Every finding on record at New East Side Nursing Home

Based on observations, interviews, and record review conducted during the Recertification survey of 11/16/22 - 11/22/22, the facility did not ensure to store, prepare, distribute, and serve food in accordance with professional standards for food safety. This was evident during Kitchen observation. Specifically, 1) a Dietary Aide (DA) was not observed changing gloves or sanitizing hands when entering and exiting the walk-in refrigerator during tray service, and 2) the walls of the walk-in refrigerator were stained with a black substance. The findings are: The facility policy titled Infection Control last reviewed 10/3/22 documented staff are to wash hands as necessary following hand washing procedures. 1) On 11/17/22 at 11:42 AM, DA #2 was observed entering and exiting the walk-in refrigerator 3 times, touching the door and handle each time, without changing gloves. Each time DA #2 exited the walk-in refrigerator, DA #2 placed food on lunch trays to be served to residents. DA #2 did not change gloves or sanitize their hands in between each entry into the walk-in refrigerator. On 11/17/22 at 11:50 AM, the Infection Preventionist was interviewed and stated staff are inserviced on handwashing protocol annually. The Kitchen is responsible for completing inservices for their staff. 2) On 11/17/22 at 12:19 PM, the vegetable walk-in refrigerator was observed with a black substance staining the upper part of walls where there was exposed wood and gaskets. The Director of Maintenance was present during the observation and stated the wood was deteriorated from cleaning and never tested for mold. The ceiling gets cleaned but the black substance is a stain and does not come off. 11/17/22 12:29 PM, the Kitchen Supervisor was interviewed and stated they do not have a daily cleaning schedule with details of what was cleaned. Staff probably do not clean the walls. 415.14(h)

Based on interview and record review conducted during the Recertification survey conducted from 11/16/22 to 11/22/22, the facility did not ensure the individual financial record was made available to the resident through quarterly statements. Specifically, quarterly statements were not provided to residents or their representative. This was evident for 1 of 1 residents reviewed for Personal Funds out of a sample of 15 residents. (Resident #50) The findings are: The undated facility policy and procedure titled Resident Personal Funds documented that all residents of New East Side Nursing Home have the right to manage his or her financial affairs. All residents will be given a receipt anytime a transaction occurs, monies due will be credited within a few days, quarterly statements shall be provided. Resident #50 was admitted with Cerebrovascular Accident (CVA) with left hemiparesis and Vascular Dementia. The quarterly Minimum Data Set (MDS) dated [DATE], documented that was moderately cognitively impaired, had clear speech, is usually understood, and usually understands others. On 11/16/22 at 3:32 PM, an interview was conducted with Resident #50 who stated that they have an account with the facility and receive statements when they request it but do not get quarterly statements. During a subsequent follow-up interview with Resident #50 on 11/21/22 at 2:12 PM, they stated they only get a bank statement when they asked for it and did not think that their representative had received a statement either. On 11/22/22 at 10:28 AM, a telephone interview was conducted with Resident #50's Representative (RR) who stated that they only receive letters about COVID. The RR further stated that they received a quarterly statement at the beginning of the year and had not gotten any other statements since. A list of resident funds from 01/01/1900 to 11/17/2022, documented that Resident #50 had a current balance of $453.73. There was no documented evidence that the resident and/or their representative had been provided with a quarterly statement. On 11/18/22 at 1:01 PM, an interview was conducted with Account Receivables (AR) who stated that statements are given per request at any time, otherwise they are given on a quarterly basis. The AR stated that statements are mailed to the representative on file and are not provided to the resident. The AR also stated that they do not have proof that it was mailed as it is only sent by regular mail, not certified mail. The AR further stated that have not had any mail returned to indicate that they may have a wrong address. On 11/21/22 at 2:17 PM, during an interview the Administrator stated that bank statements are quarterly, are mailed to the family and a copy is given to the residents. The Administrator also stated that the bookkeeper or social work staff gives out the statement. The Administrator further stated that the statements are not sent out certified mail. 415.26(h)(5)(i)

Based on observation, record review and staff interviews conducted during the Recertification survey from 11/16/22 to 11/22/22, the facility did not ensure that a person-centered comprehensive care plan (CCP) was developed and implemented to address the resident's medical, physical, mental, and psychosocial needs. Specifically, a CCP was not developed and implemented for a resident with a Hip Abduction device. This was evident for 1 of 1 resident reviewed for Position, Mobility (Resident #53), out of a sample of 15 residents investigated. The findings are: The undated facility policy titled Comprehensive Care Plan (CCP) documented the CCP will include measurable and timetables in order to meet the residents' medical, nursing, and psychosocial needs that are identified from admission assessments, the comprehensive assessment (MDS 3.0 and application of the Care Area Assessment (CAA). Additional problems, strengths or needs identified by Interdisciplinary Team (IDT) will be included in the CCP as appropriate. Resident #53 was admitted to the facility on [DATE], with diagnoses that included Osteoporosis, Cerebrovascular Accident and Non-Alzheimer's Dementia. The Significant Change Minimum Data Set (MDS) dated [DATE] documented the resident had severe impairment in cognition with long and short-term memory problems. The MDS also documented that the resident required extensive assistance of staff for bed mobility, transfer, and dressing. Physician's order dated 11/11/22 documented: Hip Abduction SMF Knee extender pillow to be used when resident is in bed; Bilateral support when in W/C to promote symmetry when sitting. On 11/16/22, between 10:26 AM and 12:38 PM, Resident #53 was observed in bed, noted with contractures on lower extremities and with no device in place. The Hip Abduction SMF Knee extender pillow was noted on the resident's nightstand. On 11/17/22 and 11/18/22, between 09:18 AM and 12:45 PM, Resident #53 was observed in the wheelchair in the room, and knee extender pillow was observed placed on the nightstand. The Comprehensive Care Plan (CCP) titled Fall dated 7/26/2022 documented that resident has potential for falls/injury secondary to diagnosis of impaired balance, impaired cognition, and history of falls. Goals included: Resident will be free of avoidable falls/injury over the next 90 days. Interventions included reduce environmental hazards, monitor for change in ADL, cognition, behavior, and mood; floor mats on right side; Adaptive equipment/devices: Bed Bolsters; PT/OT evaluation as needed. There was no documented evidence a care plan had been created that addressed resident's use of a Hip Abduction device or non-compliance with the device placement. On 11/21/22 at 09:41 AM, an interview was conducted with the Certified Nursing Assistant (CNA) #1. CNA #1 stated that resident is turned and repositioned when in bed every 2 hours and is transferred out of bed with assist of 2 staff every day. CNA #1 also stated that the kneel extender pillow is applied on the resident when in bed, but sometimes resident tries to remove the device when applied, and they always try to re-apply it and encourage resident not to remove it. CNA #1 further stated that they have not been documenting resident's removal of the device. On 11/21/22 at 10:09 AM, an interview was conducted with the Occupational Therapist Consultant (OTC). The OTC stated that resident was admitted to the facility with both knee contracture, developed at home and was started on restorative OT/PT. Hip abductor was recommended upon discharge from the therapy, which is to be applied when in bed, but resident has a habit of removing the device. The OTC also stated that Rehab is responsible for recommending devices after an assessment. The information is then placed on the CNA Accountability Record, Nursing staff is notified and the Nursing staff are supposed to initiate the care plan for the device and update the care plan as needed. The OTC further stated that they are aware that Resident had not been complying with the use of hip abductor pillow, but they are not aware that the care plan was not initiated for the device, and for resident's non-compliant behavior of removing the device. On 11/21/22 at 10:38 AM, an interview was conducted with the Registered Nurse (RN) #1. RN #1 stated that when any new device is recommended by Rehab and ordered by the Physician, the Care Plan Nurses will review and initiate the care plan and update as needed. RN #1 also stated that they cover the entire facility during the day and may initiate and update any episodic care plans that come up. RN #1 further stated that they are not aware that there was no care plan developed for the resident's device and had not been made aware that resident is removing the device when applied. On 11/21/22 at 11:14 AM, an interview was conducted with the Director of Nursing (DNS). The DNS stated that the facility has a MDS Coordinator, and specific Registered Nurses for the residents' care plans, who come on the weekend and evening shifts to check and initiate the care plans needed for the residents. The DNS also stated that the Rehab will usually send an email directly to the MDS Coordinator about their recommendations for the Care Plan Nurses to review and initiate the care plan as needed. The DNS further stated that upon assuming this role, a list of care plans was requested and rehab was asked for the list of devices, to ensure that all the care plans were up to date for the residents to be given proper care as per their plan of care. The DNS stated that they are aware that there are still some missing care plans not yet in place and are working to get them fixed. 415.11(c)(1)

