Every finding on record at Our Lady of Peace Nursing Care Residence

Based on observation, interview, and record review conducted during a Standard survey completed on 10/15/24, the facility did not ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for two (Resident #66 and #100) of four residents reviewed. Specifically, Resident #66 was not assisted with removing unwanted facial hair. Resident #100 did not receive incontinent care in a timely manner, received incomplete incontinent care, and staff did not complete proper glove changes and hand hygiene during care. Additionally, moisture barrier cream was not applied to Resident #100 per their care plan. The findings are: The policy and procedure titled AM and HS (morning and night) Care, dated 12/2023, documented during morning care staff are to assist with shaving based on preference/need. The policy documented to wash resident's genital area and buttocks and apply moisture barrier as indicated. The policy and procedure titled, Peri Care revised on 12/2017 documented the purpose of this procedure was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the residents skin condition. Wash the perineal (area of the body between the anus and genitalia) area, wiping from front to back and wash area downward from front to back. Assist or instruct the resident to turn on their side, wipe the rectal area thoroughly, wiping from the base upward and extending over the buttocks. Dry the area thoroughly, remove gloves and discard into designated container. Perform hand hygiene before touching any clean objects. The policy and procedure titled Hand Hygiene, revised on 5/2023, documented hand hygiene was the single most important practice to prevent infections and promote resident safety. Hand hygiene is practiced after contact with blood, body fluids or contaminated surfaces. The policy documented hand hygiene is practiced before moving from work on a soiled body site to a clean body site on the same resident. 1. Resident #66 had diagnoses including unspecified dementia, hypertension (high blood pressure), and type 2 diabetes (body has trouble controlling blood sugar and using it for energy). The Minimum Data Set (a resident assessment tool) dated 8/21/24 documented Resident #66 was severely cognitively impaired, was usually understood and usually understands, required supervision for personal hygiene, and had no behaviors that included refusals of care. The comprehensive care plan dated 4/28/2022 documented Resident #66 needed assistance with daily activities of daily living care. Interventions included supervision assistance with set up staff support for personal hygiene. The Certified Nurse Aide worksheet (guide used by staff to provide care) dated 8/21/24 documented staff were to anticipate needs on routine rounding for Resident #66. Review of Nursing Progress notes dated 9/3/24 to 10/7/24 revealed there was no documented evidence that Resident #66 refused to be shaved. During an observation on 10/7/24 at 10:25 AM, Resident #66 had multiple gray and white facial hairs (0.25-0.5 inches) on their upper lip and multiple long white hairs (0.5 -1 inch) present on their chin. During an observation and interview on 10/7/24 at 11:27 AM, Resident #66' facial hair remained. Resident #66's spouse stated Resident #66 did not like the facial hair and staff have never asked or attempted to shave it. During intermittent observations on 10/8/24 at 8:21 AM, 10/8/24 at 3:38 PM, and 10/9/24 at 8:36 AM, Resident #66 continued to have long facial hairs to their upper lip and chin. During an observation and interview on 10/9/24 at 8:37 AM, Certified Nurse Aide #6 provided morning care to Resident #66. Certified Nurse Aide #6 combed Resident #66's hair then wheeled Resident #66 into the dining area. Certified Nurse Aide #6 returned to the room and started to pick up dirty linen. Certified Nurse Aide #6 did not offer or attempt to remove Resident #66's facial hair, before the completion of morning care. During an interview on 10/9/24 at 8:58 AM, Certified Nurse Aide #6 stated they were finished with care for Resident #66. Certified Nurse Aide #6 stated they noticed the facial hair on Resident #66 and should have asked them if they would like to be shaved. During an interview on 10/9/24 at 11:36 AM, Registered Nurse #2 Unit Manager stated they expected the Certified Nurse Aide to ask residents if they would like to be shaved daily with care and shaving should be done automatically weekly on shower days. During an interview on 10/10/24 at 1:39 PM, the Director of Nursing stated they expected morning care to involve shaving when facial hair is noticed and as long as the resident wanted it done. During an interview on 10/15/24 at 12:54 PM, the Director of Nursing stated there was not a facility educator at the time and the Director of Nursing and Assistant Director of Nursing were filling in as educators. The Director of Nursing stated staff were educated annually and as part of their competencies, and shaving was included in these educations. 2. Resident #100 had diagnoses including unspecified dementia, history of transient ischemic accident (a blockage of blood flow to the brain), and spinal stenosis (the space inside the backbone is too small causing pressure on the spinal cord and nerves that travel through the spine). The Minimum Data Set, dated dated dated [DATE], documented that Resident #100 had moderate cognitive impairment, could sometimes understand and could sometimes be understood by others. Resident #100 was incontinent of bowel and bladder and required substantial/maximal assistance for toileting and personal hygiene. Review of the comprehensive care plan dated 9/21/24 documented Resident #100 had the potential for skin breakdown related to a history of pressure ulcers. Skin will remain clean, dry, and free of breakdown related to incontinence. Interventions included perineal cleansing, to apply protective skin barrier after each incontinent episode, and to check and change per protocol. Resident #100 was care planned to be toileted prior to laying down for a nap. A continuous observation on 10/10/24 from 9:50 AM to 10:30 AM of Resident #100 revealed the following: at 9:50 AM Resident #100 was sitting in the common area in front of the television, yelling out, Hey, I have to go to the bathroom, and was trying to get out of their wheelchair, they kept repeating themselves stating, Hello, I have to go to the bathroom. There were not any staff visible in the area to assist the resident. At 10:01 AM, Resident #100 stated repeatedly, Oh boy, oh come on. Certified Nurse Aide #1 was seated ten feet away and did not respond to the resident. At 10:30 AM Resident #100 was taken down to the 2nd floor to participate in activities and was not toileted prior. During an interview and an observation on 10/10/24 at 10:45 AM, Resident #100 was in the 2nd floor activities room, when asked if they had been toileted yet, they stated no. During an interview on 10/10/24 at 12:39 PM, a family member of Resident #100 stated the resident had not been toileted yet and the staff kept the resident parked in front of the television all the time. They stated when Resident #100 had to go to the bathroom they would need to be taken promptly but the staff do not respond soon enough. They stated the resident sat in their soiled brief for hours and caused the resident to get many urinary tract infections since they were admitted to the facility. During an observation of incontinent care on 10/10/24 at 1:08 PM, Resident #100 was taken into their room by Certified Nurse Aide #1 and Certified Nurse Aide #2 after a visitor requested the resident be taken to the restroom. Certified Nurse Aide #2 gathered supplies, filled a basin with water and applied clean gloves. The resident was transferred into their bed by the two staff members using a mechanical lift, a strong urine and feces odor was detected, the resident's pants were soaked through with urine and the resident had had a bowel movement. Resident #100 was positioned towards Certified Nurse Aide #2 while their soiled pants were removed by Certified Nurse Aide #1. Certified Nurse Aide #1 used a washcloth and removed the feces from the resident's buttocks. Perineal care/urinary incontinence care was not performed. While wearing the same gloves, Certified Nurse Aide #1 used a clean towel to dry the resident and did not apply a skin barrier cream. Without changing their gloves and performing hand hygiene, Certified Nurse Aide #1 applied a clean brief and clean pants to the resident. Certified Nurse Aide #1 took the soiled items, placed them on a barrier on the resident's bed, and put them in a garbage bag and removed them from the room without removing/changing their gloves and performing hand hygiene before they exited. Certified Nurse Aide #1 re-entered the room then took the basin to the restroom and dumped dirty water into the toilet, rinsed the basin, removed their gloves, placed basin in the resident's drawer and washed their hands. During an interview on 10/10/24 at 1:26 PM, Certified Nurse Aide #1 stated Resident #100 would try and get out of their wheelchair when they needed to go to the bathroom. They stated the resident was toileted at 8:00 AM this morning and had not been toileted since because Resident #100 did not tell them they had to go, nor did they observe the resident attempting to get out of their wheelchair. They stated that all residents should be toileted every 2-3 hours. When asked why resident #100 was not toileted every 2-3 hours, they stated it was hard to find another staff member to assist the residents who were a two assist. They stated that normally they did perineal care first, but they did not today. They stated the resident was prone to getting urinary tract infections and they should have done perineal care. They stated that they should have changed their gloves after they cleaned the resident's buttocks and before touching the clean items. They stated this was important because cross contamination could occur. During an interview on 10/10/24 at 1:33 PM with Certified Nurse Aide #2 they stated Certified Nurse Aide #1 should have changed their gloves prior to touching clean items. They stated they were uncertain why Certified Nurse Aide #1 only cleaned the resident buttocks and did not perform perineal care. They stated only if a resident had a skin breakdown they would apply a skin barrier cream. They stated it was important to change dirty gloves to decrease the risk of cross contamination. During an interview on 10/10/24 at 1:45 PM, the Assistant Director of Nursing stated the Certified Nurse Aides did their rounds every 2-3 hours to perform incontinent care. They stated they should check the resident's closet care plan for the times they were care planned for as well. The Assistant Director of Nursing stated they expected the Certified Nurse Aides providing incontinent care to use proper technique for females and males, the resident should be cleaned from front to back and would expect them to change their gloves, wash hands, and reapply clean gloves before touching any clean items. They stated Certified Nurse Aide #1 should have cleaned Resident #100's perineal area first with clean gloves front to back, remove gloves and wash hands before they reapplied another pair of clean gloves, and then proceeded to clean the residents' buttocks in an upward motion. They stated Certified Nurse Aide #1 then should have removed their soiled gloves and washed their hands, put on a new pair of clean gloves, and put on a protective barrier cream to the resident's buttocks. During an interview on 10/10/24 at 1:52 PM, the Director of Nursing stated during incontinent care they expected Certified Nurse Aides to explain to the resident what they were doing, perform complete incontinent care thoroughly by cleaning front and back, change soiled gloves, wash hands, reapply clean gloves and apply a barrier cream to protect the skin from break down. They stated it was important to change gloves whenever dirty when providing incontinent care to avoid cross contamination. During an interview 10/11/24 at 12:33 PM, Licensed Practical Nurse #3 stated that the Certified Nurse Aides did not document every time the resident was toileted, and the check and change protocol was for residents to be toileted every 2-3 hours. 10NYCRR 415.12(a)(3)

Based on interview and record review during the Standard survey completed on 10/15/24, the facility did not implement written policies and procedures for screening employees, that would prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, two (Employee #5, Agency Licensed Practical Nurse and Employee #7, Nutritional Services Aide) of 13 employees that worked in the facility and were subject to the New York State Nurse Aide Registry verification, were reviewed through the New York State Nurse Aide Registry prior to their employment as required. The findings are: 1a. The policy and procedure titled Contingent Worker last approved and last reviewed 9/6/21 documented Contingent Workers include but are not limited to: Agency Workers. Contingent Worker workforce will be tracked in the Human Capital Management System (HCMS) to meet regulatory requirements and manage facility and system access. Appropriate use of Contingent Workers. Contingent Workers generally should be used to provide services for which the Ministry does not otherwise employ resources (e.g., catering, landscaping, maintenance), or when a short-term need for additional resources or special skills exists and the hiring of additional employees is not warranted (e.g., seasonal, high census coverage, immediate need, etc.). Drug Testing and Background Check Requirements for Contingent Workers. Background Checks shall be conducted in accordance with the following: The Third Party who supplies the Contingent Worker must conduct background checks related to criminal history, employment, education, OIG (Office of Inspector General), GSA (General Services Administration) , FDA (Food and Drug Administration) debarment status and the required licenses or certifications (such as MVR (Motor Vehicle Records) and DEA (Drug Enforcement Agency) of a Contingent Worker provided the Ministry to the full extent permitted by federal, state, or local law. When there is not a Third Party, Ascension provides the services as the agency. Background checks must be successfully completed prior to the Contingent Worker's commencement date at the Health Ministry. Criminal History Requirements. Ascension strives to maintain safe and secure working environments for all colleagues, customers, business partners, visitors, and guests. All Third Parties are required to verify criminal records to ensure that Contingent Workers do not pose a safety or security risk to Ministry sites, property, or personnel. If, during an assignment, a disqualifying offense is committed by a Contingent Worker, the Third-Party who is supplying the Contingent Worker must notify the Ministry and determine the appropriate action. The policy contained no documentation regarding the New York State Nurse Aide Registry verification process. Review of Employee #5's (Agency Licensed Practical Nurse) personnel file revealed the employee was hired on 7/14/24. Review of the time sheet information provided by the facility revealed Employee #5 worked in the facility on 7/14/24 from 3:00 PM to 11:00 PM. Review of the New York State Nurse Aide Registry Verification Report for Employee #5 revealed the verification date of the report was 7/23/24. During an interview on 10/10/24 at 11:02 AM, the Associate Experience Advisor stated Employee #5 was an Agency Licensed Practical Nurse, their hire date was 7/14/24, and the employee worked in the facility on 7/14/24. The Associate Experience Advisor further stated the Nurse Aide Registry Verification Report for Employee #5 had been completed on 7/23/24 and the facility had no other evidence that verified a Nurse Aide Registry Verification Report had been completed for the employee before 7/14/24. 1b. The policy and procedure titled New Hire Procedure last approved date 6/4/24 documented the purpose was to establish proper and consistent recruiting and hiring processes, that comply with all federal, state, and local laws and/ or regulations and to attract the most qualified Associates for all approved vacancies. It is the responsibility of the Human Resources department to establish and maintain effective and efficient processes for the recruitment, screening, and employment of the applicants to fill all job vacancies. The hiring process for Contingent Workers is out of scope of this policy and follows a different process. Onboarding. Background checks. Human Resource Talent Acquisition is responsible for coordinating a background check on the selected applicant(s) in consideration. Background checks will include, but are not limited to, verification of employment, education, and professional references. The policy contained no documentation regarding the New York State Nurse Aide Registry verification process. Review of Employee #7's (Nutritional Services Aide) personnel file revealed the employee was hired on 6/25/24. Review of the Direct Supervision of Temporary Employee sheets for Employee #7 revealed they worked in the facility on 6/25/26 from 8:00 AM to 4:00 PM and on 6/26/24 from 11:30 AM to 7:30 PM. Review of the New York State Nurse Aide Registry Verification Report for Employee #7 revealed the verification date was 6/27/24. During an interview on 10/10/24 at 12:10 PM, the Associate Experience Advisor stated Employee #7 was a Nutritional Services Aide, their hire date was 6/25/24, and the employee worked in the facility on 6/25/24 and 6/26/24. The Associate Experience Advisor stated the Nurse Aide Registry Verification Report for Employee #7 had been completed on 6/27/24 and the facility had no other evidence that verified a Nurse Aide Registry Verification Report had been completed before 6/27/24. The Associate Experience Advisor stated the only documentation the facility had for the dates that Employee #7 worked in the facility was documented on the Direct Supervision of Temporary Employee sheets for the employee. During an interview on 10/11/24 at 1:57 PM, the Director of Nutrition stated Employee #7 worked at the Facility as a [NAME] delivering food to the resident units. 10 NYCRR 415.4(b)

