Every finding on record at Newark Manor Nursing Home Inc

Based on observations and interview conducted during the Recertification Survey from 02/24/2025 to 02/28/2025 for three (North, West, and South) of three resident units, the facility did not provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable, and homelike environment. Specifically, exhaust ventilation in required areas was not functional. The findings are: Observations on 02/24/2025 at 10:05 AM included a significant foul odor inside the North Hall soiled utility room and the exhaust ventilation grate in the ceiling was observed to not be drawing air out of the room when a piece of paper was placed against the grate. Observations on 02/24/2025 from 10:11 AM included the exhaust ventilation grate in the ceiling of the shared bathroom for resident rooms W-27 and W-25 was observed to not be drawing air out of the room when a piece of paper was placed against the grate. Observations on 02/24/2025 at 10:15 AM included the exhaust ventilation in the [NAME] Hall soiled utility room was not functional when a wall switch was pressed for a ceiling fan. During an interview at this time, the Director of Environmental Services stated that they think the motor on the roof is bad and that there is only one unit for the exhaust in the entire building. Observations on 02/24/2025 from 10:38 AM included the exhaust ventilation grate in the ceiling of the shared bathrooms for resident rooms S-6, S-7, S-8, and S-9 were observed to not be drawing air out of the rooms when a piece of paper was placed against the grates. 10NYCRR: 415.29, 415.29(h)(1,2), 415.29(j)(1), 10NYCRR: 713-1.9(d)

Based on observations, interviews, and record review conducted during the Recertification Survey from 02/24/2025 to 02/28/2025, for two (Resident #9 and #12) of seven residents reviewed, the facility did not ensure a medication error rate of five percent or less. There were 2 medication errors for 30 opportunities resulting in a medication error rate of 6.67 percent. Specifically, during observations of medication administration, Resident #9 did not receive the correct dose of one medication and Resident #12 did not receive one medication in the correct form as prescribed by the physician. This is evidenced by the following: The facility policy Administering Medications revised April 2019 documented medications are administered in accordance with prescriber orders and the individual administering the medication should check the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 1. Resident #9 had diagnoses that included constipation, heart failure, and anxiety. The Minimum Data Set Resident assessment dated [DATE] documented Resident #9 was cognitively intact. The active physician orders reviewed on 02/27/2025 included an order for bisacodyl (stool softner) 10 milligrams two times daily for constipation. During an observation on 02/27/2025 at 9:17 AM Licensed Practical Nurse #1 administered 5 milligrams (one tablet) of bisacodyl. In a follow up interview at 10:15 AM, Licensed Practical Nurse #1 stated the physician had ordered a total of 10 milligrams of bisacodyl and Resident #9 should have received two bisacodyl tablets as opposed to one but that they did not realize they needed to give two tablets. 2. Resident #12 had diagnoses that included a stroke, high blood pressure, and depression. The Minimum Data Set Resident Assessments dated 01/10/2025 documented Resident #12 had severe impairment of cognitive function. The active physician orders reviewed on 02/26/2025 included an order for simethicone (relieves bloating and gas) oral tablet 80 milligrams three times daily and as needed every six hours for indigestion. During an observation on 02/26/2025 at 4:15 PM, Licensed Practical Nurse #2 removed one simethicone 80 milligrams chewable tablet from the bottle, placed it in a cup with five other medications and administered the entire cup of medications. Resident #12 swallowed all medications without chewing any of the tablets. During an observation and interview on 02/27/2025 at 3:40 PM Licensed Practical Nurse #2 stated simethicone was a medication stocked by the facility. Review of the stock bottle at this time revealed the simethicone was a chewable tablet. Licensed Practical Nurse #2 stated that if the medication was a chewable (tablet) it should be put it in a separate cup from the swallowable medications and administered separately. Licensed Practical Nurse #2 said they did not realize the simethicone that was administered was a chewable tablet (versus one you can swallow whole). During an interview on 02/28/2025 at 1:18 PM the Assistant Director of Nursing stated medications should always be given per the physician order and if there is an issue or concern with an order the nurses should clarify it with the medical provider. The Assistant Director of Nursing stated if the physician order does not state chewable, and the medication on hand is chewable the order should be clarified with medical prior to administration. 10 NYCRR 415.12(m)(1)

Based on observations and interviews conducted during a Recertification Survey from 02/24/2025 to 02/28/2025, the facility did not ensure that all drugs and biologicals were properly stored in accordance with State and Federal Laws for one (North Unit) of two medication storage rooms reviewed. Specifically, multiple bottles of expired medications were found in the North Unit medication storage room. This is evidenced by the following: The facility policy Medication Labeling and Storage dated January 2023, included if the facility had discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy was contacted for instructions regarding returning or destroying those items. During an observation on 02/26/2025 at 2:25 PM, the North Unit medication storage room included the following expired medications: a. One bottle of magnesium oxide 400 milligrams that expired in November 2023. b. One bottle of vitamin D that expired in May 2024. c. One bottle of daily multivitamins with iron that expired in June 2024. d. Three bottles of docusate sodium (stool softner), two expired in May 2024 and one expired in October 2024. During an interview on 02/26/2025 at 2:57 PM with Licensed Practical Nurse Manager #1 and Licensed Practical Nurse #1, Licensed Practical Nurse #1 stated all nurses check for expired medications when they pull them from the medication storage room. Licensed Practical Nurse Manager #1 stated audits of the medication room were completed monthly and expired medications should be thrown away. Review of a facility document Med Room Audit dated 09/26/2024, revealed the last documented North Unit medication storage room audit had no expired medication bottles identified. During an interview on 02/28/2025 at 1:48 PM, the Director of Nursing stated the expired medications had most likely been pushed to the back of the shelf and not found during audits and expired medications should be removed from the medication rooms and discarded. 10 NYCRR 415.18(e)(1-4)

