 9:18 AM through 7/23/25 at 10:57 AM, Resident #9 was out of bed in a reclining chair in the dining room and TV lounge. Their bed was observed with U-Rails on both sides at the upper portion of the bed. During an interview on 7/23/25 at 9:38 AM, Resident #9 stated they used their U-Rails to turn themselves when staff were providing care. They did not know if they signed a consent or if their family might have and they were unsure if anyone from maintenance checked them. During an interview on 7/23/25 at 9:42 AM, Licensed Practical Nurse #5 they did not know if residents or family had to sign a consent for the use of U-Rails, and they did not think anyone did routine maintenance on the rails. Licensed Practical Nurse #5 stated it was important to maintain the U-Rails because if they became loose the resident could get hurt or even fall out of bed. During an interview on 7/23/25 at 10:45 AM, Certified Nurse Aide #10 stated they had not noticed anyone doing routine maintenance on the U-Rails. Certified Nurse Aide #10 stated it was important to maintain the U-Rails because if they became too loose the resident could get stuck between the rail and the mattress or if it was loose enough, they could lean on it and fall out of bed. During an interview on 7/23/25 at 10:57 AM, Registered Nurse #3 Clinical Nurse Manager stated there was not a routine maintenance schedule for the U-Rails but there should be. They stated it was important because the rails should never get loose enough for staff to notice and report it. The routine maintenance checks could prevent resident injuries due to U-Rails being loose. They did not obtain consents from residents or family, and they did not know if a consent was required prior to using U-Rails. 10 NYCRR 415.12(h)(1)

Based on observation, interview, and record review conducted during the Standard survey completed on 7/25/25, the facility did not provide services consistent with professional standards of care during medication administration for three (3) (#1, #20, and #77) of seven (7) residents observed. Specifically, Registered Nurse #2 administered medications that they had not personally prepared to Resident #1, #20, and #77. The findings are: The policy and procedure titled Medication Administration dated 10/24/24 documented nurses must only administer medications that they have personally prepared. Nurses must remain with the resident until the medication has been taken. The nurse will document administration of each medication in the medication administration record (MAR).1. Resident #20 had diagnoses that included chronic pain, hemiplegia (paralysis on one side of body), and polyneuropathy (peripheral nervous system disorder). The Minimum Data Set (a resident assessment tool) dated 5/14/25 documented Resident #20 was cognitively intact.During an observation on 7/21/25 at 9:11 AM, Registered Nurse #2 was applying a topical substance to Resident #20's left shoulder while they were sitting at the dining room table for breakfast. Registered Nurse #2 then obtained a medication cup from Licensed Practical Nurse #4, whom was at the medication cart, and administer a clear medication cup containing multiple medications to Resident #20. Review of the medication administration record for July 2025, Resident #20 was scheduled to receive Acyclovir 200 milligrams (antiviral), Probiotic 1 capsule (supplement), Vitamin B-Complex 1 tablet (supplement), tramadol hydrochloride (opioid), gabapentin (anticonvulsant) 100 milligrams 2 capsules, extra strength Tylenol (analgesic) 500 milligrams 2 tablets, Voltaren (pain reliever) external gel 1 percent topical to left shoulder in the morning (8 AM and 9 AM).The Medication Administration Audit Report dated 7/21/25, Licensed Practical Nurse #4 documented the administration of Resident #20's scheduled 8:00 AM and 9:00 AM medications on 7/21/25 between 9:06 AM and 9:10 AM. 2. Resident #77 had diagnoses that included dementia, macular degeneration (eye disease) right eye and anxiety disorder. The Minimum Data Set, dated [DATE] documented Resident #77 had moderate cognitive impairment.During an observation on 7/21/25 at 9:13 AM Licensed Practical Nurse #4 gave Registered Nurse #2 a clear plastic med cup of blue liquid. Registered Nurse #2 was observed delivering the med cup of blue liquid to Resident #77 and walking away. Registered Nurse #2 did not observe Resident #77 accept (swish/spit) the blue liquid. Review of the Medication Administration Record for July 2025, revealed Resident #77 had an order for Sodium Fluoride Solution 0.2 percent, one application by mouth two times a day (9:00 AM and 6:00 PM) for oral care. Instructions included to rinse for one minute then spit. Review of Medication Administration Audit Report for 7/21/25, Licensed Practical Nurse #4 documented the administration of Sodium Fluoride on 7/21/25 at 9:12 AM. 3. Resident #1 had diagnoses that included cerebral infarction (stroke), dysphagia (difficulty swallowing), and anxiety disorder. The Minimum Data Set, dated [DATE] documented Resident #1 was cognitively intact.During an observation on 7/21/25 at 2:14 PM, Registered Nurse #2 was at Resident #1's room with clear plastic medication cup, containing medications and applesauce. Licensed Practical Nurse #4 was observed walking away from medication cart in another direction. Registered Nurse #2 entered Resident #1's room and closed the door with medication cup in hand. Review of medication administration record for July 2025, revealed Resident #1 had orders for buspirone hydrochloride (reduce anxiety) 5 milligrams at 2:00 PM, acetaminophen (analgesic) 500 milligrams, 2 tablets three times a day (6:00 AM, 2:00 PM, 10:00 PM), and baclofen (muscle relaxant) 10 milligrams three times a day (9:00 AM, 2:00 PM, 9:00 PM).Review of Medication Administration Audit Report for 7/21/25, Licensed Practical Nurse #4 documented the administration of buspirone, acetaminophen, and baclofen on 7/21/25 at 2:14 PM. During an interview on 7/21/25 at 2:18 PM, Registered Nurse #2 stated they should not have administered medication that were prepared by another nurse. They stated if they did not prepare the medications, they do not know what they were giving. Registered Nurse #2 stated they just brought applesauce to Resident #1 and denied giving Resident #1 medications at 2:14 PM. Registered Nurse #2 stated they should not have administered Resident #20's and Resident #77's morning medications. because the medications were prepared by Licensed Practical Nurse #4. Registered Nurse #2 stated they did not sign for the administration of any medication on 7/21/25. During an interview on 7/21/25 at 2:29 PM, Licensed Practical Nurse #4 stated Registered Nurse #2 was helping them with the medication pass. They stated they were the assigned medication nurse for the unit; had not administered all the residents their medications but documented as the administrating nurse for all the medications. Licensed Practical Nurse #4 stated they prepared Resident #1's 2:00 PM medications in applesauce which included buspirone, acetaminophen, and baclofen. Registered Nurse #2 was present. Licensed Practical Nurse #4 stated they should have administered the medications because they prepared and signed for the medications. Additionally, they stated they could not verify if Registered Nurse #2 administered the medications to Residents #1, 20 and 77. During an interview on 7/22/25 at 2:59 PM, the Director of Nursing stated nurses should not be administering medications that have been prepared by another nurse because they were not following proper medication pass protocols.10 NYCRR 415.12 (l)

Based on interview, observation, and record review conducted during a Standard survey completed on 7/24/25, the facility did not ensure that residents have a right to be treated with respect and dignity, including the right to be free from any physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for one (1) (#30) of three (3) residents reviewed. Specifically, there was a lack of risk versus benefit assessments and informed consents for the alarm; the alarm sounded in the room, and Resident #30 was bothered by the use of the alarm and felt undignified.The findings are: The policy and procedure titled Resident Rights dated 5/20/24 documented that each resident's rights are protected and promoted; that each resident be encouraged and assisted in the fullest exercise of these rights; and are afforded their right to a dignified existence, self-determination, respect, full recognition of their individuality, consideration, and privacy. The policy and procedure titled Restraints dated 11/18/21 documented to provide a restraint free care while protecting resident safety, comfort and well-being; define the types of restraints, identify indications for the rare utilization of resident restraints, outline requirements of alternatives, orders obtained, and to review monitoring and documentation; and to ensure compliance with federal and state requirements for assessment and restraint reduction. The undated document titled Position Change Alarm Decision Making Tree documented the reason for the alarm request, the alternatives used before the alarm implementation, and if the alarm causes stress or anxiety which then would make the alarm a restraint. Interdisciplinary Team shall review use of a Position Change Alarm on a quarterly basis to determine need for continued use.The undated document titled Position Control Device Continued Use Determination documented the reason needed for the alarm and the use of the alarm to prevent injuries or incidents. The undated document titled Interdisciplinary Intervention for Falls Prevention documented that safety alarms such as bed or chair alarms will alarm remotely and not in the resident's room. 1. Resident #30 had diagnoses that included Parkinson's disease and dementia. The Minimum Data Set (a resident assessment tool) dated 6/17/25 documented Resident #30 was moderately cognitively intact, usually understands others, and usually understood by others. The Minimum Data Set documented the resident had a chair alarm that was used daily. The physician orders dated 1/30/25 documented Resident #30 had a chair alarm ordered and that the alarm was to be checked each shift to ensure that it is functioning. The order did not document a medical rationale. The comprehensive care plan dated 1/25/25 revealed Resident #30 was alert with confusion but could make preferences and daily choices known to staff. The comprehensive care plan documented that Resident #30 had falls on 11/2/24,11/29/24, 12/10/24, 12/25/24, 1/4/25, 1/25/25,1/29/25, 2/22/25, 3/18/25, 3/20/25, 4/15/25, 4/20/25, 7/11/25, and 7/22/25. The care plan included the use of the position change alarms. The Treatment Administration Records for January 2025, February 2025, March 2025, April 2025, May 2025, June 2025, and July 2025 revealed the chair alarm (position change alarm) was to be checked for proper functioning every shift. The Position Control Device Continued Use Determination dated 12/5/24 documented the reasons Resident #30 was to have a chair alarm was for self-transfers (transferring themselves from a sitting to a standing position or from a standing position to a sitting position), ambulated on their own, and had a history of falls. A Position Control Device Continued Use Determination dated 7/1/25 documented the indication was self-transfers and ambulation on their own still occurred which required the use of the chair alarm. An observation on 7/22/25 at 12:30 PM revealed a chair alarm pad on Resident #30's recliner chair connected to an alarm box that was connected to the wall. During an interview on 7/22/25 at 12:35 PM, Resident #30 stated that they hated the alarm when it sounded in their room as it was loud, and it bothered them. They stated the alarm was used because of falls. The resident stated they didn't want the alarm because it made them feel like a terrorist. During an interview on 723/25 at 9:30 AM, Certified Nurse Aide #9 stated Resident #30 had complained about the chair alarm. They stated that Resident #30 hated the alarm especially when it sounded in the room. They stated that the sound of the alarm bothered the resident so much the resident had thrown the alarm across the room and had attempted to pull the alarm out of the wall. They stated that they told one of the nurses about it but could not remember who they told. They stated that the alarm could be considered undignified if the resident did not like the alarm and it bothered them. During an interview on 7/23/25 at 10:15 AM, Registered Nurse Unit Manager #3 stated that chair alarms were implemented by nursing when a resident has falls. They stated the Interdisciplinary Team, which included nursing and physical therapy would decide if a resident needed an alarm. They stated that there was supposed to be a quarterly assessment completed for a chair alarm. They stated they weren't sure who would obtain consents from family or the resident for an alarm. They stated they were not aware that Resident #30 chair alarm sounded in the room. Registered Nurse Unit Manager #3 stated the alarm was supposed to alarm at the nurses' station and should activate the call light system. If the alarm sounded and it bothered the resident, it could be a quality-of-life issue. During an interview on 7/23/25 at 12:53 PM, Physical Therapist #1 stated that an assessment for use of the chair alarm should have been done quarterly and there should not have been a 7-month gap between assessments. They stated because Resident #30 had some cognitive deficits and could not be re-educated on the use of call lights that was the reason why Resident #30 had a chair alarm. They stated that nursing implements the chair alarm and that the Interdisciplinary team makes the decision to continue the chair alarm. The team does the assessment at their meetings. That's when a decision would be made to keep an alarm. During an interview on 7/24/25 at 9:30 AM, the Administrator stated assessments for alarms should be done quarterly along with the care plan for a resident. They stated the alarm should sound at the nurses' cart, the nurses' station, or sound with the call light and that it should not sound in the resident's room. They stated they would expect staff to report to the charge nurse or the nurse manager if the alarm was sounding in the resident's room and not in the nurses' station or cart. They stated that staff education was needed to ensure the alarm was not sounding in the room and to report it to someone if it was. They stated the interdisciplinary team was responsible for assessments of alarms and if a resident no longer needed an alarm, it would be removed. During an interview on 7/24/25 at 10:25 AM, the Director of Nursing stated the first time a resident complained about the noise of the alarm, they would expect staff to remove the alarm right away. They stated nursing implements the alarm, and the Interdisciplinary team was to do assessments and the risk versus benefits analysis. They stated nursing or the interdisciplinary team should obtain consents for the alarms from the responsible party or the resident. They would consider undignified if the alarm bothered the resident and it was not removed right away.10 NYCRR 415.4(a)(2)(3)

