Every finding on record at Mount Sinai South Nassau T C U

Based on record review and interviews during the Recertification Survey initiated on 12/22/2025 and completed on 12/24/2025, the facility did not ensure it maintained a quality assessment and assurance committee that included the Infection Preventionist (IP) as a member of the committee. Specifically, the Infection Preventionist did not participate and report on the Infection Prevention and Control Program (IPCP) and on incidents (for example health care associated infections) regularly to the Quality Assurance & Performance Improvement committee meetings that were held from 03/31/2025 through 09/11/2025.The finding is:The facility's policy titled Quality Management/Performance Improvement dated 09/2025 documented that all staff participates in the performance improvement process. Quality improvement data/analysis and discussion will take place quarterly at team meetings. Targeted areas for improvement are identified and prioritized based on unit, departmental, regulatory and professional standards of practice and outcomes. Staff education/teaching is integral to performance improvement.A review of the Quality Assurance and Performance Improvement (QAPI) meeting attendance sheets indicated the Infection Preventionist did not attend the Quality Assurance and Performance Improvement (QAPI) meetings held on 03/31/2025, 06/18/2025, and 09/11/1015.The review of a list of Quality Assurance Performance Improvement Committee Members, that was provided by the facility during the entrance conference was conducted. The list did not include the Infection Preventionist as the committee member.During an interview on 12/23/2025 at 11:30 AM, the Medical Director stated they started as the facilitator of the Quality Assurance and Performance Improvement (QAPI) meetings in September 2025 and were not aware that the Infection Preventionist was required to attend these meetings.During an interview on 12/23/2025 at 12:05 PM, Infection Control Practitioner #1 stated they have been working at the facility since April 2025. Infection Control Practitioner #1 stated they had never attended the Quality Assurance and Performance Improvement (QAPI) meeting because they were still in training. During an interview on 12/23/2025 at 12:16PM, the Infection Control Practitioner #2 stated they started working at the facility in February 2025. The Infection Control Practitioner #2 stated they had never attended the Quality Assurance and Performance Improvement (QAPI) meeting because they were still in training.During an interview on 12/23/2025 at 12:30 PM, the Assistant Director of Infection Prevention and Control stated that in March 2025, when the Quality Assurance and Performance Improvement (QAPI) meetings was held, they were on vacation. For the June and September 2025's Quality Assurance and Performance Improvement (QAPI) meetings they were on leave and therefore, did not attend the meetings.During an interview on 12/23/2025 at 1:12 PM, the Director of Infection Prevention and Control stated they are a member of the Quality Assurance Performance Improvement Committee. The Director of Infection Prevention and Control stated they did not attend the September 2025 Quality Assurance Performance Improvement Committee meeting because they were attending and administrative leadership meeting. The Director of Infection Prevention and Control stated that the other two members were new and were still in training. The Director of Infection Prevention and Control stated they could not recall why they did not attend the Quality Assurance and Performance Improvement (QAPI) meeting that was held in June 2025. During an interview on 12/24/2025 at 9:08 AM, the Administrator stated Infection Control issues are discussed in the daily morning meetings. The Administrator stated it was an oversight that the Infection Preventionist was not listed as a Member for the Quality Assurance Performance Improvement Committee. The Administrator stated they should have made sure the Infection Preventionist attended the quarterly Quality Assurance and Performance Improvement (QAPI) meetings. 10 NYCRR 415.27(a-c)

Based on observation, record review, and interviews during the Recertification Survey initiated on 10/17/2024 and completed on 10/22/2024, the facility did not ensure that each resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of quality of life. This was identified for one (Resident #64) of 10 sampled residents. Specifically, Nurse Practitioner # 1 was observed on 10/17/2024 walking into Resident # 64's room without knocking on the resident's door. The finding is: The policy and procedure titled Privacy During Care, revised October 2022 documented that the resident/patient is entitled to privacy during care and all staff is to knock on a closed door and ask to enter before entering the resident/patient's room (unless the staff just left the room momentarily and is returning to complete care, etc.). Resident #64 was admitted with diagnoses that include Diabetes and Cellulitis (skin infection). The Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, indicating the resident had intact cognition. During an observation and interview on 10/17/2024 at 11:00 AM, while the surveyor was interviewing Resident #64, Nurse Practitioner # 1 walked into the resident's room without knocking on the resident's door or asking permission to enter. Resident # 64 stated staff walks into their room without knocking. Resident # 64 stated they were dissatisfied and that the staff could provide better customer service. During an interview on 10/17/2024 at 11:02 AM, Nurse Practitioner # stated they didn't knock on the resident's door because they saw the Surveyor talking to the resident in the room. During an interview on 10/18/2024 at 12:02 PM, the Director of Nursing Services was interviewed and stated all staff should knock on the resident's door before entering the room. The Director of Nursing Services stated Nurse Practitioner #1 was a hospital employee who should have knocked on the resident's room before entering. 10 NYCRR 415.3(d)(1)(i)