Based on observations, interviews, and record review conducted during the Recertification Survey from 02/24/2025 to 02/28/2025, for 1 (Resident #44) of 15 resident care plans reviewed, the facility did not review and revise the resident's care plan as necessary to meet the resident's current needs. Specifically, Resident #44 had history of skin tears in addition to a current skin tear on their forearm. Their person-centered care plan was not revised to include the resident was at risk for skin tears or that they had a current skin tear or interventions to prevent ongoing skin tears. This is evidenced by the following: Resident #44 had diagnoses including dementia, failure to thrive, and depression. The Minimum Data Set Resident assessment dated [DATE], documented the resident was severely impaired of cognitive function. The Comprehensive Care Plan initiated on 12/27/2024, included Resident #44 had the potential for pressure ulcer development. The Care Plan did not include that the resident was at risk for skin tears related to frail skin or interventions to prevent further skin tears. Review of a nursing progress note documented by the Director of Nursing on 06/24/2024, revealed Resident #44 sustained a skin tear on their left forearm during a transfer using a non-mechanical lift. Review of a nursing progress note documented by Licensed Practical Nurse #4 on 10/09/2024, revealed Resident #44 had a skin tear on the top of their left-hand found during morning care possible being related to bumping their hand on the side rail of their bed. Review of a nursing progress note documented by Licensed Practical Nurse #3 on 02/10/2025 revealed Resident #44 had a half dollar sized skin tear to the right forearm. The current physician orders dated 02/11/2025 documented to cleanse right forearm skin tear with normal saline, pat dry, apply triple antibiotic ointment, and cover with dry dressing daily until healed. In a nursing progress note dated 02/17/2025 Licensed Practical Nurse #4 documented Resident #44 somtimes bumped their arms on the table while attempting to eat and was sometimes non-compliant and attempted to get out of bed unassisted. During observations on 02/24/2025 at 3:19 PM, 02/26/2025 at 9:36 AM and 02/26/2025 at 11:54 AM, Resident #44 had both forearms exposed with no arm protection to prevent skin tears. During an interview on 02/27/2025 at 9:59 AM, Certified Nursing Assistant #1 stated they know what care a resident needed by looking at the resident's care plan, and the care plan should tell them everything about the resident to provide the proper care to them. During an interview on 02/28/2025 at 12:59 PM, the Assistant Director of Nursing, stated they would know when a resident was at a higher risk for impaired skin integrity by reading their care plan including current skin impairment. The Assistant Director of Nursing stated when a resident was at risk, it should be in the resident's care plan. The Assistant Director of Nursing stated that Resident #44 did have a current skin tear, and they believed the nurse managers were updating residents care plans, but the Director of Nursing and the Assistant Director of Nursing could also update them. They stated it was important to include the risk for altered skin integrity in the resident's care plan so everyone can be aware, and that Resident #44 should have a care plan for the actual skin tears and being at risk for them. 10 NYCRR 415.11(c)(2)(iii)

Based on observations, interviews, and record review conducted during the Recertification Survey from 02/24/2025 to 02/28/2025, for one (Resident #18) of one resident reviewed, the facility did not provide appropriate treatment and services to prevent potential complications for a resident who was receiving nutrition via a feeding tube (a tube inserted directly into the stomach via the abdomen to administer nutritional supplements). Specifically, Resident #18's tube feeding was not appropriately monitored to ensure the amount infused daily was the amount ordered by the physician. Additionally, the resident had multiple documented entries in the electronic medical record of tube feeding residuals (amount of feeding tube liquid not absorbed/not tolerated creating a potential hazard) that were greater than 400 milliliters and the facility was unable to provide documented evidence that the physician had been notified or that the residuals were held and rechecked after two hours as ordered by the physician to ensure the necessary nutrition and prevent complications. This is evidenced by the following: Review of the facility policy Enteral Nutrition dated July 2012 revealed that enteral (via a feeding tube) feeding orders will be written to ensure consistent volume infusion. The following information will be included to ensure that the full volume will be infused via pump feedings, regardless of any interruption of feeding, product name, type of tube, rate of infusion (number of milliliters per hour), total calories per day, start time, and total daily volume to be infused (number of milliliters per day). Resident #18 had diagnoses including dysphagia (difficulty swallowing), failure to thrive, and chronic obstructive pulmonary disease. The Minimum Data Set Resident assessment dated [DATE], documented the resident was moderately impaired of cognitive function, had no behaviors, received 51 percent or more of their total calories, and 501 milliliters or more of their fluid needs per day through a feeding tube. The current physician orders dated 12/23/2025 included the resident was to have nothing by mouth and had a feeding tube with feedings to include: a. Continuous Fibersource High Nitrogen tube feeding at 75 milliliters per hour for 24 hours for a total volume of 1,800 milliliters, staff to document amount each shift of 600 milliliters. b. Check and record residual amounts every shift, contact the physician if residuals are greater than 400 milliliters. Recheck residuals again after two hours and if below 400 milliliters may restart feeding. Resident 18's Comprehensive Care Plan dated 01/06/2025 documented the resident was a potential risk for sub-optimal nutrition and dehydration due to having a feeding tube. Interventions included the resident was to ingest nothing by mouth, was on aspiration precautions (steps taken by the facility to prevent complications such as inhalation of liquids into the respiratory tract), received tube feedings (liquid nutrition) at 75 milliliters per hour for 24 hours, 100 milliliters of water every six hours and 50 milliliters of water three times per day with medications. Staff are to monitor weights and intakes as available and monitor for signs and symptoms of dehydration. Review of the Medication Administrator Record dated 02/01/2025 through 02/27/2025 revealed the daily amount of Fibersource High Nitrogen administered to the resident ranged from to 1275 milliliters to 3190 milliliters per day (versus the ordered 1800 milliliters). Residual amounts of the tube feedings were documented as 700 milliliters up to 902 milliliters on three occasions. There was no documented evidence that the Physician had been notified of residual tube feeding amounts greater than 400 milliliters or that the tube feeding was held, and residuals rechecked after two hours per the physician's orders. In a nutrition/dietary progress note dated 02/23/2025 the Registered Dietitian documented Resident #18 tolerated the tube feeding formula and rate well, that the resident had a weight loss over the past six months and the tube feeding amount was increased. During observations on 02/24/2025 at 10:22 AM, 02/26/2025 at 9:15 AM and 02/27/2025 at 10:15 AM, Resident #18 was receiving continuous tube feeding via a tube feeding pump set at 75 milliliters per hour. The tube feeding ready to hang formula bag was labeled with resident's name, date, and rate but did not include a start time (when a new tube feeding bag was started). During an interview on 02/27/2025 at 11:49 AM and again at 1:51 PM Licensed Practical Nurse Manager #1 stated the residents tube feeding order stated 600 milliliters each shift and the nurses documented the totals in the medication administration record. They should clear out the total (amount infused) on the machine each shift so it starts for the next shift and the nurse should look (at the amount infused) prior clearing it out. The total documented per 24-hours should be 1800 milliliters. Licensed Practical Nurse Manager #1 stated if the nurse was documenting less than 600 milliliters per shift it was most likely the tube feeding was held (for some reason). Licensed Practical Nurse Manager #1 stated that Resident #18's tube feeding runs for 24 hours, and it was hard to know when a bag was started, emptied and another one hung but the predetermined amount per shift of 600 milliliters should be documented in the medication administration record. Licensed Practical Nurse Manager #1 said they do not monitor the tube feeding intakes because the Registered Dietitian does. During a telephone interview on 02/27/2025 at 12:52 PM the Registered Dietitian stated that Resident #18 should receive 600 milliliters of tube feeding per shift and the nurses should document (the amounts) in the medication administration record. The Registered Dietitian stated they do not double check what the nurses documented but if the resident was losing weight they should then check if the nurses were documenting correctly and if there were any residuals documented. The Registered Dietitian stated they did not know how to review the resident's electronic medication administration record to review the documented tube feedings amount but nursing should. The Registered Dietitian stated the resident had a history of unplugging their tube feeding. During an interview on 02/28/2025 at 11:26 AM, Registered Nurse #1 stated that Resident #18 has been known to play with the tube feeding ports and fiddle with the tube feeding pump and has turned the feeding tube pump off. During an interview on 02/28/2025 at 1:36 PM, the Director of Nursing stated nurses should notify the physician if there were any tube feeding residuals greater than 400 milliliters and then recheck the residuals. The Director of Nursing said the nurse managers, charge nurses and the Registered Dietitian should be monitoring the resident's total tube feeding and fluid intakes (to ensure ordered amounts were being given on a daily basis). The Director of Nursing said they knew Resident #18 had recently lost weight and their tube feeding rate had been increased. During a telephone interview on 02/28/2025 at 2:05 PM, the Medical Director stated they should be notified if Resident #18 had residuals greater than 400 milliliters since there was an order in place. The Medical Director said the Registered Dietitian should be monitoring the residents tube feeding since the providers are changing the orders based on their recommendations and both nursing and the Registered Dietitian should be monitoring the resident's total fluid intakes daily and any residuals. 10 NYCRR 415.12(g)(2)