Based on observation, interviews, and record review conducted during the Recertification Survey from 11/16/2022 to 11/22/2022, the facility did not ensure a resident's Comprehensive Care Plan (CCP) was reviewed and revised to reflect a change in the resident's status. This was evident for 1 (Resident #57) out of 15 total sampled residents. Specifically, the CCP related to falls was not reviewed and revised after Resident #57 had a fall. The findings are: The policy titled CCP was undated and documented acute changes in condition will be care-planned by the appropriate discipline in a timely manner. Resident #57 had diagnoses of Alzheimer's dementia and aspiration pneumonia. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #57 was severely cognitively impaired, was totally dependent on staff to perform Activities of Daily Living and had a fall with injury since admission to the facility. On 11/16/22 at 10:33 AM, Resident #57 was observed in a low bed with floor mats surrounding the bed. A Nursing Note dated 11/7/22 documented Resident #57 was found on the floor by the Certified Nursing Assistant (CNA). Resident stated they wanted to go home. No visible injuries were observed. The Registered Nurse (RN) supervisor, Medical Doctor (MD), and family were notified. A CCP related to Resident #57's fall potential was initiated 10/13/22 and documented apply floor mats on both sides of resident's bed, provide a low bed, and reduce environmental hazards. The CCP documented an update dated 10/18/22 that Resident #57 sustained a fall and laceration to the back of the head. The Incident Report dated 11/7/22 documented safety checks were in place for Resident #57 for 72 hours. Interventions included MD and family notified, resident placed back into bed and assessed for injuries, and bilateral floor mats implemented. The CCP related to Resident #57's fall potential was updated 11/12/22 by RN #1 and documented Resident #57 did not have any falls for 1 month. There was no documented evidence the CCP related to Resident #57's fall potential was reviewed and revised after the resident sustained a fall on 11/7/22. On 11/21/22 at 04:54 PM, RN#1 was interviewed and stated they are responsible for updating the CCPs if there are episodes like a fall. The CCP must be updated if a resident falls. RN #1 confirmed they updated Resident #57's CCP on 11/12/22 and stated they wrote Resident #57 didn't have any falls the previous month. RN #1 was unable to remember what happened with this CCP update. On 11/22/22 at 10:11 AM, the Director of Nursing (DON) was interviewed and stated once an incident occurs, interventions are put in place to prevent reoccurrence. Staff documents the interventions in the resident's CCP. After reviewing Resident #57's medical record, the DON stated the CCP related to fall potential did not reflect the resident's latest fall on 11/7/22 and there was miscommunication between the interdisciplinary team. Somebody did not check that the interventions were in place on the CCP. There was no follow up to ensure everything was documented properly. 415.11(c)(2)(i-iii)

Based on record review and interviews conducted during the Recertification survey from 11/16/2022 to 11/22/2022, the facility did not ensure that an assessment accurately reflected the resident's status. Specifically, the Minimum Data Set (MDS) 3.0 assessment inaccurately documented that 1). a resident (Resident # 22) did not have gradual dose reduction (GDR) and 2). a resident (Resident # 5) was receiving hospice care. This was evident for 2 out of 2 residents reviewed for Resident Assessment out of an investigative sample of 15 residents. The findings are: The undated facility policy & procedure titled MDS 3.0 Policy documented that MDS item completion assignments will be assigned to individual team members per facility administration. The policy also documented that any discipline that completes a section will sign for the completion and accuracy of their entries in the designated location of MD. 1. Resident #22 was admitted to the facility with diagnoses that included Bipolar disorder, Parkinson's Disease, and Coronary Artery Disease. The Quarterly Minimum Data Set (MDS) dated [DATE] documented Resident #22 received antipsychotic medication on a routine basis. The MDS also documented that gradual dose reduction (GDR) was not attempted as it was documented as clinically contraindicated by the physician. The psychiatry consult dated 7/23/22 documented that the visit purpose was to evaluate appropriateness for GDR. The consult also documented a recommendation for trial of GDR to decrease Seroquel (Quetiapine) 50 mg from TID (3 times a day) to Seroquel 50 mg BID (2 times a day). The Physician Orders documented medication Quetiapine 50 mg 1 tab 3 times a day for bipolar starting on 5/27/22 was discontinued on 7/25/22 and Quetiapine 50 mg 1 tab 2 times a day was started on 7/25/22. The Medication Administration Record (MAR) documented Quetiapine 50 mg 3 times a day was administered to Resident #22 until 7/24/22 and Quetiapine 50 mg 2 times a day was being administered to Resident #22 beginning on 7/25/22. On 11/21/22 at 11:42 AM, Licensed Practical Nurse (LPN) #1 was interviewed and stated Resident #22 was on Seroquel 50 mg 3 times a day before and it was changed to 2 times a day starting 7/25/22. On 11/21/22 at 12:18 PM, Attending Physician (AP) was interviewed and stated they ordered a psychiatric consult to evaluate the appropriateness for GDR for Resident #22 in July 2022 as per CMS requirement. The AP also stated they changed the order for the anti-psychotic medication Seroquel 50 mg from 3 times a day to 2 times a day for Resident #22 as per psychiatric consult recommendation. During an interview on 11/21/22 at 10:25 AM, the MDS Coordinator (MDSC) stated they interviewed residents and interdisciplinary team members and reviewed the medical documents for the past 3 months or after the last MDS assessment to gather information for the current MDS assessment. The MDSC also stated they were responsible for completion of Section N -Medications in the MDS assessment. The MDSC further stated they reviewed the psychiatry consult dated 9/17/22 to check if GDR was recommended or not and did not notice documentation of a GDR in July when doing the Quarterly MDS assessment on 9/24/22. The MDSC further stated they did not review the psychiatry consult dated 7/23/22 which documented a recommendation for trial GDR. The MDSC stated Resident #22 did have a GDR attempt, and they made an error and should have coded that a GDR was done on the MDS assessment dated [DATE]. The MDSC further stated they only checked if the MDS assessment was completed but did not check for accuracy before submitting the MDS to CMS. 45988 2. Resident #5 was admitted to the facility with diagnoses that included Alzheimer's Disease and Schizophrenia. The Quarterly Minimum Data Set (MDS) dated [DATE] documented Resident #5 received hospice care while a resident. The Admission MDS assessment dated [DATE] did not document Resident #5 was receiving hospice care. Review of Resident #5's medical record, including current orders and recent progress notes, contained no documented evidence that the resident was receiving hospice care. On 11/21/22 at 10:10 AM, an interview was conducted with the MDS Coordinator (MDSC), who stated they are the only one responsible for MDS assessments in the facility. The MDSC also stated they complete the nursing, rehabilitation, and dietary sections of the MDS. The MDSC further stated they audit their own work to look for mistakes and with Resident #5 they made a data entry error. On 11/22/22 at 10:19 AM, an interview was conducted with the Director of Nursing (DON), who stated they are not involved with the MDS assessments, and they do not have access to MDS even though they are supposed to. The DON also stated that they cannot supervise what is going on with the MDS because the system is not set up correctly, and that the whole team should have access to the MDS data. 415.11(b)

Based on observations, interviews, and record review conducted during the Recertification Survey from 11/16/2022 to 11/22/2022, the facility did not ensure that menus were followed. This was evident for 2 (Resident #43 and #45) out of 10 residents attending the Resident Council Meeting. Specifically, Resident #43 and #45 reported there were frequent substitutions to the weekly menu and residents were not notified of the changes. The findings are: Resident #43 had diagnoses of end stage renal disease and arthritis. The Minimum Data Set (MDS) dated [DATE] documented Resident #43 was cognitively intact. Resident #45 had diagnoses of fibromyalgia and Parkinson's disease. The MDS dated [DATE] documented Resident #45 was cognitively intact. On 11/18/22 at 10:28 AM, during the Resident Council Meeting, Resident #43 and #45 reported weekly menus posted by the facility and distributed to residents were frequently inaccurate and did not correspond with actual food items served to residents during mealtimes. Residents were not informed of these changes prior to being served. The weekly Menu distributed to residents and posted on resident units dated 11/13/22-11/19/22 documented 11/15/22 chicken noodle soup for lunch, 11/17/22 oriental vegetable blend for lunch, and 11/19 borscht, cheese and fruit plate, and vanilla or chocolate pudding for dinner. The As Served Menu dated 11/13/22-11/19/22 documented 11/15/22 navy bean soup for lunch, 11/17/22 mixed vegetables for lunch, and 11/19/22 potato soup, tuna salad. Potato salad, lettuce and tomatoes, and mandarin oranges for dinner. There was no documented evidence the facility informed residents there were changes to the weekly Menu prior to being served at mealtime. On 11/21/22 at 02:55 PM, Certified Nursing Assistant (CNA) #4 was interviewed and stated the Recreation Department distributes the weekly menu to residents who request a copy and keeps a copy on the 4th floor. Generally, residents will get what is on the menu. On 11/22/22 at 09:27 AM, the Kitchen Supervisor was interviewed and stated the Recreation Department posts the weekly menu on the resident units and distributes it upon resident request. Changes to the menu are not usually communicated to the residents until they come down for lunch. The Kitchen changes the up to 2 items a week because of shortages and this is not communicated to the residents. 415.4(c)(1-3)