Based on observations, record review, and interviews during the Recertification Survey initiated on 10/17/2024 and completed on 10/22/2024 the facility did not ensure that each resident had a Baseline Care Plan that included instructions to provide effective person-centered care that meets professional standards. This was identified for one (Resident #165) of one resident reviewed for skin conditions. Specifically, Resident #165 was assessed as at risk for falls and was placed on tele-sitter remote visual monitoring using a camera in the resident's room. The resident's care plan interventions did not include the tele-sitter remote visual monitoring. The finding is: The facility's policy titled, Continuous Visual Monitoring Using Remote Tele-Sitter Technology or Virtual Safety Companion Technology, last revised 9/2022 documented that the initiation of continuous visual monitoring is a nursing intervention. It can be utilized to ensure patient safety as an additional tool in the plan of care for patients at high risk for falls, confusion, impaired mobility, etc. Communication shall be entered in the Patient Care Record as a nursing intervention to include tele-sitter monitoring continuous and the reason for monitoring. Resident #165 was admitted with diagnoses that included Lower Left Leg Cellulitis (skin infection), Dementia, and Type 2 Diabetes Mellitus. The Admission Minimum Data Set assessment dated [DATE] documented the Brief Interview for Mental Status score of 9, indicating the resident had moderate cognitive impairment. The Minimum Data Set assessment documented Resident #165 required partial to moderate assistance for standing from a sitting position. Resident #165 had a fall within the past month and in the past 2-6 months before admission. The Baseline Care Plan dated 10/10/2024 documented the resident was at risk for falls due to poor balance related to Lower Left Extremity Cellulitis. The interventions did not include the use of a tele-sitter remote visual monitoring. A nursing progress note dated 10/10/2024 at 2:37 AM documented Resident #165 presented with confusion and poor safety awareness. Resident #165 was non-compliant with the use of the call bell and bed alarm; a tele-sitter camera was requested for remote visual monitoring. The nursing progress notes dated 10/13/2024, 10/16/2024, and 10/22/2024 documented the use of the tele-sitter remote visual monitoring for enhanced safety. On 10/17/2024 at 11:28 AM, Resident #165 was observed sitting in their wheelchair watching television in their room. The tele-sitter remote visual monitoring camera was observed in the corner of the room. During an interview on 10/17/2024 at 11:28 AM, Resident #165 pointed to the tele-sitter remote visual monitoring camera in the room and stated Did you meet ET? Resident #165 further stated they were not sure why the camera was in the room. During an observation and interview on 10/22/2024 at 10:43 AM, Resident #165 stated that the camera is a spy. Resident #164 stated staff told them that they were not the only resident with the spy camera. During an interview on 10/22/2024 at 10:38 AM, Registered Nurse #1 stated the monitor in Resident #165's room is to keep an eye on a resident who is getting up out of bed and is in danger of falling or pulling at the intravenous lines. The use of a tele-sitter remote visual monitoring is a nursing intervention. Registered Nurse #1 checked Resident #165's Medical Record and stated the resident's care plan did not document the tele-sitter remote visual monitoring as an intervention. During an interview on 10/22/2024 at 02:14 PM, the Director of Nursing Services stated the use of the tele-sitter remote visual monitoring should be documented in the fall care plan as an intervention. 10 NYCRR 415.11

Based on observation, record review and interviews during the Recertification Survey initiated on 6/14/2023 and completed on 6/16/2023 the facility did not ensure that a person-centered care plan for each resident was developed and implemented that includes measurable objectives and time frames to meet a resident's medical and nursing needs. This was identified for one (Resident #117) of one resident reviewed for hydration. Specifically, on 6/14/2023 Resident #117 was administered Packed Red Blood Cells (PRBC). There was no documented evidence in the medical record of a Care Plan related to blood transfusion that included goals and interventions to monitor the resident during and after the blood transfusion. The finding is: Resident #117 was admitted with diagnoses that include Cancer, Peripheral Vascular Disease (PVD), and End Stage Renal Disease (ESRD). A 5-Day Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. The resident received Intravenous (IV) Medications and transfusion prior to and