Based on observation, interview, and record review conducted during the Standard survey completed on 10/15/24, the facility did not operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes. Specifically, the facility was not in compliance with Section 915 of the 2020 Fire Code of New York State, which requires carbon monoxide detection in all rooms and sleeping areas with fuel-burning appliances and on-going preventative maintenance of carbon monoxide detectors. This affected three (First, Second, and Third Floors) of three resident use floors and one of one Basement. The findings are: According to the 2020 Fire Code of New York State, patient rooms in nursing homes are defined as sleeping units. In residential and commercial buildings that contain a fuel burning appliance, carbon monoxide detection shall be installed in all rooms, occupiable space, dwelling units, sleeping areas, and sleeping units that contain a fuel-burning appliance. Additionally, the 2020 Fire Code of New York State stated carbon monoxide detectors shall be maintained in good working order in accordance with Section 915 of this code, National Fire Protection Association (NFPA) 720 (Standard for the Installation of Carbon Monoxide Detection and Warning Equipment), and the manufacturer's instructions/recommendations. Review of the Combination Photoelectric Smoke and Carbon Monoxide Alarm with Voice Message System, Combo Smoke/CO Alarm User Guide from the manufacturer's website revealed weekly testing is required to ensure proper operation. Testing: Test your alarm by pressing the test button until the unit chirps, then release the test button. The unit will then emit three long beeps, Fire!, three long beeps, short pause, four short beeps, Warning! Carbon Monoxide!, four short beeps, pause, one beep. The alarm and voice will sound if the electronic circuitry, horn, speaker, and battery are working. If the alarm or voice does not sound, the unit must be replaced. Battery. Note: This alarm is powered by a sealed lithium battery system. No battery installation or replacement is necessary for the life of the alarm. After ten (10) years of cumulative power up, this unit will chirp two times every 30 seconds. This is an operational end of life feature which will indicate that it is time to replace the alarm. To help identify the date to replace the unit, a label has been affixed to the side of the alarm. Write the Replace by date ([AGE] years from initial power up) in permanent marker on the label prior to installing the unit. Cleaning your alarm. Your alarm should be cleaned at least once a year. You can clean the interior of your alarm (sensing chamber) by using compressed air or a vacuum cleaner hose and blowing or vacuuming through the openings around the perimeter of the alarm. The outside of the alarm can be wiped with a damp cloth. Use only water to dampen the cloth, use of detergents or cleaners could damage the alarm. After cleaning, test your alarm by using the test button. If cleaning does not restore the alarm to normal operation, the alarm should be replaced. Observations on 10/7/24 between 9:18 AM and 3:05 PM and on 10/8/24 between 8:05 AM and 2:50 PM revealed battery-operated combination photoelectric smoke and carbon monoxide alarms with voice message system were installed on the First, Second, and Third Floors and in the Basement. Further observations revealed the facility had six resident units, (1 East, 1 West, 2 East, 2 West, 3 East, and 3 West), each resident unit had two laundry rooms and each laundry room had a combination photoelectric smoke and carbon monoxide alarm with voice message system installed in it. Continued observations revealed combination photoelectric smoke and carbon monoxide alarms were installed on the First Floor in the Kitchen and Laundry room service area in the Service corridor, and in the Boiler room in the Basement. The observations also revealed natural gas fuel burning appliances were installed on the First, Second, and Third Floors, and in the Basement. During an interview on 10/11/24 at 8:49 AM, the Maintenance Supervisor stated the facility had the same brand of ten-year battery apparated combination photoelectric smoke and carbon monoxide alarms installed on the First, Second, and Third Floors and in the Basement. The Maintenance Supervisor further stated the alarms were tested monthly and the facility had logs for the testing of the alarms. Review of CO (Carbon monoxide) Checks logs revealed the facility's ten-year battery apparated combination photoelectric smoke and carbon monoxide alarms with voice message system had been checked monthly from 1/29/24 through 10/1/24. Review of the Combination Photoelectric Smoke and Carbon Monoxide Alarm with Voice Message System, Combo Smoke/CO Alarm User Guide provided by the facility revealed it was only the first two pages of the User Guide and the first two pages did not have any evidence regarding the testing of the alarms. 42 CFR 483.70(b) 10NYCRR: 415.29(a)(2), 711.2(a)(1) 2020 Fire Code of New York State, Section 915: 915.3.1, 915.6

Based on observation, interview and record review conducted during an Abbreviated survey (Complaint # NY00318540) completed 7/25/23, the facility did not ensure that all alleged violations of abuse, neglect or mistreatment including injuries of unknown origin are thoroughly investigated for one (Resident #1) of three residents reviewed for abuse. Specifically, the facility did not review the video surveillance from 6/18/23 to 6/19/23 prior to the completion of their investigation showing employee interviews had inconsistencies in the staff statements versus what was shown on the video surveillance. In addition, not all 7-3 staff working the east unit were interviewed by the facility for an injury of unknown origin, (fracture of the humeral neck (broken top end of the arm bone). The findings are: The policy and procedure (P&P) titled Abuse Investigation and Reporting with last revised date 7/22 documented all reports of resident abuse, neglect, exploitation, and misappropriation of resident property, mistreatment, electronic mail, social media, videotaping, photographing and other imaging of residents, and/or injuries of unknown source shall be promptly reported to local, state and federal agencies and thoroughly investigated by community management. The Administrator or designee will provide any supporting documents relative to the alleged incident to the person in charge of the investigation. The role of the investigator was to interview associate members on all shifts who have had contact with the resident during the period of the alleged incident. The following guidelines should be used when conducting an interview: witness reports will be obtained in writing. Either the witness will write their statement and sign and date it or the investigator may obtain a statement, read it back to the member and have them sign and date it. The P&P titled Abuse Prevention with last revised date 6/2020 documented all residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This included freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse and physical or chemical restraint. An injury of unknow source is defined as an injury that the source of the injury was not observed by any person, or the source could not be explained by the resident and the injury is suspicious. The community would investigate and report any allegation of abuse within the timeframes as required by federal, state, and local requirements and follow the Abuse Investigation Reporting policy for roles and responsibilities of investigation. 1. Resident #1 had diagnoses including dementia, Parkinson's (tremors and rigidity of movement) disease, and history of malignant neoplasm of brain and breast. The Minimum Data Set (MDS- a resident assessment tool) dated 5/18/23 documented Resident #1 was sometimes understood, sometimes understands, and had severe cognitive impairment. The comprehensive care plan (CCP) titled Care Plan Historical Copy Date: 5/22/23 printed 7/14/2023 documented Resident #1 was alert to person with confusion/forgetfulness and was able to make simple needs know. Resident #1 needed assistance with daily activities of daily living (ADL) care. Interventions included non-ambulatory; total assist of two persons with a mechanical lift for transfers; total assist of one person for hygiene, dressing, toileting, bathing, and bed mobility; and an extensive assist of one person for eating. Observation of the facilities video surveillance coverage that pointed in the direction of Resident #1's room, was reviewed on 7/14/23 at 12:38 PM and 7/18/23 at 9:48 AM. The video footage showed on 6/18/23 at 12:34 PM CNA #1 was noted to push Resident #1 into their room and then left the room. At 1:05 PM it was observed that CNA #1 entered Resident #1's room with the mechanical lift and at 1:13 PM CNA #1 exited the room with the mechanical lift. No second staff member was observed to enter or exit room during that time frame. Review of the footage for the rest of CNA #1's shift revealed the mechanical lift was never brought back into the room. Review of the following Interdisciplinary Notes revealed: -6/19/23 at 6:01 AM, Registered Nurse (RN) #1 documented they were called to the unit by the supervisor (LPN #1) for a brief assessment of Resident #1. RN #1 documented that Resident #1 had a significant change in mental status and skin was pale, eyes were fixed, and was unable to verbalize. Resident's entire right upper extremity from elbow to the armpit had pitting edema and a significant amount of dark purple ecchymosis and showed signs of pain with movement. Resident #1 was sent to the hospital for evaluation. -6/19/23 at 10:18 AM, Licensed Practical Nurse (LPN) #1 documented that around 5:00 AM they were called to the unit by LPN #2 due to a sudden change in condition for Resident #1. LPN #1 documented that Resident #1 appeared pale, had shortness of breath, cyanotic (bluish discoloration of the skin resulting from poor circulation or oxygenation) like discoloration at bridge of nose and around lips. Resident #1 was slow to respond and there were visible purple veins to upper chest and upper right arm with edema from armpit to elbow. The medical doctor was notified and received order to send Resident #1 to the hospital. Review of the facility investigation tilted Case #NY00318540 completed by the Director of Nursing (DON) dated 6/23/23 revealed hospital documentation was reviewed to follow up on Resident #1 after they were sent to the hospital on 6/19/23. The facility investigation documented the hospital obtained an x-ray and a right humeral head fracture; age indeterminate, likely acute was found. The DON documented that review of associates began and statements were obtained. The Employee Statement signed by the Director of Quality (DOQ) dated 6/19/23 documented they spoke with Certified Nurse Aide (CNA) #1 at approximately 1:30 PM. CNA #1denies seeing bruising on arm. Documented resident was place back into bed in the afternoon using a mechanical lift with assist of a 2nd CNA. Review of the statements written by Licensed Practical Nurse (LPN) #3, CNA #2, CNA #4 and CNA # 5 revealed that none of these staff members assisted with Resident #1's afternoon transfer. There was no evidence of written statements or telephone interviews with Registered Nurse (RN) #2 and CNA # 3 who worked the other hallway on the same unit. During an interview on 7/12/23 at 9:30 AM, the Director of Nursing (DON) stated that themselves, along with the Director of Quality (DOQ), completed an investigation on Resident #1 after they became aware Resident #1 had a fracture of the humerus. The DON stated that all staff 24 hours prior to the incident occurring were to be interviewed as part of the investigation. The DON stated that the facility had video surveillance, but they did not review any video footage because they did not have access to view video footage. Review of the Our Lady of Peace Long Team Care Facility, INC (staffing schedule) dated 6/18/23 documented that the following staff on the 2 east unit were: -7:00 AM to 3:00 PM: CNA #1, CNA #2, CNA #3, CNA #4, CNA #5, LPN #3, and RN #2. -3:00 PM to 11:00 PM: CNA #3, CNA #4, CNA #6, CNA #9, LPN #4, and RN #2 (until 7:00pm) then RN #1 (until 11:00 PM). -11:00 PM to 7:00 AM: CNA #7, CNA #8, and LPN #2. During a telephone interview on 7/13/23 at 12:53 PM, CNA #1 stated that an agency CNA helped them transfer Resident #1 into bed after lunch on 6/18/23 and did not know their name. During interviews on 7/13/23 and 7/14/23 with all the 7:00 AM to 3:00 PM scheduled staff who were on 6/18/23, stated they did not help CNA #1 with any transfers after lunch on 6/18/23. During an interview on 7/14/23 at 8:40 AM, the DON stated that they did not have any other investigation notes or interviews to provide for the investigation of injury of unknown origin for Resident #1 from 6/19/23. At 10:35 AM, the DON provided a self-written timeline of video surveillance on Resident #1's room from 7:11 AM on 6/18/23 until 5:59 AM on 6/19/23. The DON stated they watched the video footage on 7/13/23 and noted that CNA #1 made a very poor decision. The DON stated after watching the video footage, CNA #1 was observed to walk into Resident #1 room with the mechanical lift and then was seen walking out of the room with the lift and that no other staff member was observed going into the room during that time period. The DON stated that CNA #1 was not reinterview for further details and that they should have been. During a further interview on 7/14/23 at 3:00 PM the DON stated that they did not review the video footage until 7/13/23 because they did not have access to view video footage. The DON stated that reviewing video footage at the time of the investigation took place would have helped. The DON stated that the DOQ had interviewed CNA #1, but they did read CNA #1 statement along with all of the other staff statements. The DON stated that they do not know who helped CNA #1 with Resident #1 afternoon transfer on 6/18/23 and that with a thorough interview they should have. They stated that after reading the other 7-3 staff member statements they should have followed up with CNA #1. During a telephone interview on 7/25/23 at 10:02 AM, the DOQ stated that one of their duties at the facility is to follow up on incidents that happen in the facility. The DOQ stated they began in person interviews of staff in the facility that could have had contact with Resident #1 in the past 24 hours and then proceeded with telephone interviews. The DOQ stated they did not review video surveillance because they did not have access to the system. They stated that they could have requested to be given access to review the footage but did not. They stated that they did interview CNA #1 via the telephone. The DOQ stated they did not inquire from CNA #1 who the second staff member was that helped with the transfer for Resident #1. They stated they should have inquired and that their interview with CNA #1 was an incomplete interview. During a telephone interview on 7/25/23 at 2:37 PM, the former Interim Executive Director stated that they worked at the facility only for a few weeks and they were working for the facility on 6/19/23. The Interim Executive Director stated that they would expect an injury of unknow origin to be investigated and reported to the Department of Health. They stated that watching the video surveillance would be part of an investigation. The Interim Executive Director stated that they did not have access to the video surveillance system but would expect the staff member that was completing the investigation to watch the footage and/or get access to watch the footage. They stated their expectation for obtaining staff statements during an investigation would be to obtain very specific statements as to who helped with the care, what type of care was given and how the care was rendered. 10 NYCRR 415.4(b)(3)