Based on observations, interviews, and record review conducted during a Recertification Survey, completed on 1/21/22, it was determined that for one (Resident #32) of one resident reviewed for hydration, the facility did not have a system in place to ensure that daily fluid intake was consistent with physician orders. Specifically, Resident #32 had physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This was evidenced by the following: The undated facility policy Intake, Measuring and Recording, included the purpose was to accurately determine the amount of liquid a resident consumed in 24 hours. The policy included that fluid intake should be recorded as soon as possible after consuming and to total the amounts of all liquids consumed at the end of each shift. Resident #32 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set Assessment, dated 12/2/21, revealed the resident was moderately impaired cognitively and received hemodialysis. Current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The current Comprehensive Care Plan included a 1200 mls fluid restriction daily, to encourage adequate fluid intake per dietary recommendations and to monitor intakes. Nutritional Assessments, dated 12/2/21 and 1/18/22, completed by the Registered Dietician (RD) included Resident #32 was on a 1200 mls fluid restriction and that fluids were documented by nursing. Review of the January 2022 Medication Administration Report (MAR) included a fluid restriction was in place but did not include the daily amount allowed. The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The amount of water given in order to administer the [MEDICATION(S)] was not documented at all. Review of the vital sign report for 1/1/22-1/18/22 revealed the amount of fluid intake was documented multiple times per day as fluids or supplements but there was no documentation of the total amounts per shift or per 24 hours. Review of [CONDITION(S)] communication reports, dated 12/1/21 through 1/19/22, revealed education was provided to Resident #32 by the [CONDITION(S)] unit regarding their fluid intake on five different occasions. In an observation on 1/18/22 at 10:50 a.m., Resident #32's door indicated a 1200 mls fluid restriction but did not include which resident in the semi-private room it was for. Resident #32 stated at the time that they did not know what their fluid restriction amounts were but that they only got a half of cup of coffee in the morning despite requesting a full cup. In an interview on 1/19/22 at 1:43 p.m., CNA #2 stated they knew if a resident was on a fluid restriction as there would be a sign on the door. The CNA #2 stated that the amount of fluids allotted for meals should be on the meal ticket. In an interview on 1/19/22 at 1:47 p.m., the Licensed Practical Nurse (LPN) stated it should be on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The LPN stated dietary calculated the fluid amounts allotted for meal trays and nursing entered the amount taken in the computer. The LPN stated they did not know who was responsible for totaling the intake at the end of the shift. In an interview on 1/19/22 at 2:52 p.m. the Director of Nursing (DON) stated nursing and dietary determined the number of fluids allotted for each department and the amounts taken are entered in the computer. The DON stated they do not review the fluid intake at the end of each shift and would need to review the policy to see who is responsible for reviewing the 24-hour totals. In an observation on 1/20/22 at the breakfast meal, Resident #32's meal ticket included the resident was on a fluid restriction but did not include the amount of the fluid restriction. The ticket included 12 ounces of fluid, but the total fluid intake line was not completed. The ticket was obtained from a Certified Nursing Assistant (CNA) #1 after the tray had been collected and was already on the meal cart. In an interview on 1/20/22 at 9:20 a.m., the RD stated that nursing monitored the fluids a resident takes in and determines the amount that dietary and nursing are allotted. The RD stated the intake form did not include total fluids at the end of a shift or 24-hour period. In a phone interview on 1/20/22 at 10:40 a.m. the [CONDITION(S)] RN stated they expected nursing to monitor a resident's 24-hour fluid intake totals when a resident was on a fluid restriction. In a phone interview on 1/20/22 at 11:43 a.m. the physician stated they expected nursing to monitor the resident's fluid intake to ensure adequate fluid and restrictions are maintained per orders. 10 NYCRR 415.12 (l) (1))

