Every finding on record at Peconic Landing at Southhold

Based on observations, record review, and interviews during the Recertification Survey initiated on 4/8/2025 and completed on 4/11/2025, the facility did not ensure that each resident was treated with respect and dignity and cared for in a manner that promoted maintenance or enhancement of their quality of life. This was identified for one (Resident #35) of one resident reviewed for Dignity. Specifically, during a lunch meal observation on 4/8/2025, Registered Charge Nurse #1 was observed standing over Resident #35 while they assisted the resident with their lunch meal. The finding is: The facility's policy titled Meal Services, last reviewed in January 2025, documented the food shall be served in a manner that meets the individual needs of each resident. Residents who are unable to feed themselves shall be fed with attention to safety, comfort, and dignity. Nursing personnel will provide assistance to those residents who cannot feed themselves independently. The staff member should sit across from the resident at eye level. Resident #35 was admitted with diagnoses including Dementia, Alzheimer's Disease, and Hypothyroidism. The Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 99, indicating the resident was unable to complete the interview and had severe cognitive impairment. The Minimum Data Set documented that the resident consumed meals with supervision or touching assistance. The Activities of Daily Living Comprehensive Care Plan, last reviewed on 3/11/2025, documented Resident #35 eats independently with assistance as needed. During a lunch meal dining observation in the [NAME] Unit on 4/8/2025 at 12:07 PM, Registered Charge Nurse #1 was observed assisting Resident #35 with their meal and feeding the resident their soup while standing next to the resident's chair. During an interview on 4/8/2025 at 12:07 PM, Registered Charge Nurse #1 stated the resident normally feed themselves; however, sometimes need staff assistance in completing their meals. Registered Charge Nurse #1 stated they should sit down while assisting a resident with their meal. Registered Charge Nurse #1 proceeded to get a chair to sit down and continued to assist Resident #35 with their lunch. During an interview on 4/10/2025 at 11:29 AM, the Director of Nursing Services stated nursing staff should sit with the resident to assist with a meal. 10 NYCRR 415.3(d)(1)(i)

Based on observation, record review, and interviews during the Recertification Survey initiated on 4/8/2025 and completed on 4/11/2025, the facility did not ensure that services provided or arranged by the facility meet the current professional standards of quality. This was identified for one (Resident # 3) of seven residents during the Medication Administration Task. Specifically, Licensed Practical Nurse #3 did not administer the Physician-ordered 6:00 PM and 9:00 PM scheduled medications to Resident #3 at the resident's refusal and left the medications at Resident #3's bedside in a souffle cup covered with tape for the resident to consume the medications on their own at a later time. The finding is: The Facility's Policy for Medication Administration dated 11/2024 documented Medications may not be prepared in advance and must be administered within one hour of their prescribed time (before and after the prescribed time). For the safety of the resident, medications being administered to the resident shall be in the presence of the nurse administering the medication, and confirmation of successful administration to the resident shall be performed before documentation of medication administration. The resident was admitted with diagnoses of Low Back Pain, Neuropathy, and Dementia. The Quarterly Minimum Data Set, dated dated dated [DATE] documented the resident had a Brief Interview for Mental Status score of 15, which indicated the resident had intact cognition. The physician's orders dated 03/27/2025 documented Acetaminophen 325 milligrams tablet, give 2 tablets (650 milligrams) by oral route three times per day Every Day at 9:00 AM; 2:00 PM; 9:00 PM for Low back pain and Gabapentin 400 milligram capsule give three capsules (1200 milligram) by oral route daily at 9:00 PM for Neuropathy, Gabapentin 400 milligrams capsule give 2 capsules (800 milligrams) by oral route twice daily at 9:00 AM and 6:00 PM. The Medication Administration Record for April 2025 documented Licensed Practical Nurse #3 administered all the Physician-ordered medications at 6:00 PM and 9:00 PM on 4/8/2025. During an observation on 4/9/2025 at 8:15 AM, Resident#3's room was observed with a medication cup that was covered with surgical tape and had two white tablets and two orange-colored capsules in it. During an interview on 4/9/2025 at 8:25 AM, Resident #3 stated they were not aware that there was a medication cup on their bedside table. Resident#3 stated they do not take their medications themselves, nurses administered the medications to them. During an interview on 4/09/2025 at 8:28 AM, Licensed Practical Nurse #1 stated they did not place the medication cup on the resident's bedside table. Licensed Practical Nurse#1 was able to identify the white round medications as Tylenol 325 milligrams tablets and orange capsule medications as Gabapentin 400 milligrams capsules. Licensed Practical Nurse#1 stated that the medications should not be left in the resident's room. Licensed Practical Nurse#1 stated Resident #3 did not have a Physician's order to administer medications themselves and the medications should not be left in the resident's room. During an interview on 4/11/2025 at 11:04 AM, Licensed Practical Nurse #3 stated on 4/08/2025 they worked as the Medication Administration Nurse and were assigned to Resident#3. The resident was very alert and did not want to take their 6:00 PM Gabapentin (two capsules) medication, therefore they left the medications in the resident's room. Licensed Practical Nurse #3 stated when they went to administer the 9:00 PM medications, the resident told them to add the Tylenol (two) tablets to the medication cup which was previously left in the room at 6:00 PM. Licensed Practical Nurse #3 stated after they put the Tylenol tablets in the medication cup, they covered the medication cup with surgical tape. They then left the medication cup at the resident's bedside table as per Resident #3's request. Licensed Practical Nurse#3 stated they should not have left any medication in the resident's room. Licensed Practical Nurse #3 acknowledged that it was not safe to leave the medications in Resident #3's room because another resident could have consumed the medications. During an interview on 4/11/2025 at 11:25 AM, the Director of Nursing Services stated the staff should not leave medications in resident rooms without supervision. During an interview on 4/01/2025 at 11:35 AM, Medical Doctor #1 stated the nurses should not leave the medications unattended in the resident's room for safety reasons. 10 NYCRR 415.11(c)(3)(i)