Based on observation, interview and record review conducted during an Abbreviated survey (Complaint NY#0000318540) completed on 7/25/23, the facility did not implement a comprehensive person-centered care plan for each resident, consistent with the resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for one (Resident #1) of three residents reviewed for care plans. Specifically, Resident #1`s care plan was not implemented in the area of transfers and eating on 6/18/23 and in the area of incontinent care on 6/19/23. The findings are: The policy and procedure (P&P) titled Care Plans-Comprehensive Person-Centered with last revised date of 10/21 documented a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs, that are identified through evaluation and assessment, is developed, and implemented for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The care planning process will facilitate resident and representative involvement, include an assessment of the residents' strengths, and needs and incorporate the resident life history, person, and cultural preferences in developing goals of care. The comprehensive care plan (CCP) will: describe the services that are to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being; incorporate identified areas and risk factors associated with the problem areas; aid in preventing or reducing decline in the residents' functional status and levels; and reflect currently recognized standards of practice for problem areas and conditions. The P&P titled Procedure: Lifting Machine, Using a Portable with last revised date of 12/17 documented that the general guideline is that two nursing associates are required to perform that procedure. Explain the procedure to the resident, ensure their comfort and understanding of the situation and always have two persons to provide the transfer. The P&P titled Procedure: Assistance with Meals with last revised date of 11/19 documented residents who require assistance with eating should be provided with self-help devices and/or provided help as needed. The residents who are unable to feed themselves should be feed with attention to safety, comfort, and dignity. Unless prohibited by a medical condition, the resident requiring active assistance should eat in a congregate setting. The P&P titled Urinary Continence and Incontinence-Assessment and Management with last revised date of 12/17 documented if the individual remains incontinent despite treating the transient causes of incontinence the staff will initiate a toileting plan. Incontinence care should be individualized at night in order to maintain comfort and skin integrity and minimize sleep disruption. If the resident does not respond and does not try to toilet or for those with such severe cognitive impairment that they cannot either point to an object or say their own name, staff will use a check and change strategy. A check and change strategy involves checking the resident continence status at regular intervals and using incontinences devices or garments. The primary goals are to maintain dignity and comfort and to protect the skin. 1. Resident #1 had diagnoses including dementia, Parkinson's (tremors and rigidity of movements) disease, and history of malignant neoplasm of brain and breast. The Minimum Data Set (MDS- a resident assessment tool) dated 5/18/23 documented they were sometimes understood, sometimes understands, and had severe cognitive impairment. Resident #1 was non-ambulatory; a total of two assist for transfers; and an extensive assist of one for all other activities of daily living (ADL's) and was always incontinent of bladder and bowel. The Care Plan Historical Copy Date: 5/22/23 (the CCP) printed on 7/14/2023 documented Resident #1 was alert to person with confusion/forgetfulness and was able to make simple needs know. Resident #1 needed assistance with ADL care. Interventions included non-ambulatory; a total assist of two persons with a mechanical lift for transfers; total assist of one person for hygiene, dressing, toileting, bathing, and bed mobility; and an extensive assist of one person for eating. Resident #1 was to be out of bed for all meals and had aspiration precautions. Resident #1 had potential for recurrence of a urinary tract infection and was incontinent of bowel and bladder. Interventions included to provided incontinent care every 2-3 hours and as needed with moisture barrier and to wear disposable incontinent products. Review of the facility investigation tilted Case #NY00318540 dated 6/23/23 and signed by the Director of Nursing (DON), documented that hospital documentation was reviewed to follow up on Resident #1 after they were sent to the hospital on 6/19/23. The facility investigation documented that the hospital obtained an x-ray and a right humeral head fracture, age indeterminate, likely acute was found. The DON documented that review of associates began, and statements were obtained. Review of the Employee Statement that was provided in the facility investigation documented the following: -A statement signed by the Director of Quality (DOQ) dated 6/19/23 documented spoke with Certified Nursing Assistant (CNA) #1 approximately 1:30 PM. Denies seeing bruising on arm. States resident placed back into bed in afternoon using a mechanical lift with assist of a 2nd CNA. Review of statements from Licensed Practical Nurse (LPN) #3, CNA #2, CNA #4 and CNA # 5 revealed that none of these staff members assisted with Resident #1's afternoon transfer. -A statement signed by CNA # 6 dated 6/19/23 documented that they took care of Resident #1 yesterday and did not notice anything unusual or bruising on Resident #1 upper body and that Resident #1 was already in bed and they change Resident #1 by themselves. -A statement signed by the DOQ dated 6/19/23 documented they spoke with CNA #8 and obtained a verbal interview. The employee statement documented CNA #8 stated around 9:30-10:00 PM they noted Resident #1 was crooked in bed and the nurse and themselves straighten Resident #1 in bed. It was documented Resident #1 was not wet at 2:00 AM and then at 5:00 AM Resident #1 had vomited, was wet and noted to have a bruise. It was documented that CNA #8 got the nurse. Review of the facility document titled Our Lady of Peace Long Team Care Facility, INC (staffing schedule) with date 6/18/23 documented the following staff on the 2 east unit were: -7:00 AM to 3:00 PM: CNA #1, CNA #2, CNA #3, CNA #4, CNA #5, Licensed Practical nurse (LPN) #3, and Registered Nurse (RN) #2. -3:00 PM to 11:00 PM: CNA #3, CNA #4, CNA #6, CNA #9, LPN #4, and RN #2 (until 7:00pm) then RN #1 (until 11:00 PM). -11:00 PM to 7:00 AM: CNA #7, CNA #8, and LPN #2. The facilities video surveillance coverage that pointed in the direction of Resident #1's room, was reviewed on 7/14/23 at 12:38 PM and 7/18/23 at 9:48 AM. The following was observed in the video footage: -On 6/18/23 at 12:34 PM CNA #1 was noted to push Resident #1 into their room and then left the room. At 1:05 PM it was observed that CNA #1 entered Resident #1 room with the mechanical lift and at 1:13 PM CNA #1 exited the room with the mechanical lift. No second staff member was observed to enter or exit room during that time frame. CNA #1 never reentered the room with mechanical lift during the rest of their shift that day. -On 6/18/23 CNA # 6 was observed to entered Resident #1 room at 5:20 PM with a meal tray. It was observed that CNA #6 exited room at 5:22 PM to get a towel and enter the room again at 5:23 PM and then exited the room. CNA #6 was observed to enter Resident #1 room two additional times for a minute each at 5:25 PM and 5:34 PM. At 5:44 PM CNA #6 entered Resident #1's room and then exited at 5:58 PM with a meal tray. Between this time frame it was not observe the mechanical lift was brought into Resident #1's room. -On 6/18/23 CNA #8 was observed exiting Resident #1's room at 11:10 PM. No staff members were observed to enter Resident #1's room after 11:10 PM until 4:20 AM when LPN # 2 entered the room for two minutes. At 4:57 AM on 6/19/23 CNA #8 was observed to enter Resident #1's room. No staff members were observed to enter Resident #1 room in between those time frames. a) During a telephone interview on 7/13/23 at 12:53 PM, CNA #1 stated that they were the caregiver for Resident #1 on 6/18/23 on the 7 AM to 3 PM shift. They stated that they asked the other CNA that was working in their hallway what residents needed to be out of bed for the day and how they transferred. CNA #1 stated that they did not know that staff members name, but they also gave them their assignment sheet for the day. CNA #1 stated that Resident #1 was a total transfer with a mechanical lift. CNA #1 stated that when a mechanical lift is performed you need, at minimal, an assist of two people. CNA #1 stated Resident #1 needed a one assist for all other care. CNA #1 stated they got Resident #1 out of bed via the mechanical lift in the morning with the staff member that gave me the assignment sheet in the morning. They stated they put Resident back to bed after lunch with a different CNA and they did not know their name. During an interview on 7/13/23 at 1:41 PM, CNA #2 stated they worked 6 AM to 2 PM on 6/18/23. They stated that they worked that hallway of the unit with just CNA #1. CNA #2 stated they gave CNA #1 an assignment sheet and told them what residents had to be up for the morning and how they transferred. CNA #2 stated they helped CNA #1 with Resident #1's transfer out of bed in the morning but did not assist with the afternoon transfer. During an interview on 7/13/23 at 2:35 PM, LPN #3 stated they did not help with transfers or provide any ADL care for Resident #1 on 6/18/23. LPN #3 stated that CNA #1 was Resident #1 caregiver on the day shift and that they instructed CNA #1 to ask them if they had any questions. LPN #3 stated that Resident #1 was a total assist of two staff members with the mechanical lift for transfers and a total care on one staff member for all other ADL's. During interviews on 7/13/23 and 7/14/23 with CNA #3, CNA #4, CNA #5 and RN #2 they stated they did not assist with any transfers with Resident #1 on 6/18/23. b) During a telephone interview on 7/13/23 at 2:57 PM, CNA #6 stated they were the caregiver for Resident #1 on 6/18/23 from 3 PM to 11 PM. They stated that Resident #1 was in bed when they started their shift. CNA #6 stated they did not get Resident #1 out of bed that shift. They stated they assisted Resident #1 in bed for dinner and provided all of Resident #1 care in bed that shift. CNA #6 stated that they usually would assist Resident #1 with the dinner while they were in bed, and they stated that if the resident is in bed when they arrive for their shift, they would not get the resident out of bed unless a nurse told them to do so. CNA #6 stated that they would look at the resident's care plan prior to providing care and the care plans were in the electronic medical record or in the resident's closets. CNA #6 stated they did not know if Resident #1 was care planned to be out of bed for meals. During a telephone interview on 7/24/23 at 2:30 PM, LPN #4 stated on 6/18/23 Resident #1 remained in bed their whole shift. They stated that CNA #6 was Resident #1 caregiver for the 3PM to 11 PM shift. Around 10:00 PM they assisted CNA #8 with incontinent care and repositioning care for Resident #1. In a further telephone interview on 7/25/23 at 1:27 PM LPN #4 stated that Resident #1 ate their dinner in bed. They stated that if the previous shift had Resident #1 out of bed, then they would keep Resident #1 out of bed for dinner but if the pervious shift had them in bed, then the resident would remain in bed. LPN #4 stated that Resident #1 would normally remain in bed for their shift, ate their dinner in bed and was a supervision assist for eating. LPN #4 stated they do not recall if Resident #1 was care planned to be out of bed for meals and if they were care planned to be out of bed for meals, then they should have been out of bed. c) During a telephone interview on 7/13/23 at 3:17 PM, CNA #8 stated that on 6/18/23 into 6/19/23 they worked from 8 PM until 7 AM. CNA #8 stated around 10 PM they provided incontinent care and repositioning to Resident #1 with the help of LPN #4. CNA #8 stated that around 2 AM they checked on Resident #1 and they were not incontinent, so they did not need to provide any incontinent care. CNA #8 stated they did their last rounds on Resident #1 around 5 AM and noted a change in condition, bruising to Resident #1 right arm and they notified the nurse. During an interview on 7/14/23 at 3:00 PM, The DON stated after watching the video footage, CNA #1 was observed to walk into Resident #1 room with the mechanical lift at 1:05 PM, then was seen walking out of the room with the lift at 1:13 PM. The DON stated that no other staff member was observed going into the room during that time period. The DON stated that per their care plan Resident #1's transfer status was a two staff member assist with a mechanical lift. The DON stated that it appeared CNA #1 did not use a two assist to perform the transfer. They stated the purpose of transferring per a resident's care plan is for safety and to prevent accidents. The DON stated that after watching the video coverage CNA # 8 did not provide care to Resident #1 as CNA #8 stated in their employee interview. During a further telephone interview on 7/25/23 at 1:44 PM, the DON stated that per Resident #1's care plan they were an extensive assist of one staff member for eating and were on aspiration precautions and was to be out of bed for all meals. The DON stated that for the dinner meal Resident #1 should be in their wheelchair, that they could be in their room, but they needed one staff member support to assist with eating. The DON stated that after reviewing the video coverage they did not see the mechanical lift go into Resident #1 room since 1:05 PM. They stated CNA #6 did not follow Resident #1 care plan by not getting out of bed for dinner and the importance of following the care plan for eating is for safety and prevent any other issues from happening. The DON stated that per Resident #1's care plan they were to have incontinent care provide every two to three hours and as needed. The DON stated that after watching video coverage, CNA #8 was seen leaving Resident #1 at 11:10 PM and did not go back into Resident #1 until 4:56 AM. The DON stated that per Resident #1 care plan the resident should have been checked to see if incontinent care was needed to be around 2:00 AM. During a telephone interview on 7/25/23 at 2:37 PM the former interim Executive Director stated that their expectation was for all staff to follow the residents care plan. They stated the reason a resident's care plan was put into place was to provide proper care to the resident and if the care plan was not followed, harm could be caused to the resident. 10 NYCRR 415.11(c)(1)

Based on observation, interviews, and record review conducted during a Complaint Investigation (Complaint #NY00280511) completed during a Standard survey started on 11/16/22 and completed 11/23/22, the facility failed to protect the residents' right to be free from mental abuse and neglect for one (Resident #27) of 3 residents reviewed for abuse. Specifically, Unit Attendant (UA) #1, who was restricted from interacting with Resident #27, entered Resident #27's room on 7/31/21 on 8 different occasions, sat on the resident's bed and spoke to the resident about harming others and themselves. This resulted in actual psychosocial harm that was not immediate jeopardy to Resident #27 who became fearful, anxious, and was unable to sleep. The finding is: The facility policy and procedure (P&P) last revised 6/2020 titled Abuse Prevention documented residents have the right to be free from abuse, including mental abuse, and neglect. Mental abuse is defined as the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Neglect is defined as the failure of the community, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. 1. Resident #27 had diagnoses including anxiety disorder, major depressive disorder, and chronic obstructive pulmonary disease (COPD). The Minimum Data Set (MDS - a resident assessment tool) dated 7/12/21 documented Resident #27 was cognitively intact, exhibited no mood or behaviors, and resided on Unit 3 West. Review of a facility Care Directive dated 7/21/21 and signed by UA #1 and the Director of Nursing (DON) documented Unit Attendant #1 was restricted from Resident #27. During an interview on 11/22/22 at 8:37 AM, the DON stated UA #1 was restricted from Resident #27 on 7/21/21 secondary to an ongoing investigation. On 6/30/21 UA #1 had left a typewritten letter on a facility copier regarding a former employee of the facility. UA #1 was suspended pending administrative review effective 7/1/21. The DON stated Resident #27 had a friendship with the former employee and the former employee visited Resident #27 on occasion. The facility determined it was a conflict of interest, with the potential to put Resident #27 in an uncomfortable situation, if UA #1 were to question Resident #27 about the former employee. UA #1's employee timecard documented they worked 7/31/21 from 1:59 PM to 9:57 PM. The facility handwrote on the timecard Unit Attendant #1 was assigned to Unit 2 West on 7/31/21. An email dated 8/3/21 at 10:27 AM from the Environmental Services Operations Manager to the Acting Executive Director documented they reviewed the 7/31/21 video coverage of Unit 3 West and UA #1 entered the room of Resident #27 on 7/31/21 at the following times: In 3:20 PM Out 3:23 PM In 3:29:29 PM Out 3:29:37 PM In 3:36:49 PM Out 3:37:46 PM In 5:22:30 PM Out 5:33:03 PM In 5:38:43 PM Out 5:55:18 PM In 7:31:40 PM Out 7:32:50 PM In 7:39:10 PM Out 7:40:00 PM In 8:45:50 PM Out 8:46:20 PM The Office of the State Long Term Care Ombudsman Case Form dated 8/2/21, completed by the Ombudsman, documented the Ombudsman met with Resident #27 at 11:30 AM. Resident #27 stated UA #1 has been coming into their room on numerous occasions without cause. Resident #27 stated they were scared of UA #1 as the UA spoke of committing suicide and hurting someone. The Ombudsman documented Resident #27 was horrified, having nightmares, and has gone into a panic. Review of the interdisciplinary (IDT) notes for Resident #27 dated 7/22/21 through 8/6/21 revealed that on 8/3/21 Social Services documented they and the ombudsmen met with the resident to discuss and get clarification on a concern brought to the ombudsmen's attention. The situation was reported to the Acting Director, Director of Nursing (DON) and the Assistant DON. All was handled quickly and appropriately. There was no additional documented evidence in the resident's IDT notes regarding the incidents, the resident's concerns and fears. The facility investigation included an email dated 8/2/21 from the Director of Social Services that documented they and the Ombudsman met with Resident #27 at 1:30 PM on 8/2/21. Resident #27 stated they are horrified and scared of UA #1. UA #1 had entered their room, sat on their bed, and spoke to them of shooting people, taking a handful of pills, committing suicide, and an obsession with a fell ow employee's daughter. Resident #27 stated they asked UA #1 to leave their room several times without success and they are scared UA #1 would harm them. Additionally, Resident #27 stated they have become very anxious and panicky at night, asking staff to search room to ensure UA #1 was not in the room. The Behavioral Health progress note signed and dated 8/3/21, by the Psychologist documented Resident #27 and facility staff report anxiety and possible panic attacks in response to incidents that resulted because they reported risk factors of a facility employee. The facility Corrective Action Form dated 8/6/21 documented UA #1 was terminated for insubordination secondary to UA #1 was instructed by multiple leaders to not enter Resident #27's room due to an ongoing investigation. UA #1 was observed on video to enter the room of Resident #27 multiple times on 7/31/21. Not following the instructions given by leadership was insubordinate behavior. Entering the room of Resident #27 while an investigation was being completed also created an uncomfortable situation for Resident #27. During an observation and interview of Resident #27 on 11/16/22 at 10:33 AM, the resident was hesitant (slow to answer questions regarding incident with UA #1) and anxious (looking down, not maintaining eye contact) when speaking about UA #1. Resident #27 stated UA #1 stated they were going to shoot up the whole building, but not me. The resident stated they were scared UA #1 was going to harm them, had nightmares, and was unable to sleep because they visualized UA #1 in their sleep. I had staff check my room and under the bed to make sure the UA wasn't in the room, it had me really scared. Additionally, Resident #27 stated they reported UA #1 to the Ombudsman because they would not be able to live with themselves if they did not report, and someone got hurt. During interviews on 11/21/22 at 12:46 PM, the DON stated they had a discussion with UA #1 on 7/21/21 regarding the restriction of UA #1 to enter the room of Resident #27, and UA #1 had a clear understanding of the restriction by signing the facility Care Directive. The DON stated staff were aware of UA #1's restriction from entering the room of Resident #27. The DON stated they considered UA #1's actions caused Resident #27 psychological harm by causing nightmares and the resident to be scared. During a telephone interview on 11/21/21 at 11:20 AM, Licensed Practical Nurse (LPN) #1, Unit Manager at time of incident, stated Resident #27 was extremely afraid of UA #1, and did not want them to enter their room. Additionally, LPN #1 stated the nurses on the floor were aware of UA #1's restriction from entering Resident #27's room. During an interview on 11/22/22 at 8:37 AM, the DON stated the Nursing Supervisors and floor staff were aware of UA #1's restriction from entering Resident #27's room and were expected to provide oversight for UA #1. The DON stated staff did not witness UA #1 enter the room of Resident #27 on 7/31/21. The facility reviewed video coverage of the unit revealing UA #1 entered the unit via a back staircase on multiple occasions and entered Resident #27's room. During an interview on 11/22/22 at 10:07 AM, the Ombudsman stated they met with Resident #27 on 8/2/21 related to the concerns (fear and nightmares) the resident had with UA #1. The resident requested to see the Psychologist for fears of retaliation secondary to reporting the incident. During an interview on 11/22/22 at 11:05 AM, the Psychologist stated they were hesitant to answer questions secondary to confidentiality, however stated they got a 3rd party report from Resident #27 about UA #1 coming into their room and spoke to them about harming themselves. The Psychologist stated Resident #27 had expressed these concerns regarding UA #1 prior to 8/2/21 as well. The Psychologist stated they urged the resident to report the concerns to the facility. The Psychologist denied having any awareness regarding shooting others. Additionally, the Psychologist stated the incident caused the resident definite emotional stress. Attempts to interview UA #1 via telephone on 11/23/22 were unsuccessful. 10 NYCRR 415.4(b)(1)(i)