Based on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure that a restraint was used in accordance with the resident's plan of care and physician's orders [REDACTED].# 42, to be released every 2 hours for 15 minutes and during meals. The MD's order did not document a medical justification for the use of this type of restraint. In addition, on multiple occasions it was observed that nursing staff did not release the seatbelt every 2 hours for 15 minutes and did not have the seatbelt released during meal times. This was evident for 1 of 2 residents reviewed for restraint use. (Resident #42) The findings are: Resident #42 was admitted to the facility with [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set ((MDS) dated [DATE] documents that the resident has severely impaired cognition, no behavioral issues, and requires the extensive to total assistance of 1 person to complete all activities of daily living (ADL). The MDS also documents that the resident has a trunk restraint that is used daily whenever the resident is out of bed. On 12/6/18, from 8:43AM to 12:08 PM and 12/7/18 from 9:09AM to 12:47 PM, multiple observations were made of the resident while she was seated in her wheelchair with the secure soft seatbelt in place. The resident was observed sitting in the hallway on her unit and then being brought to the Recreation Department on the 4th floor unit on both days. The resident was also observed on both days to be brought back down to her unit from Recreation and then placed in the Floor Day Room (FDR) to await lunch. There were no observed attempts to transfer the resident to her bed for a diaper change or to toilet the resident in any bathrooms. The resident was observed to have her secure soft seatbelt in place during each of these observations. Additionally, the resident was observed being fed by the Licensed Practical Nurse (LPN) #1 during lunch time on 12/7/18 with the secure soft seatbelt still in place. The resident was not observed to be agitated during any of the observations made on 12/6/18 and 12/7/18. At times, the resident would lightly tug on the soft seatbelt strap while seated in the wheelchair but was unable to release the restraint independently. All SA attempts to speak with resident or provide directives for resident to release restraint were unsuccessful due to the resident's severely impaired cognition. The physician's orders [REDACTED]. A Certified Nursing Assistance (CNA) ADL Care Card dated 11/28/18 documents that the resident has a safety device/restraint in place. The secure soft belt is to be used when the resident is in the wheelchair and is to be released every 2 hours for 15 minutes. A Restraints Comprehensive Care Plan (CCP) initiated on 11/14 documents that the resident is at risk for deterioration due to use of restraints related to decreased safety awareness. The goal is for the resident to be free from injury while using the least restrictive device without adverse effects. The document lists the Nursing staff and Medical Doctor (MD) are the disciplines responsible for releasing the restraint every 2 hours for 15 minutes to toilet, provide skin care, range of motion, and ambulate (if feasible). The Nursing staff is the discipline responsible for releasing the restraint for meals. A Restraint Agreement Form dated 10/3/18 documents that the resident is to have a secure soft seat belt in place due to decreased safety awareness and increased risk for falls. An Interim physician's orders [REDACTED]. A subsequent Interim Physicians' Order on 10/1/18 documents that the MD ordered for resident to have the secure soft seat belt when she is in the wheelchair. The restraint is to be released every 2 hours for 15 minutes. The is no documented evidence that the order for secure soft seatbelt was discontinued on any of the Interim Orders reviewed from 10/1/18 to present. There was no medical justification for the soft seatbelt documented on the interim order. A Rehab Restraint Review Form dated 10/1/18 documents that a secure soft belt is recommended. The resident is unable to release the restraint upon command. The reasons for using the secure soft seat belt include promoting an upright sitting position and is due to the resident constantly attempting to stand up unassisted. The recommendation is to discontinue the existing restraint and start the new restraint of a secure soft belt. A Physicians Order Sheet for Adaptive Devices dated 10/1/18 documents that the type of device to order is a secure soft belt when resident is in wheelchair. There was no documentation of a MD review or assessment of the resident's need for restraint noted in the Doctor's Progress Notes from 9/7/18 through 11/1/18. On 12/07/18 at 2:42 PM an interview was conducted with the resident's assigned CNA, CNA #1. According to CNA #1, the resident is at high risk for falls and has several interventions in place to prevent falls. The resident's bed is to be kept in the lowest position, legs are to be kept elevated, a bed alarm is in place, the call bell is to be within reach, and the secure soft seatbelt is to be used when the resident is in the wheelchair. The CNA's responsibility is to make sure that the belt is not too tight and that there is no irritation on the resident's skin from seatbelt usage. The CNA stated that the belt is only to be released during meal times if possible. The seatbelt may not be released if the resident is leaning forward in her chair, putting herself at risk for a fall. The CNA is assigned to the 7am to 3pm shift and meal times are the only time the restraint is released. The resident requires total assistance with her ADLs and the CNA will usually transfer the resident back to bed to be toileted. There are times where the aide will attempt to toilet the resident in the bathroom. The CNA checked the resident's diaper prior to lunch being served today and did not attempt to change or toilet the resident because her diaper was fairly dry. The CNAs use the CNA assignment book as their main source of information when determining how to care for residents on their assignments. On 12/07/18 at 2:53 PM an interview was conducted with LPN #1. Although she has mainly been assigned to work on another unit in the facility, LPN #1 has worked with the resident several times since she was admitted to the facility and is familiar with her care. LPN #1 states that the resident is blind and sometimes will lean forward in her wheelchair in an unsafe manner because she has sensory deficits; however, this is not reflected in the resident's CCP related to Restraint Use. Since the resident is unable to see, she believes that she is included in conversations that may be taking place around her. The resident will then attempt to move her body in the direction of the conversations without having awareness of her safety. LPN #1 states that the resident has an order for [REDACTED]. The resident was observed with the seatbelt in place during lunch time today because there were multiple residents on the floor that required staff assistance with feeding during meal time. There were more residents to assist during meal time than usual because some residents decided to eat on the unit instead of in the main dining room where the normally eat. The resident's seatbelt was not removed because of safety concerns. Resident must be closely monitored if the restraint is removed because she can attempt to stand and then fall. LPN #1 further stated that it is the judgment call of the nurse as to whether a resident's restraint release period is adjusted or changed. When LPN #1 was asked why the resident was not released from her restrain during the timeframe observed by the SA, LPN #1 stated that the resident must have been released and that the CNA documents the release times on a form that is kept separate from the CNA Accountability Record. LPN #1 then stated that she needed to attend to a resident and asked to continue the interview at a later time. A follow up interview was conducted with CNA #1 on 12/10/18 at 9:36 AM. The CNA stated that after her initial interview with the SA, she had been re-inserviced by the nurse on the unit re: the policy and procedure for restraint usage and release times. No documentation was provided by CNA #1 to verify that a formal inservice was provided to her regarding restraint policies and procedures. The CNA stated that the resident's seatbelt is to be checked and released every 2 hours. There is a restraint Monitoring Sheet that the CNA's use to document when the seatbelts are released. CNA #1 presented the Monitoring Sheet to the SA and confirmed that she had filled out the sheet and her signature was present on the dates for 12/6/18 and 12/7/18. The Monitoring Sheet documents that on 12/6/18 the resident was out of bed to the wheelchair at 8am the resident had breakfast good appetite, at 10am the resident was out of bed to wheelchair, and at 12pm, the resident was monitored for safety. The sheet then documents that on 12/7/18, the resident had breakfast- good appetite at 8am, was out of bed to wheelchair at 10am, and was at lunch - 12:45pm released X15 minutes at 12pm. A follow up interview was conducted with LPN #1 on 12/10/18 at 10:38 AM. Staff on the unit who work with the resident determine that a restraint is necessary for residents when it is determined that their safety is at risk despite alternate measures and interventions to deter at risk behavior. A trial period is initiated when a restraint is recommended to see if the resident can remove the restraint and whether it increases safety. Resident #42 would require a one-to-one staff supervision if no restraint were in place. Once the nursing staff makes observations of unsafe behavior, a psychiatric evaluation will be requested, and the nursing supervisor will be made aware. If a resident currently has a restraint in place, the LPN/RN would be responsible for initiating an observation period with the purpose of discontinuing the restraint order. There are times where a significant change in the resident's status will spur an evaluation for possible discontinuance of a restraint. Upon review of the 11/29/18 physician's orders [REDACTED]. When asked for an explanation, LPN #1 stated that orders are sometimes faxed to the pharmacy, but they may not transcribe everything onto the Monthly Order Form accurately. The process is that the night shift is responsible for reviewing and reconciling the orders and making sure any discrepancies are clarified. The evening shift and the night shift verify that the orders are correct. Both nurses sign that they have verified the accuracy of the orders. Then the MD signs to verify that orders are complete and correct. If there continues to be discrepancies in the physician's orders [REDACTED]. LPN #1 stated that since she has had to handwrite in secure soft seatbelt on the physician's orders [REDACTED]. An interview was conducted on 12/10/18 at 11:31 AM with the resident's MD who was responsible for ordering the restraint. The MD stated that he is familiar with the resident, but not specifically with the devices that have been ordered for her. The MD stated that when a restraint is needed, the interdisciplinary team will attempt other interventions. Often, a resident may have an issue that is more so related to positioning as opposed to requiring a restraint. The MD requires a lot of feedback from facility staff and nursing personnel to ensure that a restraint is necessary. Before ordering a restraint, the MD will discuss the concerns with facility staff. If the MD agrees with the recommendation for a restraint use, the interdisciplinary team will get involved to ensure that the resident/family is also made aware and in agreement. Then an MD order is written. The facility has an ongoing process of review for each resident with a restraint. The MD could not say how often the restraints are reviewed. He believes that he reviews the restraint orders when the resident's monthly physician's orders [REDACTED]. [REDACTED]. The MD does a review of all the monthly physician's orders [REDACTED]. If there is a discrepancy, the MD would cross it out and initial it. The MD makes these corrections on the physician's orders [REDACTED]. The MD stated that there would be a notation made in the MD Notes if the resident was assessed with [REDACTED]. medical review and assessment. The MD could not provide a medical justification for the use of the seatbelt as a restraint for this resident. On 12/10/18 at 12:08 PM, an interview was conducted with the Director of Nursing, DON. A restraint evaluation is completed when the nursing staff identifies a safety concern for a resident. Before placing a restraint on a resident, the facility ensures that rehabilitation department assessment is done to evaluate for other possible interventions. The interdisciplinary team meets and makes sure that the family is involved with the decision to initiate a restraint. There is a Monitoring Sheet that documents the release times of any restraint currently ordered for a resident. The MD must agree and write the order for the resident's restraint. A monthly restraint assessment is completed by the nursing supervisor and/or the DON. Restraint reduction may be initiated to determine if there is a continued need for a restraint. The DON stated that the nursing staff assigned to the resident did release the seatbelt on the morning of 12/6 and 12/7 despite the SA observations that resident had the secure soft seatbelt in place for longer than a 2-hour period and throughout meal time. The DON stated that the CNA documented that the restraint was released on 12/6 and 12/7 and that this is accurate information. The DON stated that the surveyor must have missed the release times. The DON stated that the pharmacy transcribes a resident's current physician's orders [REDACTED]. If there is a discrepancy with the orders, the nurses can hand write the orders in and then fax them to the pharmacy to clarify. Sometimes a call will need to be placed to the pharmacy to verbally inform them that there is an issue that they are not resolving. All three nurses from the 3 shifts are required to check the physician's orders [REDACTED]. The DON further stated that the MD should also be checking the accuracy of physician's orders [REDACTED]. [REDACTED]. §483.10(e)(1)