Based on observation, record review, and interviews during the Recertification Survey initiated on 4/8/2025 and completed on 4/11/2025, the facility did not ensure that all drugs and biologicals were stored in locked compartments. This was identified for one (Resident # 3) of seven residents during the Medication Administration Task. Specifically, Resident #3's room was observed with a medication cup containing medications (two tablets and two capsules) and an eye drop bottle at the resident's bedside. The finding is: The facility policy and procedure for Storage of Medications, last revised on 1/2025 documented that all Drugs are stored in an orderly manner in cabinets, drawers, or carts. These compartments are of sufficient size to prevent crowding. Each resident was assigned a cubicle or drawer to prevent the possibility of a drug for one resident being given to another resident. The Facility Policy for Medication Administration dated 11/2024 documented Medications may not be prepared in advance and must be administered within one hour of their prescribed time (before and after the prescribed time. For the safety of the resident, medications being administered to the resident shall be in the presence of the nurse administering the medication, and confirmation of successful administration to the resident shall be performed before documentation of medication administration. Resident #3 was admitted with diagnoses of Low Back Pain, Neuropathy, and Dementia. The Quarterly Minimum Data Set, dated dated dated [DATE] documented the resident had a Brief Interview for Mental Status score of 15, which indicated the resident had intact cognition. The physician's orders dated 03/27/2025 documented Acetaminophen 325 milligrams tablet, give 2 tablets (650 milligrams) by oral route three times per day Every Day at 9:00 AM; 2:00 PM; 9:00 PM for Low back pain; Gabapentin 400 milligram capsule give three capsules (1200 milligram) by oral route daily at 9:00 PM for Neuropathy; Gabapentin 400 milligrams capsule, give two capsules (800 milligrams) by oral route twice daily at 9:00 AM and 6:00 PM; and Refresh Relieva 0.5 %-0.9 % eye drops, instill one drop in each eye at 9:00 PM and 4 times daily as needed for bilateral Conjunctival Xerosis (dryness and roughness of conjunctiva). During an observation on 4/9/2025 at 8:15 AM, Resident#3's room was observed with a medication cup that was covered with surgical tape and had two white tablets and two orange-colored capsules in it. Additionally, there was an eye drop bottle of Refresh Relieva 0.5 %-0.9 % was observed on the left bedside table. During an interview on 4/9/2025 at 8:25 AM, Resident #3 stated they were not aware that there was an eye drop and a medication cup on their bedside table. Resident#3 stated they do not take their medications themselves, nurses administered the medications to them. During an interview on 4/09/2025 at 8:28 AM, Licensed Practical Nurse #1 stated they did not place the medication cup and the eye drops on the resident's bedside table. Licensed Practical Nurse#1 was able to identify the white round medications as Tylenol 325 milligrams tablets and orange capsule medications as Gabapentin 400 milligrams capsules. Licensed Practical Nurse#1 stated that the medications should not be left in the resident's room. Licensed Practical Nurse#1 stated Resident #3 did not have a Physician's order to administer medications themselves and the medications should not be left in the resident's room. During an interview on 4/09/2025 at 8:45 AM, Licensed Practical Nurse #2, the Unit Manager, stated the medications should not be left unattended in a resident's room for safety reasons. During an interview on 4/11/2025 at 11:04 AM, Licensed Practical Nurse #3 stated on 4/08/2025 they worked as the Medication Administration Nurse and were assigned to Resident#3. The resident was very alert and did not want to take their 6:00 PM Gabapentin (two capsules) medication, therefore they left the medications in the resident's room. Licensed Practical Nurse #3 stated when they went to administer the 9:00 PM medications, the resident told them to add the Tylenol (two) tablets to the medication cup which was previously left in the room at 6:00 PM. Licensed Practical Nurse #3 stated after they put the Tylenol tablets in the medication cup, they covered the medication cup with surgical tape. They then left the medication cup at the resident's bedside table as per Resident #3's request. Licensed Practical Nurse #3 stated they also accidentally left the resident's eye drops in the resident's room and forgot to place them in the medication cart. Licensed Practical Nurse#3 stated they should not have left any medication in the resident's room. Licensed Practical Nurse #3 acknowledged that it was not safe to leave the medications in Resident #3's room because another resident could have consumed the medications. During an interview on 4/11/2025 at 11:25 AM, the Director of Nursing Services stated the staff should not leave medications in resident rooms without supervision. During an interview on 4/01/2025 at 11:35 AM, Medical Doctor #1 stated the nurses should not leave the medications unattended in the resident's room for safety reasons. 10 NYCRR 415.18(e)(1-4)

Based on record review and staff interviews during the Recertification Survey initiated on 4/8/2025 and completed on 4/11/2025 the facility did not ensure its Facility Assessment considered specific staffing needs for each resident unit (Rehabilitation unit and Long-Term Care unit) in the facility for each shift such as day, evening, and night. This was identified during the Sufficient and Competent Nurse Staffing Review Task. Specifically, the Facility Assessment last updated on 7/10/2024 did not consider staffing needs for each of the facility's two units for each shift such as day, evening, and night. The finding is: A review of the Facility assessment dated [DATE] was conducted during the sufficient staffing task. The Facility Assessment included the total number of nursing staff available for the entire facility for each shift. The Facility Assessment documented that staffing levels are adjusted as needed to meet the care needs and acuity of the member population (residents). The Facility Assessment further documented the staffing needs of the entire facility for each shift as follows: -For the 7:00 AM - 3:00 PM nursing shift the facility required two Registered Nurses for the entire facility. -For the 3:00 PM - 11:00 PM nursing shift the facility required two Registered Nurses for the entire facility. -For the 11:00 PM - 7:00 AM shift the facility required one Registered Nurse for the entire facility. -For the 7:00 AM - 3:00 PM nursing shift the facility required three Licensed Practical Nurses for the entire facility. -For the 3:00 PM - 11:00 PM nursing shift the facility required 2.5 Licensed Practical Nurses for the entire facility. -For the 11:00 PM - 7:00 AM shift the facility required one Licensed Practical Nurse for the entire facility. -For the 7:00 AM - 3:00 PM nursing shift the facility required eight Certified Nursing Assistants for the entire facility. -For the 3:00 PM - 11:00 PM nursing shift the facility required seven Certified Nursing Assistants for the entire facility. -For the 11:00 PM - 7:00 AM shift the facility required four Certified Nursing Assistants for the entire facility. The facility assessment did not include a breakdown of Registered Nurses, Licensed Practical Nurses, and Certified Nursing Assistants needed for each of the two units (Rehabilitation unit and Long-Term Care unit). During an interview on 4/10/2025 at 11:40 AM, the Staffing Coordinator stated the