Based on observations, interviews, and record review conducted during a Recertification Survey, completed on 1/21/22, it was determined that for one (Resident #41) of six residents reviewed, the facility did not review and revise the resident's care plan (with input from the resident or resident representative, to the extent possible) to reflect the resident's current needs. Specifically, Resident #41's Comprehensive Care Plan (CCP) was not revised following the addition of an antipsychotic medication prescribed for delusions/hallucinations. This was evidenced by the following: Resident # 41 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the interdisciplinary progress notes, dated 10/25/21 through 1/12/22 revealed the following: a. On 10/22/21 the psychiatrist documented that Resident #41 had met the criteria for delusional parasitosis (psychiatric condition related to delusions of bugs) and recommended to start [MEDICATION(S)] 0.5 mg at bedtime, increase to twice a day and may need 2-3 mg per day. The psychiatrist recommended to avoid confrontation but also to avoid complete validation while acknowledging the resident's helplessness, pain, and frustration. b. On 10/27/21 the Licensed Practical Nurse documented that Resident #41 was sent out to the hospital for evaluation due to seeing bugs everywhere and was very hard to redirect. The note included that the resident returned from the hospital that night but continued to talk about bugs on their hands and food. c. On 11/8/21 the Registered Nurse (RN) #1 documented the physician increased the [MEDICATION(S)] to 0.5 mg in the a.m. and 1 mg at bedtime. d. On 12/1/21 the Physician documented that the [MEDICATION(S)] was increased to 1 mg twice a day for delusional parasitosis/[CONDITION(S)]. e. On 1/12/21 the physician documented that the [MEDICATION(S)] was up to 1.25 mg twice a day The current CCP, dated as revised 12/13/21, included a history of seeing bugs and was a risk for impaired skin that included picking and scratching behaviors. The behavioral intervention plan, dated 12/22/21, included Geri sleeves (protective arm sleeves). The current Resident Profile (care plan used by the Certified Nursing Assistants) included no behavioral plan. During multiple observations from 1/18/22 through 1/20/22 Resident #41 was observed out of bed, dressed in a chair, doing their nails, reading or eating with a visitor. No behaviors were observed. In an interview on 1/19/22 at 1:43 p.m. RN #1 stated Resident #41 was seen by psychiatry who recommended [MEDICATION(S)]. RN#1 stated they were responsible for developing and revising care plans and that the care plan should include a new antipsychotic medication. When interviewed 1/20/22 at 3:15 p.m. the Director of Nursing stated the CCP should be revised when a resident was started on a new antipsychotic medication and had an increase in hallucinations. 10 NYCRR 415.11 (c)(2) (ii-iii)

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #20) of one resident reviewed for hospitalization , the facility did not ensure a written notification, which specifies the duration of the bed-hold policy, was provided to the resident and/or the resident's representative at the time of transfer to the hospital. This is evidenced by the following: Resident #20 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing progress notes dated 1/12/22, revealed the staff were alerted that Resident #20 was on the floor and had an open area that was 2.5 cm x 5 with blood on the back of their head. The resident was transferred to the hospital. Further review of the medical record revealed there was no documented evidence that the resident and/or the resident's representative had been notified in writing of the facility's bed-hold policy. Interviews conducted on 1/20/22 included the following: At 10:45 a.m., the Social Worker (SW) stated the Billing Office was responsible for notifying the residents and/or resident representative of the bed-hold policy. The SW stated that the residents are also notified upon admission about the bed-hold policy. At 11:12 a.m., the Administrative Assistant (Billing Office) stated the nurses will verbally notify them of a resident that is being discharged . The Administrative Assistant stated if a resident goes to the hospital, they fill out a notice of discharge and the bed-hold policy and mail it to the residents and/ or the resident representative. When asked why this particular did not receive the bed-hold policy the administrative assistant stated it was an oversight. At 1:33 p.m., the Administrator stated it was the responsibility of the Billing Office to send out the bed-hold policy notice to the resident and/ or resident representative. The Administrator stated they would expect that the Billing Office would send the notification regarding the bed-hold policy out as soon as they know a resident is being discharged . [10 NYCRR 415.3(h)(4)(i)(a)]

Based on observation, interviews, and record review conducted during the Recertification Survey, it was determined that for one (Resident #26) of three residents reviewed for pressure ulcers, the facility did not provide the necessary services to promote healing of a pressure ulcer. Specifically, the nurse did not follow physician orders [REDACTED]. This is evidenced by the following: Resident # 26 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 4/27/19, revealed the resident was cognitively intact and had two Stage III pressure ulcers. The facility policy, Skin Care Guidelines, revised (MONTH) (YEAR), included unless specifically stated otherwise, only normal saline or a wound cleanser should be used to cleanse a wound. Review of the Record of Visit form (used by the wound clinic), dated 5/30/19, revealed the resident's left hip ulcer had 90 percent [MEDICATION NAME] (new tissue growth) with a small amount of drainage. The treatment was to clean the hip wound with normal saline, place [MEDICATION NAME] (dressing that absorbs destructive components of wound fluid and creates optimal environment for cell growth) on the wound bed and cover with bordered foam. The Medical Assessment, dated 6/14/19, revealed per the wound clinic that the resident's left hip culture was positive for Staphylococcus (a bacteria) with multiple organisms and to continue the treatment per the wound clinic. Medical Orders, dated 6/14/19, included to flush the left hip ulcer with normal saline, pat dry, place [MEDICATION NAME] in wound bed and cover with bordered foam. During an observation of wound care on 6/12/19 at 2:29 p.m., the Licensed Practical Nurse (LPN) filled a basin with water. She then used a washcloth with soap, and washed the wound. She took another washcloth and rinsed the wound with water. When asked if the wound should be washed with soap and water, the LPN responded it is not in the physician orders [REDACTED]. When interviewed on 6/13/19 at 2:53 p.m., the Registered Nurse Manager said the wound should not have been washed with soap. During an interview on 6/14/19 at 1:34 p.m., the Director of Nursing said the nurse should have followed the physician orders [REDACTED]. (10 NYCRR 415.12)

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for two of five residents reviewed for unnecessary medications, the facility did not develop a person-centered Comprehensive Care Plan (CCP). Specifically, Resident #15 did not have a care plan developed for a new [DIAGNOSES REDACTED].#20 did not have a care plan developed for diuretic use. This is evidenced by the following. 1. Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had severely impaired cognition and diabetes. A Medical Assessment, dated 2/21/19, revealed that the resident was newly diagnosed with [REDACTED]. The current Physician orders [REDACTED]. The CCP, last reviewed 4/16/19, did not include the [DIAGNOSES REDACTED]. During an interview on 6/13/19 at 11:29 a.m., the Registered Nurse Manager (RNM) reviewed the resident's CCP and Certified Nursing Assistant (CNA) Care Profile, and then stated diabetes including goals and interventions should have been included in the care plan. She said diabetes should have been added to the resident's [DIAGNOSES REDACTED]. When interviewed on 6/13/19 at 11:39 a.m., the Registered Dietician (RD) stated that she was not aware that the resident had a new [DIAGNOSES REDACTED]. After reviewing the previous medical evaluations and laboratory results, the RD stated that they had missed the diabetes diagnosis. The RD stated that dietary would have addressed the [DIAGNOSES REDACTED]. During an interview on 6/14/19 at 10:47 a.m., the Director of Nursing stated that the resident's CCP should include a plan of care for diabetes. 2. Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 4/11/19, revealed that the resident was cognitively intact and received diuretics (fluid pills). Physician orders, signed 5/16/19, included [MEDICATION NAME] 40 milligrams (mg) daily for the [DIAGNOSES REDACTED]. The CCP, last reviewed 4/30/19, does include the use of diuretics. When interviewed on 6/13/19 at 2:00 p.m., the RNM stated the resident's CCP should include the use of diuretics. She said it is usually addressed either under the incontinence or dehydration headings. During an interview on 6/14/19 at 10:47a.m., the DON stated that the resident's CCP should include the use of diuretics. (10 NYCRR 415.11(c)(1)