Based on record review and interviews conducted during the recertificaiton survey, the facility did not ensure the accuracy of a resident's assessment. Specifically, a Minimum Data Set (MDS) inaccurately documented that a resident received oxygen and ventilator/respirator therapy while in the facility. This was evident for 1 of 36 residents reviewed. (Resident #9 ) The findings are: The facility's Minimum Data Set(MDS) Policy and Procedure reviewed on 02/2018 documented that using a prescribed set of definitions, information for the MDS completion may come from a variety of sources such as staff, resident, family interviews, and the clinical record. It also documented that each individual who completes a portion of the assessment certifies the accuracy of that portion of the assessment. Resident #9 was admitted to the facility with a [DIAGNOSES REDACTED]. The most recent Quarterly MDS dated [DATE] documented that the resident has moderate cognitive impairments. Under the MDS Section 'O', Special Treatments, Procedures, and Programs, the resident is documented as using oxygen therapy and a ventilator or respirator while a resident. A review of the resident's entire medical record from the MDS assessment reference dates was completed. There was no documented evidence that the resident received any oxygen and/or ventilator/respirator therapy while a resident of the facility. An interview was conducted with the MDS Coordinator on 12/6/18 and 12/10/18. The MDS Coordinator (MDS-C) stated that she is the person responsible for completing the MDS assessments for every resident in the facility. Upon reviewing the resident's 9/14/18, the MDS-C stated that she had made an error when inputting this particular residents information. She stated that the facility does not have ventilator services and that she will review the residents chart again and file a correction on the MDS. The MDS-C is the sole person who compiles information through record review, conducting interviews, and through observations. She also inputs all of the MDS assessments in the facility. Once an MDS assessment has been completed, the MDS-C will review the information that has been inputted to ensure accuracy. There are no follow up audits or reviews done to ensure the accuracy of MDS assessments. Whenever the MDS-C initiates a new MDS assessment to be completed for a resident, she will review the previous MDS to compare the information that has been gathered. Occasionally, she will find discrepancies and file a MDS correction. The MDS-C is part of the Quality Assurance team but states that MDS accuracy is not a topic that they have ever reviewed. 415.11(b)