Based on interviews and record review conducted during a Complaint Investigation (Complaint #NY00280511) completed during a Standard survey started on 11/16/22 and completed 11/23/22, the facility did not have evidence that all alleged violations of abuse or mistreatment were thoroughly investigated for one (Resident #27) of three residents reviewed. Specifically, there was a lack of statements/interviews with other residents that had the potential for victimization. The finding is: The facility policy and procedure (P&P) titled Abuse Investigation and Reporting, last revised 8/2020, documented all reports of resident abuse shall be thoroughly investigated by community management. The individual conducting the investigation will, at a minimum interview other residents to whom the accused employee provides care or services. Refer to F 600 Free from Abuse and Neglect- scope and severity (S/S) =G 1. Resident #27 had diagnoses including anxiety disorder, major depressive disorder, and chronic obstructive pulmonary disease (COPD). The Minimum Data Set (MDS - a resident assessment tool) dated 7/12/21 documented the resident was cognitively intact, exhibited no mood or behaviors, and resided on Unit 3 West. Review of facility Care Directive dated 7/21/21 and signed by Unit Attendant (UA) #1 and the Director of Nursing (DON) documented Unit Attendant #1 was restricted from Resident #27. UA #1's employee timecard documented they worked 7/31/21 from 1:59 PM to 9:57 PM. The facility handwrote on the timecard Unit Attendant #1 was assigned to Unit 2 West on 7/31/21. Environmental Services Operations Manager reviewed the video coverage from 7/31/21 of the Unit 3 West and documented that UA #1 entered the room of Resident #27 on 7/31/21 on 8 separate occasions. The Office of the State Long Term Care Ombudsman Case Form dated 8/2/21, completed by the Ombudsman, documented the Ombudsman met with Resident #27 at 11:30 AM. Resident #27 stated UA #1 has been coming into their room on numerous occasions without cause. Resident #27 stated they were scared of UA #1 as the UA spoke of committing suicide and hurting someone. The Ombudsman documented Resident #27 was horrified, having nightmares, and has gone into a panic. The facility investigation included an email from the Director of Social Services (at the time of the incident) dated 8/3/21 that documented one other resident interviewed. The resident interviewed stated UA #1 had entered their room, spoke to them, and made them worried because UA #1 seemed shaky and kind of off. During an interview on 11/21/22 at 7:44 AM the DON stated, there was no additional documentation other than what was in the resident's medical record and what had already been provided. During an interview on 11/21/22 at 12:04 PM, the Social Worker (SW) stated they were responsible for interviewing residents during the investigation of the incident reported on 8/2/21. The SW stated they interviewed Resident #27 and one other resident because the UA #1 had been terminated. During an interview on 11/22/22 at 8:59 AM, the DON stated the Social Worker was responsible to obtain resident interviews and they (DON) were not involved in the investigation. The facility investigation included the one other resident interview, and no other residents were interviewed during the investigation 415.4(b)(3)

Based on observation, interview, and record review conducted during a Standard survey started on 11/16/22 and completed on 11/23/22, the facility did not ensure the resident environment remains as free from accident hazards as possible and that each resident receives adequate supervision and assistance devices to prevent accidents for one (Resident #104) of four residents reviewed. Specifically, Resident #104 was transferred and ambulated without the use of a gait belt (assistance safety device) as planned. The finding is: Review of the facility policy and procedure titled Safe Lifting and Moving of Patients revised date 12/2019 included the following: In order to protect the safety and well-being of associates (employees) and residents, and promote quality care, this community uses appropriate techniques and devices to lift and move residents. Associates responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. Review of an undated facility form, titled, Gait Belt Procedures identified by the Therapy Department Director as the current procedure to follow for residents requiring contact guard, limited assist, or extensive assist with transfers and/or ambulation. The form documented resident care providers will use gait belts when ambulating or transferring residents who are unsafe to ambulate /transfer independently. Support at the waist allows the resident to use their arms to help themselves to the extent possible while walking or transferring. 1. Resident #104 has diagnoses which include Alzheimer's disease, unsteady on feet and repeated falls. The Minimum Data Set (MDS - a resident assessment tool) dated 7/29/22 documented Resident #104 was severely cognitively impaired, required extensive assistance of one person to transfer and ambulation. The facility comprehensive Care Plan, identified by the Director of Nursing (DON) as current dated 5/19/22 and 5/25/22 documented Resident #104 required extensive assistance of 1 person with a rolling walker for transfers and ambulation. The Physical Therapy Plan of Care dated 10/12/22 documented Resident #104 required maximum assist of one with rolling walker for transfers and ambulation. An undated education power point slide identified as current by the DON documented, Gait Belts: to be used with all residents requiring contact guard, limited and extensive assistance, stored on the back of each resident's door. During an observation on 11/22/2 at 9:34 AM Certified Nursing Assistant (CNA) # 1 transferred Resident #104 out of bed to a standing position to the rolling walker without a gait belt. While walking Resident # 104 to the bathroom, CNA #1 guided the walker and held onto the resident's right arm in the axilla (armpit) area. Resident #104 shuffled their feet and had an unsteady gait. When CNA #1 guided the resident to sit onto the toilet, the resident's feet slid forward with their legs straight causing the resident to be lowered and sat on the front edge of the toilet in an unsafe position. CNA #1 boosted the resident back onto the toilet seat by grasping the resident under their arms. During an interview on 11/22/22 at 10:04 AM, CNA #1 stated it's the facility's policy to use a gait belt for any resident that requires limited or extensive assistance with transfers. CNA #1 stated Resident #104 was an extensive assist with ambulation and transfers. The CNA stated they should have used a gait belt for the resident's safety. Gait belts were supposed to be stored on the back of the resident's bedroom door, but there was not one there, so they should have retrieved one prior to transferring the resident out of bed. During an interview on 11/22/22 at 1:31 PM, Licensed Practical Nurse (LPN) Unit Manager (UM) #2 stated Resident #104 required extensive assistance of one staff member for transfers and ambulation. The staff were required to use a gait belt for resident's safety to ensure they have a grasp on the resident to provide guidance without pulling on resident's extremities. During an interview on 11/22/22 at 1:42 PM, the Therapy Department Director stated staff were expected to use gait belts for any resident requiring limited to extensive assistance with transfers or ambulation for the resident's safety to provide something for the staff to hold onto for stability. During an interview on 11/23/22 at 10:01 AM, the DON stated CNA #1 should have applied a gait belt to Resident #104 as required for a safe transfer and ambulation. The DON stated the gait belt provides something for the staff member to hold onto and provides more stability to the resident. 415.12 (h)(2)

Based on interview and record review conducted during the Standard Survey completed on 1/10/2020 the facility did not ensure the pharmacist reported any irregularities to the attending physician and the facilities Medical Director and Director of Nursing (DON). Specifically, one (Resident #132) of seven resident's residents reviewed for drug regimen reviews had issues involving the lack of Consultant Pharmacist's identification of duplicate therapy of antipsychotic medication, specifically [MEDICATION NAME] and [MEDICATION NAME] for two months. The finding is: The policy and procedure titled Pharmacy Services- Role of the Pharmacy Consultant dated 4/2018 documented the pharmacy consultant determines that drug records are in order and reconciled through a Medication Regime Review (MMR). If any irregularity is noted during the MMR, the pharmacist is required to notify the attending physician, DON and medical director. The MMR will be conducted monthly, irregularities include, but not limited to, the use of any drug that meets the criteria for an unnecessary drug. 1. Resident #132 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- a resident assessment tool) dated 5/30/19 documented the resident had severe cognitive impairment, received antipsychotic medication on a routine basis, and had no behavioral symptoms. The Care Plan dated 12/18 documented Behavior Problem resident is pleasant, calls out at times and can scratch and dig in skin without reason at times. The plan included to monitor for changes in mood/behavior; offer reminders and re-direct prn (as needed). The Care Plan documented on 4/18 [MEDICAL CONDITION] drug use with the potential for drug related complications associated with use of [MEDICAL CONDITION] medications. The Care Plan documented medications utilized to address concerns over picking skin. physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. The Consultation Report dated 6/14/19 revealed a pharmacy recommendation to switch the medication [MEDICATION NAME][MEDICATION NAME] ([MEDICATION NAME]) 25 mg (milligrams) every 12 hours for itching to [MEDICATION NAME]. There were no other irregularities identified. The Consultation Report dated 7/19/19 revealed a pharmacy recommendation but did not include any irregularities related to the duplicative drug therapy of [MEDICATION NAME] and [MEDICATION NAME]. The Consultation Report dated 8/26/19 documented the resident was receiving two antipsychotics: [MEDICATION NAME] and [MEDICATION NAME]. Consider a gradual dose reduction GDR of [MEDICATION NAME]. The rationale documented was due to the risk for drug interactions and cumulative side effects, uncontrollable falls are increased in the presence of duplicate antipsychotic therapy. During interview on 1/9/20 at 10:53 AM, the Consultant Pharmacist stated he had no concern with utilizing two antipsychotic medications simultaneously. The [MEDICATION NAME] and [MEDICATION NAME] were utilized for symptoms related to dementia, combative with care, in addition Psychogenic itch (an excessive impulse to scratch, gouge or pick at skin). Picking at scabs until they bleed is harmful. The Consultant Pharmacist then stated the itching had settled down in August, therefore recommended a gradual dose reduction (GDR) of [MEDICATION NAME]. During interview on 1/10/2020 at 1:57 PM, the Director of Nurses (DON) stated the medical record and physician's orders [REDACTED]. Irregularities are expected to be identified and reported to the DON and the physician. There were no irregularities were reported until (MONTH) and should have been identified sooner. 415.18(c)(2)