Based on interview and record review conducted during the Standard survey started on 7/25/22 completed 7/29/22, the facility did not ensure that each resident's drug regimen is free from unnecessary drugs. An unnecessary drug is any drug when used for excessive duration and without adequate indication for its use. Specifically, one (Resident #29) of five residents reviewed for unnecessary medications was treated with an antibiotic for an excessive duration, without adequate indication for its continued use. The finding is: Review of facility policy and procedure (P&P) titled Antibiotic Stewardship, effective 10/2017, documented the Antibiotic Stewardship Program (ASP) will guide safe, appropriate, effective and responsible use of antibiotic agents. The ASP is coordinated interventions designed to improve and measure the appropriate use of antibiotic agents by promoting the selection of the optimal antibiotic regimen including dosing, duration of therapy and route of administration. The ASP Committee will: -Monitor antibiotic resistance patterns and make appropriate changes in antibiotic use guidelines. -Restrict antibiotic use through automatic stop orders and other means as deemed necessary based on quality and safety. -Use the McGeer Criteria, or other evidence-based guidelines and standard procedures aimed at optimizing antibiotic use. 1. Resident #29 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- a resident assessment tool) dated 5/4/22 documented Resident #29 was severely cognitively impaired' rarely/never understood, and was sometimes able to understand others. Additionally, the MDS documented the resident had not had a urinary tract infection ([CONDITION(S)]) in the last 30 days and was receiving antibiotic medication. Review of Urologist Progress Note, dated 3/29/21, documented Resident #29 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] -2/10/21 diagnosed with [CONDITION(S)] (bacteria) and treated with course of [MEDICATION(S)] (antibiotic) -3/19/21 diagnosed with E. Coli (bacteria) initially treated with [MEDICATION(S)] (antibiotic), which was switched to [MEDICATION(S)] (antibiotic). -History of [CONDITION(S)] with two recent infections. Daughter would like to resume low-dose antibiotic prophylaxis. Restart [MEDICATION(S)] 50mg (milligrams) QD (daily) for [CONDITION(S)] prophylaxis. Return in six months for routine follow up. Review of physician Admission History and Physical dated 5/27/21 documented Resident #29 was on [CONDITION(S)] prophylaxis, [MEDICATION(S)] (generic [MEDICATION(S)]-antibiotic medication) 50 milligrams (mg) daily (QD), under the monitoring of urologist. Review of the current Comprehensive Care Plan with a revision date of 3/6/22 documented Resident #29 was incontinent of urine and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included to monitor/document/report signs/symptoms (s/sx) of [CONDITION(S)]: frequency, urgency, malaise (fatigue), foul smelling urine, fever, nausea/vomiting, altered mental status, loss of appetite, behavioral changes. The plan did not reflect a current [CONDITION(S)], or long- term antibiotic use. Review of physician Order Summary Report documented the following: -5/27/21 [MEDICATION(S)] ([MEDICATION(S)]) 50mg QD for [CONDITION(S)] prophylaxis ([MEDICATION(S)]). -9/4/21 [MEDICATION(S)] (antibiotic) 800-160mg one tablet two times a day for [CONDITION(S)] for three days. -3/6/22 [MEDICATION(S)] 800-160mg one tablet two times a day for [CONDITION(S)] for 5 days. -5/23/22 Please obtain urology follow up regarding antibiotic prophylaxis. Review of Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -5/1/21 through 8/30/21 [MEDICATION(S)] 50mg at bedtime for [CONDITION(S)] [MEDICATION(S)]. -9/1/21 through 9/30/21 [MEDICATION(S)] 50mg at bedtime for [CONDITION(S)] [MEDICATION(S)]-Hold 9/4/21 through 9/6/21; [MEDICATION(S)] 800-160mg one tablet two times a day for [CONDITION(S)] for 3 days -10/1/21 through 2/28/22 [MEDICATION(S)] 50mg at bedtime for [CONDITION(S)] [MEDICATION(S)]. -3/1/22 through3/31/22 [MEDICATION(S)] 50mg at bedtime for [CONDITION(S)] [MEDICATION(S)]; [MEDICATION(S)] 800-160mg one tablet two times a day for [CONDITION(S)] for 5 days. -4/1/22 through 7/28/22 [MEDICATION(S)] 50mg at bedtime for [CONDITION(S)] [MEDICATION(S)]. Review of Lab Results Report documented the following: -9/3/21 Urine Culture positive for [CONDITION(S)] Variicola (abnormal) documenting [MEDICATION(S)] resistant to the organism. -3/2/22 Urine Culture positive for E. Coli (abnormal) documenting [MEDICATION(S)] resistant to the organism. Review of provider notes documented the following: -9/6/21 Urine culture collected on 9/3/21 showed [CONDITION(S)] Variicola. The [CONDITION(S)] was sensitive to [MEDICATION(S)], and a three -day course was started. -1/27/22 Resident has been followed by urology and receives [MEDICATION(S)] prophylactically, but staff notes that family does not want any further urology appointments. -3/7/22 Staff has noted some decreased ability to ambulate, with occasional lethargy. A urine culture was positive for E. Coli, and patient has been placed on [MEDICATION(S)] twice a day for five days. Resident remains on [MEDICATION(S)] ([MEDICATION(S)]) for prophylaxis, but this isolate was not sensitive to same. -5/23/22 treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Six month follow up was requested. Plan documented long term drug therapy. Patient does currently receive [MEDICATION(S)] 50mg daily. Requested urology follow up of the same. -6/14/22 There was no documentation regarding urology follow- up. -7/27/22 There was no documentation regarding long term drug therapy, or urology follow up. Review of nursing Progress Notes documented the following: -9/29/21 at 8:15 AM Call placed to resident's daughter. Message left regarding appointment with Urologist tomorrow. This appointment was made to see if resident still needs to take [MEDICATION(S)] daily for [CONDITION(S)] prevention. -9/29/21 11:46 AM Per Assistant Director of Nursing (ADON) resident's urology appointment for tomorrow is to be cancelled. -5/23/22 10:35 PM MD in today for 30 day and annual visit. Resident will need a urology follow up regarding antibiotic prophylaxis. -5/24/22 9:32 AM Resident's daughter called regarding follow up urology appointment. Daughter stated does not want resident to see a urologist. Feels it would be too stressful. Medical Doctor (MD) called and updated. 5/27/22 9:23 AM Spoke with resident's daughter this am. Daughter is following up with resident's urologist. 5/27/22 1:41 PM Progress notes faxed over to unit from Urologist office dated 3/29/21. Placed in MD book. During an interview on 7/27/22 at 3:00 PM, Licensed Practical Nurse (LPN) #1 stated they had called the family regarding urology follow up and the family did not want the resident to go. During an interview on 7/28/22 at 11:00 AM, Registered Nurse (RN) #1 Resident Care Coordinator (RCC) stated if a long- term antibiotic was prescribed by a consultant it has to be approved by the MD. It is not something we like to do. If family refuses a consultant follow up the facility MD would then take it from there. During interview on 7/29/22 at 9:57 AM, the Director of Nurses (DON) stated if the family declined I would expect the RN RCC to be monitoring, but I don't see anything documented other than the family declined when an appointment was scheduled for the resident. There should be a progress note. The Consultant Pharmacist and I look at antibiotic use. We meet monthly, discuss, and have quarterly antibiotic stewardship meetings. Maybe, there should have been discussion about a urology tele-visit. I think after a year of [MEDICATION(S)] antibiotic use we are supposed to reevaluate and follow up with the prescriber. During interview on 7/29/22 at 11:23 AM, the Consultant Pharmacist stated antibiotic use was tracked at interdisciplinary team (IDT) meeting quarterly. Family said no to urology follow- up so we did hold off in January 2022. The MD is very involved and wanted it revisited. It has been discussed at length. Resident #29 was on [MEDICATION(S)] when they were admitted from the community and has had two [CONDITION(S)]'s since admission. During interview on 7/29/22 at 1:10 PM, MD stated Resident #29 came to the facility on [MEDICATION(S)]. [MEDICATION(S)] doesn't guarantee they won't get an infection; the hopes are it will prevent or make it less likely. Ideally, I would defer to urology. Maybe, this would have been a good time for a telehealth visit. The family didn't want to stir things up with the resident, as they don't tolerate perturbation (change). That is less than a perfect answer. I would have hoped to defer to urology and may or may not have documented. I may have been waiting, pending the consult. During interview on 7/29/22 at 1:21 PM, the Urology office RN stated it has been over a year since Resident #29 was seen by the Urologist. If the organism was resistant, to the antibiotic, they would have to evaluate the resident, look in to discontinuing the antibiotic or possibly changing something. The urologist would have to see the resident. If Resident #29 has been on an antibiotic and was still getting [CONDITION(S)]'s there was no benefit to the [MEDICATION(S)]. 415.12(l)(1)