Based on observations, record review, and interview conducted during the recertification survey, the facility did not ensure that services provided met professional standards. Specifically, the Nursing staff did not clarify the absence of a physician's orders [REDACTED]. This was evident for 1 of 2 residents reviewed for restraint use. (Resident #42) The findings are: Resident #42 was admitted to the facility with [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set ((MDS) dated [DATE] documents that the resident has severely impaired cognition, no behavioral issues, and requires the extensive to total assistance of 1 person to complete all activities of daily living (ADL). The MDS also documents that the resident has a trunk restraint that is used daily whenever the resident is out of bed. On 12/6/18, from 8:43AM to 12:08PM and 12/7/18 from 9:09AM to 12:47PM, multiple observations were made of the resident while she was seated in her wheelchair with the secure soft seatbelt in place. The resident was observed sitting in the hallway on her unit and then being brought to the Recreation Department on the 4th floor unit on both days. The resident was also observed on both days to be brought back down to her unit from Recreation and then placed in the Floor Day Room (FDR) to await lunch. There were no observed attempts to transfer the resident to her bed for a diaper change or to toilet the resident in any bathrooms. The resident was observed to have her secure soft seatbelt in place during each of these observations. Additionally, the resident was observed being fed by the Licensed Practical Nurse (LPN) #1 during lunch time on 12/7/18 with the secure soft seatbelt still in place. The resident was not observed to be agitated during any of the observations made on 12/6/18 and 12/7/18. At times, the resident would lightly tug on the soft seatbelt strap while seated in the wheelchair but was unable to release the restraint independently. All State Agency (SA) attempts to speak with resident or provide directives for resident to release restraint were unsuccessful due to the resident's severely impaired cognition. The physician's orders [REDACTED]. A Certified Nursing Assistance (CNA) ADL Care Card dated 11/28/18 documents that the resident has a safety device/restraint in place. The secure soft belt is to be used when the resident is in the wheelchair and is to be released every 2 hours for 15 minutes. A Restraints Comprehensive Care Plan (CCP) initiated on 11/14 documents that the resident is at risk for deterioration due to use of restraints related to decreased safety awareness. The goal is for the resident to be free from injury while using the least restrictive device without adverse effects. The document lists the Nursing staff and Medical Doctor (MD) are the disciplines responsible for releasing the restraint every 2 hours for 15 minutes to toilet, provide skin care, range of motion, and ambulate (if feasible). The Nursing staff is the discipline responsible for releasing the restraint for meals. A Restraint Agreement Form dated 10/3/18 documents that the resident is to have a secure soft seat belt in place due to decreased safety awareness and increased risk for falls. An Interim physician's orders [REDACTED]. A subsequent Interim Physicians' Order on 10/1/18 documents that the MD ordered for resident to have the secure soft seat belt when she is in the wheelchair. The restraint is to be released every 2 hours for 15 minutes. The is no documented evidence that the order for secure soft seatbelt was discontinued on any of the Interim Orders reviewed from 10/1/18 to present. There was no medical justification for the soft seatbelt documented on the interim order. A Rehab Restraint Review Form dated 10/1/18 documents that a secure soft belt is recommended. The resident is unable to release the restraint upon command. The reasons for using the secure soft seat belt include promoting an upright sitting position and is due to the resident constantly attempting to stand up unassisted. The recommendation is to discontinue the existing restraint and start the new restraint of a secure soft belt. A Physicians Order Sheet for Adaptive Devices dated 10/1/18 documents that the type of device to order is a secure soft belt when resident is in wheelchair. There was no documentation of a MD review or assessment of the resident's need for restraint noted in the Doctor's Progress Notes from 9/7/18 through 11/1/18. On 12/07/18 at 2:42 PM an interview was conducted with the resident's assigned CNA, CNA #1. According to CNA #1, the resident is at high risk for falls and has several interventions in place to prevent falls. The resident's bed is to be kept in the lowest position, legs are to be kept elevated, a bed alarm is in place, the call bell is to be within reach, and the secure soft seatbelt is to be used when the resident is in the wheelchair. The CNA's responsibility is to make sure that the belt is not too tight and that there is no irritation on the resident's skin from seatbelt usage. The CNA stated that the belt is only to be released during meal times if possible. The seatbelt may not be released if the resident is leaning forward in her chair, putting herself at risk for a fall. The CNA is assigned to the 7am to 3pm shift and meal times are the only time the restraint is released. The resident requires total assistance with her ADLs and the CNA will usually transfer the resident back to bed to be toileted. There are times where the aide will attempt to toilet the resident in the bathroom. The CNA checked the resident's diaper prior to lunch being served today and did not attempt to change or toilet the resident because her diaper was fairly dry. The CNAs use the CNA assignment book as their main source of information when determining how to care for residents on their assignments. On 12/07/18 at 2:53 PM an interview was conducted with LPN #1. Although she has mainly been assigned to work on another unit in the facility, LPN #1 has worked with the resident several times since she was admitted to the facility and is familiar with her care. LPN #1 states that the resident is blind and sometimes will lean forward in her wheelchair in an unsafe manner because she has sensory deficits; however, this is not reflected in the resident's CCP related to Restraint Use. Since the resident is unable to see, she believes that she is included in conversations that may be taking place around her. The resident will then attempt to move her body in the direction of the conversations without having awareness of her safety. LPN #1 states that the resident has an order for [REDACTED]. The resident was observed with the seatbelt in place during lunch time today because there were multiple residents on the floor that required staff assistance with feeding during meal time. There were more residents to assist during meal time than usual because some residents decided to eat on the unit instead of in the main dining room where the normally eat. The resident's seatbelt was not removed because of safety concerns. Resident must be closely monitored if the restraint is removed because she can attempt to stand and then fall. LPN #1 further stated that it is the judgment call of the nurse as to whether a resident's restraint release period is adjusted or changed. When LPN #1 was asked why the resident was not released from her restrain during the timeframe observed by the SA, LPN #1 stated that the resident must have been released and that the CNA documents the release times on a form that is kept separate from the CNA Accountability Record. LPN #1 then stated that she needed to attend to a resident and asked to continue the interview at a later time. A follow up interview was conducted with CNA #1 on 12/10/18 at 9:36 AM. The CNA stated that after her initial interview with the SA, she had been re-inserviced by the nurse on the unit re: the policy and procedure for restraint usage and release times. No documentation was provided by CNA #1 to verify that a formal inservice was provided to her regarding restraint policies and procedures. The CNA stated that the resident's seatbelt is to be checked and released every 2 hours. There is a restraint Monitoring Sheet that the CNAs use to document when the seatbelts are released. CNA #1 presented the Monitoring Sheet to the SA and confirmed that she had filled out the sheet and her signature was present on the dates for 12/6/18 and 12/7/18. The Monitoring Sheet documents that on 12/6/18 the resident was out of bed to the wheelchair at 8am the resident had breakfast good appetite, at 10am the resident was out of bed to wheelchair, and at 12pm, the resident was monitored for safety. The sheet then documents that on 12/7/18, the resident had breakfast- good appetite at 8am, was out of bed to wheelchair at 10am, and was at lunch - 12:45pm released X15 minutes at 12pm. A follow up interview was conducted with LPN #1 on 12/10/18 at 10:38 AM. Staff on the unit who work with the resident determine that a restraint is necessary for residents when it is determined that their safety is at risk despite alternate measures and interventions to deter at risk behavior. A trial period is initiated when a restraint is recommended to see if the resident can remove the restraint and whether it increases safety. Resident #42 would require a one-to-one staff supervision if no restraint were in place. Once the nursing staff makes observations of unsafe behavior, a psychiatric evaluation will be requested, and the nursing supervisor will be made aware. If a resident currently has a restraint in place, the LPN/RN would be responsible for initiating an observation period with the purpose of discontinuing the restraint order. There are times where a significant change in the resident's status will spur an evaluation for possible discontinuance of a restraint. Upon review of the 11/29/18 physician's orders [REDACTED]. When asked for an explanation, LPN #1 stated that orders are sometimes faxed to the pharmacy, but they may not transcribe everything onto the Monthly Order Form accurately. The process is that the night shift is responsible for reviewing and reconciling the orders and making sure any discrepancies are clarified. The evening shift and the night shift verify that the orders are correct. Both nurses sign that they have verified the accuracy of the orders. Then the MD signs to verify that orders are complete and correct. If there continues to be discrepancies in the physician's orders [REDACTED]. LPN #1 stated that since she has had to handwrite in secure soft seatbelt on the physician's orders [REDACTED]. An interview was conducted on 12/10/18 at 11:31 AM with the resident's MD who was responsible for ordering the restraint. The MD stated that he is familiar with the resident, but not specifically with the devices that have been ordered for her. The MD stated that when a restraint is needed, the interdisciplinary team will attempt other interventions. Often, a resident may have an issue that is more so related to positioning as opposed to requiring a restraint. The MD requires a lot of feedback from facility staff and nursing personnel to ensure that a restraint is necessary. Before ordering a restraint, the MD will discuss the concerns with facility staff. If the MD agrees with the recommendation for a restraint use, the interdisciplinary team will get involved to ensure that the resident/family is also made aware and in agreement. Then an MD order is written. The facility has an ongoing process of review for each resident with a restraint. The MD could not say how often the restraints are reviewed. He believes that he reviews the restraint orders when the resident's monthly physician's orders [REDACTED]. [REDACTED]. The MD does a review of all the monthly physician's orders [REDACTED]. If there is a discrepancy, the MD would cross it out and initial it. The MD makes these corrections on the physician's orders [REDACTED]. The MD stated that there would be a notation made in the MD Notes if the resident was assessed with [REDACTED]. medical review and assessment. On 12/10/18 at 12:08 PM, an interview was conducted with the Director of Nursing, (DON). A restraint evaluation is completed when the nursing staff identifies a safety concern for a resident. Before placing a restraint on a resident, the facility ensures that rehabilitation department assessment is done to evaluate for other possible interventions. The interdisciplinary team meets and makes sure that the family is involved with the decision to initiate a restraint. There is a Monitoring Sheet that documents the release times of any restraint currently ordered for a resident. The MD must agree and write the order for the resident's restraint. A monthly restraint assessment is completed by the nursing supervisor and/or the DON. Restraint reduction may be initiated to determine if there is a continued need for a restraint. The DON stated that the nursing staff assigned to the resident did release the seatbelt on the morning of 12/6 and 12/7 despite the SA observations that resident had the secure soft seatbelt in place for longer than a 2-hour period and throughout meal time. The DON stated that the CNA documented that the restraint was released on 12/6 and 12/7 and that this is accurate information. The DON stated that the surveyor must have missed the release times. The DON stated that the pharmacy transcribes a resident's current physician's orders [REDACTED]. If there is a discrepancy with the orders, the nurses can hand write the orders in and then fax them to the pharmacy to clarify. Sometimes a call will need to be placed to the pharmacy to verbally inform them that there is an issue that they are not resolving. All three nurses from the 3 shifts are required to check the physician's orders [REDACTED]. The DON further stated that the MD should also be checking the accuracy of physician's orders [REDACTED]. [REDACTED]. 415.11(c)(3)(i)