Based on interviews and record review conducted during the Recertification Survey, it was determined that for 1 of 25 residents reviewed for advanced directives, the facility did not develop a system to ensure advance directives were documented in a manner that was consistent with resident wishes. Specifically, the facility did not have advanced directive policies that addressed identifying the primary decision maker, and Resident #55's Medical Orders for Life-Sustaining Treatment (MOLST) was not signed by the resident's Health Care Guardian. This is evidenced by the following: Resident #55 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 5/29/19, revealed the resident had severely impaired cognition. The resident's facility face sheet revealed the emergency contact information has Son A as the #1 contact, financial, and Health Care Guardian. Son B was listed as an emergency contact #2. A Determination of Medical Decision-Making Capacity-Documentation Form, dated 3/22/19, revealed that the resident lacked the ability to understand and appreciate the nature and consequences of Do Not Resuscitate (DNR) and life-sustaining treatment orders due to dementia, and was signed by the attending physician on 3/22/19 and the concurring physician on 4/2/19. The MOLST, dated 4/17/19, was signed by Son B, (checked off as a Health Care Agent), and witnessed by the Social Worker. The facility did not have a policy for Advanced Directives. Interviews conducted on 6/12/19 included the following: a. At 9:44 a.m., the Registered Nurse Manager after reviewing the medical record, said that Son A should have signed the resident's MOLST. She said that when the resident has an issue she calls Son A. She said the resident did ask staff to e-mail Son B with issues, as he is second on the contact list. b. At 9:54 a.m., the Social Worker said she was responsible for completing the MOLST. She said Son B was at the facility, so she asked him to sign the MOLST. c. At 10:18 a.m., the Director of Nursing reviewed the resident's record and then said Son A is the Health Care Guardian and should be the only one to sign the MOLST. d. At 3:09 p.m., the Administrator said they have a policy on Cardiopulmonary Resuscitation and Do Not Resuscitate. The policies did not include information regarding identifying the primary decision maker. (10 NYCRR 415.3(e)(1)(ii))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for 1 of 22 residents reviewed for care planning, the facility did not ensure that each resident's care plan was reviewed and revised to reflect the resident's current condition. Specifically, Resident # 10's care plan was not revised to reflect a significant weight loss. This is evidenced by the following: Resident #10 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 3/29/19, revealed the resident had moderately impaired cognition and no weight loss. Review of the resident's weights for the last six months revealed a 10.1 percent weight loss from (MONTH) 2019 (116.6 pounds) to (MONTH) 2019 (104.8 pounds). The Comprehensive Care Plan, last revised on 4/11/19, did not include potential/actual weight loss. Medical progress note, dated 5/14/19, included that the staff reports that the resident has not been eating much. She was always tired and slept a lot. The resident has a [DIAGNOSES REDACTED]. A medical order, dated 5/31/19, included give 60 milliliters of 2 cal HN( high calorie supplement) four times a day for weight loss. Interviews conducted on 6/13/19 included the following : a. At 10:57 a.m., the Registered Dietitian Nutritionist said weight loss was not addressed in the current care plan, but should be. b. At 11:04 a.m., the Registered Nurse Manager said the care plan does not reflect the resident's weight loss. c. At 11:30 a.m., the Director of Nursing said the care plan is not resident centered and does not reflect the resident's weight loss. She said she expects the care plans to reflect and address all areas of the resident's life. (10 NYCRR 415.11(2)(iii))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for two of two residential units, the facility did not establish and maintain an Infection Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. Specifically, the facility was unable to provide evidence of a complete Infection Control Program that investigates, controls, and prevents infections in the facility. This is evidenced by the following: Review of the Infection Control Program on 2/20/18 at 10:01 a.m. with the Registered Nurse (RN) responsible for Infection Control and Staff Development, revealed that the Monthly Infection Logs from (MONTH) (YEAR) to (MONTH) (YEAR) did not include any data analysis or control measures that were implemented to trend any areas of concern, and did not investigate the use of antibiotics. This included, but is not limited to, the following: a. The Infection Control Line List, dated 10/2/17 through 10/10/17, revealed four urinary tract infections [MEDICAL CONDITION] for four different residents and the organism was E. coli. When interviewed, the RN said she was unable to provide any documentation of data review or follow up. The RN said that she looked to see who the primary caregivers were for the residents, but she did not have any documentation. She said that she did not complete any peri care audits. She said if she provided education, it was done verbally, and there was no documentation. The RN said that she does not have any documentation related to follow up activities in response to the Infection Control Line List. b. The Infection Control Line List for (MONTH) (YEAR) included a resident that was started on an antibiotic on 2/2/18 after a bladder procedure. The resolve date was documented as 3/4/18. The RN was unable to provide a policy or guideline for completing the Infection Control Log. When interviewed, the RN said that the resolve date was the date that the antibiotic was completed. She said the resolve date was not based on the resident's symptoms. She said that she did not remember who told her that the resolve date was the last day of the antibiotic. The RN said that the policies for the Antibiotic Stewardship are being developed by an area hospital and have not been implemented. c. The Infection Control Line List for (MONTH) (YEAR) revealed that the same resident was listed on 12/15/17 and was being treated with Keflex (antibiotic) for UTI, and on 12/16/17 was being treated [MEDICATION NAME](antibiotic) for a UTI. The RN said that since the antibiotic was changed it was considered a new infection and not a continuation of the 12/15/17 infection. The RN was unable to provide any documentation that the resident's symptoms were reviewed, if an antibiotic was changed, or if the reason was investigated. When interviewed on 2/20/18 at 10:58 a.m., the Director of Nursing (DON) asked who was documenting the resolve date. She said an assessment should be completed after the resident completes the antibiotics. The DON said the Infection Control Line List did not include control measures and did not include any information that the infections or that the use of antibiotics was investigated. The RN and DON both said audits were not completed, and they could not provide documentation that the program used evidence-based surveillance criteria to define infections and the use of the data collection tool. (10 NYCRR 415.19(a)(1-3))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #28) of five residents reviewed for unnecessary medications, the facility did not develop a plan of care for each resident that includes measurable objectives and interventions to address care and treatment related to clinical [DIAGNOSES REDACTED]. Specifically, there was no Comprehensive Care Plan for the use of an anticoagulant (blood thinner) medication. This is evidenced by the following: Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 1/15/18, revealed that the resident was cognitively intact and received an anticoagulant seven days a week. Review of the physician's orders [REDACTED]. Review of the 12/18/17 Comprehensive Care Plan (CCP) and the Certified Nursing Assistant (CNA) Care Guide, updated 1/31/18, revealed no documentation related to the use of a blood thinner. When observed and interviewed on 2/14/18 at 10:41 a.m., the resident had multiple bruises on all four extremities. The resident said she gets bruises because she takes a blood thinner. Interviews conducted on 2/16/18 included the following: a. At 1:39 p.m., the CNA stated that the bruises on the resident's extremities have been the same since admission. The CNA said that she usually knows when a resident is on a blood thinner after reading the CNA Care Guide. The CNA said she was not aware that the resident was on a blood thinner. b. At 1:47 p.m., the Licensed Practical Nurse (LPN) said the resident has very fragile skin. The LPN said the resident was not on any medications that put her at high risk for bruising or bleeding. She stated that the resident was on Xarelto, but that was for [MEDICAL CONDITION]. c. At 2:03 p.m., the Registered Nurse Manager (RNM) stated that the resident's skin is paper thin. The RNM said that the resident was not on a blood thinner or it would be on the CCP. The RNM reviewed the physician's orders [REDACTED]. She said that is a blood thinner and should have been care planned. The RNM said it was an oversight not to address the blood thinner on the CCP and the CNA Care Guide. When interviewed on 2/20/18 at 11:30 a.m., the Administrator said that the Quality Assurance Committee has not done any audits for care planning. The (MONTH) (YEAR) facility policy, Comprehensive Care Plan, directed that the CCP for each resident will include measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified on the Comprehensive Assessment. (10 NYCRR 415.11(c)(1))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #28) of five residents reviewed for unnecessary medications, the facility did not ensure that each resident's drug regime was free from unnecessary medications. Specifically, the resident's as needed anti-anxiety medications did not have an indication for use and were not evaluated and reordered every 14 days by the physician. This is evidenced by the following: Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 1/15/18, revealed that the resident was cognitively intact. Review of the physician's orders [REDACTED]. There were no other orders for the [MEDICATION NAME], and the 1/18/18 orders did not contain an indication for usage. Review of the Medication Administration Records revealed that the resident was administered the as needed [MEDICATION NAME] twice in (MONTH) (YEAR), once in (MONTH) (YEAR), and not at all in (MONTH) (YEAR). Review of the physician's visit notes since admission did not include an indication for use of the as needed [MEDICATION NAME], evaluate the resident's anxiety, or the need to continue the as needed medication. Interviews conducted on 2/16/18 included the following: a. At 10:50 a.m., the Certified Nursing Assistant said she did not really think the resident was anxious and she never told the nurse that the resident was nervous. b. At 10:54 a.m., the Licensed Practical Nurse (LPN) said that sometimes the resident has some anxiety but will usually talk to the LPN. The LPN said she had a good rapport with the resident, and she has never given the resident the as needed medication for anxiety. c. At 10:57 a.m., the Registered Nurse Manager (RNM) said the resident does not really have anxiety. She said it was more anger and frustration about her food. The RNM said she was not familiar with the regulation that as needed psychoactive medications had to be reordered every 14 days, and that the physician should re-evaluate the need for an as needed psychoactive medication every 14 days. d. At 11:14 a.m., the Director of Nursing (DON) said that she was aware that psychoactive medications ordered on an as needed basis have to be re-evaluated for necessity within 14 days. She said she was not aware they had to be reordered every 14 days. The DON stated that the physician should be documenting the need for the [MEDICATION NAME] but he did not address it at all. e. At 11:56 a.m., the Pharmacy Consultant stated that she was aware that the as needed psychoactive medications need to be reordered every 14 days. She said she looks for that when she does her pharmacy reviews and must have missed it for the resident. She said there needs to be an indication for usage and documentation by the medical staff of the need to continue the as needed medication beyond 14 days. f. At 12:19 p.m., the Physician stated that the reason for the as needed psychoactive medication should be written so it is clear what the medication is used for. When asked if he was aware of the regulation to re-evaluate and reorder as needed psychoactive medications every 14 days, the Physician did not answer the question. When interviewed on 2/20/18 at 11:30 a.m., the Administrator said that the Quality Assurance Committee has completed audits to ensure that the indication for medication use and the evaluation for need was documented by the physician. She said she was not aware that as needed psychoactive medications needed to be reordered every 14 days. (10 NYCRR 415.12(l)(2)(i))