Based on observation, interview and record review conducted during the Standard survey completed on 12/21/18, the facility did not ensure that residents who have not used [MEDICAL CONDITION] drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record and residents who use [MEDICAL CONDITION] drugs receive gradual dose reductions (GDR) and behavioral interventions, unless clinically contraindicated, in an effort, to discontinue these drugs. One (Resident #84) of five residents reviewed for [MEDICAL CONDITION] medications had an issue involving the administration of [MEDICATION NAME] without documentation of behaviors or a specific condition to support the use of the medication. In addition, there was no medical work-up prior to the start of the medication. The finding is: Review of a policy and procedure (P&P) entitled Psychotherapeutic Drug Review dated 5/1/18 revealed the purpose of the policy is to ensure that a patient/resident is not given psychotherapeutic medications (anti-psychotic, anti-depressant, anti-anxiety, sedative/ hypnotic, and psychopharmacologic drugs) unless a comprehensive assessment identifies clear indications of need necessary to treat a specific condition as diagnosed and documented in the medical records and includes parameters for their use. The indication for any [MEDICAL CONDITION] medication will be thoroughly documented in the clinical record to include an appropriate supporting [DIAGNOSES REDACTED]. The medical record must show documentation of adequate indication and diagnosed condition. 1. Resident #84 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 11/26/18 revealed that the resident was cognitively intact, understood and understands. Section E (Behavior) of the MDS revealed the resident had no potential indicators of [MEDICAL CONDITION]. There were no physical behavioral symptoms exhibited, however verbal behavioral symptoms occurred. The resident was not at significant risk for physical illness or injury; there was no significant interference with the resident's care, participation in activities or social interactions and there was no impact on others. Section N (Medications) of the MDS revealed the resident did not receive an antipsychotic medication for the past seven days. Review of the History and Physical, completed by Physician, dated 11/20/18 revealed per the resident's family, the resident had delusions postop. She was placed on 12.5 mg of [MEDICATION NAME] (antipsychotic medication used to treat [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder) which seemed to help her sleep, however she continued to have sun downing (late day worsening of confusion and agitation) as well as anxiety. The MD documented a plan to discontinue the [MEDICATION NAME]; initiate [MEDICATION NAME] (antianxiety medication) at 2:00 PM, monitor her behaviors for the next two weeks and then determine if continuation is needed. The physician suspected that once the resident acclimated to the new facility and was off narcotics, her [MEDICAL CONDITION] would improve. Clinical Physician order [REDACTED]. Review of Medication Administration Records dated 11/2018 and 12/2018 revealed [MEDICATION NAME] 25 mg, 0.5 tablet was administered at bedtime for depression/anxiety from 11/26/18 to 12/18/18. A Psychopharmacological Medication Monthly Monitoring Form (Behavior Charting) dated 11/20/18 to 11/30/18 revealed no behaviors were noted except on 11/22/18 during the 3:00 PM-11:00 PM shift. The 11/22/18 entry identified the behavior as Other with no explanation documented. The Psychopharmacological Medication Monthly Monitoring Form dated 12/1/18 to 12/18/18 revealed no documented evidence of behaviors. Interdisciplinary Progress Notes dated 11/20/2018 through 11/26/2018 revealed there was no documentation of specific behaviors to justify the use of an antipsychotic medication. A Social Work Progress Note dated 11/26/18 documented that the Director of Social Work met with the resident's daughter (Health Care Agent) because she was concerned about her mother's mood and behavior. Per the daughter, the resident had a long history of difficult behaviors and can be combative at times. When the resident was at previous facility, she was put on [MEDICATION NAME] which significantly improved her mood and behavior and really seemed to even her out. The daughter was concerned that the [MEDICATION NAME] was discontinued upon admission to the facility and reported that the resident was very unhappy again, acting out, and very combative with family and companion aides. The family requesting that that the resident be put back on [MEDICATION NAME] as this worked so well for her previously. An untitled Care Plan dated 11/26/18 revealed the resident was receiving a psychotic medication related to BPSD. Medication discontinued upon admission and re-initiated on 11/26/18. A Progress Note, written by the Nurse Practitioner (NP), dated 11/29/18 documented Dementia with behavioral disturbance unstable. Continue [MEDICATION NAME] 12.5 mg by mouth daily at bedtime. During an interview on 12/17/18 at 12:47 PM, the resident was appropriate, and no behaviors were noted. The resident was calm through the interview with no agitation noted. Observation on 12/19/18 at 11:01 AM revealed the resident was walking down the hall using a wheeled walker with a Therapy Aide and followed by a wheelchair. There were no signs of behaviors or agitation. The resident was speaking to staff appropriately with no out bursts. During an interview on 12/19/18 at 11:32 AM, a Licensed Practical Nurse (LPN #1) stated On my shift, she has never been combative or had any behaviors. She has always been pleasant with me. When I would go in and do treatments on her, she has always been pleasant and nice. During an interview on 12/19/18 at 12:03 PM, the Registered Nurse (RN #1) Resident Care Coordinator stated I think we did not have her on the [MEDICATION NAME] on admission. The daughter stated she had been on it at the other facility and requested that she put back on it. Behaviors that she had includes being anxious, resistive to care, and combative at times. We would document these behaviors in the nurses notes and behavior charting book when she has them. I truly feel it was the family who wanted the antipsychotic medication. I have seen her anxious and irritable. But that is it. During an interview on 12/19/18 at 12:26 PM, the Social Worker stated She came to us from another facility and she was put on [MEDICATION NAME] there. When she came here, the doctor chose not to put her back on it and to trial her without it. The family was notified of this and agreed. The daughter came to me a few days after and requested that her mother be put back on the [MEDICATION NAME] because the personal care givers reported to her that they have seen a difference in her attitude and behaviors i.e. yelling, being mean and mood change. The daughter was not happy that the [MEDICATION NAME] was not re-started here. I told her that I would speak to nursing but did not guarantee the medication would be restarted. I also told her that there were a couple of other options they could try and possibly have her be seen by Psych (psychiatry). I spoke to nursing about the discussion with the daughter and they contacted the Nurse Practitioner, who ordered the [MEDICATION NAME]. The daughter also stated that her mother had these mood swings and behaviors all of her life but has never been on anything for them. During an interview on 12/20/18 at 8:32 AM, the Nurse Practitioner stated The resident had been on this medication previously and the family stated she had been well controlled on that medication. I placed her on it partially because the family requested, but also because she was on it before, it was a low dose and she did so well on it. If she hadn't been on this medication before, I would not have chosen this medication for the behaviors, but because she was doing so well I didn't want to change it. It was reported to me that she was having increased anxiety and sun downing-like symptoms. I did not check to see if the behaviors were documented, I assumed the nurses documented the behaviors. During a telephone interview on 12/21/18 at 8:33 AM, the Physician stated A dose of 12.5 mg of [MEDICATION NAME] will not do anything for any types of behaviors like [MEDICAL CONDITION]. The only thing a dose like that would be good for, would be as a sleep aid. Personally, I suspect that dose would not have any effect on her behaviors. That dose is a useless dosage and it would be considered an unnecessary medication. 415.12(l)(2)(i)(a-d)(ii)

Based on interview and record review conducted during the Standard survey completed 9/12/16, the facility did not develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. One (Resident #28) of 16 residents reviewed for comprehensive care plans did not have a care plan developed to address a risk of dehydration for a resident receiving multiple diuretics (medication to promote the excretion of urine) with an elevated BUN (blood urea nitrogen - blood test to determine kidney function and hydration status) level. The finding is: 1. Resident #28 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 7/12/16 revealed the resident is cognitively intact. Review of physician's orders [REDACTED]. Review of Laboratory Reports revealed the resident had an elevated BUN as follows: - 7/28/16 - BUN - 47 (normal 8 - 13 - 8/9/16 - BUN - 40 - 9/6/16 - BUN - 53. Review of the current comprehensive care plan initiated 7/6/16 revealed there was no care plan to address the resident's risk for dehydration. Interview with the Registered Dietitian (RD) on 9/12/16 at 8:30 AM revealed the use of multiple diuretics would put the resident at risk for dehydration and it should be care planned for. 415.11(c)(1)

Based on interview and record review conducted during a Complaint investigation (Complaint #NY 539) during the Standard survey completed on 9/12/16, the facility did not ensure a resident received proper treatment and care for [MEDICATION NAME] (fluids administered in a manner other than through the digestive tract) fluids. One (Resident #32) of one resident reviewed for [MEDICATION NAME] fluids lacked clarification of a Physician's order for hypodermoclysis (infusion of a fluid through a needle under the skin) and the resident received 780 ml (milliliters) of an incorrect fluid over a 12 hour period. The finding is: 1. Resident #32 has [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS - a resident assessment tool) dated 6/10/16 revealed that the resident was mildly cognitively impaired, sometimes understands, and sometimes understood. Review of the facility policy entitled Hypodermoclysis Therapy dated 1/10/12 revealed that recommended solutions for infusion are D5W ½ NS, sodium chloride 0.3%, or 0.9% sodium chloride and that the solution must be [MEDICATION NAME]. 5% [MEDICATION NAME] (D5W) or 10% [MEDICATION NAME] (D10W) must not be used. Review of a Physician's Order dated 4/13/15 at approximately 2:30 PM revealed an order for [REDACTED]. Review of the April 2015 Medication Administration Record [REDACTED]. Review of a Nursing Progress Note dated 4/13/15 at approximately 3:50 PM revealed that orders obtained from the Physician included hypodermoclysis of D5W at 60 ml/ hour for 24 hours. Review of a Medication Variance form dated 4/13/15 at approximately 7:30 PM revealed the resident received D5W ½ Normal Saline (NS) (.45% saline solution) at 60ml/ hour for approximately five continuous hours. The Nurse Practitioner (NP) was notified at approximately 8:30 PM of the error and there were no new orders for the resident. Attached to the Medication Variance was an undated, handwritten note signed by the Director of Nursing (DON) that revealed a timeline of events concerning the fluid infusion. The timeline revealed the resident received D5W ½ NS at 60 ml/ hour from 2:30 PM to 7:30 PM and D5W at 60 ml/ hour from 7:30 PM to approximately 9:00 AM for approximately 12 hours. The total infusion of D5W was 780 ml. Review of a Nursing Progress Note dated 4/14/15 at approximately 4:19 AM revealed hydroclysis therapy continues in R (right) thigh D5W at 60cc(cubic centimeters)hr(hour) and that the site of insertion was healthy with no redness or swelling. Review of a Physician's Order dated 4/14/15 revealed an order clarification: D5W ½ NS at 60 ml/ hour for 24 hours per the MD (medical doctor) 4/13/15 for hypodermoclysis. Review of a Nursing Progress Note dated 4/14/15 at approximately 9:00 AM revealed that the Physician ordered the hypodermoclysis to be discontinued, stat (immediately) CMP (comprehensive metabolic panel), and neurological checks every hour for 12 hours. Review of a Physician Acute Visit note dated 4/14/15 revealed the resident was started on hypodermoclysis, overnight the resident received D5W for a slightly elevated sodium level, and had been ordered 0.9 NS but the D5W was hung. Interview on 9/9/16 at approximately 3:15 PM revealed Registered Nurse (RN) #1 wrote the wrong solution on the Physician's Order, the MAR, and in the Nursing Progress Note. RN #1 stated that D5W ½ NS should have been in those places. RN #1 went to the supply room to obtain the fluid and used D5W to initiate hypodermoclysis. Interview with RN #2 on 9/9/16 at approximately 3:45 PM revealed RN #2 saw that D5W ½ NS fluid was running. She checked the order in three places including the Physician's Orders, the MAR, and the Nursing Progress Note and noted the fluid ordered was D5W. RN #2 stated that she called the DON concerning the order for the hypodermoclysis and that the wrong fluid was hung. RN #2 also stated that she did not obtain a discontinuation order for the D5W ½ NS because it wasn't on her mind. RN #2 stated that she hung D5W fluid to infuse into the resident after the Medication Variance was completed. RN #2 could not remember if the DON told her to call the Physician to clarify the order before hanging the new fluid. Interview with the DON on 9/9/16 revealed that she received a phone call from RN #2 concerning a Medication Variance. The DON asked RN #2 if there was a clarification but could not remember what RN #2 did. The DON stated that she would expect her staff to get a clarification of the Physician's order or at least call the nurse who hung the fluid to find out why they hung that fluid and not the fluid that was on the order. The DON stated that the hand written note with the Medication Variance form was her investigation of the variance. 415.12(k)(2)