Based on observation, interview and record review the facility did not ensure that garbage and refuse were disposed of properly. Specifically, three (3) commercial garbage bins were observed not to be properly covered. In addition, the area adjacent to and surrounding the bins was full of debris. This was observed during the Kitchen/Food observation task. The findings are: On 4/25/17, at approximately 9:45AM the State Surveyor(SA) conducted an observation of the facility's garbage storage area with the facility Food Service Director. The following were observed: behind the metal gate were three metal commercial garbage bins. The three bins contained closed black garbage bags which were visible at the top of the bins. Each bin had intact heavy gauge plastic lids. The lids were attached to the garbage bins but were not covering the bins. The following litter was observed on the concrete floor adjacent to the bins: one soda can, one latex glove, a piece of a wet corrugated box, and other various smaller pieces of refuse. On 4/27/17 at 9:50 AM the outside area that holds three commercial garbage bins was observed. The three bins have moveable, black plastic lids but they were not covering the bins which were holding multiple black plastic garbage bags. The concrete floor was littered with one soda can, one clear plastic drink bottle, used latex gloves, one piece of saturated corrugated paper box and other various smaller pieces of refuse. On 4/28/17 at 9:25 AM the same area was observed. The three garbage bins were empty but the bins remain uncovered. The concrete floor was littered with afore-mentioned refuse. On 4/28/17 at approximately 11:41 AM this SA met with the Director of Housekeeping and together went outside to the garbage holding area. He slid the gate to the left and viewed the uncovered garbage containers and the concrete floor. He pulled out the middle rolling bin and on the floor behind the bins were 3 black garbage bags and saturated corrugated paper boxes which were tied up and approximately 12 high. On 4/28/17 at 11:48 AM the Director of Housekeeping was interviewed and stated, The garbage bins are supposed to be covered with the lids. The staff member who is assigned to maintain the area has been out for approximately one month due to surgery. While the other person was out I should have been monitoring the area. I will clean up the litter and garbage on the floor. He then proceeded to cover all the bins and close the gate. The facility's policy titled, Waste Disposal dated 4/28/17 documented, It is the policy of The New East Side Nursing to dispose of its kitchen and household waste in a proper and sanitary manner. 415.14 (h)

Based on observations and interviews, the facility did not ensure that food was stored under sanitary conditions to prevent cross-contamination of other food in the refrigerator. Specifically (1) Raw animal food (chicken and beef), were not stored on shelves below vegetables and were not stored in drip-proof containers (2) Food storage and Kitchen areas were observed with dirt and debris, mouse droppings, and a dead mouse. This was evident during the initial kitchen observation and tour made by the Sanitarian. The findings are: On 3/2/16 at 9:23 AM and 11:11 AM, during initial kitchen observation, the meat freezer was observed with four bags of raw chicken stored on the top shelf on a piece of cardboard. The middle shelf was observed with five heads of cabbage next to three bags of raw ground meat on a piece of cardboard. On 3/2/16 at 9:29 AM, the food storage room was observed with two empty mousetraps by the front entrance and by the emergency supply. White and brown colored debris was also observed around the storage area floor underneath shelving units. On 3/2/16 at 10:57 AM, the sanitarian observed the kitchen's pan and utensils storage room with debris and small black droppings on the floors and shelves. On 3/2/16 at 11:02 AM, the sanitarian observed the dishwashing area with debris and an accumulation of dust. On 3/2/16 at 11:12 AM, the sanitarian observed the dry foods and food storage room in the kitchen with debris and small black droppings on the floor, a trapped dead mouse underneath a shelving unit, and dust and trash (plastic cups) on the floor. On 3/2/16 at 11:25 AM, the sanitarian observed the basement housekeeping storage room with small black droppings on the floor. On 3/2/16 at 1:10 PM, the sanitarian observed the third floor electrical closet with soiled brown substance and an accumulation of dust. On 3/7/16 at 11:20 AM, a follow up observation of the meat freezer was made and observed five bags of raw ground meat on a piece of cardboard in the middle shelf. On 3/2/16 at 11:11 AM and 3/7/16 at 11:29 AM, the Food Service Supervisor stated the delivery person is responsible for unpacking and storing the raw meat in the refrigerator. He stated that they are not supposed to store vegetables below raw meat, the vegetables are suppose to be stored on the top shelf, and raw meat is to be stored in containers. The supervisor further stated that the cabbage was stored next to the raw meat because it will be used to cook with the ground meat on Saturday. He stated that his staff mops the kitchen floors three times a day and if they see any pests, they would contact the exterminator. On 3/7/16 at 11:24 AM, the dietary worker who is responsible for unpacking and storing raw meat as well as cleaning the kitchen and storage areas was interviewed. The dietary worker stated that he is supposed to store raw meat in a container and not supposed to store raw meat with vegetables. He further stated he just didn't store it properly that time. Dietary worker stated he cleans the floors daily and mops it one to two times a day. He further stated if he sees insects or rodents he would tell the supervisor verbally and that he has not seen any pests recently. The facility policy and procedure for Storage Policy (Dated 1/8/16) was reviewed. .Store raw meat, fish, and poultry on the lower shelves to avoid any possible drippings . 415.14 (h)

Based on record reviews and interviews it was determined that the facility did not ensure that drug regimen reviews were conducted at least once a month by a Licensed Pharmacist. The findings were noted for 5 out of 5 sampled residents reviewed for Unnecessary Medications In addition it was determined that none of the 57 in house residents had a drug regimen review performed during the month of February 2016 by a Licensed Pharmacist. The findings are: 1) Resident #21 is a [AGE] year old with [DIAGNOSES REDACTED]. The last Pharmacist Monthly Drug Regimen Review was performed on 1/31/16. There was no documented evidence a review was performed during the month of February 2016. 2) Resident #68 is an [AGE] year old with [DIAGNOSES REDACTED]. The last Pharmacist Monthly Drug Regimen Review was performed on 1/31//16. There was no documented evidence a review was performed during the month of February 2016. 3 )Resident #27 is a [AGE] year-old with [DIAGNOSES REDACTED]. The last Pharmacist Monthly Drug Regimen Review was performed on 1/31//16. There was no documented evidence a review was performed during the month of February 2016. On 03/04/2016 11:07AM the Director of Nursing (DON) was interviewed and stated, My understandin is every monththe Pharmacy Consultant comes here to evaluate and reviw the medicationss. He did not come here in February to do the monthly review. So out of the 55 residents no one had a chart review performed in February. I started as the DON her in November 2015. I am working as the DON here for 4 months. I thought the month of February is so short and that they will come in the first week of March. The regulation says the Pharmacy Consultant should be doing the medication review every month. It has been 33 days since he was here doing the reviews. It is my responsubility to see that he comes. I should have called him at least a week prior to the end of the month. It is my responsibility that I did not follow up since he was not here by the end of the month. Pharmacist Monthly Drug Regimen Review performed on 1/31/16. No documented evidence a review was performed in the month of February 2016. On 03/04/2016 11:22 AM the President of the Pharmacy Consulting company was interviewed and stated, The regulation states a pharmacy medication review needs to be done every 30 days. It was 33 days since the reviews were done. The Pharmacist did not come at all or perform any reviews for the last 33 days. The Pharmacist had to suddenly leave the country for a death in the family. He just returned late last night. He is on his way right to do the reviews today. He will look at the February Medication Administration Records and Physicians orders. I was not aware that the Pharmacist left the country. He did not tell me he was leaving. If I was aware I would have had someone else come to perform the reviews. I don't know what day he left or what the circumstances are, This is not the way we practice. I would have had the charts reviewed. It is my stupidity that this happened. On 03/04/2016 1:28 PM Pharmacy Consultant was interviewed and stated, A drug regimen review needs to be done every month. The last time I came here to do the drug regimen review was on 1/31/2016. It was 33 days since I performed the last drug regimen review for every resident in the building. I did not do any reviews during the month of February. My brother past away in Pakistan. I left the country on Wednesday night Feburary 24th. I had a booking to come back on February 28th, but he passed away and I had to stay 4 more days. I just got back last night. In the chaos of everything I just never did it. Things were so crazy I did nor get a chance to notify my boss at the Pharmacy consulting company that I would not be available to perform the reviews. On 03/04/2016 1:36PM the Administrator was interviewed and stated, I expect the Pharmacy Consulting company to send a Pharmacy Consultant once a month to perform the pharmacy drug regimen reviews. They review charts, they inspect the refrigerators for expiration dates, they make recommendations. This is the first that I have heard of it that they did not show up on time. I assume responsibility for this being overlooked. The facility policy titled Drug Regimen Reviews dated 2/2010 documents, The Consultant Pharmacist shall review the drug regimen of each resident at least monthly and report any irregularities to the Director of Nursing or the Attending Physician(if applicable) and the Administrator. 3) Resident #27 is a [AGE] year-old with [DIAGNOSES REDACTED]. The Pharmacist Review of Medication Therapy log documented the last Drug Regimen Review (DRR) was done 1/31/16. There was no documented evidence that the pharmacy review was done in February 2016. Resident #34 is a [AGE] year-old with [DIAGNOSES REDACTED]. The Pharmacist Review of Medication Therapy log documented the last Drug Regimen Review (DRR) was done 1/31/16. There was no documented evidence that the pharmacy review was done in February 2016. 2) Resident #5 is an [AGE] year old with [DIAGNOSES REDACTED]. The Pharmacist Review of Medication Therapy log documented the last Drug Regimen Review (DRR) was done 1/31/16. There was no documented evidence that the pharmacy review was done in February 2016. On 3/7/16 at 8:51 AM, the Registered Nurse (RN) Supervisor (MP) was interviewed. The RN supervisor stated that the pharmacist reviews the medications monthly and usually leaves a note in the pharmacy book if there were any recommendations made. If there were no recommendations, the pharmacist will check off no irregularities on the Pharmacist review of medication therapy form. She then stated that it's not to her knowledge that she is supposed to check if drug regimen review is done.