facility has one Long Term Care unit and one Rehabilitation unit, and they were responsible for staffing both units. The Staffing Coordinator stated the Director of Nursing Service provides them with final instruction regarding the staffing levels for each unit. During an interview on 4/11/2025 at 9:40 AM, the Director of Nursing Service stated that they have been employed at the facility since 12/2024 and have not had the opportunity to review the Facility Assessment. The Director of Nursing Service stated that the numbers presented in the staffing portion of the Facility Assessment reflected staffing levels for the entire facility. The Director of Nursing Service stated that the Facility Assessment must include staffing needs for each unit and each shift; however, they were not involved with updating the Facility assessment dated [DATE] as they were not employed at the time the assessment was reviewed. During an interview on 4/11/2025 at 10:00 AM, the Administrator stated the Facility Assessment is updated annually by the Assistant Administrator and themselves. The Administrator stated the staffing levels documented in the Facility Assessment are based on the facility's 60 beds [the entire facility]. The Administrator stated they were not aware that the staffing levels should be broken down per unit per shift and that they would update the Facility Assessment to reflect the staffing lever for each unit. 10 NYCRR 415.26

Based on observation, interviews and record review during an abbreviated survey (NY00364658) the facility did not ensure each resident received adequate supervision and assistance to prevent accidents for one (Resident #1) of three residents reviewed. Specifically, Resident #1 was served the wrong consistency food and choked and required chest thrusts, supplemental oxygen and a chest x-ray. The facility's policy and procedure titled Choking with a review date of 2024 documented the facility will implement procedures to minimize the risks of choking. Modified diets will be implemented as appropriate. The facility's undated policy and procedure titled Diet Changes and Reports documented the nurse supervisor/charge nurse is responsible for notifying the dietary manager on duty of any changes in the resident's diet or meal service. Notification of the dietary manager may be through handwritten or electronic communication. Oral communication is permitted. However, all oral communication must be followed-up with written/electronic communication. Resident #1 had diagnoses that included Vascular Dementia, Depression, and anxiety disorder.Resident #1's Admission Minimum Data Set assessment dated [DATE] documented Resident #1 had a Brief Interview for Mental Status of 12 indicating a moderate cognitive impairment. The Minimum Data Set had no documentation that Resident #1 had a swallowing disorder or a needed a mechanically altered diet. Resident #1's Comprehensive Care Plan titled: Nutrition effective 11/27/2024 documented Resident #1 had the potential for alteration in nutritional status. Interventions included but were not limited to provide diet as per physician's order and to monitor texture tolerance and to monitor for signs and symptoms of swallowing problems. An updated note to the Comprehensive Care Plan dated 12/12/2024 documented that on 12/10/2024 Resident #1 experienced a near choking incident while eating a cucumber salad, abdominal thrusts were performed. Resident #1's diet was downgraded to mechanical ground and no raw fruits and no raw vegetables. Resident #1 will be evaluated by the Speech Language Pathologist. A Dietary Progress Note dated 12/12/2024 documented that on 12/10/2024 during the lunch meal service Resident #1 experienced a near choking episode while eating a cucumber salad. Abdominal thrusts were performed, and the resident was ok. The cucumber salad was served as small, bite sized cubes. Resident #1's diet was downgraded to mechanical ground and no raw fruits/vegetables. Resident #1 was to be seen by the Speech Language Pathologist for an evaluation. A Nursing Progress Note dated 12/12/2024 documented on 12/12/2024 during the dinner meal service the nurse was called to the dining room by the Dietary Aide and Resident #1 was observed to have a plate of salad in front of them and the resident had consumed some of the salad. Resident #1 appeared to have a partially obstructed airway and had extreme difficulty breathing. Nursing administered a firm pat on Resident #1's back and partially chewed pieces of lettuce and tomato were expelled. Resident #1's oxygen saturation was 84% and slight cyanosis (a bluish-purple discoloration of the skin, lips, and nail beds caused by a low level of oxygen in the blood) was noted to Resident #1's bilateral hands and lips. Resident #1 continued to cough. An oxygen mask was applied and Resident #1's oxygen saturation increased to 96-97%. Resident #1 continued to bring up small pieces of salad. The Medical Doctor was notified, and a chest x-ray was ordered. A Nursing Progress Note with the note documenting Correction dated 12/13/2024 documented that on 12/10/2024 Resident #1 was observed having a choking episode while eating a cucumber salad, abdominal thrusts were performed by nursing staff with the expulsion of the food particles. Resident #1 did not lose consciousness, oxygen saturation decreased to 89% and oxygen was administered via a nasal canula (a device that gives you additional oxygen through your nose) and their oxygen saturation increased to 95%. The Medical Doctor was informed and instructed staff to continue to monitor for signs and symptoms of aspiration (accidental inhalation of foreign materials, such as food into the lungs). A physician's order dated 12/10/2024 documented Resident #1 was to receive a mechanically soft food consistency with no raw fruits and vegetables. The Electronic Medical Record Messaging system the facility used to communicate a change in a resident's diet to the kitchen was reviewed and there was no documented evidence that the diet change for Resident #1 was initiated on 12/10/2024 or was communicated to the kitchen. A Speech Language Pathologist evaluation dated 12/12/2024 documented their clinical impression for Resident #1 was to continue a downgraded diet of mechanical ground and no raw fruits or vegetables. Resident #1's chest x-ray report dated 12/13/2024 document a chest x-ray was performed, and the impression was clear visualized lungs. Resident #1's computer printed dinner meal ticket dated 12/12/2024 documented Resident #1 had a salad choice of 1 each Tomato and Mozzarella Salad which was circled and balsamic was noted as the salad dressing of choice. On the bottom of the meal ticket a handwritten addition noted no raw fruit or vegetables and soft food. The facility's recipe for a Salad Side-Tomato and Mozzarella (Tomato and Mozzarella Salad) documented the ingredients as fresh tomato, a fresh mozzarella cheese ball, and the salad mix as field greens. The facility's investigation documented on 12/12/2024 Resident #1 was inadvertently served tomato and mozzarella salad over a bed of lettuce. Staff was alerted that Resident #1 was having difficulty breathing and nursing staff removed particles of lettuce from Resident #1's oral cavity and administered oxygen due to a low oxygen saturation of 84%. Resident #1's oxygen saturation