Based on observation, interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #5) of three residents reviewed for Activities of Daily Living (ADLs), the facility did not provide the necessary care to maintain the resident's personal hygiene. The issue involved the lack of oral care. This is evidenced by the following: Resident #5 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 2/11/18, revealed that the resident's cognitive function was severely impaired and required the extensive assistance of one staff for personal hygiene. The Comprehensive Care Plan, dated as last reviewed on 9/1/17, revealed that the oral care was to be completed as needed. The Certified Nursing Assistant (CNA) Resident Care Plan, dated 1/31/18, revealed the resident had missing teeth and there were no specific directions for the resident's oral care. During an observation on 2/14/18 at 12:16 p.m., the resident's teeth had white caked debris, missing teeth, teeth that were discolored, and the resident's breath had a foul odor. On 2/20/18 at 8:50 a.m., the resident's lower teeth had a brown discoloration. Interviews conducted on 2/20/18 included the following: a. At 12:21 p.m., the Registered Nurse Manager (RNM) stated that the resident had crooked teeth and was seen by a dentist. She said that the dentist was aware of the resident's loose teeth and did not want to intervene as he wanted them to fall out naturally. The RNM stated that the resident should receive oral care after every meal. She said she expects staff to do oral care after each meal and, at the very least, every shift. The RNM reviewed the resident's CNA Care Card and stated that there was nothing specific documented for oral care. She said the CNAs should know to complete ADLs. b. At 12:25 p.m., the CNA stated she provided personal care for the resident that day which included bathing. She stated that the resident did not receive oral cares that morning, but it was her responsibility. The CNA asked if she could provide oral care at that time. c. At 1:25 p.m., the Director of Nursing stated that the facility does not have a policy that specifically addresses oral care. (10 NYCRR 415.12(a)(3))