Based on interview and record review conducted during the Standard survey completed 9/12/16, the facility did not maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete and accurately documented. One (Resident #13) of 16 residents' medical records reviewed for complete and accurate documentation did not include physician documentation to address the reason for an increased dose of an antidepressant medication for a resident without evidence of increased behaviors. The finding is: 1. Resident #13 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 8/19/16 revealed the resident is cognitively intact. Review of a Medication Review Report revealed a Physician's Order dated 5/21/15 revealed an order for [REDACTED]. Review of a Physician's Order dated 6/22/16 revealed an order for [REDACTED]. Review of an Interval Visit Note dated 6/21/16 revealed the physician documented that the resident was pleasant and cooperative, she does have anxiety at baseline and did have some anxiety today, but did otherwise appear without any evidence of [MEDICAL CONDITION] or acute agitation. Additional review of the Interval Visit Note revealed there was no documentation regarding the need to increase the dose of [MEDICATION NAME] SR. Review of Physician's Progress and Interval Visit Notes dated 4/8/16 through 9/8/16 revealed there was no documentation of behavior changes to support the increased dose of [MEDICATION NAME] SR. Review of Psychopharmacological Medication Monthly Monitoring Forms dated 5/16/16 through 8/31/16 revealed there was no documentation of increased behaviors. Review of A Note to Attending Physician/Prescriber form dated 7/7/16 revealed the Consulting Pharmacist documented Please ensure documentation supporting increased dose of [MEDICATION NAME] as appropriate.The Physician signed the form and documented that he reviewed the recommendation and NNO (no new orders). Interview with the Director of Nursing (DON) on 9/9/16 at 12:45 PM revealed she had just contacted the Physician and the Physician's plan is to increase the dose of [MEDICATION NAME] SR in an effort to decrease the [MEDICATION NAME]. The DON stated that the Physician did not believe he documented the reason in his 6/2016 Progress Note and he would fax the documentation to the facility. Interview with the Pharmacist on 9/9/16 at 1:15 PM revealed he was not aware of a plan for a Gradual Dose Reduction (GDR) of [MEDICATION NAME] while increasing the [MEDICATION NAME] SR. The Pharmacist stated that as as of 9/9/16, there had not been a reduction in the [MEDICATION NAME]. Review of a faxed addendum to the 6/21/16 Interval Visit Note, dated 9/9/16, revealed the Physician documented that the resident's Depression was stable and pharmacy recommendations were reviewed. However, [MEDICATION NAME] can be used to help maintain focus. I increased the [MEDICATION NAME] with the goal being to review patient's anxiety and focus over time, and then try to wean the [MEDICATION NAME] off at my next interval visit. If patient has been doing well on behavior charting, then a GDR attempt will be appropriate for [MEDICATION NAME] at that time. Interview with the Physician on 9/12/16 at 9:10 AM revealed he planned to decrease the [MEDICATION NAME] on his next visit if the resident's behaviors were stable. 415.22(a)(1,2)

Based on observation, interviews, and record review conducted during the Standard survey completed on 8/6/15, the facility did not ensure that a resident received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Two (Resident #1, 75) of 24 residents reviewed for quality of care had an issues. (Resident #1) involved [MEDICAL CONDITION]-embolism deterrent stockings (TEDS-elastic stockings used to prevent blood clots) not applied per physician's orders [REDACTED]. The findings are: 1. Resident #1 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 5/20/15 revealed the resident is cognitively intact and receives diuretics (medication that increases excretion of water from the body). During an interview with Resident #1 on 8/3/15 at 11:12 AM, the resident stated that her ankles are swollen and she used to wear stockings but she does not like to wear them anymore. Observation during the time of the interview revealed the resident was wearing white socks and sneakers, and her bilateral ankles were swollen, with the right greater than the left. Review of the physician's orders [REDACTED]. During further observation on 8/4/15 at 9:21 AM the resident was sitting in her wheelchair in her room, and not wearing TEDS stockings. Review of the Treatment Administration Record (TAR) dated June 2015 revealed TEDS stockings were circled starting 6/6/15 on the 7:00 AM to 3:00 PM shift. Review of the TAR dated 7/1/15 through 7/31/15 revealed the TEDS stockings were not listed as a treatment. Review of Nursing Progress Notes dated 6/1/15 through 8/1/15 revealed no documentation the resident refused her TEDS stockings or that education was provided to the resident regarding the stockings. Review of Nursing Progress Note dated 7/26/15 at 9:20 PM revealed both lower extremities are very [MEDICAL CONDITION]. There are no further notes addressing the [MEDICAL CONDITION]. Review of the certified nurse aide (CNA) Closet Care Plan last updated 7/27/15 revealed TEDS are to be applied in the morning and removed at night. During an interview on 8/5/15 at 12:05 PM, with the CNA assigned to the resident, the CNA stated the resident has refused to wear her TEDS for a month or two. The CNA stated she informed the nurse about the refusals. During an interview with the Registered Nurse (RN) Resident Care Coordinator (RCC) on 8/6/15 at 8:39 AM, the RN RCC reviewed the July 2015 TAR and stated the TEDS were not listed. The RN RCC stated she was not aware of the resident's refusals; had she known she would have discussed this with the resident and obtained an order to discontinue the stockings. 2. Resident #75 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has severely impaired decision making, is non-ambulatory and requires total care for her activities of daily living. Review of the resident's Care Plan Detail dated 6/16/15 revealed the resident is at risk for pressure ulcers related to in part, the resident's limitations in her mobility. An approach to address this concern is positioning and pressure relieving devices per PT/ OT (Physical Therapy/Occupational Therapy) recommendations. Review of the Closet Care Plan dated 7/30/15 and updated 8/6/15 by PT revealed the resident is equipped with a specialized positioning, Broda chair with additional padding to the foot plate. Elevate leg rests to ensure feet are properly positioned flat on pads. During an observation of Resident #75 in the dining room on 8/3/15 from 12:00 PM through 1:30 PM, revealed the resident was seated in her Broda chair, in an upright position; the foot rest attachment positioned down, below the feet, and the resident's feet are suspended, not touching the footrests. During an observation of the resident in her room on 8/5/15 at 3:01 PM, the resident was seated in her Broda chair, with her legs extended. The foot rest is positioned below the resident's feet approximately two inches, providing only slight foot support, as the resident's feet are noted to be in a plantar-flexed position. Interview with the OT on 8/5/15 at 3:40 PM revealed OT is responsible for positioning concerns for the residents, and for the evaluation of Resident #75's Broda chair, assigned and evaluated in April, 2014. The OT stated since the last annual assessment in September, 2014, the resident has not had a full evaluation, but individual progress notes may have been documented in the Electronic Medical Record (EMR). During an observation of the resident in her room on 8/6/15 at 12:01 PM, revealed the resident was seated in her Broda chair, more in an upright position, watching TV. The resident is seated with the foot rest attachment positioned down, and the resident's feet are not touching the footrests, and it is not supporting the resident's feet. As a result, the resident's feet are in a plantar-flexed position. Review of the resident's MDS assessments revealed two quarterly assessments dated 3/27/15 and 6/19/15. The functional assessment (Section G.-Functional Status) of the resident which includes review of a resident's mobility devices, including a resident's wheelchair (or other seating/ positioning devices), is checked off as reviewed for this resident. Interview with the PT on 8/6/15 at 12:10 PM revealed that the OT is not available today. The PT stated as far as the quarterly assessments conducted by PT and OT, they are the MDS assessments, which reviews the resident's functional status, and range of motion. The PT stated this may include a review of the Medical Records, and staff interview, to determine if there have been any mobility changes, or change of condition for the resident. The PT stated this does not necessary mean the therapist will assess the resident in person, only if a concern is brought to their (OT/PT) attention. Following the interview with the PT regarding the resident's positioning concern (lack of appropriate foot support) on 8/6/15 at 12:05 PM, the PT assessed the resident's positioning in the Broda chair at 12:20 PM. The assessment revealed the resident's foot rests are in the highest position, and the PT notes the feet are unsupported and in a plantar-flexed position. The PT stated the foot rest cannot be situated any higher for this chair, and the foot rest needs to be built up in order to provide support to the resident's feet. The PT stated she will attend to this task in the immediate future. 415.12

Based on interview and record review conducted during the Standard survey completed 8/6/15, it was determined that for one (Resident #46) of three residents reviewed for incidents and accidents, the facility did not rule out abuse, neglect, and mistreatment. The issue includes lack of an investigation regarding a resident who was found unsupervised outside of the building. The finding is: 1. Resident #46 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 6/5/15 revealed the resident is cognitively intact and is independent for locomotion on and off of the nursing unit. Review of the Elopement/ Unsafe Wandering Risk Evaluation dated 4/4/15 revealed the resident's score was 14 which placed him in the category of high risk to wander; has medical [DIAGNOSES REDACTED]. Review of the Occupational Therapy (OT) Progress Note dated 5/13/15 revealed the resident was evaluated for assessment of mobility in his standard wheelchair. The resident expressed a wish to be able to leave the unit for activities and to sit on the patio. Resident was able to self-propel in wheelchair with upper and lower extremities safely, resident was able to press buttons to operate the elevator, self-propel on and off of elevator, and was able to state which floor he lives on. OT updated the certified nurse aide (CNA) Closet Care Plan to reflect independent in self-propelling wheelchair on and off unit, throughout facility, supervision outside of the facility. Review of a Behavior Progress Note written by an Registered Nurse (RN) dated 5/20/15 at 12:54 PM revealed the resident attempted to abscond the building without telling staff at 12:30 PM. The resident wanted to enjoy the sun. Interventions included the CNA stopped the resident prior to leaving the floor and asked where he was going. The resident stated he was going to take off and not come back. The Licensed Practical Nurse (LPN) reminded him to tell staff before he left the floor. The resident stated I do not have to. After the LPN reminded him he agreed to tell staff when he would leave the unit and stated well I am going to the lobby to sit in front of the fireplace. The RN found the resident outside on the sidewalk starting to come back inside the building after deciding it was too cold out. Re-educated the resident to agreement to notify staff and the outcome of notifying the police if the resident could not be found. During an interview with the Administrator on 8/5/14 at 1:45 PM, the Administrator stated no Accident/ Incident Report (A&I) was completed when the resident was found on the sidewalk. During an interview with the OT on 8/5/15 at 2:15 PM who evaluated the resident on 5/13/15, the OT stated the resident was able to use the elevator safely and able to self-propel, was given a lower wheelchair. The OT stated the resident could be independent throughout the facility but required supervision outside. When asked about the elevator in the lobby to exit the building, the OT stated she did not show the resident how to use that elevator and she would expect him to be supervised if he went down that elevator and onto the sidewalk. The OT further stated that recently the Physical Therapist (PT) evaluated the resident and made him supervision off of the unit. During a phone interview with the RN Supervisor on 8/5/15 at 2:51 PM, who found the resident outside on the sidewalk on 5/20/15, the RN Supervisor stated the nurse on the floor informed her the resident left the unit and might leave the building, so she went to find him. The RN Supervisor stated she checked the Activity Room first because he likes to go there then she went to the lobby. She then walked outside and found the resident on the sidewalk right below the patio self-propelling in his wheelchair back into the building. The RN Supervisor stated she re-educated the resident not to go outside alone and that the facility would have to call the police if they could not find him. The RN Supervisor stated she did not fill out an A&I because the resident was coming back into building when she found him. During an interview with the Third Floor RN Resident Care Coordinator (RCC) on 8/6/15 at 8:44 AM, the RN RCC stated the resident just moved to her unit very recently. The RN RCC stated anything that happens out of the ordinary she would add to the Care Plan Detail and complete an A&I the day he was found on the sidewalk. Review of the policy and procedure entitled Occurrence Reporting last revised June 2003 revealed the objective of the policy is to assure that appropriate and immediate intervention is done on the resident's behalf and to prevent the possibility of a re-occurrence. 415.4(b)(3)