returned to 97% and they were able to take small sips of fluid. The Medical Doctor was notified and ordered a chest x-ray. The x-ray was negative. On 1/10/2025 at 12:30 PM Resident #1 was observed in the dining area eating lunch. Resident #1 was eating what appeared to be a mechanically ground food consistency and no raw fruits or vegetables were observed on Resident #1's plate. The meal ticket next to Resident #1's plate documented Resident #1 was on aspiration precautions, was to receive extra sauce/gravy and no raw fruits or vegetables. Resident #1 did not respond to the surveyor's greeting or questions. During an interview on 1/10/2025 at 1:35 PM, Dietary Aide #1 stated during the dinner meal service on 12/12/2024 they took Resident #1's meal order. Dietary Aide #1 stated they circled the salad selection and wrote balsamic as Resident #1's salad dressing choice. Dietary Aide #1 stated they thought they reviewed Resident #1's meal ticket prior to taking the order and their thumb may have been covering up the handwritten notation of no raw fruit or vegetable and soft food at the bottom of the meal ticket. Dietary Aide #1 stated they would not have given Resident #1 the salad had they read the bottom of the ticket because uncooked lettuce and tomato are raw foods. Dietary Aide #1 stated they observed Resident #1 choking and alerted the Charge Nurse who removed Resident #1 from the dining room to provide care. During an interview on 1/10/2025 at 2:49 PM, Licensed Practical Nurse #1 stated they were called to the dining room by Dietary Aide #1. Licensed Practical Nurse #1 stated they observed Resident #1 having difficulty breathing and they gave Resident #1 a back pat and Resident #1 expelled pieces of lettuce and tomato. Licensed Practical Nurse #1 stated they gave Resident #1 oxygen and informed the Medical Doctor who ordered a chest x-ray. Licensed Practical Nurse #1 stated Resident #1 should not have received a salad if they had a physician's order for no raw fruits or vegetables and the meal ticket documented no raw fruits or vegetables. During an interview on 1/10/2025 at 2:49 PM, the Dietary Manager stated when there is a change related to a resident's diet orders the nurses on the unit inform the kitchen using the electronic medical record messaging system. The Dietary Manager reviewed the message log and there was no documented message regarding a diet change for Resident #1 on 12/10/2024. The Dietary Manager stated the first message regarding Resident #1's diet change was documented on 12/12/2024 at 7:10 pm documenting Change texture to Mechanical Ground and an additional message documenting no raw fruit/vegetables. During an interview on 1/10/2025 at 2:27 PM, the Speech Language Pathologist stated they were asked to evaluated Resident #1 on 12/12/2024 after Resident #1 had a choking episode on 12/10/2024. The Speech Language Pathologist stated Resident #1 did not have any swallowing problems prior to 12/10/2024 and that 12/12/2024 was the first time they evaluated Resident #1. The Speech Language Pathologist stated they agreed with the diet downgrade to mechanical soft with no raw fruits or vegetables. During an interview on 1/10/2025 at 2:58 PM, the Medical Doctor stated they were informed that Resident #1 had a choking incident on 12/10/2024 and 12/12/2024. The Medical Doctor stated Resident #1 should not have received the raw lettuce and raw tomato on 12/12/2024 because there was a physician's order dated 12/10/2024 indicating Resident #1 could not have raw fruits and vegetables. The Medical Doctor stated on 12/12/2024 after they were informed that Resident #1 ingested raw lettuce and tomato and had difficulty breathing, they provided an order for Resident #1 to have a chest x-ray to rule out aspiration (accidental inhalation of foreign materials, such as food into the lungs) which could lead to respiratory distress. During a concurrent interview on 1/10/2025 at 3:49 PM, the Director of Nursing Services they stated when a diet change is made to a resident's diet it must be transmitted to the kitchen and by the next meal the change should be initiated. The Director of Nursing Services stated the lettuce was meant to be a garnish and was not meant for consumption. The Director of Nursing Services was directed to the recipe which indicated the green as part of the recipe. The Director of Nursing Services stated Resident #1 should not have received the salad because Resident #1's diet order and meal ticket indicated no raw fruits or vegetables. During an interview on 1/13/2025 at 3:54 PM, Certified Nursing Assistant #2 stated they were the assigned Certified Nursing Assistant for Resident #1 on the evening shift on 12/12/2024 and they were in the dining room when Dietary Aide #1 observed Resident #1 having difficulty breathing. Certified Nursing Assistant #2 stated Resident #1 normally ate independently and did not recall them having a special diet before the choking incident on 12/10/2024. Certified Nursing Assistant #2 stated the dietary aides are responsible for taking resident meal orders and are supposed to check the meal tickets when the residents are served the meal. Certified Nursing Assistant #2 stated that they should not eat raw fruits and vegetables if that is what is indicated on the meal ticket because the resident could choke if they get the wrong food consistency. During an additional interview on 1/27/2025 at 1:04 PM, the Dietary Manager stated once the kitchen received an electronic message regarding a diet change the meal service software was updated. The Dietary Manager stated there were no messages in the messaging system on 12/10/2024 regarding Resident #1's diet downgrade. The Dietary Manager stated meal tickets are printed for the coming week and not daily so the handwritten notation on Resident #1's meal ticket on 12/12/2024 indicating no raw fruits or vegetable should have been followed and Resident #1 should not have received the salad portion of the meal. The Dietary Manager stated there was a communication log in Resident #1's dining room and the dietary aides should read it prior to meal service for diet changes. The communication log indicated that Resident #1 had a diet change and was not to have raw fruits or vegetables. The Dietary Manager stated the dietary aides should initial each note indicating they have read the note. The Dietary Manger stated there was one set of initials next to the note for Resident #1, but they could not determine the Dietary Aide the initials corresponded to. During an interview on 1/27/2025 at 2:21 PM, Registered Nurse #1 stated they were present on 12/10/2024 during the incident and gave Resident #1 abdominal thrusts. Resident #1 was choking on the cucumber salad. Registered Nurse #1 stated they initiated a change in Resident #1's diet order indicating a mechanically altered diet and no raw fruits or vegetables and they asked the Dietary Manager to write a note in the communication log in the dining room. The log would indicate that Resident #1's diet was changed. Registered Nurse #1 stated they wrote a Nursing Progress Note on 12/10/2024 related to Resident #1's choking on the cucumber salad. Registered Nurse #1 stated the Nursing Progress Note was dated 12/13/2024 because they made a correction to the progress note on 12/13/2024 but were unable to recall the correction