Based on interviews and record reviews, it was determined that for one (Resident #19) of three residents reviewed for indwelling urinary catheters (tube inserted into bladder to drain urine often referred to as 'Foley') the facility did not provide appropriate treatment and services. The resident was not assessed by urology as recommended for continued use of an indwelling catheter despite multiple urinary tract infections [MEDICAL CONDITION]. This is evidenced by the following: Resident #19 has [DIAGNOSES REDACTED]. The current Comprehensive Nursing Care Plan includes that the resident has an indwelling Foley catheter related to a [MEDICAL CONDITION] bladder and is not a candidate for a suprapubic catheter. Review of Medication Administration Records from November 2015 through present revealed that the resident was administered a course of antibiotics for UTI's in November 2015, December 2015 (two courses), January 2016, July 2016 and August 2016. Additionally, the resident had two emergency room visits for catheter related complications in July 2016 and August 2016. The MARs also revealed the resident was administered three different medications for bladder spasms in the same time period. Review of urology consults revealed the following: a. On 6/25/15 the consult included a [MEDICAL CONDITION] bladder and recommended a cystoscopy (a diagnostic test that allows the doctor to visualize the bladder) and to place a Foley catheter. b. On 8/31/15 the urologist documented that the cystoscopy revealed no mass or [MEDICAL CONDITION] and to follow up in one month. c. On 10/7/15 the urology consult included to continue the Foley, would not recommend a suprapubic catheter at this time and to follow up with the resident in six months. The consult was initialed by the attending physician that it was read. There was no further urology follow up in the medical record or documentation related to why the follow up was not done. Interviews conducted on 10/26/16 included the following: a. At 11:49 a.m., the Licensed Practical Nurse (LPN)/charge nurse stated that if a follow up is recommended by a consultant the physician is notified, if in agreement, the physician signs the consult and then the secretary makes the appointment. b. At 1:41 p.m., the Director of Nursing (DON) stated a urologist changed the resident's catheter in the emergency room in August when it was clogged but there is no documentation related to the ongoing use of the catheter or the frequency of the resident's UTI's. She said that resident was not seen by the urology office as recommended as it was missed and she does not know why. The DON said there is no documentation as to why the resident did not get the follow up as recommended. (10 NYCRR 415.12(d)(2))

Based on observations, interviews and record reviews, it was determined that for one (Resident #50) of three residents reviewed for quality of care related to pain, the facility did not provide the necessary interventions to meet the residents' highest level of functioning. Specifically, a pain assessment revealed the resident verbalized constant pain and this was not addressed by the interdisciplinary team. This is evidenced by the following: Resident #50 has [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) Assessment, dated 10/7/16, revealed that the resident's cognition is moderately impaired (cues and supervision required), is understood by others and usually understands others. Physician orders, last signed on 8/11/16, included Tylenol 650 milligrams (mg) every four hours as needed for mild pain or fever. There is no other pain medication ordered. The current Comprehensive Nursing Care Plan revealed that the resident is at risk for pain. Approaches included providing and promoting general comfort measures such as repositioning and pain medications. The most recent physician progress notes [REDACTED]. Review of a pain assessment, dated 10/7/16, revealed that the resident reported almost constant pain that made it hard for her to sleep at night and limits her day to day activities. The resident coded the worst pain at 7 out of 10 (moderate). The assessment was signed by the Registered Nurse/Nurse Manger (NM). Review of Medication Administration Records revealed the as needed Tylenol was documented as administered 15 times in September and 5 times in October. There was no other pain medication documented as administered. In an observation on 10/21/16 at 11:44 a.m., the resident was sitting in a wheelchair in her room and leaning far to the left. When interviewed at that time, the resident stated that she had been up since 6:30 a.m. and that her back hurt. She added that she has [MEDICAL CONDITION] and aches all the time. Interviews conducted on 10/26/16 include the following: a. At 9:11 a.m., the resident stated that she aches mostly in the neck and back. She said that she did not tell anyone because they know. She said she just gets Tylenol and it doesn't really help much. b. At 9:42 a.m., the Certified Nursing Assistant stated that the resident is in pain most of the time. She said the resident complained of back pain that morning when getting up. She added that she moans when they use the stand lift which is pretty much all of the time. c. At 9:48 a.m., the Licensed Practical Nurse (LPN) stated that the resident will tell them when she is in pain and it is usually in the evening. She added that if the pain assessment documented an increase in pain it should be addressed by the physician. The LPN said that the resident may possibly need a routine order. She said that the resident used to be on [MEDICATION NAME] (narcotic pain reliever) but it was discontinued due to non-use over a month ago. When interviewed on 10/27/16 at 11:59 a.m., the LPN/interim NM stated that when she saw the pain assessment (after surveyor intervention) she notified the physician for review. (10 NYCRR 415.12)