Based on observation, interview and record review conducted during the Standard survey completed on 1/10/20 the facility did not ensure that a resident's drug regimen was free from unnecessary [MEDICAL CONDITION] medications for two (Resident #132, 149) of seven residents reviewed for unnecessary medications. Specifically, the lack of a documented [DIAGNOSES REDACTED].#132). Additionally, the lack of adequate indications to justify the initiation and continued use of [MEDICATION NAME] antipsychotic medication (#149). The facility policy titled [MEDICAL CONDITION] Medication dated 9/2018 documented medications shall generally be used only for the following Diagnoses: [REDACTED]. in addition in addition to the following conditions: behavioral symptoms present a danger to the resident/others and symptoms are due [MEDICAL CONDITIONS] or behavioral interventions have been attempted and included in the plan of care. [MEDICAL CONDITION] medications will not be used if the only symptoms are one or more of the following: wandering, restlessness, mild anxiety, [MEDICAL CONDITION], fidgeting, nervousness, or uncooperativeness. Nursing shall monitor and report the following side effects and adverse consequences of antipsychotic medications to the health care practitioner. 1. Resident #132 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- a resident assessment tool) dated 5/30/19 documented the resident had severe cognitive impairment, received antipsychotic medication on a routine basis, and had no behavioral symptoms. The Care Plan dated 12/18 documented Behavior Problem resident is pleasant, calls out at times and can scratch and dig in skin without reason at times. The plan included to monitor for changes in mood/behavior; offer reminders and re-direct prn (as needed). The Care Plan documented on 4/18: [MEDICAL CONDITION] drug use with the potential for drug related complications associated with use of [MEDICAL CONDITION] medications. The Care Plan documented medications utilized to address concerns over picking skin. There were no non-pharmacological interventions were included on the Care Plan. Further review of the Care Plan dated 4/18 revealed High risk for pressure injury and other skin related injuries related to medications, decreased mobility, and history of wounds. There were no documented non-pharmacological interventions implemented to prevent digging and picking of the skin. physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Additionally, Behavior Monitoring for Antipsychotics dated 5/1/19 through 5/15/19 revealed there was no documented evidence of behaviors. Review of Interdisciplinary Notes dated 5/1/19 through 5/15/19 revealed there was no documented evidence of behaviors. Review of a Physician's Progress Note dated 5/15/19 documented the resident had issues lately with picking on her skin, most recently on the face. Resident #132 picked their skin on the left cheek and it started bleeding. The resident was started on [MEDICATION NAME] since there is some [MEDICATION NAME] effect and is on [MEDICATION NAME]. One of these medications can be discontinued depending on the response moving forward. Review of a Gradual Dose Reduction (GDR) signed 5/31/19 revealed a failed GDR of [MEDICATION NAME] 3/14/19 and the resident continued to pick at skin causing open sores. Condition after failed treatment attempts appear behavioral, calling out has increased. [MEDICATION NAME] 12.5 mg started 5/15/19. Further review of the Physician's Progress Notes dated 7/25/19 documented overall clinically stable with dementia with behaviors and will continue [MEDICATION NAME] twice daily as well as [MEDICATION NAME], no dose reduction will be performed at this time. Further review of the physician progress notes [REDACTED]. There will be no dose reduction at this time as the patient has an issue with scratching and [MEDICATION NAME] seems to have helped this behavior. During interview on 1/8/20 at 1:36 PM, Licensed Practical Nurse (LPN) #1 stated the resident's behaviors included picking at scabs until they bleed, then would occasionally ingest (eat) the scab. During interview on 1/8/20 at 1:43 PM, Certified Nurse Aide (CNA) #3 stated the resident's behaviors included picking at the scabs on their skin and was unaware of non-pharmacological interventions provided. The nurses applied cream to the face. During interview on 1/8/20 at 1:46 PM, Registered Nurse (RN) #2 stated the resident's behaviors included picking at their skin. The physician prescribed medicated cream to the face, but it was ineffective. It's not like we could use mitts, as this would be restraining. A dermatology consult was done on 11/20/19. Non pharmacological interventions included 1:1 and redirection but these were ineffective due to the dementia and should have been addressed on the comprehensive care plan. RN #2 stated she did not know the reasoning unsure for the delay in the dermatology consult. Report of Consultation dated 11/20/19 documented Neurologic Pruritus, on multiple medications affecting neurotransmitters and recommended [MEDICATION NAME] (nerve pain medication). During an interview on 1/9/20 at 8:26 AM, LPN #2 stated behaviors included tongue rolling, picking at scabs, Sometimes until they bleed. In addition, LPN #2 stated the resident would occasionally call out, but typically was very pleasant. LPN #2 stated resident #132 did not know why they were scratching and picking at their skin. During an interview on 1/9/20 at 1:11 PM, the Director of Nurses (DON) stated she was told by the family the resident had a history of [REDACTED]. During an interview on 1/9/20 at 10:53 AM, the Consultant Pharmacist stated he had no concern with utilizing two antipsychotic medications simultaneously. The [MEDICATION NAME] and [MEDICATION NAME] were utilized for symptoms related to dementia, combative with care, in addition Psychogenic itch which was detrimental and harmful to Resident #132. Picking at scabs until they bleed is harmful. The Consultant Pharmacist then stated the itching had settled down in August, therefore recommending a gradual dose reduction (GDR) of [MEDICATION NAME]. During an interview on 1/9/20 at 10:12 AM, the Medical Director stated the [MEDICATION NAME] and [MEDICATION NAME] were utilized for dementia with agitation, Meaning having delusions and neurological [MEDICAL CONDITION], self-harming as they were scratching until they bled. The intention was to reduce the antipsychotics. Additionally, the Medical Director stated the Effect of the [MEDICATION NAME] acts as a [MEDICATION NAME] receptor blocker. During an observation and interview on 1/10/20 at 8:58 AM, CNA #1 & CNA #2 repositioned the resident in bed. There were no behaviors present. CNA #1 stated the resident's behaviors included picking skin and eating the scabs, but typically they were pleasant. During an interview on 1/10/20 at 10:05 AM, the Social Worker stated the resident's behaviors included digging and scratching of the skin and felt that Resident #132 was distressed. The Social Worker then stated 1:1 and redirection had been provided but ineffective. The Social Worker further stated, Family stated this behavior had started prior to admission. The Social Worker stated non-pharmacological interventions are expected to be addressed on the care plan and were not. During an interview on 1/10/20 at 1:39 PM the DON stated, Scratching of the skin and picking scabs until they bleed can be detrimental to one's health. The DON stated she was aware of indications for use of antipsychotic medications and considered anxiety related to the dementia caused the scratching and compulsive behavior. The DON further stated between the medication changes, We tried to keep them busy. Involved activities, attempted cream to the face, but would expect documented non-pharmacological interventions prior to the [MEDICATION NAME]. Initially an allergic reaction couldn't be ruled out, this was not the case, it was much worse. 2. Resident #149 was admitted with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident was severely cognitively impaired, usually understood and sometimes understands. Section E: documented there were no behaviors. Section N: documented the resident received antipsychotic medications on a routine basis. Review of Interdisciplinary Notes dated 5/10/19 through 5/31/19 revealed the personal care aide reported on 5/18/19 the resident was being combative and attempting to ambulate stating, I have to go to work and the baby was outside the window. Patient resistive to redirection and a one-time dose of [MEDICATION NAME] (anti-anxiety medication) 0.5 mg (milligrams) was ordered. There were no further behaviors reported. Review of the Physician's Progress Notes dated 5/19/19 documented dementia with behaviors and was clinically stable. Review of an Interdisciplinary Note (IDT) dated 5/29/19 documented the resident was transferred to another unit for long term care and the resident was oriented to room and surroundings. The Care Plan documented Potential for Falls related to noncompliance and change in environment. The Care Plan further documented Behavior Problem dated 5/31/19 the resident is over all pleasant and can become verbally aggressive and anxious at times. Planned interventions included allow resident to express concerns, monitor for changes in mood and 1:1 visits. An Interdisciplinary Note dated 6/1/19 documented the resident had a witnessed fall on the floor and a urine culture and sensitivity (C&S) was sent to the lab. On 6/2/19 the resident refused to stay in bed, in a wheel chair wandering the unit, trying to leave unit, looking for her daughter, attempting to self-transfer, stating they wanted to go home to spouse and go grocery shopping. 1:1 redirection provided but ineffective. The Medical Director was notified of the resident not sleeping well at night and an order was obtained for [MEDICATION NAME] 25 mg daily and monitor for behavior changes. Review of a physician's orders [REDACTED]. Review of a final Microbiology (urine culture and sensitivity) report dated 6/3/19 revealed 50,000 - 99,999 cfu/ml (colony forming unit/milliliter) (normal - no growth) Staphylococcus aureus, positive [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus, infection caused by a type of staph bacteria that's become resistant to many of the antibiotics) Further review of the physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Bactrim DS 800 mg-160 mg daily starting 6/3/19 through 6/7/19 for a urinary tract infection. Report of Consultation Psych dated 6/28/19 documented the patient was not sleeping and getting anxious. Patient with mild side effects of [MEDICATION NAME], shaking a lot, will hold off on increasing [MEDICATION NAME]. Review of a Gradual Dose Reduction (GDR) form dated 6/26/19 documented [MEDICATION NAME] 25 mg daily for dementia with anxiety and behavior. The [MEDICATION NAME] was started 6/2/19 and increased to [MEDICATION NAME] 50 mg daily on 6/23/19. Additionally, documented the resident was restless at times, wanders and increased anxiety looking for spouse. The resident is redirected with little effect and likes to color. Review of a Gradual Dose Reduction (GDR) form dated 12/18/ 19 documented [MEDICATION NAME] 50 mg for dementia with anxiety and behaviors. Further comments documented included the resident remains pleasant on current therapy. Sleep patterns fluctuate, poor safety awareness and attempts to self ambulates, less anxiety and resident is cooperative with no verbal aggression. Further review of the MAR's dated 6/23/19 to 1/9/20 revealed the resident was still receiving [MEDICATION NAME] at 50 mg daily. During intermittent observations on 1/8/20 at 9:10 AM revealed the resident was eating breakfast in the dining area and was pleasant and calm. On 1/9/20 at 8:46 AM the resident was coloring in the common area and there were no behaviors observed. During an interview on 1/8/20 at 1:58 PM, Licensed practical Nurse (LPN) #1 stated the resident's behaviors included self-transferring. The resident never sits still and is always attempting to stand out of the wheel chair. During interview on 1/9/20 at 8:35 AM, LPN#2 stated the resident's behaviors were self-transferring and toe tapping. That's how I can tell when the resident is anxious. LPN #2 then stated the resident was past employed as a food court worker at a mall and cleaned off tables. They need to keep busy, offering to help. The resident will fold towels and color that seems to help. During interview on 1/9/20 at 9:07 AM, Registered Nurse (RN) #2 stated the resident believed they could still ambulate and that was not the case. Behaviors included self- transferring and picking objects up off the floor. The RN could not recall any additional behaviors. The [MEDICATION NAME] was started on 6/2/19 initially for anxiety more so than aggression. RN#2 stated she did not take into consideration the change in the resident's environment, or the urinary tract infection. The RN was unsure if there could have been a correlation to the positive urine culture. During interview on 1/9/20 at 10:35 AM, CNA #3 stated the resident constantly wanted to get out of the chair and wanted to be busy. During interview on 1/9/20 at 11:06 AM, the Consultant Pharmacist stated the [MEDICATION NAME] was indicated for dementia with increased anxiety. Self-transferring is not an indication for the use of the [MEDICATION NAME]. In this case self-transferring posed a risk to increased falls which was potentially harmful to the resident justifying the use. The Consultant Pharmacist further stated, starting [MEDICATION NAME] on 6/2 and Bactrim DS on 6/3 was appropriate because the medical director treated the symptoms of the urinary tract infection and the anxiety caused daily distress. During interview on 1/9/20 at 2:05 PM, the Medical Director stated the [MEDICATION NAME] was given for behaviors with agitation and depression. The resident must have been symptomatic with a UTI on 6/3 which was treated but he could not recall the symptoms. There is no reason the [MEDICATION NAME] and the Bactrim DS could not be given simultaneously. During interview on 1/10/20 at 1:57 PM, the Director of Nurses (DON) stated she was aware the [MEDICATION NAME] and the Bactrim DS were initiated a day apart; the resident was obviously symptomatic requiring treatment in addition to anxiety and believed to have affected their quality of life. The physician would not order both medications if they were not necessary. The DON stated Resident #149 behaviors included anxiety, [MEDICAL CONDITION], and self-transferring and has a known improvement with the [MEDICATION NAME] and would expect documentation to justify an adequate indication for the [MEDICATION NAME]. Anxiety, [MEDICAL CONDITION], or self-transferring are not appropriate indication for the [MEDICATION NAME]. 415.12 (l)(2)

Based on observation, interview, and record review conducted during a Standard survey completed on 1/10/20, the facility did not ensure that each resident received adequate supervision and assistive devices to prevent accidents for one (Resident #209) of nine residents reviewed for accidents. Specifically, a resident on aspiration precautions and care planned for small bites and sips, alternate solids with liquids, encourage to eat slow, supervision assistance with eating, and one person staff support was not adequately supervised during meals and was observed to cough several times during the breakfast meal on 1/9/20. The findings are: Review of the policy titled Aspiration Precautions last revised 1/2020 revealed under General Guidelines: Consult speech therapist for patients with dysphagia, as needed and as ordered by healthcare provider; Monitor resident when eating/ drinking: follow speech pathology recommendations from swallow assessment and consult when there are changes. Review of Minimum Data Set (MDS, a resident assessment tool) dated 10/ 2019 provided by facility revealed Section G: Functional Status defines Supervision as oversight, encouragement or cueing. Review of ADL (activities of daily living) Crosswalk guide dated 02/2015 provided by facility revealed Supervision- oversight, encouragement or cueing. 1. Resident #209 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated 12/18/19 documented the resident had severe cognitive impairment, is usually understood and sometimes understands. Section K: Swallowing/ Nutritional Status documented resident is holding food in mouth/ cheeks or residual food in mouth after meals and coughing or choking during meals or when swallowing medications. Review of the Care Plan printed 1/9/2020 revealed the following approaches: - 5/31/19 Aspiration Precautions: eat upright during and for 30-90 minutes after meal, elevate HOB (head of bed) 30-45 degrees AAT (at all times) except T&P (turning and positioning). - 7/3/19 I need to take small bites and sips and alternate solids and liquids for swallow safety. - 10/30/19 I need supervision assistance with eating. I need 1 person staff support with eating. Encourage to eat slow. Provide scoop plate for all meals. During an observation on 1/9/20 during the breakfast meal the following was observed: 9:10 AM- Resident was given his food for the meal. Resident's wife cut up his banana and placed on his plate with the eggs and toast. The resident began to eat immediately. 9:15 AM- Resident was given his drinks (nectar thick prune juice and milk) for the meal. Resident at that time did not drink his liquids. 9:15 AM to 9:26 AM Resident continue to feed himself his solids. Resident did not drink any of his liquids. No staff came over to encourage him to alternate his solids or liquids or to eat slowly. By this time resident finished at least 50% of his solids and none of his liquids. 9:26 AM- Resident began to cough. The DON (Director of Nursing) walked over to the resident's table and checked on the resident. At 9:27 AM she left the table. 9:27 AM to 9:29 AM- Resident continued to eat, there was no staff intervention. 9:29 AM- Resident began to cough again with no staff intervention. 9:29 AM to 9:49 AM- Resident continued to eat his breakfast food. Resident did not drink any liquids in this timeframe. There was no staff intervention. At 9:48 AM a staff member did sit at the table across form the resident, assisting another resident with their meal. This staff member did not intervene with Resident #209. 9:49 AM- Resident began to cough, there was no staff intervention. Resident took a drink of liquid. 9:50 AM- Resident began to cough again, there was no staff intervention. 9:51 AM- Resident began to cough again with no staff intervention. 9:51 to 9:55 AM Resident drank the rest of his prune juice and then his milk. Review of meal ticket for Breakfast dated Thurday [DATE]/20 revealed Alerts: Aspiration Precautions, No straws, Slow Feeding, Supervision. Review of physician's orders [REDACTED]. Review of a Nurse Practitioner Routine Visit Note dated 12/9/19 documented under Assessment: [DIAGNOSES REDACTED]. No straws. Aspiration precautions. Review of Modified [MEDICATION NAME] Swallow Study dated 9/24/18 revealed moderate oropharyngeal with aspiration and penetration present. Silent aspiration of thin liquid present along with penetration of pharyngeal stasis deemed due to premature spillage of material during lengthy mastication (chewing) of regular solids. Patient had decreased aspiration and penetration with soft solids (enhanced puree) with nectar thick liquid while utilizing small bites/ sips and double swallow. Plan of care: recommend continue enhanced puree diet with nectar thick liquids, encourage small bites/ sips, double swallow and slow rate with all consistencies to assist with clearing potential oral and pharyngeal stasis, Aspiration precautions, recommend patient be followed by speech therapy. Review of Speech Therapy Progress note dated 6/28/19 revealed swallow assessment completed due to referral from nursing wife concern with coughing. Resident with intermittent coughing with and without by mouth intake. Presents with mild to moderate oropharyngeal dysphagia. At this time recommend continue dysphagia mechanically altered solids, nectar thick liquids, ok toast with no crust, ok banana cut up by staff, ok fried egg, no straws, aspiration precautions, and slow eating rate. During an interview on 1/9/20 at 10:33 AM, the Speech Language Pathologist (SLP) stated the resident was on a dysphagia mechanically altered diet, nectar thick liquid consistency. He should be taking small bites and alternating solids and liquids. When alternating solid and liquids it doesn't mean after every bite, he needs to drink something. He could take a few bites and then a sip of liquids. He is supervision with his meals, which means he should be getting more cueing and reminders. Staff should be visually watching him and if he continues to just eat the solids they should intervene and encourage him to drink some liquids. Supervision is keeping a visual eye on him and not to be left alone during meals. I would expect staff to be doing this. His cough is a constant dry cough, he coughs all the time. He has had 2-3 modified [MEDICATION NAME] swallows and I will not change his diet consistency until he was to have another [MEDICATION NAME] swallow. During an interview on 1/9/20 at 10:45 AM, The Director of Rehab and Assistant Director of Rehab stated he is supervision with meals. Supervision means he doesn't have to have someone sitting with him, but as staff circulates the room, they are to give him occasional cues. They should be keeping a general eye on him and doing the cues as needed, such as telling him to drink his liquids after a few bites of solids. 'We would expect staff to be in the dining visually watching him. I do not expect dietary staff to be intervening and giving him the verbal cues as they are not trained for this. During an interview on 1/9/20 at 1:29 PM Registered Nurse (RN #1) Unit Manager, stated the resident is supervision with meals. Supervision is when staff would be watching him. They should go over and encourage him to take sips, but he sometimes will refuse. This morning was unusual as we did not get him up till late. He normally is a night get up, but we had a call in, so he was gotten up later than normal. That is why he was the only one eating in the dining. He coughs all the time and he has never had aspiration pneumonia. I understand though that his care plan was not followed, and we should have been going over and encouraging him and checking on him when he was coughing. The resident can feed himself, he doesn't need help. During an interview on 1/10/20 at 10:13 AM, the DON (Director of Nursing) stated this resident coughs all the time. We just recently had the verbiage changed on the care plan, so no staff member needs to be sitting next to him. The resident himself will refuse help. I did go in there and assist him, and there were other staff members near the dining area. 415.12(h)(2)