Based on observation, interview and record review, conducted during the Standard survey completed 8/6/15, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents. Two (Residents #19, 46) of three residents reviewed for accidents had issues. Resident #46 with wandering behaviors was not placed on the Resident Wanderer list and there was incomplete documentation that every 15 minute checks were completed as planned. In addition, Resident #19's safety devices were not in place as recommended by therapy and per the resident's plan of care. The findings are: 1. Resident #46 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 6/5/15 revealed the resident is cognitively intact and is independent for locomotion on and off of the nursing unit. Review of the Elopement/ Unsafe Wandering Risk Evaluation dated 5/27/15 revealed the resident's score was 12 which placed him in the category of high risk to wander. Comments included resident is now allowed to leave the unit if he alerts staff he is leaving, where he is going, and when he is returning. Review of the Care Plan Detail, last reviewed 6/18/15, revealed the resident is at high risk for falls related to unaware of safety needs, wandering, gait/balance problems. Interventions include 15 minute safety checks (initiated on 3/13/15). Further review revealed the resident has cognitive loss, is alert and oriented to surroundings but demonstrates confusion at times, he wanders and is an elopement risk. Review of the certified nurse aide (CNA) Closet Care Plan, last updated 7/29/15, revealed the resident is confused at times, elopement risk, on 15 minute safety checks and requires supervision off the nursing unit secondary to wandering. Review of the Physical Therapy (PT) Progress Note dated 7/24/15 revealed the resident has been changed this date to require supervision off the nursing unit. Resident has been uncooperative with staff at times with re-direction. He has been leaving the unit without notifying the staff and has mobilized himself to areas around the facility and been unable to find his way back. Therapist spoke with resident this date to educate him regarding his need to be accompanied by a staff or family member when off the unit. The resident acknowledged an understanding of therapists request, nursing staff notified of recommended change. Observation of the Security Desk in the lobby on 8/5/15 at 11:05 AM revealed a list of residents at risk for wandering/elopement, last updated 7/20/15, posted behind the desk. The list did not include Resident #46. During an interview at the time of observation the Head of Security stated he knows Resident #46 and he is accompanied with someone when he comes downstairs. Review of the 15 minute resident safety check sheets dated 7/31/15 through 8/4/15 revealed the checks were not documented as follows: - 7/31 from 3:00 PM to 10:45 PM - 8/1 from 3:30 PM to 11:45 PM - 8/2 from 7:15 AM to 11:45 PM - 8/3 from 7:15 AM to 10:45 PM - 8/4 from 3:00 PM to 11:00 PM Observation of the Security Desk in the lobby on 8/6/15 at approximately 9:00 AM revealed the resident's at risk for wandering/ elopement list was updated to include Resident #46. During an interview with the Administrator on 8/6/15 at 9:26 AM, the Administrator stated she is the person responsible for updating the wanderer list and she should have updated it when the resident was made supervision off the unit. The Administrator stated the 15 minute checks probably do not have to be done as frequently anymore but they should have been signed off that they were done. 2. Resident #19 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is cognitively intact and in understood and understands. Review of an Occupational Therapy (OT) Evaluation and Plan of Treatment dated 10/3/14 revealed recommendations that include a bariatric (severe obesity) wheelchair with the use of a Velcro seat belt, and a Dycem (non- slip material) on the top of the wheelchair seat cushion. Review of the Care Plan Detail dated 6/25/15 revealed the resident is at risk for falls related to; the inability to balance or bear weight unless supported by staff, the resident slides forward in the wheelchair and has a history of falls. Interventions include; a self- release seat belt to be worn when out of bed in the wheelchair and Dycem on top of the wheelchair seat cushion. Review of Closet Care Plan last revised 7/30/15 revealed the resident requires a bariatric wheelchair, Velcro seat belt and a Dycem to wheel chair. Resident observations on 8/5/15 revealed the following; - Approximately 7:40 AM the resident was mechanically transferred by CNA #1 and the Licensed Practical Nurse (LPN) from the bed into the wheelchair. There was no Dycem on or under the wheelchair seat cushion and the Velcro safety belt was not secured. - Approximately 9:00 AM through 9:50 AM the resident was noted to slide her hips forward in the wheelchair and lean forward. - Approximately 11:58 AM the resident was being wheeled by CNA #2 from her room to the dining room with the Velcro belt (strap) unsecured. Resident observations on 8/6/15 revealed the following; - Approximately 9:00 AM through 10:00 AM the resident was observed to be sliding and leaning forward in her wheelchair, and there was no Velcro safety belt (or strap) in place. During an interview with the Registered Nurse (RN) Resident Care Coordinator (RCC) on 8/6/15 at 10:01 AM, the RN RCC stated if the Dycem and seat belt are care planned, the devices should be in place. During a resident observation and an interview with the Therapy CNA #3 on 8/6/15 at 10:08 AM, Therapy CNA #3 was observed to be placing and adjusting a Velcro strap to the resident's wheelchair. Therapy CNA #3 stated the resident recieved a new wheelchair on Monday (8/3/15) and the safety seat belt had not been switched over to the new chair. Therapy CNA #3 went on to say, a temporary Velcro strap was to be used but the strap is too small and cannot be secured properly. Therapy CNA #3 stated she was just placing a larger strap and will let maintenance know the safety belt needs to be changed over to the resident's new chair. Therapy CNA #3 stated the safety belt should have been in place if the resident was in her wheelchair. The resident tends to slide forward in her chair. Observation of the resident on 8/6/15 at approximately 10:25 AM, during a mechanical transfer from the wheelchair into the bathtub, revealed there was no Dycem in place as planned to the top of the wheelchair seat. At the time of the observation CNA #1 pulled out a square piece of Dycem from her pocket and placed the Dycem on the wheelchair seat and stated the Dycem should have been in the residents chair. 415.12(h)(1)(2)

Based on interview and record review conducted during the Standard survey completed on 8/6/15, it was determined one (Resident #46) of 24 residents reviewed for Medical Records, the facility did not maintain Medical Records for each resident in accordance with accepted professional standards and practices that are complete and accurately documented. Specifically, 15 minute resident safety check sheets were not available prior to 7/31/15 and were incomplete from 7/31/15 through 8/5/15. The finding are: 1. Resident #46 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS- a resident assessment tool) dated 6/5/15 revealed the resident is cognitively intact and is independent for locomotion on and off of the nursing unit. Review of the Care Plan Detail last reviewed 6/18/15, revealed the resident is at high risk for falls related to unaware of safety needs, wandering, gait/ balance problems. Interventions include 15 minute safety checks (initiated on 3/13/15). Review of the certified nurse aide (CNA) Closet Care Plan, last updated 7/29/15, revealed the resident is to have 15 minute safety checks completed. Review of the 15 minute resident safety check sheets dated 7/31/15 through 8/4/15 revealed the checks were not documented as follows: - 7/31 from 3:00 PM to 10:45 PM - 8/1 from 3:30 PM to 11:45 PM - 8/2 from 7:15 AM to 11:45 PM - 8/3 from 7:15 AM to 10:45 PM - 8/4 from 3:00 PM to 11:00 PM During an interview with the Director of Nursing (DON) on 8/5/15 at 2:00 PM the DON stated she does not think they keep the 15 minute check sheets for longer than a week, but she would double check. During further interview with the DON on 8/6/15 at 12:54 PM, the DON stated they did not have any 15 minute check sheets prior to 7/31/15, and they do not keep them for longer than a week because they are an internal document. 415.22(a)(1-4)