after their admission to the facility. The Nursing Progress Note dated 6/13/2023 documented the Physician was aware of the blood work results. The Physician ordered two units of Packed Red Blood Cells to be transfused. The first unit of PRBC is transfusing with no issues. A Nursing Progress Note dated 6/14/2023 documented the resident was receiving 2 Units of PRBC due to the resident's low hemoglobin level. A second PRBC unit was started at 10:15 PM and completed at 1:10 AM. The medical record lacked documented evidence of a Care Plan related to blood transfusion that included goals and interventions to monitor the resident during and after the blood transfusion. The Clinical Nurse Coordinator, Registered Nurse (RN) was interviewed on 6/16/2023 at 2:58 PM and stated that there should have been a Comprehensive Care Plan (CCP) initiated for the blood transfusion by the RN that started the transfusion that included goals and interventions to monitor the resident. The Director of Nursing Services (DNS) was interviewed on 6/16/23 at 3:46 PM and stated that there should have been a CCP initiated by the RN that initiated the blood transfusion. 10 NYCRR 415.11(c)(1)

Based on observation, record review and interviews during the Recertification Survey initiated on 6/14/2023 and completed on 6/16/2023, the facility did not ensure that resident records were complete and accurately documented in accordance with professional standards of practice. This was identified for one (Resident #69) of one resident reviewed for Skin Condition. Specifically, Resident #69 was admitted to the facility with a left dorsal (back) hand and forearm discoloration, however, there was no documented evidence of the identified left-hand and forearm discolorations in the medical record. The finding is: Resident #69 was admitted with diagnoses that included Type II Diabetes Mellitus, Hypertension, and Heart Failure. A review of the Baseline care plan dated 6/10/2023 was conducted on 6/15/2023 at 4:30 PM. The Baseline care plan did not include documented evidence of the resident's left dorsal hand and forearm discoloration. The Skin-Body [NAME] Assessment form (form to indicate skin issues upon admission) dated 6/10/2023 did not include evidence of left dorsal hand and forearm discoloration. A review of the progress notes from the admission to 6/15/2023 revealed no indication of the dorsal left hand and left forearm discoloration. Certified Nurse Aide (CNA) #1 was interviewed on 6/15/2023 at 2:45 PM. CNA #1 stated the resident was admitted with several areas of discoloration including the discoloration on the back of the left hand and the forearm when the resident was first admitted from the hospital on 6/9/2023. Registered Nurse (RN) #1 was interviewed on 6/15/2023 at 2:54 PM. RN #1 stated that the resident was admitted to the facility from the hospital with discolorations to the left hand and the forearm. RN #1 stated that the resident received Intravenous antibiotic therapy in the hospital. RN #1 stated when a resident is admitted to the facility a full body assessment is conducted. All alterations in the resident's skin should be documented in the Skin-Body [NAME] section of the Admission Data Collection form by the admitting RN. RN #2, who was the unit's Clinical Care Coordinator, was interviewed on 6/15/2023 at 3:58 PM. RN #2 stated the admission RN was responsible to document all alterations in skin integrity issues observed during the admission assessment on the Skin-Body [NAME] section of the Admission Data Collection Form. RN #2 stated that Resident #69's admission assessment did not include the discoloration to the left dorsal hand and the left forearm on the Skin-Body [NAME] section of the Admission Data Collection Form. The Director of Nursing Services (DNS) was interviewed on 6/16/2023 at 3:34 PM. The DNS stated that the admission nurse should have documented all bruising and discoloration including the dorsal hand and the forearm identified during the admission assessment on the Skin-Body [NAME] section of the Admission Data Collection Form. 10 NYCRR 415.22(a)(1-4)

Based on interview and record review during the recertification survey, the facility did not ensure that each resident had an opportunity to formulate Advance Directives. This was evident for 8 (Residents #3, #5, #7, #8, #11, #113, #114, and #162) of 8 residents reviewed for Advanced Directives. Specifically, 1) Resident #3 stated he expressed his Advance Directives to the Social Worker (SW), however the Advance Directives were not identified on the medical record; 2) Resident #7 stated she did not have a discussion regarding advance directives upon admission, however would like to establish an Advance Directive; 3) Resident #11's family member stated that they had an Advanced Directive in place but it was not documented in the medical record. The findings include but are not limited to: The Facility policy on Advance Directives dated 10/18 documented that if a competent patient makes his/her wishes known and a document has not been executed, the appropriate staff will assist the patient in completing the Health Care Proxy form (RN or Social Work), Do Not Resuscitate Orders (RN), and MOLST (Social Work). The nurse will inquire of the patient whether he/she has an Advance Directive already in existence and if there is someone available to retrieve the document for the patient's medical record. If a patient has an advance directive and