Based on interviews and record reviews, it was determined that for two of seven residents reviewed for accidents and incidents (A/Is) and one of one reviewed for misappropriation of property, the facility did not thoroughly investigate injuries of unknown origin (Resident #46, Resident #32 and Resident #43) to rule out abuse, neglect or mistreatment and misappropriation of property. This is evidenced by the following: 1. Resident #46 has [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) Assessment, dated 8/9/16, revealed the resident has severe cognitive impairments and requires extensive assistance of one staff for all Activities of Daily Living (except eating). A Care Plan (CP), dated 5/19/16, revealed the resident is not independent in ambulation, transfers, or ADLs related to dementia and includes approaches to assist with cares as needed. An Integrated Progress Note (PN), dated 10/6/16 (3:00 p.m. to 11:00 p.m. shift), documented that a Certified Nursing Assistant (CNA) reported that during evening cares, she discovered a 2 centimeter (cms) by 2 cms purple bruise on the left shin of unknown origin. Review of an A/I, dated 10/6/16, revealed the resident was unable to tell what happened due to dementia. There is a statement from the CNA who discovered the bruise and a statement from a CNA who worked 10/5/16, day shift. There are no additional interviews between 10/5/16 day shift to 10/6/16 evening shift. 2. Resident #32 has [DIAGNOSES REDACTED]. A MDS Assessment, dated 9/16/16, revealed the resident's cognitive skills for daily decision making is moderately impaired requiring total dependence on staff for toileting and extensive assistance for all other ADLs (except eating). Review of an A/I, dated 10/16/16, revealed a CNA saw blood on the left arm. There was a 1 inch by 1 1/2 inch abrasion to the left wrist with ecchymosis (bruising). The resident said he did not know what happened. There is a statement from the CNA (10/16/16) who discovered the injury and a statement from a CNA, dated 10/15/16. There are no additional interviews. Interviews conducted on 10/27/16 included the following: a. At 10:28 a.m., Licensed Practical Nurse (LPN) #1 said if a resident has bruises of unknown origin, she immediately reports this to a Registered Nurse (RN) who then initiates an investigation, including witness statements from different shifts, going back at least 24 hours. b. At 10:49 a.m., the Administrator (ADM) said an A/I investigation should look back 24 hours, over all shifts. She said she was not sure who should be interviewed and referred the surveyor to the RN who completed both A/I investigations. The ADM said this RN has been at the facility for less than a year and had on the job training on how to write an A/I. c. At 11:22 a.m., a RN/Nurse Manager (RN/NM) said she was in the process of learning how to write A/Is. The RN/NM said she was taught to go back 24 hours and get a statement from the CNA that worked the same shift. She added our training is to go back to the preceding day, not to interview every shift in between. I just went back as I have been taught---to go back a day. d. At 11:49 a.m., LPN #2/Acting NM said, When completing an I/A investigation, I interview the staff that took care of the resident and obtain witness statements. She said she works backwards from the shift on which the bruise was identified, to try to determine the cause. 3. Resident #43 has [DIAGNOSES REDACTED]. A MDS Assessment, dated 7/28/16, revealed that the resident's cognitive skills for daily decision making are moderately impaired. In an interview on 10/21/16 at 10:44 a.m., the resident said his wallet, containing money, was missing. He said he had lost about $130 and now has a locked drawer. The Review of Missing Items Log Book, dated 12/29/14 to 9/23/16, did not include any report of a missing wallet or money. Interviews conducted on 10/26/16 included the following: a. At 10:01 a.m., the Social Worker said she remembered that the resident reported his wallet missing at one time. The SW said the resident's family member had been involved. The SW said she had documented on a complaint form because the resident thought it was stolen rather than missing. Review of a Complaint Form, dated 4/4/16, revealed that a family member wanted a formal complaint filed because the resident's wallet was missing, a total of $80 and a can of change. The plan of correction was that the resident was instructed on keeping money locked up or in the Business Office. The resident was given a key to a locked drawer. b. At 11:24 a.m., the SW said that at the time of admission, residents are asked if they want a locked drawer. The SW said she was unable to find documentation specific to the use of a locked drawer for this resident. Interviews conducted on 10/27/16 included the following: a. At 12:31 p.m., the resident said he had lost everything in his wallet, not only money but any cards he had in it, including his social security card. b. At 12:47 p.m., the SW said at the time of report (4/4/16), the family member reported that the wallet contained money and his social security card. The SW said, To be honest, I did not think about reporting the wallet stolen and did not investigate any further or file a police report. (10 NYCRR 415.4(b)(2-4))

Based on observation, interviews and record reviews, it was determined that for one (Resident #39) of five residents reviewed for unnecessary medications, the facility did not ensure that each resident's drug regime is free of unnecessary medications. Issues included a lack of specific target symptoms of the resident's depression with corresponding care plan approaches and a lack of thorough and timely tracking of behaviors with medication changes. This is evidenced by the following: Resident #39 has [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) Assessment, dated 10/14/16, revealed the resident's cognition is moderately impaired. A Mood Interview score of 00 (out of 27, 27 being highest severity), and no symptoms of [MEDICAL CONDITION], rejection of care or wandering. A Certified Nursing Assistant (CNA) Accountability card, dated April 2016, documented the resident likes family visits/outings, socials, music and watching television. Review of the 3/25/16 Psychoactive Medication Review revealed the resident receives [MEDICATION NAME] XR 75 mg daily, and [MEDICATION NAME] was discontinued. A 6/13/16 Psychiatric Consult Follow UP Visit included to increase dosage of [MEDICATION NAME] XR to 112.5 mg and monitor response. A Care Plan (CP), dated 10/18/16, for [MEDICAL CONDITION] Drug Use, included lifelong use of an antianxiety medication and [MEDICATION NAME] XR (antidepressant medication). Interventions included psych evaluation as needed, monitor mood and monitor for lethargy. Physician orders, dated 10/27/16, directs [MEDICATION NAME] XR 112.5 milligrams (mgs) daily for depression. In an interview on 10/24/16 at 3:10 p.m., Certified Nursing Assistant (CNA) #1 described the resident as calm, sweet, and is usually joking. CNA #1 said she has never witnessed the resident cry and could not state any signs of depression. CNA #1 said she is not aware of any problems with the resident's sleeping. In an interview on 10/25/16 at 9:26 a.m., a Registered Nurse/Nurse Manager (RN/NM) said any resident that has behaviors, has a CP for behaviors and behavior logs. The RN/NM said the Social Worker writes the behavior CP with strategies and interventions then initiates a behavior log which is kept in the Medication Administration Record [REDACTED]. When asked how nursing tracks the effects of [MEDICATION NAME] XR, the RN/NM said, Behavioral logs are completed to document the resident's behavior throughout the day. She said the behavior logs will document what the resident was doing when the nurses checked on him. When asked what target behaviors for depression, specific to Resident #19, would be on the behavior logs? The Director of Nursing (DON) said staff would initiate a Reaction to Medication Sheet with expected outcome. She stated it was the responsibility of the RN/NM to initiate the forms and the Behavior Tracking Logs. The DON then directed the Unit Secretary to look into the overflow file for behavior tracking logs. On 10/25/16 at 9:38 a.m., the DON said no additional behavior tracking logs had been found in the chart. She said some logs were found for 1/19/16 to 1/24/16 and 2/5/16 to 2/11/16. However, the logs did not include specific target behaviors or signs/symptoms of depression. The DON said, There should be tracking sheets in the chart. She said it should have been done. She said there should be specifics/target signs addressing his depression. The DON said, The nurses are data collectors for the physician so he can evaluate medication use and the effectiveness. On 10/25/16 at 11:58 a.m., the resident was in his room, watching an old black and white movie on tv. He said he just takes the pills the nurses give him and does not know what they are for. He said he has no trouble sleeping and does not cry about anything. In an interview on 10/26/16 at 10:11 a.m., a Social Worker (SW) said for each change in medication, Behavior Tracking logs are put in the resident's chart. The SW added, Maybe not for an increase but I don't know why nursing would not track effects of an increase. On 10/26/16 at 11:48 a.m., the DON said that is where we are lacking, the target symptoms for depression and the tracking of medication changes. On 10/27/16 at 10:12 a.m., CNA #2 said the resident never has any behaviors. She describes him as very easy going and a jokester, no refusal of cares, no wandering, no anger issues, no hitting and he sleeps well. CNA #2 said she has not seen him cry or voice that he is sad. CNA #2 said the nurses usually informs me if someone is on a behavior log. The nurses instruct us to look for changes in mood but she has never had anyone tell her a resident is on a log due to use of depression medication. (10 NYCRR 415.12(l)(1))