Based on observation, interview and record review conducted during the Standard survey completed on 9/5/14, the facility did not ensure that a resident received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. One (Resident #1) of 13 residents reviewed for quality of care had issues involving oxygen that was removed during care by certified nurse aides; the lack of a facility policy and procedure for certified nursing personnel to administer/ remove oxygen therapy during resident care; and barrier cream that was not applied to reddened skin after the provision of incontinence care as planned. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy. The findings are: 1. Resident #11 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 7/30/14 revealed that the resident is cognitively intact, understands and is understood. The MDS documented that the resident requires extensive staff assistance for most activities of daily living (ADLs) and was identified at risk for pressure ulcers. a.) Review of physician's orders [REDACTED]. by inhalation to treat [MEDICAL CONDITION]) 0.083% inhalation, give one unit dose via nebulizer four times a day for asthma; and [MEDICATION NAME] (drug by inhalation to treat lung disease) MDI (metered dose inhaler) 90 microgram inhaler two puffs every 4 to 6 hours as needed. physician's orders [REDACTED]." Review of the MOLST form dated 7/28/14 revealed the resident signed a consent for comfort measures to be used to relieve pain and other symptoms and reduce suffering, and oxygen, suctioning and manual treatment of [REDACTED]. An Acute Visit physician progress notes [REDACTED]. Review of an Interval Visit physician progress notes [REDACTED]. The Assessment/ Plan documented that the resident had recent pneumonia and the resident was at risk for pneumonia "which could be a life-threatening illness." Review of an Acute Visit Progress Note, written by the Nurse Practitioner (NP), dated 8/29/14 revealed the resident was seen at staff request for cough, congestion and shortness of breath. A chest x-ray revealed the resident had a pleural effusion (excess fluid build-upp around the lungs) and congestion at the left base. The Assessment/ Plan documented "continue with "O2 2L NC" Review of physician's orders [REDACTED]. Review of physician's orders [REDACTED]. Review of the untitled Electronic Comprehensive Care Plan printed on 9/2/14 and identified as current, revealed the resident has asthma and [MEDICAL CONDITION], with a revision on 8/10/14 for pneumonia diagnosed by x-ray with planned interventions to obtain a pulse oximetry (the measurement of the amount of oxygen in the blood) reading every shift. An additional revision on 8/28/14 documented that the resident had increased shortness of breath and increased [MEDICAL CONDITION] (swelling due to an accumulation of fluid) in the left lower extremity. A repeat chest x-ray revealed a left lower lobe infiltrate (pneumonia) and cardiomegaly (enlarged heart) with planned interventions to obtain vital signs (blood pressure, temperature, pulse, respiratory rate), monitor intake/ output every shift, administer medications as ordered, and apply oxygen as ordered. Observation on 9/4/14 at approximately 8:30 AM revealed a Licensed Practical Nurse (LPN) entered the resident's room to administer a breathing treatment via face mask. The resident was in semi-fowlers (a back lying position with the head of the bed up at 30 degrees) position prior to and after administration of the treatment and was wearing oxygen via the nasal cannula. The resident had a respiratory rate of of approximately 20 to 24 breaths per minute (normal 12-20), the resident had a loose non-productive cough. Observation on 9/4/14 at approximately 9:05 AM revealed two certified nurse aides (CNAs #1, #2) entered the resident's room to provide care for the resident, who was in bed in a semi-fowler's position. The resident was breathing at a rate of approximately 24 to 26 breaths per minute and was wearing oxygen via the nasal cannula at 2 L/minute . The CNA stated that the resident was "congested" and having problems breathing and prepared to transfer the resident to the bathroom upon the resident's request. CNA #1 removed the oxygen via nasal cannula and the two CNAs transferred the resident from the bed to the wheelchair and transported the resident to the toilet. Immediately upon transfer to the wheelchair, the resident's breathing became labored, her facial color became ashen, and her breathing pattern became progressively labored and faster during the observation. CNA #2 noted the resident's respiratory distress and stated she needed to get the nurse to put the oxygen back on. In addition, the resident stated she was nauseous and coughed up a copious amount of yellow and clear phlegm in a wash basin. At 9:24 AM, the RN Resident Care Coordinator (RCC) entered the room and placed the oxygen back on the resident. The RN RCC did not obtain a pulse oximetry reading prior to resuming the oxygen. Review of a Progress Note, written by the RN RCC, dated 9/4/14 at 10:21 AM revealed the CNA informed the RN RCC that the resident became short of breath during morning care. The RN RCC documented that she applied O2 at 2 L/ minute via nasal cannula, the pulse oximetry was 93% (normal 90 to 100%)on nasal oxygen, the resident continues on antibiotics for pneumonia, and respirations were 40 to 44 breaths per minute. There was no documentation that the RN was informed of the productive cough and nausea. Additional observation on 9/4/14 at 10:59 AM revealed two CNAs (#2, #3) transferred the resident from the toilet to the wheelchair and the resident was not wearing oxygen. The resident's breathing was labored, skin ashen and the respiratory rate was approximately 36 breaths per minute with the use of accessory muscles. After approximately two minutes, CNA #2 put the resident's nasal oxygen on when the resident was sitting in the wheelchair. Interview with the LPN Medication Nurse on 9/4/14 at 11:07 AM revealed that only nursing staff can put oxygen on the resident; however, CNAs can reapply the oxygen if they have to remove the oxygen for care. The LPN Medication Nurse stated there is no facility policy/ process for having the nurses remove oxygen for care; the CNAs can remove it as long as they do not touch the dials on the oxygen machine. The LPN stated if a resident is having difficulty breathing and the pulse oximetry falls below 90, the nurses will instruct the CNAs not to take off the oxygen. The LPN stated that the resident's pulse oximetry level was "okay" after her breathing treatment in the morning prior to her care and she had a nonproductive cough. The LPN stated the resident had fluid problems and pneumonia which is causing her breathing problems. During an interview on 9/4/14 at 2:43 PM, CNA #2 stated that she did not take Resident #11's oxygen off, CNA #1 did. CNA # 2 stated that Resident #11 is short of breath all the time. The CNA stated that the CNAs can take oxygen off to provide care if needed; however for this resident she would not have removed the oxygen. Interview with the RN Supervisor on 9/4/14 at approximately 2:00 PM with the Physician evaluated Resident #11 on 9/2/14 for increased congestion and when she accompanied the Physician during his evaluation, the resident was wearing oxygen. The RN Supervisor stated she knew the resident was being treated for [REDACTED]. Interview with the Physician on 9/4/14 at approximately 3:00 PM revealed Resident #11 had [DIAGNOSES REDACTED]. Interview with the NP on 9/5/14 at approximately 10:20 AM revealed she evaluated the resident many times and recalled that in late August, the resident had a pleural effusion on the chest X-ray. The NP stated she felt that the resident should have gone to the hospital; however, the resident and family opted for medical treatment in the facility. Review of a facility policy and procedure (P&P) entitled "Oxygen Therapy" dated 3/03 revealed a physician's orders [REDACTED]. The P&P documented that liter flow rates may only be adjusted by licensed nursing staff, Physical and Occupational Therapists, COTAs (certified occupational therapy assistants) and PTAs (physical therapy assistants). The P&P did not identify which nursing staff can apply and/or remove oxygen therapy for a resident. Review of the Clinical Nursing Skills & Techniques 5th Edition by Perry and Potter indicates oxygen is regarded as a medication and various disease states such as pneumonia use oxygen therapy to correct impaired gas exchange and resultant [MEDICAL CONDITION] (low oxygen level). In summary, Resident #11 had a [DIAGNOSES REDACTED]. The CNA removed the resident's oxygen during personal care and the resident became tachypneic (abnormal fast breathing).The facility does not have a P&P to indicate criteria for nursing personnel to administer/ remove oxygen therapy during resident care. b.) Review of the untitled Electronic Comprehensive Care Plan (CCP)printed on 9/4/14 revealed Resident #11 was identified at risk for urinary incontinence with planned interventions to toilet the resident upon request and provide incontinence care as needed. Observation on 9/4/14 at approximately 9:05 AM revealed two CNAs (#1, #2) entered the resident's room to provide care for the resident. The two CNAs transferred the resident from the bed to the wheelchair, took the resident to the bathroom, and transferred the resident to the toilet. A small amount of fecal incontinence was observed when the resident's incontinence brief was removed. Immediately upon sitting on the toilet, the resident had a large soft bowel movement and urinated in the toilet. CNA #1 cleansed the resident's buttocks and peri-area with soap and water and rinsed and dried the resident. The resident's buttocks along the natal cleft (the groove between the buttocks) were reddened and the skin along the coccyx (tailbone) was slightly denuded (the removal of the upper layer of skin). After cleansing the resident's skin, the CNA did not apply barrier cream. Additional observation on 9/4/14 at 10:59 AM revealed two CNAs ( #2, #3) transferred the resident from the toilet to the wheelchair. The resident's buttocks were cleansed with soap and water and remained reddened and slightly denuded. The CNAs did not apply barrier cream. The observation revealed there was barrier cream in the resident's bathroom and on the bedside stand. Review of a facility P&P entitled "Incontinent Care" dated 2/09 revealed a procedure to apply barrier cream/ ointment if barrier cream is "indicated". (there was no definition of indications) Interview with CNA #2 on 9/4/14 at 2:43 PM revealed it is facility policy to apply barrier cream to a resident who is incontinent of bowel and/ or bladder. 415.12

Based on observation and interview conducted during the Standard survey completed on 9/5/14, the facility did not ensure the proper storage of drugs and biologicals in accordance with State and Federal laws. One (Fourth Floor) of four nursing units observed for medication storage had issues involving the exchange of narcotic keys between nurses without a medication count and a the medication cart that was left unlocked and unattended on two separate days. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy. The finding is: 1. a.) During an observation of a medication pass on the Fourth Floor Unit on 9/3/14 at approximately 8:17 AM, the part time Registered Nurse (RN) Resident Care Coordinator (RCC) requested "the keys" from an agency Licensed Practical (LPN) Medication Nurse. The LPN was observed to hand "the keys" to the RCC. The RCC proceeded to a medication cabinet at the nursing station, opened the cabinet, and replaced supplies. During an interview (in the presence of the RN RCC) on 9/3/14 at approximately 8:20 AM, the LPN Medication Nurse stated that the narcotic cabinet keys are on the key ring that was given to the RN RCC. At approximately 8:21 AM, the RN RCC stated that she is allowed access to the narcotic cabinet. When asked how the facility would prevent diversion if the keys are shared, the RCC did not answer. The RN RCC smiled and said "I was just putting away a needle." During a second interview on 9/3/14 at approximately 8:23 AM, the LPN stated that there are narcotics in the cabinet, and that she is responsible for the narcotics. When the LPN was asked how she ensures there is no drug diversion, the LPN replied "I trust her." b.) Observation on 9/3/14 at approximately 11:30 to 11:55 AM, the Fourth Floor Unit medication cart was unattended and unlocked for approximately 30 minutes. There were three residents in the vicinity of the unlocked and unattended medication cart. During an interview on 9/3/14 at approximately 11:57 AM, the full time RN RCC stated that the LPN had gone to lunch. The RCC was observed to lock the cart. At the time of the observation, the RN RCC stated that the medication cart should not be left unlocked or unattended. The RN RCC also stated that the narcotic keys should not be shared among staff members. During a second observation on 9/4/14 at approximately 10:00 AM, the medication cart was again left unattended and unlocked. At approximately 10:12 AM, the Pharmacy Consultant was observed to walk past the unlocked, unattended cart and proceeded to lock the medication cart. During an interview on 9/4/14 at approximately 10:15 AM, the Pharmacy Consultant stated that the expectation is that there is a chain of command for the keys and the holder of the keys is responsible. The Pharmacy Consultant also stated that the medication cart is to be locked when not in use. During an interview on 9/4/14 at approximately 1:30 PM, the Director of Nursing (DON) stated that the nurses should not be sharing the narcotic keys and the medication carts should be locked if unattended. 415.18(e)(1)(2)