does not have access to the documents every effort will be made to assist the patient in developing a new document. If the patient does not wish to create a new document, the nurse will document in the Patient Profile in the comment space in the advance directive section the specific wishes of the patient. If a patient (or family) states that the patient has executed an advance directive, but it is not made available, staff shall document that an advance directive has been made. 1) Resident #3 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Admission assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS Section S further documented that Resident #3 has no Advanced Directives in place, did not have a Healthcare Proxy, and the Healthcare Proxy was not invoked. The Social Service Initial assessment dated [DATE] documented that Resident #3 had no Power of Attorney, no Guardian, and no Living Will. The assessment further documented that Resident #3 did not have short-term or long-term memory impairment and was oriented to person, place, time, and situation. The Social Worker (SW) Progress Note dated 4/10/19 documented Resident #3 was admitted to the facility with a [DIAGNOSES REDACTED]. The progress note did not document discussion of advance directives. Resident #3 was interviewed on 4/24/19 at 11:37 AM. Resident #3 stated that he expressed his advance directives during intake and he informed the social worker that he wanted to designate his girlfriend as his healthcare proxy. He stated the facility should have paperwork on file. 2) Resident #7 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The MDS Admission assessment dated [DATE] documented a BIMS score of 15, indicating intact cognition. The MDS Section S further documented no Advanced Directives were in place, Resident #7 did not have a Healthcare Proxy, and the Healthcare Proxy was not invoked. The Social Service Initial assessment dated [DATE] documented that Resident #7 had no Power of Attorney, no Guardian, and no Living Will. The assessment further documented that Resident #7 did not have short-term or long-term memory impairment and was oriented to person, place, time, and situation. The Social Worker Progress Note dated 4/13/19 documented Resident #7 was admitted to the facility after hospitalization for right [MEDICAL CONDITION]. The progress note did not document discussion of advance directives. Resident #7 was interviewed on 4/24/19 at 12:14 PM. Resident #7 stated she did not have a discussion regarding advance directives upon admission. Resident #7 stated she wanted to establish an Advance Directive but did not know how to develop an Advance Directive. 3) Resident #11 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The MDS Admission assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 0 indicating severely impaired cognition. The MDS Section S further documented no Advanced Directives were in place, Resident #11 did not have a Healthcare Proxy, and the Healthcare Proxy was not invoked. The Social Service Initial assessment dated [DATE] documented that Resident #11 had no Power of Attorney, no Guardian, and no Living Will. The assessment further documented that Resident #11 was oriented only to self at the time of the assessment. The Social Worker Progress Note dated 4/13/19 documented Resident #11 was admitted to the facility after experiencing symptoms of [MEDICAL CONDITION]. The progress note did not document discussion of advance directives. Resident #11 was interviewed on 4/24/19 at 1:52 PM. Resident #11 is not aware of whether her advance directives were in place. The Resident's family member stated that the facility was provided a copy of the advance directive document upon admission. The Registered Nurse (RN) Coordinator was interviewed on 4/25/19 at 11:17 AM. The RN Coordinator reviewed the medical record of Resident #3, #7, and #11. The RN Coordinator stated there were no advance directives documented in the record for Residents #3, #7, and #11. The RN coordinator stated that residents who are alert and oriented do not require an advance directive. If a resident does not have the advanced directive in the record, the facility would contact the next of kin listed on the emergency contact sheet to make healthcare decisions. The Social Worker (SW) was interviewed on 4/25/19 at 11:43 AM. The SW stated that all residents are asked if they have a Living Will or Advance Directive during the Social Services Initial Assessment. The SW will obtain a copy and place it in the medical record if the Resident has the copy with them. If the resident does not have the copy at admission, she would mark none in the medical record and wait for the resident to provide a copy of the document. The SW does not document if there are follow up attempts to obtain the copy of the Advance Directive. If the resident does not have an Advance Directive, the SW then asks the residents if they are interested in developing one. When the resident wishes to develop an Advance Directive, she will document the review, complete the Advance Directive and have it signed by two witnesses. The SW stated she would not document if the resident refuses the offer. The Director of Nursing Services (DNS) was interviewed on 4/26/19 at 12:03 PM. The DNS stated that the nurses ask if the residents have Advance Directives upon admission to the facility. If the resident has a copy, the RN would place it in the medical record. If a resident does not have the copy, it is expected that the SW follow up and ensure a copy is in the record. If a resident wishes not to be resuscitated, the RN reports it to the Doctor and a Do Not Resuscitate order is placed in the medical record. If the resident wishes to initiate a proxy, the SW will assist with invoking a proxy. The DNS stated that the SW should document all efforts to establish Advance Directives or declination of the offer. 415.3(e)(1)(ii)