Based on observations and interviews, the facility did not maintain an effective pest control program so that the facility is free of pests and rodents. Specifically, mouse droppings and a dead mouse were observed in storage areas. This was evident in more than two areas within the kitchen and housekeeping and maintainence areas. The findings are: On 3/2/16 at 9:29 AM, the food storage room was observed with two empty mousetraps by the front entrance and by the emergency supply. White and brown colored debris was also observed around the storage area floor underneath shelving units. On 3/2/16 at 10:57 AM, the sanitarian observed the kitchen's pan and utensils storage room with debris and small black droppings on the floors and shelves. On 3/2/16 at 11:02 AM, the sanitarian observed the dishwashing area with debris and an accumulation of dust. On 3/2/16 at 11:12 AM, the sanitarian observed the dry foods and food storage room in the kitchen with debris and small black droppings on the floor, a trapped dead mouse underneath a shelving unit, and dust and trash (plastic cups) on the floor. On 3/2/16 at 11:25 AM, the sanitarian observed the basement housekeeping storage room with small black droppings on the floor. On 3/2/16 at 1:10 PM, the sanitarian observed the third floor electrical closet with soiled brown substance and an accumulation of dust. On 3/7/16 at 11:29 AM, the Food Service Supervisor stated his staff mops the kitchen floors three times a day and if they see any pests, they would contact the exterminator. On 3/7/16 at 11:24 AM, the dietary worker who is responsible for cleaning the kitchen and storage areas was interviewed. The dietary worker stated he cleans the floors daily and mops it one to two times a day. He further stated if he sees insects or rodents he would tell the supervisor verbally and that he has not seen any pests recently. On 3/4/16 at 2:40 PM, the Director of Housekeeping (DH) was interviewed and stated that he is at the facility once or twice per week because he is part-time. He further stated that note pads are placed on the units so staff can document any housekeeping or maintenance concerns, but most of the staff report any concerns verbally to the Administrator or Director of Maintenance and he comes in if needed. He stated that the exterminator comes to the facility weekly and reports any findings to him afterwards. The DH further stated that the Kitchen is responsible for cleaning the dry food storage area, and if there are any mouse droppings or signs of pests it should be reported to him immediately and then cleaned. He stated that the Housekeeping storage room is only accessible by himself and the Director of Maintenance, and he has not had any knowledge of issues in that room. He stated that Housekeeping is responsible for cleaning the housekeeping storage room, but only chemicals are stored there. He stated if there are any mouse droppings, the exterminator has to visit by the next day, and the area is cleaned and baited/sprayed. The DH stated that he is aware that there have been sitings in the Kitchen for about a month so the exterminator has been focusing on that area. He stated that he saw the droppings in the dry food storage room, and the sitings have been on and off. He stated the exterminator stayed longer and baited the yard, but the exterminator visits have not been increased. The DH stated that although the exterminator took action, no mice were caught. He determines the program is effective based on by what he sees when he visits or the verbal complaints. 415.29(j)(5)

Based on observations, record review, and interviews, the facility did not ensure that an ongoing program of activities was provided to the resident. This was evident in 1 of 2 residents reviewed for Activities. (Resident #64) The findings are: Resident #64 is a [AGE] year old with [DIAGNOSES REDACTED]. Multiple observations were conducted. On 3/2/16 at 12:09:24 PM and 2:38 PM, 3/3/16 at 9:19 AM and 10:37 AM the resident was observed lying in bed in a hospital-type gown. The Admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented: severe cognitive impairment, no speech, total dependence on one staff for activities of daily living, moderate hearing difficulty and preferences for activities (Section F) was completed by staff assessment.Family or significant other involvement in care discussions. The Care Area Assessment (CAA) Summary triggered Activities. The Recreation Initial/Annual assessment dated [DATE] was reviewed. There were no documented preferences on the assessment.The Recreation Reassessment/Quarterly (Not dated) was reviewed. There was no preferences documented. There was no evidence that the family was asked about the resident's preferences for activities in the resident's medical record. The Comprehensive Care Plan (CCP) dated 12/15/15 and revised on 2/27/15 for Activity Tolerance documented interventions which included: Resident passive participant; Provide reassurance to resident and family; Provide bedside activities as needed; Out of bed to activity room as tolerated. On 3/2/16 at 2:33 PM and on 3/4/16 at 1:05 PM and 2:39 PM, resident's mother was interviewed during stage one review and stage two respectively. Resident's mother stated that resident stays in bed all day. She stated that she wants him to watch television but there's no television available. She further stated that she hasn't seen anyone come in to do any activity with him and that she didn't tell staff what he likes to do because they didn't ask her. Resident's mother stated that she put glasses on resident and gave him a newspaper herself when resident was observed holding a newspaper. On 3/4/16 at 12:41 PM, the Certified Nursing Assistant (CNA) was interviewed. The CNA stated that resident does not go to recreational activities because he is in his room but recreation visits him. On 3/4/16 at 12:53 PM, the Recreation Director was interviewed. She stated that she completes the admission and readmission assessments as well as create and update the CCP. The initial assessment dated [DATE] was incomplete due to resident not being able to respond and resident's mother was not able to answer questions because she didn't know resident's interest. The director stated she tries to communicate and touch resident but because resident does not respond, he doesn't go to activities. She further stated the recreational therapist (RT) would do room visits with him and do bedside activities. Bedside activities is when the RT plays music and does hand massage. She further stated that the RT usually comforts, talk, and sings to resident. On 3/4/16 at 12:57 PM, the RT was interviewed. She stated that she visits resident once a week in his room where she talks and checks on resident. She further stated that she doesn't do any activity with him except to help put a blanket over him. The recreation Activity Participation Sheet was reviewed from 12/11/2015 to 2/26/15. Resident #64 received a room visit once a week but activity provided was not specified. The facility policy and procedure for Duties and Responsibilities of the Activities Department (Dated 1/1/2009) was reviewed. .the activities director shall develop activities for individual patients who may be unwilling or are unable to participate in group activities, such activities include books, magazines, newspapers offered .or to be read by activity staff . 415.5(f)(1)