they made. During an interview on 1/27/2025 at 2:39 PM, the Dietary Supervisor stated they are responsible for initiating dietary changes in the dining software. The Dietary Supervisor stated the dietary aides are to read the communication book in the dining room prior to meal service so they are aware of any changes in the resident diets. The Dietary Supervisor stated the meal tickets are printed once a week and if any changes occurred after they were printed, they (the Dietary Supervisor) made a handwritten notation at the bottom of the meal ticket. The Dietary Supervisor stated they wrote the no raw fruits/vegetable at the bottom of Resident #1's dinner meal ticket dated 12/12/2024. The Dietary Supervisor stated Resident #1 should not have received a salad. During an interview on 1/27/2025 at 2:54 PM, the Dietician stated if there is a change in a resident's diet they informed the Dietary Manager of the change. The Dietician stated Resident #1 should not have received salad if the resident's diet indicated no raw fruits or vegetables. The Dietician stated a resident could have difficulty swallowing and choke if they received the incorrect consistency food. 10 NYCRR 415.12(h)(1)

Based on observation, record review and staff interviews conducted during the Recertification survey initiated on 12/7/2023 and completed on 12/13/2023, the facility did not ensure that services provided by the facility as outlined in the Comprehensive Care Plan (CCP) must meet professional standards of quality. This was identified for two (Resident # 9, Resident # 33) of seven residents observed during the Medication Administration Task. Specifically, 1) Resident # 9 was receiving Lovenox (an anticoagulant medication) subcutaneously (under the skin). The Nursing staff were not rotating the Subcutaneous (sq) injection sites. and; 2) Licensed Practical Nurse (LPN) #2 was observed administering medications from the medication cart that were pre-poured into a medication cup for Resident # 33. The findings are: The Policy and Procedure for Injection Site Rotation dated February 2019 documented to record the site when subcutaneous injections are given. 1). Resident # 9 was admitted with diagnoses that included Respiratory Failure and Acute Embolism and Thrombosis of left Femoral Vein. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 99 which indicated severe cognitive impairment. The resident received 7 days of anticoagulants and 7 days of injections during the MDS look-back period. The physician's order dated 10/31/2023 documented to administer Enoxaparin (Lovenox) 80 milligrams (mg)/0.8 miliLiter(mL) subcutaneous syringe- inject 0.8 milliliter (80 mg) by subcutaneous route every 12 hours for an unspecified diagnosis. On 12/8/2023 at 9:20 AM, during a medication administration observation, Resident #9's abdomen was observed with multiple ecchymosis (bruising) to the abdomen. A review of the Medication Administration Record (MAR) from November 1, 2023, to December 10, 2023 revealed the injection site of Enoxaparin was not documented except on December 8, 2023 at 8 AM. The Medication Nurse, Licensed Practical Nurse (LPN) # 1 from the 7AM - 3PM nursing shift, was interviewed on 12/11/2023 at 2:13 PM. LPN #1 stated that the Lovenox is given subcutaneously, the site should be documented on the MAR, and injections should be rotated. The site was not documented on the MAR as it should have been. LPN #1 further stated that they would not know where the previous shift had administered the Lovenox subcutaneous medication because the injection site was not documented on the MAR. The Director of Nursing Services (DNS) was interviewed on 12/11/2023 at 2:50 PM and stated the site of Lovenox administration should be documented and rotated. The medication should not be given to the same site on consecutive days to prevent bruising and injuries to the resident. The resident's Physician was interviewed on 12/13/2023 at 1:03 PM and stated if the subcutaneous injection of Lovenox is not rotated bleeding, pain, and tissue damage can occur. 2) The policy and procedure for Administering Medications dated 12/7/2023 documented medications may not be administered in advance. Resident #33 has diagnoses that include Dementia and Hypertension. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 99 which indicated severe cognitive impairment. The resident was receiving a diuretic and antipsychotic medications. The physician orders dated 3/23/2022 documented -May Crush Meds Together as Manufacturer Allows and Mix with applesauce or pudding. On 12/08/2023 at 10:33 AM, Licensed Practical Nurse (LPN) # 2 was observed administering scheduled morning medications from a souffle cup stored in the top drawer of the medication cart. LPN #2 was asked why the medications were pre-poured/dispensed into the souffle cup. LPN #2 did not provide a comment and shrugged their shoulders. LPN #2 stated they were poured previously on their shift. The LPN stated the medications should have been given after being poured. All the medications were crushed together and mixed with applesauce. The Medication Administration Record (MAR) for December 2023 documented on December 8, 2023, the morning medications included Seroquel (antipsychotic medication) 25 milligrams (mg) tablet; Tylenol (pain and fever reducer) 325 mg x 2 tablets (650 mg); Senna (bowel medication) 8.6 mg tablet x 2 tablets (17.2 mg); Namenda (cognition-enhancing medication) 10 mg x 1 tablet; Multi vitamin with minerals- 1 tablet; Lasix (diuretic) 20 mg 1 tablet; and Depakote sprinkles (anti-epileptic medication) 125 micrograms (mcg) 1 capsule. The Director of Nursing Services (DNS) was interviewed on 12/13/2023 at 2:43 PM and stated LPN #2 should have administered the medications immediately to the resident after the medication is dispensed from the blister packs or bottles. Medications should not be poured and then stored in the medication cart to be given at a later time. This can contribute to a Medication error. The Physician was interviewed on 12/13/2023 at 12:47 PM and stated that Nurses should administer medications immediately after it is dispensed from the bottle or packets. Medications should not be dispensed and stored in the cart to be administered at a later time to minimize the risk for errors. 10 NYCRR 415.11(c)(3)(i)