Based on record review and interviews during the recertification survey the facility did not ensure that Accident/Incident (A/I)Reports related to falls were thoroughly investigated. This was identified for 1 of 2 residents reviewed for accidents. Specifically, Resident #13 had two falls on 4/08/2019. The Accident/Incident (A/I) Reports did not thoroughly investigate the fall incidents regarding the functioning of the resident's call bell, whether the call bell was within the resident's reach, and if the resident was wearing footwear at the time of the incidents. The finding is: The facility's policy and procedure dated 10/2018 titled Call [NAME]s documented .3. Call bell devices are available for residents/patients with special needs . 6. At no time is the system to be disconnected or turned off such that the beeping sound is inaudible. The undated facility's policy and procedure titled Occurrence Report documented . II. The Manager or Supervisor of the area where the fall occurred will review the report for accuracy, completeness, and neatness and submit the report directly to the Risk Management Department . Resident #13 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 0 indicating the resident was severely impaired in cognition. The resident required limited assist of one person for walking in and out of the room and for locomotion on and off of the unit, and required extensive assist of two persons for toileting. The MDS documented the resident had no functional limitation in range of motion of the upper and lower extremities and had no history of fall. The Comprehensive Care Plan (CCP) developed for At Risk for falls dated 4/8/19 documented interventions that included call light within reach, prompt response to all requests and to ensure the resident wears appropriate, well fitting footwear to minimize the risk of slipping. The A/I Report dated 4/8/19 at 2:20 AM documented an unwitnessed fall in the resident's room. The resident was found on the floor. The Nurse Supervisor documented that the resident did not use the call bell for assistance. The resident slipped and fell on her buttocks while ambulating to the bathroom. The report did not document if the resident's call bell was functional, was within reach or if the resident was wearing non-skid footwear. The Nurse's Progress Note dated 4/8/19 at 6:45 AM documented an unwitnessed fall. The resident did not use the call bell. The resident slipped and fell on her buttocks while walking to bathroom. The Note documented no visible injuries. The Immediate (STAT) Computerized [NAME]ography (CT) of the head result was negative. The A/I Report dated 4/8/19 at 12:40 PM documented an unwitnessed fall in the resident's room. The resident found sitting on the floor. The Report documented the resident was sitting in her chair immediately prior to the fall. The Report did not mention that the resident just fell 10 hours earlier. The Report did not document if the resident's call bell was functional, was within reach or if the resident was wearing non-skid footwear. An interview was held with the Certified Nursing Assistant (CNA) #1 on 4/25/19 at 9:57 AM. CNA #1 stated that the resident could ambulate independently and could use the call bell. An interview with the Director of Nursing Services (DNS), who was also responsible for the completeness of the A/I Report, was conducted on 4/26/19 at 9:00 AM. The DNS stated the staff should have investigated and documented the status of the call bell, to determine if it was functional or within reach of the resident. The DNS also stated that staff should have included in the investigation if the resident was wearing footwear to minimize the risk of slipping as indicated in the care plan. The DNS further stated that the history of falls should have been checked on the list of contributing factors for the A/I Report fall dated 4/8/19 at 12:40 PM. 415.4(b)(1)(ii)

Based on observations, record review and interviews and during the Recertification survey, the facility did not ensure that services are provided as outlined by the comprehensive care plan. This was identified for one (Resident #62) of 19 sampled residents. Specifically, for Resident #62, the Registered Nurse (RN) was observed on 4/24/19 to not follow the Physician's Do not Crush order for the Potassium Chloride tablet and the RN crushed the medication. The finding is: Resident #62 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. physician's orders [REDACTED]. The resident was observed seated in bed on 4/24/19 at 12:20 PM. The resident was observed with a small plastic cup containing white crushed material on the over-the-bed table. The resident's family member was present in his room. A Certified Nursing Assistant (CNA) was observed bringing the Lunch tray into the room and placing the tray on a shelf. The resident was observed sipping soup from a cup at 12:50 PM. The medication cup was now observed to be empty. The resident was asked about the white crushed material