Based on observation, interview and record review conducted during the Standard survey completed on 12/12/18, the facility did not ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing for one (Resident #105) of three residents reviewed for pressure ulcers. Specifically, the pressure ulcer treatment was not completed as planned. Additionally, the physician's orders [REDACTED]. The finding is: 1. Resident #105 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Minimum Data Set (MDS- a resident assessment tool) dated 12/3/18 documented the resident was cognitively intake, understood, understands and had an unstageable pressure ulcer upon admission with slough and or/ eschar (dead tissue). The facility policy and procedure entitled Wound Care/ Dressing Change dated 12/2017 documented the purpose of the procedure was to provide guidelines for dressing changes of wounds to promote healing. Additionally, review and verify physician's orders [REDACTED]. Care Plan dated 11/26/18 documented the resident had an unstageable pressure injury of the right gluteal fold/ ischium (lower part of hip bone) with interventions to complete treatments as indicated, and to see the physician order [REDACTED]. Skin assessment sheet dated 12/10/18 documented an unstageable full thickness pressure injury to the right gluteal fold that measured 4 centimeters (cm) in length x 1.5 cm in width x 1 cm in depth. Slough tissue present with bloody sanguineous (mixture of serum and blood) drainage. Treatment plan for Santyl (sterile ointment to remove dead skin tissue) and a dry clean dressing. physician's orders [REDACTED]. Opti foam to sacral slit (indentation/ intact skin) topically two times a week for [MEDICATION NAME]. During an observation of pressure ulcer care on 12/11/18 at 8:47 AM, Registered Nurse (RN) #2 was assisted by Licensed Practical Nurse (LPN) #2. The resident was rolled onto her left side toward LPN #2 who reached over the resident and removed two dressings. The sacral foam dressing was loose and had no drainage. The right gluteal foam dressing was removed and had a large amount of serous (pale yellow, transparent body fluid) drainage. The right gluteal pressure ulcer was open, the sides of the ulcer were red and moist, the base was unable to be visualized. RN #2 cleansed the sacral slit area with wound cleanser, applied Skin Prep to the peri wound, applied Santyl to the sacral slit area and covered the area with a foam adhesive dressing. RN #2 then cleansed the right gluteal unstageable ulcer with wound cleanser, and began to apply an adhesive foam dressing (without Santyl) over the pressure ulcer. At this time the surveyor asked the nurse to stop and verify the treatments. LPN #2 left the room to obtain additional supplies and the treatments were completed as planned by RN #2. During an interview on 12/11/18 at 9:07 AM, LPN #2 stated the treatment was done incorrectly. Santyl should have been applied to the right gluteal ulcer not the sacral area. During an interview on 12/11/18 at 9:12 AM, RN #2 stated she had never completed this resident's treatment before. Normally, she would check the computer to review the order prior to completing the treatment, but today she did not. RN #2 further stated she should have applied Santyl to the right gluteal ulcer, not the sacral slit. During an interview on 12/11/18 at 9:39 AM, RN #3 (covering the unit) stated RN #2 should have checked and /or clarified the order prior to doing the treatment. During an interview on 12/11/18 at 3:43 PM, the Director of Nursing stated the nurse should have checked and /or clarified the order prior to doing the treatment. 415.12 (c)(2)

Based on observation, interview, and record review conducted during the Standard survey completed on 12/12/18, the facility did not ensure that a resident, with an indwelling catheter (Foley - tube inserted into the bladder to drain urine), received the appropriate care and services to prevent urinary tract infections (UTI's) to the extent possible. Specifically, one (Resident #219) of two residents reviewed for urinary catheter had issues that involved improper handling of the urinary catheter tubing and urinary collection bag. The finding is: 1. Resident #219 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Minimum Data Set (MDS - a resident assessment tool) dated 11/20/18 documented the resident has severe cognitive impairment and has an indwelling urinary catheter. The facility policy and procedure entitled Catheter Care, Urinary revised 12/2017 included the following: The purpose of this procedure is to prevent catheter-associated UTI's. Be sure the catheter tubing and drainage (collection) bag are kept off the floor. The Medication Record For 8/2018 included the following: - [MEDICATION NAME] (antibiotic) 500 mg (milligram) tablet every eight hours x five days for UTI signed as given on 8/14/18, 8/15/18, and 8/16/18. - [MEDICATION NAME] (antibiotic) 600 mg tablet every 12 hours x five days for UTI [MEDICAL CONDITION] ([MEDICAL CONDITION] - an antibiotic resistant bacteria) and VRE ([MEDICATION NAME] resistant [MEDICATION NAME] - an antibiotic resistant bacteria) in urine signed as given on 8/17/18, 8/18/18, 8/19/18, 8/20/18, and 8/21/18. The Medication Record For 9/2018 included [MEDICATION NAME] (antibiotic) 200 mg tablet every 12 hours for UTI signed as given on 9/21/18, 9/22/18, 9/23/18, 9/24/18, and 9/25/18. Intermittent resident observations revealed the following: - 12/6/18 at 11:07 AM resident in front of the nurse's station seated in a wheelchair (w/c) with the catheter tubing touching the floor. 11:17 AM resident at a table in the unit dining room in a w/c with the catheter tubing touching the floor. 11:48 AM resident in the dining room seated in a w/c at a table moving the w/c back and forth with the catheter tubing touching the floor and the left front wheel of the w/c. - 12/11/18 8:01 AM resident in the dining room seated in the w/c at a table with the catheter tubing touching the floor. During an observation of care on 12/11/18 at 9:42 AM, Certified Nurse Aide (CNA) #1 removed the urinary collection bag from the privacy bag attached to the lower rear of the w/c; she placed the urinary collection bag with attached tubing onto the floor then pushed the urinary collection bag and tubing on the floor to the front of the w/c. During an interview on 12/11/18 at 9:49 AM, CNA #1 stated, I try to make sure it (the tubing) doesn't tug, I took it (collection bag and tubing) out of the privacy bag and slid it (collection bag and tubing) under the chair. It's odd the privacy bag is in the back of the w/c and not the front. During an interview on 12/11/18 at 9:53 AM, CNA #2 stated, The bag and tubing should never touch the floor. It's infection control, anything could happen. During an interview on 12/11/18 at 9:53 AM, Licensed Practical Nurse (LPN) #1 stated, If the tubing or bag touches the ground it's contaminated and we would have to get a whole new bag and tubing. During an interview on 12/11/18 at 9:55 AM, the Registered Nurse (RN) Assistant Director of Nursing stated, We don't want the tubing to drag on the floor for infection control reasons and it could pull the catheter out. During an interview on 12/12/18 at 7:35 AM, the RN Director of Nursing stated, I would not slide the bag and tubing on the floor because of infection control. 415.12(d)(1)

Based on observation, interview, and record review conducted during the Standard survey completed on 12/12/18 the facility did not ensure that a resident's drug regimen was free from unnecessary [MEDICAL CONDITION] medications for one (Resident #27) of five residents reviewed for usage of [MEDICAL CONDITION] medications. Specifically, the issue involved the lack of specific targeted behaviors and lack of documented evidence of behaviors to support the continued use of antipsychotic medication. The finding is: 1. Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Minimum Data Set (MDS- a resident assessment tool) dated 4/26/18, 7/19/18, and 9/11/18 documented the resident had severe cognitive impairment, received antipsychotic medication on a routine basis, had no behavioral symptoms, and no rejection of care. The facility policy entitled [MEDICAL CONDITION] Medication dated 9/2018 documented [MEDICAL CONDITION] medications shall generally be used only for the following [DIAGNOSES REDACTED]. in addition to the following conditions: behavioral symptoms present a danger to the resident/ others and symptoms are due [MEDICAL CONDITIONS] or behavioral interventions have been attempted and included in the plan of care. [MEDICAL CONDITION] medications will not be used if the only symptoms are one or more of the following: wandering, restlessness, mild anxiety, fidgeting, nervousness, or uncooperativeness. physician's orders [REDACTED]. The Care Plan documented mood state related to depression dated 4/20/18. There were no specific targeted behaviors documented related to mood. Behavior problem dated 12/6/18. There were no behaviors currently and the resident had a history of [REDACTED]. [MEDICAL CONDITION] drug use dated 4/27/18. There were no specific targeted behaviors documented for use of [MEDICAL CONDITION] medications. Gradual Dose Reduction (GDR) dated 11/7/18 documented a GDR was clinically contraindicated at that time as it may cause a decompensation of symptoms and pose a risk to the resident's well-being and quality of life. Comments documented the resident calls out and attempts to self-transfer at times and 1:1 (one on one support) given with some effect. During an observation of morning care on 12/10/18 at 11:00 AM the resident displayed no agitation or other behavioral problems. The resident was cooperative during care. Interdisciplinary Notes dated 7/1/18 through 12/10/18 documented a nurse's note dated 9/2/18 that the resident was calling out, attempting to self-ambulate, toileted, food given and 1:1 with little effect. Also, a Social Work (SW) note dated 9/17/18 documented that the resident continues to utilize [MEDICATION NAME] (medication used to improve resident's mental status) for dementia, [MEDICATION NAME] (antidepressant) for depression, and anxiety at this time. Resident calls out and attempts to self-transfer. 1:1 given with some effect. There was no other documentation of any resident behavioral symptoms. During an interview on 12/11/18 at 9:00 AM the Registered Nurse (RN) #1 Unit Manager revealed he did not know what the resident's [DIAGNOSES REDACTED]. The resident was reviewed for a GDR on 11/7/18 but it was contraindicated for her condition because she calls out and attempts to self-transfer at times. He did not know how often she did this because he has not seen these behaviors however, he would expect staff to document if the resident had these behaviors. He added, the Physician or Nurse Practitioner decide if a GDR is contraindicated and would base it on staff observations and documentation. During an interview on 12/11/18 at 9:48 AM, the SW stated, the resident had a history of [REDACTED]. When asked if these behaviors were a threat to the resident or others the SW stated, no. During an interview on 12/11/18 at 1:42 PM, the Physician stated the [DIAGNOSES REDACTED]. He tries to reduce resident's medication when he sees them, polypharmacy is a big issue and that a GDR would not be contraindicated for this resident. During a telephone interview on 12/12/18 at 8:55 AM, the Consultant Pharmacist stated, typically nursing homes use [MEDICAL CONDITION] medications for dementia with behavioral associated disorders but these medications are indicated for [MEDICAL CONDITION] and [MEDICAL CONDITION] disorders. Regardless of diagnosis, if used in a nursing home there has to be some behaviors causing distress to him/herself or causing danger to self or others. During an interview on 12/12/18 at 9:58 AM, the Director of Nursing (DON) when asked what the resident's targeted behaviors are stated, obviously the doctor thought the medication was warranted for her, we're not the prescribers. After review of the care plan the DON stated, she's care planned for depression and mood state so they would look for signs of depression, periods of anxiety and calling out at times. The DON added, her behaviors are not a threat to herself or others but we look for therapeutic effects on people, so they (residents) can enjoy the things in life. 415.12 (l)(2)