Based on record review, observation, and interviews during the Recertification Survey from 12/7/23 to 12/13/23 and Abbreviated Survey (Complaint #NY 00327126), the facility did not ensure each resident received adequate supervision and assistance according to the plan of care to prevent accidents. This was identified for two (Resident #5 and Resident #19) of three residents reviewed for Accidents. Specifically, 1) Resident #5's care plan documented the resident required floor mats at their bedside to prevent injuries. Resident # 5 had a fall on 12/5/2023 and the Certified Nursing Assistant (CNA) # 1 did not apply the bilateral floor mats as per the Comprehensive Care Plan (CCP). 2) Resident #19 was observed with multiple bottles of supplements and an eye drop bottle on their windowsill. Resident #19 did not have a physician's order for the identified supplements and the eye drops and was not assessed to safely self-administer the medications and supplements. The findings are: The floor mats policy dated 9/1/2023 documented it is the policy of the facility to provide and use floor mats as per the physician's request to prevent injury of residents who might migrate out of the bed. The use of floor mats will be documented in residents' Plan of Care and CNA care plan. 1) Resident # 5 has diagnoses that include unspecified Dementia with behavioral disturbance and Hypertension. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident's Cognitive Skills for daily decision-making skills were severely impaired. The Physician Order dated 11/21/2023 document to place floor mats to both sides of the bed. The Fall/Injury CCP dated 06/17/2020 documented the resident had a potential for falls and injuries as evidenced by a history of falls, secondary to impaired mobility, and Dementia. Interventions included to apply bilateral floor mats when the resident was in bed. The Certified Nursing Assistant (CNA) care plan dated December 2023 documented to place floor mats on the right and the left side of the bed every day 7:00 AM to 3:00 PM, 3:00 PM to 11:00 PM, and 11:00 PM to 7:00 AM. The Incident/ Accident report dated 12/5/2023 documented that at approximately 4:15 PM the resident was found lying on their back on the floor in their room next to the bed. The resident is care planned to have the bed in the lowest position and have floor mats placed next to the bed in the event he would migrate from the bed. When the CNA placed the resident to the bed, the CNA did not place the floor mats down next to the bed. The CNA (CNA #1) was called immediately and admitted that they had forgotten to place the floor mats in position. CNA #1 was interviewed on 12/13/2023 at 11:48 AM and stated on 12/5/2023 they were the assigned CNA during the 7 AM to 3 PM for Resident # 5 and forgot to put the floor mats down. CNA #1 stated I made a mistake, I forgot to put them down. I didn't follow the care plan. The Director of Nursing Services (DNS) was interviewed on 12/13/2023 at 12:25 PM and stated the investigation concluded that the CNA did not follow the CCP. CNA #1 should have followed the CCP to prevent injuries to the resident. The Physician was interviewed on 12/13/2023 at 1:00 PM and stated that the resident requires floor mats to prevent an injury in the event that a fall happens. 49457 2) The facility policy titled Self-Medication dated January 2023 documented that should the interdisciplinary team determine that the resident is safe to administer their own medications, and the resident wishes to do so, the resident will be provided with a locked receptacle to store the medications. The interdisciplinary team will assess each resident's mental, physical, and visual ability to determine if the resident is capable of self-administration of medications, and until a decision is made by the interdisciplinary team, medications will continue to be administered in accordance with facility policies governing the administration of medications. Resident #19 was admitted with diagnoses including Vitamin B12 Deficiency Anemia, Vitamin D Deficiency, Calcium Deficiency, and Dry Eye Syndrome. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 15 which indicated the resident had intact cognition. During an observation on 12/7/2023 at 12:26 PM, the following was observed on Resident #19's windowsill: -A bottle of Calcium 600 + D (3) 600 milligrams-5 micrograms (200 unit) tablet. -A bottle of an Eye Health Plus Lutein 300 micrograms-200 milligrams-27 milligrams-2 milligrams tablet. -A bottle of Vitamin B-12 Extended Release 1,000 micrograms tablet, -A bottle of the Lubricating eye drops 0.5 %. Resident #19 was interviewed on 12/07/2023 immediately after the observation of the multiple bottles placed on their windowsill. Resident #19 stated they lived independently in an apartment on the grounds of this facility prior to being admitted to the facility after a fall. Resident #19 stated they self-administered their medications at home, and they continue to do so since admission to the facility on [DATE]. Resident #19 stated they have been keeping these medications on the windowsill in their room and self-administering them daily since admission on 10/17/2023. Resident #19 stated that facility staff have not spoken to them about these medications at all. The medical record was reviewed and there were no physicians' orders for the supplements and eye drops found on the windowsill. Registered Nurse (RN) #1, the charge nurse, was interviewed on 12/13/2023 at 1:50 PM and stated the facility policy is to call the resident's doctor upon identifying medications in the resident's personal possession. RN #1 states, they were unaware that Resident #19 was self-administering medications and storing them in their room. Physician #1 was interviewed on 12/13/2023 at 12:30 PM and stated they were unaware that Resident #19 was storing medications or eye drops on the windowsill in their room or that they were self-administering the medications prior to today (12/7/2023). Physician #1 stated that it is the facility's policy that the Physician should be made aware of all medications, including supplements and eye drops, that a Resident is taking. 10 NYCRR 415.12(h)(1)

Based on observations, record review, and staff interviews during the Recertification Survey initiated on 12/7/2023 and completed on 12/13/2023, the facility did not ensure that an Infection Prevention and Control Program (IPCP) designed to help prevent the development and transmission of infection was maintained. This was identified for two (Resident # 5 and Resident # 16) of seven residents observed during the Medication Administration Task. Specifically, during observation of the Medication Administration, Licensed Practical Nurse (LPN) #2 did not wash their hands according to the Center for Disease Control (CDC) guidance after rendering care to Resident # 5. Additionally, LPN #2 touched the medication tablet using their bare hands to pick up medication for Resident # 16. The findings are: The facility's policy for Hand Washing dated November 2017 documented hand washing shall be regarded as the single most important means of preventing the spread of infection. Employees must perform appropriate (20) second hand washing procedure under the following conditions including but not limited to before preparing and handling medications. Resident # 5 had diagnoses that include unspecified Dementia with Behavioral Disturbance and Hypertension. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident had severely impaired cognitive skills for daily decision making. Resident # 16 had diagnoses that include Hypertension, Hyponatremia, and Bipolar Disorder. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had intact cognition. Licensed Practical Nurse (LPN) # 2 was observed washing their hands, after a medication pass, in Resident # 5's bathroom on 12/8/2023 at 10 AM. LPN #2 performed hand washing for less than 7 seconds. After washing their hands LPN #2 turned the faucet off by using their bare hands and then used a paper napkin to dry their hands. LPN #2 then proceeded to leave the bathroom to render care to the next resident. LPN #2 was interviewed on 12/8/2023 immediately after the observation and stated that they are supposed to wash their hands for at least 30 seconds while singing a song. LPN #2 was not able to state why they did not wash their hands for a full 30 seconds. LPN #2 did not comment when they were informed of the observation of them not using a barrier to turn off the faucet after washing their hands. LPN #2 was observed on 12/12/2023 at 9:10 AM administering a Calcium Carbonate tablet to Resident # 16. The tablet fell directly onto the surface of the medication cart. LPN #2 picked up the medication tablet with their bare hands and then administered the medication to Resident #16. LPN #2 was interviewed on 12/12/2023 immediately after the observation of them picking up a medication with their hands. LPN #2 did not comment on the observation. The Director of Nursing Services (DNS), who was also the Infection Preventionist, was interviewed on 12/13/2023 at 1:26 PM and stated LPN #2 should have washed their hands for a minimum of 15 to 20 seconds. LPN #2 should have turned off the faucet using a paper towel instead of using their bare hands. LPN #2 should not have used their bare hands to touch medications and should have disposed of the medication if the medication came in contact with the surface of the medication cart because the medication cart could be dirty. The Attending physician was interviewed on 12/13/2023 at 1:20 PM and stated not washing hands properly can cause the spread of infection. If the nurse does not wash their hands properly and do not dispense medications properly, this can contribute to a spread of germs and or viruses. 10 NYCRR 415.19(b)(1-4)

Based on observation, record review, and interviews during a Focused Infection Control Survey conducted on 12/28/2022 the facility failed to maintain an infection prevention and control program (IPCP) designed to help prevent the development and transmission of communicable diseases and COVID-19 infection. Specifically, Certified Nursing Assistant (CNA) #1 did not utilize appropriate Personal Protective Equipment (PPE) when entering a COVID-19 positive resident's room. The finding is: The facility Infection Control policy and procedure last updated 8/8/2022 documented for Standard, Contact, and Droplet Precautions, eye protection will be used by Healthcare Personnel (HCP) who enters the room of a resident who is either confirmed or suspected of having COVID-19. The policy further documented when available, HCP will use an N95 filtering facepiece respirator before entering the room or care area of a Person Under Investigation (PUI) or confirmed COVID-19 positive resident. Resident #1 has diagnoses that include COVID-19 infection, Coronary Artery Disease, and Hypertension. An annual Minimum Data Set (MDS) assessment dated [DATE] documented the resident had short and long-term memory problems and required assistance for all Activities of Daily Living (ADL). A Physician's order dated 12/21/2022 documented that Resident #1 was placed on droplet precautions for 10 days. A Comprehensive Care Plan dated 12/21/2022 for Actual Viral Infection documented Resident #1 was positive for COVID-19 infection. Interventions included to implement precautions and utilize proper PPE as indicated. The CCP note section documented the resident was positive for COVID-19 infection by Polymerase Chain Reaction (PCR) testing and to implement Droplet precautions for 10 days. During a tour of the [NAME] unit on 12/28/2022 at 1:57 PM, CNA #1 was observed walking down the hall toward Resident #1's room wearing a surgical mask. A sign was observed on Resident #1's door that documented Contact and Droplet Precautions. CNA #1 donned (put on) a gown and a pair of gloves outside the resident's room and then entered Resident #1's room. CNA #1 did not put on eye protection and an N95 mask before entering Resident #1's room. Prior to leaving the resident's room CNA #1 doffed (took off) the gown and gloves and then exited the room wearing a surgical mask. CNA #1, who worked on the 7:00 AM - 3:00 PM shift and cared for Resident #1 on 12/28/2022, was interviewed on 12/28/2022 at 2:05 PM. CNA #1 stated that they (CNA #1) were informed during the morning report that Resident #1 was COVID-19 positive, and they (CNA #1) observed the precaution sign on the resident's door prior to entering the resident's room. CNA #1 stated that they also received in-service education regarding the use of proper PPE when caring for a COVID-19 positive resident. CNA #1 was unable to state why they (CNA #1) were not wearing eye protection and an N95 mask prior to entering Resident #1's room. The Registered Nurse (RN) Staff Educator was interviewed on 12/28/2022 at 2:23 PM. The RN Staff Educator stated all staff were in-serviced on the use of appropriate PPE for residents who are on Transmission Based Precautions (TBP) such as residents who are on Droplet and Contact Precautions. The in-service education was conducted in November 2022 and remains ongoing. The RN Staff Educator stated that full PPE is required when caring for a COVID-19 positive resident. The RN Staff Educator further stated that CNA #1 should have put on an N95 mask and eye protection prior to entering Resident #1's room. The Assistant Director of Nursing Services (ADNS) was interviewed on 12/28/2022 at 2:52 PM and stated that N95 masks are kept at the nurse's station for staff use. The ADNS stated staff were educated to don an N95 with a surgical mask, face shield or goggles, gown, and gloves prior to entering the room of a COVID-19 positive resident. The ADNS further stated that CNA #1 should have been wearing an N95 mask and eye protection prior to entering Resident #1's room. The Administrator was interviewed on 12/28/2022 at 3:16 PM. The Administrator stated all staff were educated on the appropriate PPE to be worn when going into a COVID-19 positive resident's room. The Administrator stated extra N95 masks are kept at the nurse's station and on the PPE cart. The Administrator further stated CNA #1 should not have entered Resident #1's room without an N95 mask and eye protection. NYCRR 415.19(a)(1-3)

Based on observation, record review, and staff interviews during the recertification survey, the facility did not ensure that a bladder assessment was completed for a resident who was identified with a decline in bladder function. This was identified for one (Resident #5) of one resident reviewed for bladder and bowel incontinence. Specifically, the Admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident was continent of bladder. The subsequent MDS Assessments dated 6/16/19 and 9/8/19 documented the resident was frequently incontinent of bladder. There was no documented evidence that a bladder assessment was conducted to address the root cause for the decline in the resident's bladder function. The finding is: Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission MDS assessment dated [DATE] documented the resident had short and long-term memory problems, was independent for transfers and required supervision with set up help of one staff member for toileting. The MDS further documented the resident was continent of bladder and was not on a toileting program. The Quarterly MDS assessment dated [DATE] documented the resident was independent for transfers, required extensive assist of two staff members for toileting and was frequently incontinent of bladder. The Significant change MDS assessment dated [DATE] documented the resident required extensive assist of one staff member for transfers and was frequently incontinent of