THIS WAS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED 9/11/13. Based on observation, interview and record review conducted during the Standard survey completed on 9/5/14, the facility did not ensure that each resident is given the appropriate treatment and services to maintain or improve his or her abilities. One (Resident #45) of seven residents observed for morning care was not encouraged to participate in ADLs (activities of daily living) as planned. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy. The finding is: 1. Resident #45 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 7/30/14 revealed the resident has moderate cognitive impairment, sometimes understands, is usually understood, and needs total assistance with personal hygiene. During an interview on 9/2/14 at 1:07 PM, the Registered Nurse (RN) Resident Care Coordinator (RCC) stated that Resident #45 has contractures (loss of joint mobility) of the right digits, elbow, wrist, shoulder, right, and ankle. The RN also stated that the resident receives range of motion (ROM) via ADLs. Review of a Long Term Care Positioning Evaluation, completed by OT, dated 8/5/14 revealed nursing recommendations to provide: ROM via ADLs. Review of the Closet Care Plan (Care Plan used by certified nurse aides (CNAs) to provide care) last updated 8/8/14 revealed an approach for staff to provide limited assistance for grooming and extensive assistance for upper and lower extremity bathing and dressing. The programming section of the Care Plan documented "AAROM (active assist range of motion) to BLEs (bilateral lower extremities)". The Closet Care Plan did not address the resident's upper extremities. Review of the Resident Care Plan dated 8/14/14 revealed the resident was identified at risk for an alteration in activities of daily living and upper extremity range of motion related to dementia. Care Plan approaches included encouraging the resident to participate with ADLs. The Resident Care Plan documented a goal for the resident to maintain the highest level of function with all ADL's throughout the next review as evidenced by the OT Screen. During an interview on 9/4/14 at 7:27 AM, the CNA stated she already cleaned the resident's uppers (upper body) and provided oral care (she washed the dentures). When asked if the resident did anything himself, the CNA stated "No, I do everything." During observation of morning care on 9/4/14 at 7:35 AM, the CNA cleaned the resident's glasses and applied them and also combed the resident's hair. The CNA did not encourage or cue the resident to participate in completing these tasks. During further interview on 9/4/14 at 10:00 AM, the CNA stated she didn't know that the resident gets ROM with ADLs, it wasn't on the Closet Care Plan. The CNA stated she will try it if they want her to. During an interview on 9/4/14 at 10:20 AM, the Occupational Therapist stated that Resident #45 gets ROM through ADLs which means he gets ROM through daily activities. The Occupational Therapist explained that limited assistance means the resident can get physical assist if needed. The Therapist stated she would expect Resident #45 to be able to put his glasses on and comb his hair on a good day. She stated she would expect the CNA to offer him these items so he could complete the tasks himself if he wanted to. During an interview on 9/4/14 at 2:40 PM, the Director of Nursing (DON) stated that Resident #45 never wants to do his own care. The DON stated that she would expect the CNA to ask the resident if he wants to participate, but the aides probably got into a routine and they do it for him. 415.12(a)(2)

Based on observation, interview and record review conducted during the Standard survey completed on 9/11/13, the facility did not conduct an accurate assessment, using the Resident Assessment Instrument (RAI) specified by the State, of the resident's dental status. Two (Residents #25, 81) of three residents reviewed for oral/ dental status had an issue with an inaccurate and/or incomplete assessment of the resident's oral/ dental status on the RAI. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy. The findings are: 1. Resident # 25 has [DIAGNOSES REDACTED]. Review of a Resident Dental Review dated 11/16/12 revealed the resident has complete upper and lower dentures and that the resident stated the lower denture is "non-retentive." The Dentist documented "this is due to shape of bone remaining." The Dentist documented a treatment plan for a "possible new CL (complete lower) denture if warranted". Review of the quarterly Minimum Data Set (MDS - an assessment tool) 8/7/13 revealed the resident is cognitively intact, understands, and is understood. The "Oral/ Dental Status" section of the MDS documented that the resident has "mouth or facial pain, discomfort or difficulty chewing," however the MDS did not indicate that the resident has broken and/or ill fitting dentures. Review of the current Resident Care Plan dated 8/20/13 revealed a problem area related to the resident's inability to wear full dentures due to an ill fitting lower denture and he chooses to eat without his dentures at this point in time. Interview with the resident on 9/4/13 at approximately 11:00 AM revealed he has not worn dentures for almost one and a half years because his previous dentures were loose. The resident stated that he currently eats without any teeth. Observation of the resident at the time of the interview revealed the resident was edentulous (toothless) and there were no dentures in place. Interview with the Registered Nurse (RN) MDS Nurse on 9/10/13 at 11:30 AM revealed the resident did not have dentures in his mouth, thus she did not code him with loose dentures. 2. Resident #81 has [DIAGNOSES REDACTED]. Review of a Nursing History Assessment, completed by an RN, dated 7/23/13 revealed the section pertaining to the resident's oral status was incomplete. The questions regarding "[MEDICAL CONDITION]" and "Full Upper Dentures" were not answered. Review of the admission MDS dated [DATE] revealed the resident has moderate cognitive impairment; understands and is understood by others, has mood indicators with feeling tired and trouble concentrating on things; and does not have behavioral symptoms such as verbal/vocal screaming or making disruptive sounds. The MDS also documented that the resident requires staff assistance with transfers and ambulation. Review of the most recent Resident Care Plan dated 8/8/13 revealed the resident was newly admitted to the facility (7/23/13) and was in a period of adjusting to the facility. Interview with the RN who completed the Nursing History Assessment on 9/11/13 at 12:40 PM revealed that she was going to check on the resident's denture status, but never got back to complete the Assessment. Observations on 9/5/13 at approximately 8:30 AM and 9/6/13 from 8:00 AM to 8:30 AM revealed the resident had no upper teeth and six lower, front teeth that were discolored and chipped/ broken. Review of the document entitled Resident Dent completed by the Dentist on 8/2/13 revealed no documented evidence that the resident has six remaining teeth. When the "Resident Dent" was received with the RN MDS Coordinator on 9/11/13 at 12:30 PM, the RN stated she thought the darkened areas on the form were the resident's teeth, when in actuality, the darkened areas represented the roots. Additional review of the MDS dated [DATE] revealed the residents oral/dental status located in Section L revealed the resident had no broken natural teeth. Observation on 9/11/13 at approximately 1:15 PM revealed the RN MDS Coordinator inspected the resident's mouth and noted that the resident has natural teeth that are chipped/broken. The RN MDS Coordinator stated she could see a "mistake had been made" and "we will have to do something different." 415.11(a)(2)(1x)

Based on observation, interview and record review conducted during the Standard survey completed on 9/11/13, the facility did not ensure that residents had the right to choose activities, schedules, and health care consistent with his or her interests, assessments, and plans of care; and make choices about aspects of their life in the facility that were significant to them. Two (Residents #49, 62) of three residents reviewed for choices were not provided a choice regarding the time to awaken in the morning (#49, #62), the time to go to bed at night (#62) or the number of showers to receive each week (#49). There was no actual harm with potential for more than minimal harm that is not immediate jeopardy. The findings are: 1. Resident #49 has [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS - an assessment tool) dated 3/10/13 and a Quarterly MDS dated [DATE] revealed the resident is cognitively intact. Review of the Resident Care Plan dated 6/20/13 revealed the resident has hearing loss, utilizes a left (L) hearing aid, and approaches direct staff to repeat phrases as needed and to rephrase if necessary. Additional review of the Resident Care Plan revealed that the resident scored 13 (13 to 15 - cognitively intact) on the BIMS (Brief Interview for Mental Status) due to good temporal orientation and recall ability, and moderately impaired decision making. The Care Plan documented that the resident demonstrates confusion at times and defers to his family for all health care decisions and decisions of significance. The Care Plan also documented an approach for the social worker to continue to encourage the resident to make independent decisions and to make (his) needs known as much as possible. During an interview on 9/5/13 at 2:18 PM, the resident stated he receives two showers each week, and indicated that "maybe it could be one". The resident indicated his preference for getting up in the morning by stating "I feel I get up too early." When interviewed on 9/6/13 at 11:25 AM, the resident confirmed that he would "like to sleep in until 9:00 AM" but they get him up about 7:00 AM to get him ready for breakfast. The resident also stated that he gets "at least a couple of showers each week, and that one would be enough" for him. The resident stated that he didn't think he was given a choice. Interview with Food Service/Dietary Staff for the 6th Floor (where Resident #49 resides) on 9/6/13 at 10:05 AM revealed that the facility has an "open breakfast" period, where residents can have breakfast anytime from approximately 7:30 AM until 9:30 AM. Observations on 9/9/13 at 8:15 AM, and on 9/10/13 at 8:25 AM revealed the resident was out of bed, fully dressed and seated in the dining room eating breakfast. Interview with the resident's CNA on 9/10/13 at 9:15 AM revealed that she was assigned to the resident for the month of August 2013. The CNA explained that the CNAs rotate assignments throughout the units in the facility and she was assigned to him 3 months ago (May 2013). The CNA stated she is familiar with Resident #49's care and that he receives two showers per week on Sunday and Wednesday, during the day. The CNA stated that the resident has not complained about his showers, but that he does seem reluctant at times to receive them. During the interview, the CNA stated she got the resident out of bed at 7:30 AM today (9/10/13) and will usually get him up between 7:30 and 8:00 AM. The CNA said the resident doesn't complain with this time frame, however she had gotten him up at 7:00 AM one time and he did not like getting up at that time. Review of the 6th Floor 7:00 AM - 3:00 PM Assignment Sheet revealed that Resident #49 is scheduled to receive a shower on Sundays and Wednesdays. Review of the Social Services section of the medical record revealed documentation of an undated, unsigned "Resident Preferences," review sheet. Interview with the Social Worker (SW) on 9/10/13 at 10:05 AM revealed that the "Resident Preferences" sheet was done at the same time as the Social History/ assessment dated [DATE]. Additional review of the "Resident Preferences" sheet revealed the resident's "usual time to arise is "8:00 to 9:00 AM" and the "Bathing Preferences" section regarding "How Often or What Days" was blank. Review of Social Service "Team Care Meeting Notes" dated 3/19/13 and 6/20/13 revealed the section on the top of the notes to indicate if the resident attended the Team Care meetings was blank. Additional review of the Meeting notes revealed the following individuals attended the meeting: the resident's daughter and son-in-law; the Resident Care Coordinator (RCC), a Registered Nurse (RN), the Social Worker (SW), the Registered Dietetic Technician (DTR) and a representative from Activities staff. Review of the Social Service notes dated 3/5/13 to 4/23/13 revealed Resident #49 is able to make simple daily choices independently, but defers to his daughter for health care decisions and those of significance. Additional review of the notes revealed no documented evidence the SW reapproached the resident to obtain further information regarding his personal preferences for his daily routine, or to determine if there were any concerns related to his daily/ weekly routine. Interview with the SW on 9/10/13 at 10:05 AM revealed that the Resident Preferences Review Sheet was filled out on 3/6/13, with the help of the resident's daughter, even though the resident was in the room at the time; and at times the daughter didn't know some of the information. The SW said when she tried to obtain the information, the resident didn't want to participate with the questions. The SW stated that as far as the frequency of his bathing preferences, the daughter did not pursue that, because she didn't know his past preference. The SW said when she tried to bring up the subject, the resident "declined to give me an answer on that." The SW was aware that the resident preferred to get up later, from 8:00 AM to 9:00 AM. The SW stated that she initially obtained the resident's preferences for his customary routine, however there is no formal review of these preferences during quarterly or annual assessments. The SW stated there is a discussion of any resident problems or preferences during the Team Care Meetings, but the resident does not attend the Care Plan Meetings. 2. Resident # 62 has a [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is cognitively intact. Review of the Nursing History assessment dated [DATE], the Resident Care Plan date 7/2/13 and the undated Closet Care Plan revealed there was no documentation regarding the resident's choice of when to get up in the morning or when to go to bed at night. During an interview on 9/4/13 at 2:16 PM, the resident stated he does not choose when to get up in the morning. The resident stated "The staff just come in and get me up and I am usually asleep". Observation on 9/6/13 at 7:00 AM, revealed the resident was in bed asleep. When observed on 9/6/13 at 7:12 AM, the resident was in bed asleep when CNA #2 entered the resident's room. CNA #2 was observed standing in front of the resident's night stand and the resident opened his eyes. CNA #2 did not speak to the resident and then exited the room. Observation on 9/6/13 at 7:20 AM, revealed the resident was in bed with his eyes closed. When observed on 9/6/13 at 7:41 AM, CNA #1 knocked on the resident's door. The resident was in bed with his eyes closed. The CNA was observed to turn on the light and stated "Are you awake?" The resident opened his eyes and did not respond. The CNA entered the room with a brief, towel and wash cloth. During an interview on 9/6/13 at 8:13 AM, the resident stated he was asleep when the CNA came in and woke him up this morning. The resident stated he would like to sleep in, but be up in time for breakfast. When interviewed on 9/6/13 at 9:15 AM, the Unit 4 Dietary Aide stated that breakfast is supposed to be served from 8:00 AM to 9:00 AM, but she serves it later so residents can have a hot breakfast. The Dietary Aide stated it is not the resident's fault if they are not up. During an interview on 9/10/13 at 11:31 AM, the Registered Nurse (RN) Resident Care Coordinator (RCC) stated the Closet Care Plan does not document when the resident wants to get up in the morning or go to bed at night. "The resident would have to tell us when he wants to get up." The RN RCC stated the resident usually gets up around 8:00 AM. After review of the Resident Care Plan dated 7/2/13, the RN RCC stated that the resident makes his own decisions. After review of the resident's medical record, the RN stated there is a social history and was hoping that the resident's choice regarding when to get up and go to bed was on there, "but it is not." The RN RCC stated the times the resident wants to get up and go to bed would be documented ion the Care Plan.. When interviewed on 9/10/13 at 11:47 AM, CNA #4 stated he routinely takes care of Resident #62 and that the resident gets up at least by 8:00 AM. The CNA stated if the resident had a particular time he wanted to get up or go to bed, it would be on the care plan. The CNA stated the resident has told him on a few instances that he wanted to sleep in later. During an interview on 9/4/13 at 2:17 PM, the resident stated he does not choose when to go to bed at night. The resident stated "I went to bed at 7:00 PM at home. I like to go to bed at 7:00 PM". The resident stated when he is put to bed after 7:00 PM, "I get mad." He stated no one has really asked him what time he wanted to go to bed. During an interview on 9/10/13 at 4:41 PM, the evening shift CNA (#5) stated the resident asks the nurse for his pills after supper because he likes them before he goes to bed. CNA #5 stated she puts the resident to bed about 7:30 PM. The CNA stated that it is not documented any place when resident wants to go to bed. 415.5(b)(1,3)