Based on observation, interview, and record review conducted during a Standard survey completed on 7/26/17, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. Two (Residents #271, 322) of six residents reviewed for unnecessary medications had issues involving the lack in attempt of a gradual dose reduction (GDR) of an antipsychotic medication; the lack of evidence of behavioral concerns and supporting documentation to support the continued use of the antipsychotic medication. The findings are: 1. Resident #322 was admitted [DATE] with diagnoses which include unspecified dementia with behavioral disturbances, diabetes, and dysphagia (difficulty swallowing). Review of the Minimum Data Set (MDS-a resident assessment tool) dated 5/9/17 revealed the resident is severely cognitively impaired. Review of the Care Plan with a start date of 10/13/16 revealed the resident has behaviors which include attempting to self-transfer and can become combative with care. Review of the Medication Administration Record [REDACTED]. The medication had a start date of 7/18/16 and an end date of 6/13/17. Additionally, there was an order for [REDACTED]. Review of Interdisciplinary Notes dated 1/2/17 through 6/12/17 lacked documentation of any behaviors to warrant the use of antipsychotic medications. Review of Daily Charting for behavioral symptoms dated 1/1/17 to 6/12/17 revealed there was no documentation of the resident having any behaviors. Review of a pharmacy recommendation dated 6/7/17 revealed the resident was receiving two antipsychotics but needs to have evidence in the chart of the following conditions exist: The symptoms being are identified as being due [MEDICAL CONDITIONS] (auditory/visual/other hallucinations, delusions), the behavior symptoms present a danger to the resident or others. The symptoms are significant enough that the resident is experiencing inconsolable/persistent distress, a significant decline in function or substantial difficulty receiving needed care. The Physician neither agreed or disagreed. He checked the other box with the following notation: [MEDICATION NAME] one mg PO (by mouth) continues at bedtime and discontinue [MEDICATION NAME] Bid. The recommendations were signed 6/12/17. Review of the MAR indicated [REDACTED]. During intermittent observation of the resident on 7/24/17 and 7/25/17 between approximately 10:05 AM and 12:30 PM revealed there were no verbal outbursts, no attempts to self-transfer, and no hitting. The resident was calm and pleasant. Review of Interdisciplinary Notes, 24 Hour Unit Reports, and Daily Charting for behavioral symptoms lacked dated 6/13/17 through 6/30/17 lacked documentation of the resident's response to the discontinuation of the [MEDICATION NAME]. Interview with Assistant Director of Nursing (ADON) on 7/24/17 at 11:45 PM revealed there were no other notes and confirmed when a GDR occurs staff should be monitoring and documenting resident behaviors for 10-14 days following the GDR. Interview with Director of Nursing (DON) on 7/25/17 at 11:25 AM revealed the resident was flagged for BMRC (Behavior Management Review Committee) because he had no [DIAGNOSES REDACTED]. Interview with the Consultant Pharmacist on 7/25/17 at 12:30 PM revealed there should have been a GDR sooner or documentation of contraindications for the GDR. There should also be documentation of the resident's behavior following the discontinuation of an antipsychotic medication. Review of a facility policy entitled Guidelines for Charting and Documentation dated 12/16 revealed the purpose of charting and documentation is to provide a complete account of the resident's care, treatment, response to the care, signs, symptoms and the progress of the resident's care. Review of a facility policy entitled Antipsychotic Medication with a revised date of 5/2017 revealed the physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risk to the resident and others. The attending physician will identify, evaluate and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications. 2. Resident # 271 was admitted to the facility on [DATE] with diagnoses of dementia, major [MEDICAL CONDITION], and hypertension (HTN). Review of the Minimum Data Set (MDS- resident assessment tool) dated 5/12/17 revealed the resident is severely cognitively impaired, sometimes understands and is sometimes understands. Section E - Behavior documented the resident exhibited hallucinations and delusions during the assessment look back period. Section N - Medications documented the resident received antipsychotic medication during the assessment look back period. Review of a physician order [REDACTED]. Review of a physician order [REDACTED]. Review of a current physician order [REDACTED]. Review of the Medication Administration Records (MAR) dated July 20, 2016 through July 25, 2017 revealed the resident was administered [MEDICATION NAME] 0.25 mg as ordered. Review of the Interdisciplinary Team (IDT) Notes dated 11/1/16 through 7/25/17 revealed there were no documented behavioral concerns. Review of the Physicians Progress notes dated 1/1/17 through 6/30/17 revealed there were no documented behavioral concerns or documentation to support the continued the use of [MEDICATION NAME]. Review of the Behavior Symptoms Resident Detail report dated 1/1/17 through 7/25/17 revealed there were no behavior symptoms documented, except one Yes response documented on 6/6/17. There was no additional information documented to describe the behavior. Review of the Certified Nurse Aide (CNA) Daily Charting dated 1/1/17 through 7/25/17 revealed no documented evidence that the resident exhibited any behavioral symptoms. Review of a Psychoactive Medication Evaluation form dated 7/14/17 reveled resident has delusions/ hallucinations at times, can become paranoid with staff at times and may refuse care. Resident seen by psychologist 2/18/16 for delusions/ paranoia. Additional review revealed a documented comment; IDT dis: 7/19/16 no adverse behaviors at this time. The last dose change documented was 7/20/16. Review of a Psychoactive & Sedative/Hypnotic Utilization By Resident report for records updated between 6/1/2017 and 7/26/17 prepared by the Consultant Pharmacist printed on 7/26/17 revealed the following documentation: - 6/16 resident displays paranoia; s/s (sign/ symptoms) cont (continue) - 12/16 cont (continue) s/s intermitt (intermittently) - 6/17 sees dead people- behav (behavior) cont but epis- epis (episode to episode) controll (controlled) by redirection ? During interview on 7/25/17 at approximately 9:20 AM, the Registered Nurse (RN #1) Unit Manager stated she attends the BMARC Behavior Modification Assessment Review Committee meetings along with Social Worker, the Pharmacy Consultant, Assistant Director of Nursing (ADON). The discussion is based on what the nursing staff reports to her. RN #1 stated she reviews the documentation from the nurses and from the CNA's. The RN stated she would expect behaviors to be documented in the Nursing Progress Notes. I usually get my information from what I see, from what the staff tell me and I bring this information to the meetings for discussion. I didn't think documentation was an issue. During interview on 7/25/17 at approximately 9:30 AM, the Consultant Pharmacist stated his information is gathered from the Unit Manager and the Social Worker during monthly meetings. They tell me what happens, I go by their word, I was unaware there was poor documentation. I don't necessarily read the nursing documentation. I have no time to review the entire medical record. I'm only in the facility for a limited amount of time. The Consultant Pharmacist stated typically there should be supporting documentation for the use of [MEDICAL CONDITION] medications. During an interview on 7/25/17 at approximately 9:47 AM, the Social Worker (SW) stated she usually copies and pastes her information from month to month on her assessments and gathers her information from the nursing staff. The SW stated the resident did see dead people in her television in the past but can't recall when and did not document the episode. The SW further stated, she (the resident) does hallucinate and refuses care at times. During interview on 7/25/17 at approximately 10:03 AM, the Physician stated he relies on the nursing staff to inform him of accurate information and he would expect the resident's behaviors to be documented. Additionally, the Physician stated, I should have added supporting documentation for the use of the med. During an additional interview on 7/25/17 at approximately 12:59 PM, the Consultant Pharmacist stated that the resident should have had a GDR of the [MEDICATION NAME] or a documented rational for the continued use. During an interview on 7/26/17 at approximately 12:23 PM, CNA #2 stated she has been at the facility for about a year. The CNA further stated that the resident does not have any behaviors and has not had any recent episodes of seeing dead people that she is aware of. During interview on 7/26/17 at approximately 2:15 PM, the Director of Nursing (DON) stated that she expects accurate documentation from nursing and supporting documentation from the Physician. If it's not documented then it wasn't done. Review of a policy entitled Nursing Summaries and/or Assessments with a revised date of 12/16 revealed under Management/Behavior section: the documentation should describe any problem(s) noted during the month and the frequency of such problem(s). Indicate if the resident was belligerent, friendly, cooperative, etc. Review of the policy entitled Behavioral Assessments, Intervention and Monitoring revised 5/2017 revealed under the Monitoring section; The IDT will monitor the progress of the individuals with impaired cognition and behavior until stable. New or emergent symptoms will be documented and reported. 415.12(l)(1)

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED ON 4/13/15. Based on interview and record review conducted during the Standard Survey completed on 6/7/16, the facility did not periodically review and revise the Comprehensive Care Plan. Two (Residents #159, 264) of 14 residents reviewed for Care Plans had did not have Care Plan revisions to include changes with diuretic, diabetic (Resident #159) and anticoagulant (Residents #159, 264) medications. The findings are: 1. Resident #159 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 5/5/16 revealed the resident is cognitively intact, is understood and understands. Review of the Medication Review Report, on or after date 3/11/16, included the following: - [MEDICATION NAME] ([MEDICATION NAME]. Diuretic medication that promotes the excretion of urine) Give 20 milligram (mg) by mouth two times a day for [MEDICAL CONDITION] (swelling caused by excess fluid accumulation) - Eliquis (anticoagulant medication used to prevent blood from clotting) give 2.5 mg orally two times a day related to acute venous (relating to vein) embolism and [MEDICAL CONDITION] (clotting within a blood vessel). Review of Phone Order dated 3/20/16 revealed the following order: - Humalog Solution (Insulin) 100 unit/ml (milliliter) inject as per sliding scale subcutaneously before meals and at bedtime: If 0 - 120 = 0 units 121 - 200 = 5 units 201 - 250 = 8 units 251 - 300 = 12 units 301 - 350 = 16 units 351 - 400 = 20 units If over 400, give 20 units and recheck in 1 hr (hour); If recheck is less than 400, do not give any more insulin, monitor BS (blood sugar) at next scheduled time. Review of the Comprehensive Care Plan, Last Care Plan Review Dated 6/3/16, included the following: - Focus: The resident is on diuretic therapy ([MEDICATION NAME] 20mg daily) r/t (related to) hypertension. Goal: The resident will be free of any discomfort or side effects of diuretic therapy through next review date. Interventions: Administer diuretic medications as ordered by physician. Monitor for side effects and effectiveness Q (every) shift. - Focus: Potential for blood clot r/t (related to) dx (diagnosis) venous [MEDICAL CONDITION]. Medication - Xarelto (anticoagulant medication used to prevent blood from clotting) daily D/C (discontinue). Goal: Resident will not develop blood clot through next review. Interventions: Monitor for s/sx (signs/symptoms) of blood clot, such as pain, swelling, Discoloration, SOB (shortness of breath), headache. - Focus: Potential for altered glucose levels r/t dx Diabetes Mellitus. Medication [MEDICATION NAME] (oral blood glucose lowering drug) FSBS (finger stick blood sugar) at 0630 (6:30am) and 1630 (4:30pm) with no coverage, notify MD <80 or >400. Goal: Resident ' s blood sugar will be within acceptable limits as determined by the MD/NP (nurse practitioner). Interventions: Diet as ordered. Finger stick blood sugars as ordered and prn (as needed). Medications and labs per order. Interview with the Registered Nurse (RN) Unit Manager on 6/6/16 at approximately 11:43 AM revealed, the resident is on Eliquis not Xarelto, both are anticoagulants but are different medications. In addition the interview with the RN Unit Manager revealed, the resident receives [MEDICATION NAME] twice a day and the resident is receiving sliding scale insulin coverage (dose of insulin based on blood glucose level). RN Unit Manager stated, And this is why my DON (Director of Nursing) said not to put specifics on the Comprehensive Care Plan. The Care Plan should have been updated whenever any changes are made. 2. Resident #264 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has severe cognitive impairment, is understood and understands. Review of the Comprehensive Care Plan, Revision 6/6/16, included the following: - Focus: Nutrition - Dx (diagnosis): Acute [MEDICAL CONDITIONS] [MEDICAL TREATMENT] tx (treatment), [MEDICATION NAME] (anticoagulant medication used to prevent blood from clotting). Review of the Medication Review Report, signed by the Physician on 4/26/16, revealed no current physician's orders [REDACTED]. Interview with the Registered Nurse (RN) Unit Manager on 6/6/16 at approximately 11:43 AM revealed, the resident is no longer receiving [MEDICATION NAME]. The [MEDICATION NAME] was D/C ' d in November of 2015. Interview further revealed the Comprehensive Care Plan was reviewed 2/5/16 and 3/31/16 and the [MEDICATION NAME] probably should not be on the Care Plan. 415.11(c)(2)(iii)

Based on observation, interview, and record review conducted during the Standard survey completed on 6/7/16, the facility did not ensure that a resident with an indwelling catheter (a tube inserted into the bladder to drain urine) received the appropriate care and services to prevent urinary tract infection. One (Resident #284) of one resident observed for indwelling catheters had catheter drainage bag and catheter tubing positioned directly on the floor. The finding is: 1. Resident #284 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 4/28/16 revealed the resident is cognitively intact, is understood, and understands. Further review of the MDS revealed the resident has an indwelling catheter. Observation of AM Care (morning hygiene routine) on 6/6/16 at approximately 8:11 AM revealed certified nurse aide (CNA) #1 ambulated the resident from the bed to the toilet, where the resident sat on the toilet. The front (clear side) of the urinary drainage bag and approximately twelve inches of the tubing were lying directly on the floor of the bathroom. CNA #1 assisted the resident with washing his face, arms, hands, and back. At approximately 8:24 AM CNA #1 donned the resident's underpants and sweatpants, passing the urinary drainage bag and tubing through the right pant leg. CNA #1 then placed the urinary drainage bag back (solid) side directly on the bathroom floor with approximately twelve inches of tubing lying directly on the bathroom floor. At approximately 8:27 AM CNA #1 attached the urinary drainage bag to the rolling walker (RW) that was located in front of the resident, removing the drainage bag and tubing from lying directly on the floor. During an interview with CNA #1 on 6/6/16 at approximately 8:45 AM the CNA stated, We don't want the bag to touch the ground because that will contaminate the bag.Usually I empty the bag and put it on the walker, today the bag was empty and I think that threw me off. Review of Physician's Verbal Order dated 5/26/16 revealed the following: -[MEDICATION NAME](antibiotic medication) 500 mg (milligrams). Give 1 tablet by mouth two times a day for UTI for 10 days. Review of the Medication Administration Record [REDACTED]. Interview with the Registered Nurse (RN) Unit Manager on 6/6/16 at approximately 11:56 AM revealed, The drainage bag should be hung from the walker when a resident is sitting on the toilet, never want the bag or tubing to touch the floor.Touching the floor would present a high risk for infection. Further interview revealed the resident recently (5/26/16) underwent a cystoscopy (a diagnostic test to inspect the interior lining of the bladder and urethra) when the urologist diagnosed a UTI. 415.12(d)(1)

Based on interview and record review conducted during a Standard survey completed on 6/7/16, it was determined that the facility did not maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete and accurately documented. One (Resident #11) of 14 residents' clinical records were not accurately documented. Nurses Notes did not accurately reflect a resident's health care proxy was notified in regards to various medication changes specifically [MEDICATION NAME] (a blood thinner) to Eliquis (medication to help prevents platelets in your blood sticking together and forming a clot) in 11/2015 and an increase in [MEDICATION NAME] (antianxiety) and discontinuation of [MEDICATION NAME] (antidepressant) in 4/2016. The findings are: 1. Resident #11 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 4/26/16 revealed the resident has severe cognitive impairment. Review of the Physicians Orders dated 11/13/15 revealed an order to D/C (discontinue) [MEDICATION NAME] and start Eliquis 5 mg (milligrams) po (by mouth) twice a day. Review of the 11/2015 MAR (Medication Administration Review) revealed the resident's [MEDICATION NAME] was discontinued on 11/13/15 and Eliquis 5 mg po twice a day was initiated. Review of the Nursing Progress Notes dated 11/1/15 through 11/30/15 revealed no documentation that the health care proxy was notified of the change of medication from [MEDICATION NAME] to Eliquis. Review of the Psychological Services Consultation dated 3/31/16 revealed the following comments and recommendations: Patient with anxiety signs and symptoms, mild depression, moderate impaired cognitive function: patient with increased frustration: recommend discontinuing the [MEDICATION NAME] and changing the [MEDICATION NAME] to two times per day: monitor mood and depression signs and symptoms: if depression increases consider a different anti-depressant: music may benefit his mood: follow up one to two times per month as needed. Review of the Physicians Orders dated 4/4/16 revealed a verbal order to discontinue [MEDICATION NAME] 0.5 mg po qd (daily) and [MEDICATION NAME] 10 mg po qd. Start [MEDICATION NAME] 0.5 mg po twice daily for anxiety and major [MEDICAL CONDITION]. Review of the MAR indicated [REDACTED]. Review of the Nursing Progress Notes dated 3/15/16 through 4/15/16 revealed no documentation that the resident ' s Health Care Proxy was notified of the medication changes during this time frame. During an interview on 6/3/16 at 10:33 AM the resident's spouse stated They never notify me of any changes in medication, treatments. Im not sure if he's had changes in his medications. They do call me when he falls. During an interview on 6/7/16 at 9:31 AM Registered Nurse (RN#2)stated The family is verbally updated on a daily basis.They are here every day because he has quite a few behaviors.The family was involved in the consult with the Psychologist, but I do not see any supporting documentation that the health care proxy was notified in regards to the medication changes.There should be documentation in the Nursing Notes that the family was updated with the changes. Interview with the DON (Director of Nursing) on 6/7/16 at 10:33 AM revealed the resident's family is in the facility on a daily basis, verbally updated on information and is highly involved with the residents care. It is expected of the Nurses to document in the Nurses Notes if there are such changes in medications. 415.22(a)(1-2)