Based on observations, record review, and interview, the facility did not ensure that services were provided by qualified persons in accordance with resident's written plan of care . Specifically, resident #64 did not receive recreational/activities in accordance with his written plan of care. This was evident in 1 of 25 sampled residents reviewed. The findings are: On 3/2/16 at 12:09 PM and 2:38 PM; On 3/3/16 at 9:19 AM and 10:37 AM; On 3/4/16 from 9:41 AM to 12:48 PM and at 3:27 PM; On 3/7/16 at 8:48 AM, resident #64 was observed lying in bed with no stimulation such as a television or radio. Resident #64 is a [AGE] year old who is severely impaired with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) Admission assessment dated [DATE] documented that family participated in assessment but preferences for activities (Section F) was completed by staff assessment triggering Family or significant other involvement in care discussions. The Care Area Assessment (CAA) Summary triggered Activities. The Recreation Reassessment/Quarterly (Not dated) was reviewed. There was no preferences documented. There was no evidence that the family was asked about the resident's preferences for activities in the resident's medical record. The Comprehensive Care Plan (CCP) was reviewed for Activity Tolerance. The CCP was created on 12/15/15 and last updated on 2/27/16. Interventions included Resident passive participant; Provide reassurance to resident and family; Provide bedside activities as needed; Out of bed to activity room as tolerated. The Recreation Initial/Annual assessment dated [DATE] was reviewed. There was no documents preferences or assessment. On 3/2/16 at 2:33 PM and on 3/4/16 at 1:05 PM and 2:39 PM, resident's mother was interviewed during stage one review and stage two respectively. Resident's mother stated that resident stays in bed all day. She stated that she wants him to watch television but there's no television available. She further stated that she hasn't seen anyone come in to do any activity with him and that she didn't tell staff what he likes to do because they didn't ask her. Resident's mother stated that she put glasses on resident and gave him a newspaper herself when resident was observed holding a newspaper. On 3/4/16 at 12:41 PM, the Certified Nursing Assistant (CNA) was interviewed. The CNA stated that resident does not go to recreation activities because he is in his room but recreation visits him. On 3/4/16 at 12:53 PM, the Recreation Director was interviewed. She stated that she completes the admission and readmission assessments as well as create and update the CCP. The initial assessment dated [DATE] was incomplete due to resident not being able to respond and resident's mother was not able to answer questions because she didn't know resident's interest. The director stated she tries to communicate and touch resident but because resident does not respond, he doesn't go to activities. She further stated the recreational therapist (RT) would do room visits with him and do bedside activities. Bedside activities is when the RT plays music and does hand massage. She further stated that the RT usually comforts, talk, and sings to resident. On 3/4/16 at 12:57 PM, the RT was interviewed. She stated that she visits resident once a week in his room where she talks and checks on resident. She further stated that she doesn't do any activity with him except to help put a blanket over him. The recreation Activity Participation Sheet was reviewed from 12/11/2015 to 2/26/15. Resident #64 received a room visit once a week but activity provided was not specified. The facility policy and procedure for Duties and Responsibilities of the Activities Department (Dated 1/1/2009) was reviewed. .the activities director shall develop activities for individual patients who may be unwilling or are unable to participate in group activities, such activities include books, magazines, newspapers offered .or to be read by activity staff . 415.11(c)(3)(ii)

Based on observation and interviews, the facility did not ensure that food items were labeled and dated properly. This was evident during the Kitchen Task and observations conducted of the nourishment refrigerator on the 2nd floor. This resulted in no actual harm with potential for more than minimal harm. The findings are: On 2/4/15 at 10:00 AM during the initial tour on the 2nd floor nourishment refrigerator the following was observed: One plastic bag contained two containers of yogurt dated 12/6/14; A clear plastic container was observed with an unidentified brown substance dated 11/12/2013. The following undated and unlabeled items were also observed: A white paper bag of 10 half and half non dairy creamers, one plastic cup of slaw salad, a zip lock bag of sliced meat, sliced cheese was wrapped in aluminum foil and one slice of bread was also noted. The LPN (Licensed Practical Nurse) was interviewed immediately. She stated that all foods should be dated and labeled and that It is the responsibility of the nurses to check the refrigerator daily. On 2/05/2015 at 10:31 AM the FSD (Food Service Director) was interviewed and stated that the dietary department is responsible for keeping the refrigerators clean. On 2/05/2015 10:38: AM the RN (Registered Nurse) Supervisor was interviewed and stated that the nurse on the unit is responsible for dating and labeling residents' food before placing it in the refrigerator. On 2/5/2015 at 10:51 AM the DON (Director of Nursing) was interviewed. She stated that it is the responsibility of the nursing staff to check the refrigerators every shift to ensure food is dated labeled. 415.14(h)

Based on observations and staff interviews, the facility did not ensure that food was stored under sanitary conditions to prevent food borne illness. Specifically, a large undated carton containing cracked eggs was observed in the emergency reach in refrigerator. This was evident during the Initial Kitchen Tour. This resulted in no actual harm with potential for more than minimal harm. The findings are: During the initial brief tour of the kitchen conducted on 2/28/14 at 9:25 AM, the following observation was made: In the emergency reach in refrigerator, one large undated carton containing 3-4 cracked eggs was observed. The Food Service Director (FSD) was interviewed on 2/28/14 at 10:47 AM and stated that the eggs were delivered on Tuesday, 2/25/14 and should have been dated at the time of delivery. The FSD further stated that the Food Service Worker (FSW) who stored the eggs on 2/25/14 was responsible for dating them and that the cracked eggs are separated and discarded when the carton is removed from the refrigerator. The FSD further stated that he is responsible for ensuring that the food in the refrigerator is dated and that he checks the refrigerators every morning. On 3/4/14 at 11:50 AM the Food Service Worker (FSW) was interviewed and stated when eggs are delivered, they are dated and then stored in the refrigerator. 415.14(h)

Based on observation and staff interviews the facility did not ensure that food were stored to prevent possible food bourne illness. Specifically, boxes containing a food were observed stored directly on the floor. This was evident during the initial tour of the kitchen. This resulted in no actual harm with potential for more than minimal harm. The finding is: On 2/24/12 at 9:19 am, during the initial tour of the kitchen, boxes of macaroni, bananas, hot cereal, applesauce and spaghetti were observed stored directly on the floor. The Administrator and Dietary Aide were interviewed immediately and stated that the delivery came in early that morning and it was placed on the floor. They both stated that it should have been placed on the dolly truck and put in the refrigerator. 415.14(H)

Based on staff interviews and record review, the facility did not allow the resident's legal representative to participate in care planning when the facility decided to discontinue an existing form of treatment. This was evident for 1 out of 3 families that were interviewed about participation in care planning out of 15 sampled residents (Resident #55). This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. The finding is: Resident # 55 is a year old female with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS 3.0) dated documents the resident as being severely impaired in her ability to make decisions regarding daily living, and requires extensive assisance with activities of daily living. On 1/31/11 @ 11:57 AM, the Resident's husband was interviewed. He stated that he is not informed when the facility changes treatment for [REDACTED]. The resident's medical record documents her husband as her designated health care proxy (HCP), and other family members as her additional contacts. The resident's medical record documents a physician's orders [REDACTED]. The nurse note dated 10/13/10 documents: 'restraint reduction x 3 days in progress restraint removed, but sliding from w/c. The Comprehensive Care Plan (CCP) dated 10/25/10, and reviewed on 1/14/11 for restraint use documents: 'discuss with resident/designated representative/HCP agent the team recommendations, and the positive/negative consequences of restraint use... that restraint reduction was attempted on 10/13/10-10/15/10 and was unsuccessful'. There was no documented evidence that family/HCP was consulted prior to initiating the care plan for restraint reduction. On 2/3/11 at the Director of Nursing (DON) was interviewed. She stated that on 10/25/10 the resident's husband was notified of the attempt at reduction and the need to continue with the use of the restraint. This was after the attempt at reduction was unsuccessful. 415.3(c)(2)(ii)(c)

Based on staff and family interviews and record review, the facility did not immediately notify the resident's legal representative when the facility decided to discontinue a restraint. This was evident for 1 out of 3 sampled residents whose family member was interviewed in a total sample of 15 residents. (Resident #55). This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. The finding is: Resident #55 is a year old female with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS 3.0) dated 10/24/10 documents the resident as being severely impaired in her ability to make decisions regarding daily living, and requires extensive assistance with activities of daily living. The resident's medical record documents her husband as her designated health care proxy (HCP), and other family members as her additional contacts. On 1/31/11 at 11:57 AM, the Resident's husband was interviewed. He stated that he is not informed when the facility changes treatment for [REDACTED]. A physician's orders [REDACTED]. The nurse notes dated 10/13/10 documents: "restraint reduction x (times) 3 days in progress restraint removed, but sliding from w/c." The Comprehensive Care Plan (CCP) dated 10/25/10 documented for restraint use: "discuss with resident/designated representative/HCP agent the team recommendations, and the positive/negative consequences of restraint use... that restraint reduction was attempted on 10/13/10-10/15/10 and was unsuccessful." There was no documented evidence that family/HCP was consulted prior to initiating the care plan for restraint reduction. On 2/3/11 at the Director of Nursing (DON) was interviewed. She stated that on 10/25/10 the resident's husband was notified of the attempt at reduction and the need to continue with the use of the restraint. This was after the attempt at reduction was unsuccessful. The facility did not notify the resident's husband prior to changes in the treatment. 415.3(c)(2)(ii)(c)