Based on observation, interview and record review conducted during the Standard survey completed on 9/11/13, the facility staff did not promote care in a manner that enhanced each resident's dignity. Two (Residents #8, 34) of 27 residents observed for dignity had issues involving medication administration in a public area and dressing a resident in an undignified manner. Residents #14 and #82 were involved. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy. The findings are: 1. Resident #8 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - an assessment tool) dated 8/2/13 revealed the resident is cognitively intact, understands and is understood. Review of physician's orders [REDACTED]. Review of the current Resident Care Plan dated 8/15/13 revealed the resident is not a candidate for medication self administration, requires supervision for medication administration and planned approaches include nursing staff administration of medications which could include the hallway and dining room per her request. Observation on the 6th Floor on 9/9/13 at approximately 9:20 AM revealed the Licensed Practical Nurse (LPN) Medication Nurse (#1) had the medication cart in the middle of the dining room and 14 residents were still eating breakfast in the dining room, seated at four different tables. The LPN Medication Nurse was observed to administer oral medications to Resident #14. After administration of the medications, she placed some papers on the dining room table where two residents were seated eating breakfast and proceeded to use this surface rather than her medication cart to complete her documentation. The LPN then called out to Resident #8 by name, loud enough for all in the dining room to hear. Upon locating Resident #8 at approximately 9:30 AM, the LPN Medication Nurse administered two puffs of [MEDICATION NAME] HFA 220 mcg to Resident #8, who was seated with four other residents who were still eating breakfast. After administration, the nurse instructed the resident to rinse her mouth out with water and spit it into a plastic eight ounce cup. At 9:37 AM, the LPN Medication Nurse then called out to Resident #82 by name, loud enough for all in the dining room to hear. The LPN then administered oral medications to Resident #82. Interview with LPN Medication Nurse #2 on 9/11/13 at 12:15 PM revealed that although many residents have care plans to receive medications in the dining room, she always keeps the medication cart aside and out of the dining room during the residents' meals. In addition, she stated that she does not administer eye drops, inhalers or injections in the dining room because it's too public; she will take the resident to a private area for administration of these medications. Interview with the Registered Nurse (RN) Director of Nursing (DON) on 9/11/13 at 1:20 PM revealed she expects the Medication Nurses to administer inhalers in a setting as private as possible and she would not expect to have an inhaler, requiring a rinse and spit, administered in the dining room during meals. 2. Resident #34 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has severe cognitive impairment and short and long term memory problems. The MDS documented that the resident requires total assistance for activities of daily living (ADLs), including dressing. Review of an Annual Occupational Therapy (OT) screen dated 8/13/13 revealed recommendations to provide "Total (A)" (total assistance) for LE (lower extremity) dressing. Review of the Resident Care Plan dated 8/29/13, revealed the resident was identified at risk for decline of upper extremity range of motion (ROM) due to a [DIAGNOSES REDACTED]. Review of the Closet Care Plan (used by Certified Nurse Aides (CNAs) to provide care) dated 8/29/13 revealed the resident requires total assistance for bathing and dressing. Observation on 9/9/13, from 10:45 AM to 11:20 AM revealed two CNAs (#1, #2) provided morning care to Resident #34. After providing morning care and ROM (range of motion) services, CNA #1 and #2 were observed to dress Resident #34. Both of the CNAs were observed to simultaneously put on the resident's slacks and then her socks. The CNAs both assisted with putting on the resident's slacks at the same time, and then assisted with putting on the resident's socks at the same time. 415.5(a)

Based on observation, interview and record review conducted during the Standard survey completed on 9/11/13, the facility did not inform the resident's physician of a significant change in the resident's physical, mental, or psychosocial status. One (Resident #81) of 11 residents reviewed for notification of change, displayed increased agitation, which included entangling himself in a call light cord, and the Physician was not notified. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy. The finding is: 1. Resident #81 has [DIAGNOSES REDACTED]. Review of the most recent Resident Care Plan dated 8/8/13 revealed the resident was "newly admitted " to the facility on [DATE] and was in a period of adjusting to the facility. Review of the admission Minimum Data Set (MDS - an assessment tool) dated 7/29/13 revealed the resident has moderate cognitive impairment; understands and is understood by others; has mood indicators with feeling tired and trouble concentrating on things; and does not have behavioral symptoms such as verbal/vocal screaming or making disruptive sounds. The MDS also documented that the resident requires staff assistance with transfers and ambulation. During the morning of 9/6/13, from approximately 9:15 AM to 10:30 AM, the resident was observed in his room, continually yelling out loudly for "help". A Licensed Practical Nurse (LPN #1) and two Certified Nurses' Aides (CNAs #1,2) were observed going into the resident's room offering reassurance, tactile support, and utilizing environment items such as turning on the television, giving him his rosary, allowing more window light in the room, and putting on soft music. The resident was not able to calm himself during this period of time, often asking staff to undo what he has just asked them to do. Observation revealed staff were not able to calm the resident, as he continued to yell out, and could be heard in the hallway where other residents reside. Interview with LPN #1 on 9/6/13 at approximately 11:15 AM revealed the resident's agitation had increased during this two hour period of time. Review of an Interdisciplinary Nursing Note darted 9/8/13 at 11:23 PM revealed that LPN #2 documented that the resident was "yelling out, very demanding and impatient. Found resident wrapping call light cord around his neck." Separate telephone interviews on 9/10/13 between 4:45 PM and 5:30 PM with the two CNAs (#3,4) who worked the evening of 9/8/13, revealed that Resident #81 was very agitated and restless before dinner. The CNAs had repeatedly placed the resident back and forth into his lounge chair and then his wheelchair, and they could not satisfy him. The CNAs stated that after they left the room, the resident continued to yell out and made attempts to get out of his lounge chair to sit in his wheelchair. The CNAs stated that the resident's daughter was in the room and witnessed that the resident became entangled in his call light cord. Observation on 9/9/13, from approximately 9:00 AM to 10:30 AM, revealed that Resident #81 was agitated, yelling out and required continuous staff interventions in his room. The resident was heard from outside his room demanding and arguing with LPN #1. Interview with LPN #1 on 9/9/13 at approximately 10:00 AM revealed that Resident #81 was experiencing increased agitation. During an interview on 9/9/13 at approximately 11:15 AM, the Social Worker stated that Resident #81's overall agitation and anxiety had increased since his admission. Review of the medical record, including interdisciplinary Nursing Notes, physician progress notes [REDACTED]. agitation and notify him of the incident of entanglement with the call light cord. 415.3(e)(2)(ii)(b)

Based on observation, interview and record review conducted during the Standard survey completed on 9/11/13, the facility did not provide a safe, clean, comfortable and homelike environment to the extent possible. One (Resident #34) of twenty residents reviewed for resident care equipment had an issue involving a wheelchair arm bolster that was worn and ripped, allowing the foam padding to migrate. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy. The findings are: 1. Resident #34 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - an assessment tool) dated 5/24/13 revealed the resident has severe cognitive impairment and short and long term memory problems. The MDS documented that the resident requires total assistance for activities of daily living (ADLs). Review of the Resident Care Plan dated 8/29/13 revealed the resident has "special positioning needs" with an approach to utilize bolsters on both arms of her wheelchair. Additional review of the Care Plan revealed the resident was identified at risk for skin breakdown related to requiring assistance with all mobility and incontinence. The Resident Care Plan documented an approach for positioning and pressure relieving devices per Occupational Therapy (OT) recommendations. Review of the Closet Care Plan (used by certified nurse aides (CNAs) to provide care) dated 8/29/13 revealed the resident has a "Tilt-in-Space" wheelchair (specialized adjustable, reclining wheelchair) with bilateral (B) bolsters. Interview with the Occupational Therapist Registered (OTR) on 9/9/13 at 2:10 PM revealed that the (B) armrest bolsters on the resident's wheelchair are in place to keep the resident's arms protected. Interview with the Registered Nurse (RN) Resident Care Coordinator (RCC) on 9/9/13 at 2:20 PM revealed she believed the (B) bolsters are on the wheelchair for positioning the resident in her chair. Intermittent observation of the resident's Tilt-in-Space wheelchair from 9/4/13 to 9/6/13 between the hours of 9:30 AM and 4:00 PM revealed there was one bolster on each armrest of the positioning wheelchair. The blue bolster on the right armrest was observed to be mildly worn. The pink bolster on the left armrest was worn, cracked and ripped open along a seam, allowing the foam cushioning to be exposed and migrated away from the top of the armrest. The observation revealed there was little to no padding provided to the top of the left armrest. Review of a "Rehabilitation Referral for Therapy Services" dated 9/9/13 revealed the OT department was informed of the condition of the wheelchair bolsters and both "arm bolsters were replaced secondary to increased wearing on previous bolsters." 415.29(b)