in the cup observed earlier. The resident stated he had mixed the crushed pill in his soup and was trying to finish it slowly. The resident's family member stated that the resident had difficulty swallowing medications and it takes him a while to finish consuming medicines and food. The Registered Nurse (RN) who had administered the medications to Resident #62 was interviewed on 4/24/19 at 2:00 PM. The RN stated that she had crushed the Potassium Chloride pill because the resident had specifically asked for it to be crushed as the resident feels he cannot swallow it. The RN also stated that she did not notice the order that Potassium Chloride could not be crushed. The Director of Nursing Services (DNS) was interviewed on 4/24/19 at 2:05 PM and stated that the RN should have informed the Physician about resident's difficulty with swallowing whole pills. 415.11(c)(3)(i)

Based on record review and staff interviews during the recertification survey, the facility did not ensure that for any irregularities noted by the pharmacist during the Medication Regimen Review (MRR), the attending physician document in the resident's medical record his or her rationale when there was no change in medication to occur. This was evident for 1 (Resident #8) of 5 residents reviewed for unnecessary medication. Specifically, Resident #8 had a Pharmacy MRR dated 4/18/19 which documented a pharmacist concern for the current use of [MEDICATION NAME] injection versus Aspirin 325 milligram (mg) twice daily for [MEDICAL CONDITIONS]. The Attending Physician did not respond whether he agreed or disagreed and did not document his rationale in the medical record. The finding is: Resident #8 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15 indicating the resident was independent for daily decision making. The MDS also documented that for 7 days the resident received injections of any type and was administered 7 days of anticoagulant medication during the review period. The Pharmacy MRR dated 4/18/19 documented that the pharmacist had a concern for the current use of [MEDICATION NAME] injection versus the use of Aspirin 325 milligram (mg) twice daily as a recommendation for [MEDICAL CONDITIONS]. The Attending Physician did not respond whether he agreed or disagreed and did not document his rationale in the medical record. Review of the medical record revealed that the Attending Physician did not respond with a rationale for the use of [MEDICATION NAME] injection versus Aspirin 325 mg tablet twice daily for [MEDICAL CONDITION] as recommended by the Pharmacist. An interview with the Medical Director was conducted on 4/25/19 at 1:00 PM. The Medical Director stated that he did not see the need to write a rationale since the resident was doing well with [MEDICATION NAME]. 415.18(c)(2)

Based on observation, record review, and interviews during the recertification survey, the facility did not ensure that each resident's drug regimen was free from unnecessary medication. This was evident for 1 of 5 residents reviewed for unnecessary medication. Specifically, Resident #11 was receiving an antidepressant medication ([MEDICATION NAME]) as needed with a [DIAGNOSES REDACTED]. Additionally, there were no non-pharmacological interventions documented prior to the administration of the PRN medication. The finding is: The facility policy on medications: [REDACTED]. The personnel administering a PRN medication must document the reason for and the patient's response to the PRN medication. Resident #11 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 0 indicating severely impaired cognition. The MDS documented that Resident #11 did not exhibit physical or verbal behavioral symptoms directed towards others and no behavioral symptoms not directed towards others during the 7-day look back period. The MDS documented Resident #11 received an Antidepressant medication 5 days out of the 7-day look back period. A Physician order [REDACTED]. The Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. RN#2 administered [MEDICATION NAME] to Resident #11 on 4/15/19, 4/16/19/, 4/18/19, 4/19/19, 4/22/19, and 4/24/19. The Comprehensive Care Plan for History of Agitation/Depression dated 4/12/19 documented the goal of Episodes of Depressive behavior will decrease to 1-2 times per week. The interventions included: administer medications as ordered and monitor for adverse side effects, monitor episodes of depression and agitation, prompt activity participation daily and praise efforts, orientation and re-direction as needed when exhibiting anxiety, provide calm environment if resident is agitated, and psychiatric consultation as indicated/ordered by MD. The Nurse's Progress notes written by RN #1 and RN #2 were reviewed from 4/12/19-4/25/19. RN #1 documented Patient is on [MEDICATION NAME], no unusual behavior/adverse effects in her note dated 4/17/19. RN #1 documented all needs attended to, safety maintained on 4/20/19. RN #1 did not document the reason for the administration of [MEDICATION NAME] on 4/17/19 or 4/20/19. RN #2 documented Patient is on [MEDICATION NAME], no unusual behavior/adverse effects, patient noted sleeping during rounds on 4/16/19. RN #2 did not document patient's behavior and reason for the administration of [MEDICATION NAME] on 4/17/19, 4/19/19, and 4/22/19. RN #2 documented stable patient, patient sleeping during rounds on 4/24/19 and did not document the reason for the administration of [MEDICATION NAME]. Resident #11 was observed sitting in her bed on 4/24/19 at 1:52 PM with a family member present. Resident #11 had difficulty responding to questions. Resident #11's family member stated that Resident #11 does not have a history of depression and does not take antidepressant medication. The family member further stated that Resident #11 has recently seen a neurologist that diagnosed Resident #11 with Dementia. The Certified Nursing Assistant (CNA) #1 was interviewed on 4/25/19 at 2:05 PM. CNA #1 stated that she normally provides care for Resident #11 on the 7 AM-3 PM shift. CNA #1 has worked with Resident #11 on weekdays since Resident #11's admission on 4/12/19. CNA #1 stated that Resident #11 has never presented with agitation or in a depressed mood during her shift and described Resident #11 as a very pleasant person. The Registered Nurse (RN) Coordinator for the 7 AM-7 PM shift was interviewed on 4/25/19 at 2:20 PM. The RN Coordinator stated that Resident #11 does not have the [DIAGNOSES REDACTED]. The RN Coordinator stated that Resident #11 is generally pleasant and [MEDICATION NAME] is prescribed to be administered as needed. The RN Coordinator stated [MEDICATION NAME] is prescribed to be administered in response to changes in Resident #11's behavior and the RNs are expected to attempt non-pharmacological interventions such as redirection to an activity, offering a snack, and utilizing familial supports. The RN Coordinator further stated that Resident #11 was administered [MEDICATION NAME] during the night shift and was not aware of any changes in behavior that occurred during the night shift. The Medical Director (MD) was interviewed on 4/25/19 at 2:43 PM. The MD stated that Resident #11 was transferred from the acute care unit at the hospital on [DATE]. The [MEDICATION NAME] medication order was carried over with her transfer and continued because he was informed by the previous physician that the medication was effective for sleep. The MD stated that he reconciled the medication list and based his evaluation on the previous physician's assessment. The MD stated [MEDICATION NAME] was prescribed to treat restlessness and agitation at bedtime. The MD presented the physician's progress note dated 4/7/19 which stated, We started [MEDICATION NAME]-Sleep better. The MD stated that he does not order a psychiatric consultation unless a psychiatric condition is worsening. The MD stated that Resident #11 was stable throughout her stay at the facility and the he did not understand what behavioral interventions could be used for sleep. The nurses were expected to administer the medication if they see Resident #11 was restless at bedtime. CNA #2 for the 3 PM-11 PM shift was interviewed on 4/25/19 at 3:23 PM. CNA #2 stated that she has provided care for Resident #11 on the weekday night shift since the resident's admission on 4/12/19. CNA #2 stated that Resident #11 is always calm and polite. Resident #11's mood has always been stable throughout her stay at the facility and Resident #11 never presented with agitation or appeared restless. RN #2 for the 7 PM-7 AM shift was interviewed on 4/26/19 at 9:46 AM. RN #2 stated that Resident #11 does not present as agitated, verbally aggressive or with a depressed mood. RN #2 stated that Resident #11 sometimes falls asleep earlier in the day and wakes up at 11 PM or 12 AM. Resident #11 appears restless and has a hard time getting back to sleep. RN #2 described Resident #11's restlessness as getting out of the bed and sitting at the side of the bed. RN #2 stated she administers the medication to help Resident #11 relax and get a restful night sleep. RN #2 stated that she walks with Resident #11 up and down the hallway to expend her energy, plays a stimulatory program on the television with pictures and music, and tries to give her whatever she wants to make her comfortable. RN #2 stated that when she does not administer the medication, Resident #11 gets restless again. RN #1 for the 7 PM-7 AM shift was interviewed on 4/26/19 at 9:48 AM. RN #1 stated that she has provided care for Resident #11 on a few nights. RN #1 stated that Resident #11 presented as restless at night and unable to sleep. Resident #11 never presented with agitation during the time RN #1 provided care. RN #1 stated that Resident #11 is a fall risk and would get out of the bed without calling for assistance. RN #1 stated that she administered [MEDICATION NAME] to help her sleep through the night. RN #1 further stated that her interventions prior to giving medication included redirecting her, take her to the bathroom and offering a drink of water. The Director of Nursing Services (DNS) was interviewed on 4/26/19 at 12:23 PM. The DNS stated that the RNs are expected to document the indication of use prior to administering the PRN medication. The RNs should attempt nonpharmacological interventions prior to administering a [MEDICAL CONDITION] medication. The DNS stated that the facility's policies and procedures reflect the hospital regulations and there is no specific policy addressing the use of [MEDICAL CONDITION] medication for residents. 415.12(l)(2)(i)