Based on interview and record review conducted during an Abbreviated survey (Complaint #NY 142) completed on 12/11/15, the facility did not ensure that each resident has the right to refuse treatment, participate in experimental research, and to formulate an advanced directive. One (Resident #1) of three residents reviewed for advanced directives had issues with the activation and utilization of an undated Health Care Proxy (HCP) - a legal document in which an individual appoints a Health Care Agent to make future medical decisions when the individual loses the ability to make decisions) form. The finding is: 1. Resident #1 has [DIAGNOSES REDACTED]. Review of a Health Care Proxy Activation Form, signed by two physicians on 10/13/12 and 10/17/12, revealed the resident lacks the capacity to make health care decisions; the lack of capacity is due to dementia; and the probable duration is permanent. The Activation Form documented that the resident appointed her spouse as the Primary Health Care Agent and her niece as the Alternate Health Care Agent . Review of an undated Health Care Proxy (HCP) form revealed the resident designated her husband as the primary Health Care Agent and a niece as the substitute Health Care Agent. Review of a Nurse Progress Note dated 7/14/15 at 2:51 PM revealed the resident was moaning out in pain when moving her left leg and medication given for pain had little effect. The Nurse Practitioner (NP) was contacted and a new order was received to obtain X-rays of the left knee and hip. Review of an RN (registered nurse) Assessment Note dated 7/14/15 at 9:11 PM revealed the X-ray results were received which showed a left [MEDICAL CONDITION]. The RN documented that the NP was in the building; was informed of the X-ray results; and went to see the resident and her spouse who was visiting. The NP discussed the X-ray results with the resident's husband, including options to send the resident to the emergency room (ER) and/or seeing an orthopedic physician (doctor who specializes in the treatment of [REDACTED]. The spouse declined for the resident to be sent out of the facility and stated make her comfortable here. The RN documented that the resident was placed on bed rest and pain medication was ordered. Review of a Social Work (SW) Progress Note dated 7/15/15 revealed the resident's care plan was reviewed. The Social Worker documented that the resident had a HCP which was activated. Review of a SW Assessment and History form dated 7/15/15 revealed it was noted the morning of 7/15/15 that the HCP on file, which assigned the resident's spouse as the primary agent and the niece as secondary, was not dated. Administration brought this to the spouse's attention and the spouse stated he would look through files at home. The spouse returned with the same undated HCP that was in the chart. The facility went through all of the resident's records and found an additional HCP that was dated 2005. The spouse was informed and the chart was updated accordingly. Review of a Living Will/Health Care Proxy, signed by the resident on 8/22/05, revealed the resident appointed two nieces as her primary Health Care Agent and substitute. Review of a Nurse Progress Note dated 8/12/15 revealed a Licensed Practical Nurse (LPN) called the Health Care Agent (resident's niece) and reviewed the X-ray results, the Physician's recommendations, the spouse's request for continued bedrest, and an in house orthopedic consult if possible to be arranged. The LPN documented that the niece stated she agreed with the current plan and she remains in close contact with the resident's spouse. Interview with the resident's Physician on 12/11/15 at 11:45 AM revealed the Physician has cared for Resident #1 for many years and she was well known (to the physician) along with the resident's spouse. The Physician stated that the couple did not have children and there were no visitors during the many home visits that he made. The Physician stated that the spouse has always made decisions for the resident and thought he (the spouse) was the Health Care Proxy (Agent). I went to the nursing home many times to see the resident and her spouse, especially after the [MEDICAL CONDITION] finding to discuss her status and options with the spouse. The spouse was insistent that the resident not be sent out of the facility. I told the spouse that the resident needed to be seen at the ER (emergency room ) by an orthopedist as they do not usually go to the nursing home. I was finally able to arrange an orthopedic evaluation at the facility a couple of weeks later. I did not tell the spouse that the resident was not a surgical candidate. I encouraged him to have her sent to the hospital, but he kept refusing . Interview with the Director of Nursing (DON) on 12/11/15 at approximately 12:10 PM revealed that the interdisciplinary team was concerned regarding the spouse's refusal of an ER evaluation of the broken hip. The DON stated that she decided to do a chart review and found that the HCP naming the spouse as the resident's primary Health Care Agent was not dated. The DON stated they looked through all the files for the resident and found a HCP that was signed and dated by the resident in 2005 that named two nieces as the Health Care Agents. The team reached out to the spouse regarding the incomplete, undated HCP and the recently found HCP, which named the niece as the resident's Agent. At this time, the primary contact was changed to the niece. Telephone interview with the Social Worker on 12/11/15 at approximately 1:15 PM revealed a previous social worker had followed through with the initial HCP and did not notice that the form was undated. The Social Worker stated she was not aware of the HCP dated 2005 in the resident's old record. The Social Worker stated that she and the DON reviewed the 2005 HCP, they activated the niece as the primary contact and Health Care Agent, and posted a new contact sheet for the resident with the niece listed as primary. 415.3(e)(2)(iii)

Based on interview and record review conducted during the Standard survey completed on 4/13/15, the facility did not maintain clinical records on each resident in accordance with accepted professional standards and practices that are accurate and complete. One (Resident #290) of one resident medical record reviewed for [MEDICAL TREATMENT] had issues involving the lack documentation that the dressing was removed from the AV (arteriovenous) shunt site (a tube or device implanted in the body to redirect the passage of blood from an artery to a vein) after [MEDICAL TREATMENT] treatments per the physician's orders [REDACTED]. The finding is: 1. Resident #290 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 1/12/15 revealed that the resident has severe cognitive impairment and receives [MEDICAL TREATMENT] services. Review of an Interdisciplinary Progress Note dated 11/3/14 revealed that while the resident was out to [MEDICAL TREATMENT], the [MEDICAL TREATMENT] center called the facility to report that the resident's [MEDICAL TREATMENT] shunt in his left forearm would not stop bleeding, even with the pressure dressing applied. The Progress Note documented that the [MEDICAL TREATMENT] center transferred the resident to a nearby hospital's emergency room . Review of the Comprehensive Care Plan dated 1/13/15 revealed the resident goes to [MEDICAL TREATMENT] three times a week on Mondays, Wednesdays, and Fridays. Review of the current 60 day physician's orders [REDACTED]. Review of the Medication Administration Records (MARs) and the Treatment Administration Records (TARS) dated from December 2014 through April 8, 2015 revealed an entry to "Please remove dressing from [MEDICAL TREATMENT] site 4 hrs after [MEDICAL TREATMENT]". Additional review of the MARs and TARs dated December 2014 through April 8, 2015 revealed no documentation that the dressing was removed from the [MEDICAL TREATMENT] site after [MEDICAL TREATMENT] treatments. Review of Interdisciplinary Progress Notes dated 12/2014 to 4/8/15 revealed there was no documentation that the [MEDICAL TREATMENT] site dressing was removed in accordance with the physician's orders [REDACTED]. Interview with the 3E Registered Nurse (RN) Unit Manager (UM) on 4/10/15 at 10:30 AM revealed the instructions to "Please remove dressing from [MEDICAL TREATMENT] site 4 hrs after [MEDICAL TREATMENT]" was a recommendation from the [MEDICAL TREATMENT] center. The RN UM stated that this was included because the resident likes to pick at the bandage, and it is to be checked four hours after arrival to check to see if the dressing is intact and to check for any bleeding and then the dressing is removed. Interview with the 3E A-side Licensed Practical Nurse (LPN) on 4/10/15 at 10:41 AM revealed that she works part time, about two days per week, and is familiar with Resident #290 and his renal status. The LPN stated that when the resident returns from [MEDICAL TREATMENT], she takes his vitals (temperature, blood pressure, pulse, respiratory rate), checks for a bruit (audible sound of blood flow with a stethoscope) and thrill (a "buzzing" vibration felt by palpation), and then checks the shunt site to make sure the dressing is intact, clean, and if there is any drainage/ bleeding. The LPN stated that the dressing is left on and then the evening shift removes the bandage. Interview with the 3:00 PM to 11:00 PM shift 3E A-side LPN on 4/10/15 at 3:10 PM revealed that she works the evening shift five evenings each week and this has been her schedule for about three years. The LPN stated she will do her first rounds and check the resident's vitals and then remove the AV shunt dressing on his (L) forearm between 3:00 and 4:00 PM. The LPN stated that she checks the site, looks for any signs of bleeding or problems, and then checks for a bruit and a thrill. The LPN stated that although the MARs have a column for documentation that the dressing was removed four hours after [MEDICAL TREATMENT], they (the staff) don't really have to sign this off, as it is for "FYI" (for your information) purposes. The LPN stated that a column was started yesterday in the TARs section of the medical record to now sign off that the shunt dressing is removed four hours after the [MEDICAL TREATMENT] treatment, on the resident's [MEDICAL TREATMENT] days. Review of the MAR/ TAR dated 4/2015 revealed that beginning 4/9/15, there is a separate, isolated column directing to "Remove (dressing) LFA (left forearm) from [MEDICAL TREATMENT] (on the) 3-11 shift". The entry was initialed as completed on 4/10/15. 415.22(a)(1)(2)

Based on record review and staff interview conducted during an Abbreviated survey (complaint #NY 956) completed 1/19/12, the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well being in accordance with the comprehensive assessment and plan of care. Specifically, for one (Resident #1) of nine residents reviewed for quality of care, the facility did not ensure PT/INR ([MEDICATION NAME] time/international normalized ratio - blood tests to monitor the time it takes for blood to clot) were completed according to the physician orders. Resident #1 did not receive [MEDICATION NAME] (anticoagulant medication used to thin the blood) as ordered and subsequently developed a blood clot in the left lower extremity. This resulted in actual harm that is not immediate jeopardy. The findings are: 1. Resident #1 was admitted to the nursing home on 1/7/12 with [DIAGNOSES REDACTED]. Review of the hospital Discharge Summary dated 1/6/12 revealed discharge instructions for [MEDICAL CONDITION] ([MEDICAL CONDITION] - obstruction in a blood vessel due to a blood clot) [MEDICATION NAME] (prevention) including directions to continue [MEDICATION NAME] to maintain an INR between 2 and 3. Review of the Sub-Acute Rehabilitation Unit admission orders [REDACTED]. In addition there was a physician order [REDACTED]. Review of the entire medical record revealed there was no documented evidence of PT/INR results dated for 1/9/12 Monday (M) or 1/11/12 Wednesday (W) or physician orders [REDACTED]. Review of the nurse's Progress Note dated 1/7/12 at 3:15 PM revealed extremities: Pink warm and mobile, pedal pulses present bilaterally, extremities positive for CSM (Circulation, Sensation, Movement). Left leg 1+ (positive) non-[MEDICAL CONDITION] (swelling caused by excess fluid accumulation) encouraged to elevate lower extremity. Review of the physician History and Physical dated 1/9/12 revealed "There is slight swelling, trace of [MEDICAL CONDITION] at the left ankle. Ankle is tender on minimal palpation. She is on [MEDICATION NAME] for [MEDICAL CONDITION]". Review of the nurse's Progress Note dated 1/11/12 from 6:00 AM to 6:00 PM revealed Left 2 + [MEDICAL CONDITION] LLE (left lower extremity) doctor in to see patient. Review of a Comprehensive Physician order [REDACTED]. There is no flow (blood flow). Review of a Comprehensive Physician order [REDACTED]. Review of PT/INR results documented on the [MEDICATION NAME] Work Sheet dated 1/12/12 revealed PT of 14.8 (normal 11 to 13.5 seconds)/ INR 1.3 (normal). The medical goal was 2 - 3. During an interview on 1/17/12 at 3:00 PM the 7:00 AM to 3:00 PM RN (Registered Nurse) Assistant Unit Manager that transcribed the order for PT/INR Q MWF dated 1/7/12 stated "It was 2:30 PM and I was leaving at 3:00 PM. I honestly made a mistake because I didn't make a lab requisition request, complete a [MEDICATION NAME] Worksheet located in a binder at the desk to record the test results or document 'PT/INR' on the resident's MAR indicated . Interview on 1/17/12 at 3:30 PM with the Sub-Acute Medical Director revealed his expectation is for the PT/INR to be obtained as ordered and that he would be notified of the results. 415.12

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEYS COMPLETED 3/31/11 AND 2/25/10. Based on record review and staff interview conducted during an Abbreviated survey (complaint #NY 956) completed 1/19/12, the facility did not ensure that residents are free of significant medication errors. Specifically, for one (Resident #1) of nine residents reviewed for medications, the facility did not ensure that Resident #1 received [MEDICATION NAME] (an anticoagulant medication to thin blood) for [MEDICAL CONDITION] ([MEDICAL CONDITION] - obstruction in a blood vessel due to a blood clot) [MEDICATION NAME] (prevention). The resident subsequently developed a [MEDICAL CONDITION] in her left lower extremity. This resulted in actual harm that is not immediate jeopardy. The finding is: 1. Resident #1 was admitted to the nursing home on 1/7/12 with [DIAGNOSES REDACTED]. Review of the hospital Discharge Summary dated 1/6/12 revealed discharge instructions including "[MEDICAL CONDITION] and continue [MEDICATION NAME] po (by mouth)". Review of the "Sub-Acute Rehabilitation Unit admission orders Transfer/Post Op Medication Orders" form dated 1/6/12 for "[MEDICATION NAME] ([MEDICATION NAME]) per prescriber - oral everyday" circled and initialed by the same RN Assistant Unit Manager. The order did not include the dose of [MEDICATION NAME] that was to be administered. Review of the entire medical record including the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the physician History and Physical dated 1/9/12 revealed "There is slight swelling, trace of [MEDICAL CONDITION] at the left ankle. Ankle is tender on minimal palpation" and "She is on [MEDICATION NAME] for deep vein [MEDICATION NAME]". Review of the nurse's Progress Note dated 1/11/12 at 6:00 AM to 6:00 PM revealed Left 2 + [MEDICAL CONDITION] LLE (left lower extremity) doctor in to see patient. Review of a Comprehensive Physician order [REDACTED]. Doppler results dated 1/11/12 documented extensive acute [MEDICAL CONDITION] left lower extremity. During an interview on 1/17/12 at 3:00 PM, the 7:00 AM to 3:00 PM RN Assistant Unit Manager stated "It was 2:30 PM and I was leaving at 3:00 PM. I called the attending physician to let him know the resident had arrived and gave a summary about the resident's condition. I circled and initialed the medications including the [MEDICATION NAME] as reviewed with the physician but I didn't review or ask for a clarification of the [MEDICATION NAME]". When interviewed on 1/17/12 at 3:30 PM the Sub-Acute Medical Director stated "I don't remember if the nurse called me or not. My expectation is that the nurses notify me when the admission arrives and to review the medications and should've asked for a clarification of the [MEDICATION NAME] order". 415.12(m)(2)