Based on record review and staff interview during the Recertification Survey the facility did not ensure that nutritional care and services were provided to each resident to maintain acceptable parameters of nutritional status for 1 of 3 residents reviewed for Nutrition out of a total Stage 2 sample of 18 residents. Specifically, Resident #29 had a 7.1% weight loss in a 2-week period. The resident was not on a Physician-prescribed weight loss program and there was no documented evidence the weight loss was acknowledged by the dietician or that interventions for the weight loss were put in place. The finding is: Resident #29 was admitted on [DATE] with [DIAGNOSES REDACTED]. The 6/2/2016 Admission Minimum Data Set (MDS) assessment documented a Brief Interview of Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The documented weight in the 6/2/2016 MDS was 134 pounds. The Medical Nutrition Therapy Assessment, dated 5/27/2016, documented a weight of 140.6 pounds. The assessment also documented that the resident's usual body weight (UBW) was unknown; her ideal body weight (IBW) was 105 pounds, plus/minus 10%; and that the resident had [MEDICAL CONDITION] and did not want supplements. The diet recommended in the assessment was a cardiac diet. A Nutrition Comprehensive Care Plan (CCP), dated 5/27/2016, documented that Resident #29 was to consume greater than 50%-75% of meals during the Transitional Care Unit (TCU) stay and that high calorie, high protein foods would be provided. There was no documentation in the CCP regarding what the resident's weight goal was or that the resident was expected to lose weight or was on a weight-loss diet. A Dietary note, dated 5/31/2016, documented that Resident #29 was not a big eater and that the diet was changed to chopped meals to make consumption easier and diet preferences were obtained. There was no documentation regarding the resident's weight. A Nurse's note dated 6/8/2016 at 6:40 AM documented the resident's weight was 131.4 pounds, up from 130.4 pounds. A Dietary note dated 6/8/2016 at 10:33 AM documented that the resident was eating fairly well and that 50%-100% of her meals were consumed on 6/6/2016 and 6/7/2016. There was no documentation regarding the resident's weight. Resident #29 was discharged on [DATE]. On 10/14/2016 at 1:14 PM two staff Dieticians were interviewed. They stated that weights are usually documented in progress notes and that Resident #29's weight loss should have been addressed in the 6/8/2016 progress note. On 10/14/2016 at 1:21 PM the Registered Nurse (RN) wound care nurse was interviewed. She stated that residents who have hip surgery tend to gain weight and that heart failure could lead to weight gain. She stated that if a resident loses weight, the nursing staff should notify the dietician. On 10/14/2016 at 1:34 PM the Medical Director was interviewed. He stated that he was not concerned at all about a 10 pound weight loss in a post op (operation) hip resident. The facility's policy titled Weights/Weighing the Resident/Patient, dated 10/2015, states that a weight gain/loss of 5 pounds or more in one week or one month requires follow up by the MD/Nursing/Dietician. 415.12(i)(1)

Based on record review, staff and resident interviews during the Recertification Survey, the facility did not shower a resident who needed assistance with showering. This was evident for one resident reviewed for Activities of Daily Living in a total Stage 2 Sample of 17. The finding is: Resident # 198 has a [DIAGNOSES REDACTED]. The admission Minimum Data Set assessment documented the resident's Brief Interview Mental Score was 15 indicating that the resident's cognition was intact. The plan of care dated 11/12/15 documented that the resident required extensive assistance of one person for bathing. The interventions documented that the resident was to be showered twice per week as per schedule. The shower schedule documented that the resident was to be showered on Fridays and Mondays. During an interview with the alert lucid resident on Monday, 11/16/15, at 2:00 PM, the resident stated that he had not been showered that morning. During an interview with the unit Registered Nurse (RN) on 11/16/15 at 2:10 PM, the RN stated that after reviewing the nursing notes for both Friday and Monday, there was no documented evidence that the resident had refused or received a shower. During a subsequent interview on 11/17/15 at 11:00 AM with Resident # 198, the resident explained that he had not been offered a shower since his admission to this unit and that he did not know that he could have a shower. The resident stated that had staff offered him a shower, he would have agreed to be showered. An interview was conducted with the 7 AM to 3 PM shift Certified Nurse Aide (CNA) on 11/16/15 at 2:15 PM. She stated that the resident was already up and dressed when she started her shift and that it was the night shift who had gotten the resident up. In addition, she stated that she did not offer the resident a shower Monday morning. A phone interview was conducted with the 11 PM to 7 AM aide on 11/17/15 at 12:30 PM. She stated that she offered the resident a shower Monday morning although the resident said he was tired and refused. She explained that she gave the resident a bed bath. The CNA further explained that she did not report that the resident had refused the shower since he had a sponge bath. An interview with the Director of Nursing Services on 11/17/2015 at 1:15 PM revealed that this resident is routinely scheduled for early morning therapy and is gotten up by the 11 PM to 7 AM shift. The DNS further explained that the shower schedule is for the morning shift to complete and if the resident had refused, it should have been reported and documented. 415.12 (a) (3)