bladder. An Admission Assessment Form dated 3/19/19, documented in the section of the assessment titled Continence, that the resident did not have a Foley catheter, and did not indicate the resident was incontinent of bladder. The base line Resident Care Plan dated 3/19/19 to 3/22/19 documented the resident uses the toilet. A Comprehensive Care Plan (CCP) dated 3/19/19 documented the resident was incontinent of bladder and can be continent at times. The CCP was updated on 6/24/19 and documented the resident was frequently incontinent of urine and that this was not a decline as the resident had Dementia and was variable. During an interview conducted on 9/27/19 at 10:32 AM with the 7:00 to 3:00 PM Certified Nursing Assistant (CNA), she stated that she has cared for the resident from admission. The CNA stated that she observed the resident had a change in her ability in her ADLs and reported the change to the nurse. The CNA stated on admission the resident was dressing herself with supervision, was walking in her room and to the bathroom. The CNA stated that the resident was continent of bladder and knew when she wanted to use the bathroom, and now the resident was incontinent of bladder and does not know when she needs to use the bathroom. The CNA further stated that the resident now wears a diaper and was on a toileting program. During an interview conducted on 9/27/19 at 11:30 AM with the MDS Registered Nurse (RN), she stated the RN that completed the MDS was not available, however, according to the documentation in the care plan history, on admission the resident was continent of bladder. The RN stated the resident was noted to have a decline in bladder function when the Quarterly MDS Assessment was completed and that the change in bladder was updated on the CCP to reflect the resident was now incontinent. During the interview the RN was asked if a bladder assessment was completed to determine the cause for the decline in the resident's bladder function. The RN stated that the facility does not have a bladder assessment that is used when a resident is identified with a decline in bladder function and to her knowledge an assessment was not completed when a decline in bladder function was identified. The MDS RN stated when the CCP was initiated, it was not indicated on the CCP that the resident was continent of bladder, however, it was documented in the care plan history that the resident was continent of bladder on admission. During an interview conducted on 9/27/19 at 11:50 AM with the Director of Nursing Services (DNS), she stated that a bladder assessment was not completed when the resident was identified with a decline in bladder function. The DNS was unable to say why a bladder assessment was not completed and who was responsible for completing the assessment. During an interview conducted on 9/27/19 at 12:18 PM with the Nurse Practitioner (NP), she stated that when the resident was admitted she had a decline in cognitive ability which led to the resident's change in activities of daily living and her requiring more staff assistance. The NP was unable to say why a bladder assessment was not completed when the resident was identified with a decline and that she did not complete a bladder assessment. The NP further stated she was unable to say if the Physician completed an assessment to determine the cause of the resident's decline in bladder function. During an interview conducted on 9/27/19 at 12:33 PM with the Physician, he stated that he was aware of the resident's decline in bladder function and that it was expected due to the resident [DIAGNOSES REDACTED]. The Physician stated that he did not complete a bladder assessment for the resident and that it made sense to complete a bladder assessment to determine the underlying cause for the decline. 415.12(d)(2)

Based on record review and staff interview during the recertification survey, the facility did not ensure that a Comprehensive Care Plan was developed that includes measurable objectives and timeframes to meet each resident's medical needs. This was evident for one of two residents reviewed for nutrition in a total of nineteen Stage 2 sampled residents. Specifically, in an initial nutritional assessment Resident #93 was identified as being at high risk for weight loss, dehydration and pressure ulcer development and there was no documented evidence that a nutrition CCP was developed that identified the resident's risk factors for weight loss. The finding is: Resident #93 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged to home on 10/6/16 and was readmitted on [DATE]. An Admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental (BIMS) Score as 15 which indicated intact cognition. The resident required set up help only for eating. The resident's height was 59 inches and the resident's weight at this time was 114 pounds (lbs). The resident had no problem eating or swallowing. The resident had no weight loss at this time. A 5-Day assessment dated [DATE] documented a BIMS of 15, and no mood or behavior problems. The resident required set up help only for eating, had a weight loss and was not on a physician-prescribed weight loss program. The resident's weight was 108 lbs. A Dietary History and Assessment initiated on 9/21/16 and completed 9/27/16 documented in the Pertinent Nutritional [DIAGNOSES REDACTED].*) next to it puts the resident at high risk for weight loss and dehydration. The box next to Depression was checked indicating that the resident had a [DIAGNOSES REDACTED]. A review of the medical records was conducted on 12/13/16 and there was no documented evidence that a nutrition CCP was developed that reflected the resident's risk factors for weight loss during the resident's initial stay in the nursing home. The medical record revealed a nutrition CCP was developed after the resident was readmitted to the nursing home. The resident's electronic weight record documented the resident was readmitted on [DATE]. On 9/30/16 the resident weighed 117 pounds and on 11/2/16 after admission the resident's weight was 108 pounds. An interview was conducted on 12/13/16 at 2:18 PM with the Registered Dietitian (DTR). The DTR stated that a care plan was not initiated because the resident did not trigger for Nutrition. The DTR stated that on admission a CCP was not initiated because the resident was eating well and her skin was intact. The DTR stated that when she completed the initial assessment on the resident, the resident was not assessed to be at risk for weight loss. The DTR stated the resident's weight and intake was being monitored but there was no goal as the resident was eating well and had no skin issues. A subsequent interview was conducted on 12/14/16 at 10:56 AM with the DTR. A review of the initial Nutritional Assessment was conducted with the DTR and it was documented the resident had a [DIAGNOSES REDACTED]. When the DTR was asked should she have developed a Nutrition CCP she stated a CCP should have been developed or an explanation documented in the comment box why a CCP was not developed. 415.11(c)(1)

Based on observation, record review and staff interview during the recertification survey, the facility did not ensure that each resident's medication regimen was free from unnecessary medication. This was evident for one (Resident #34) of five residents reviewed for unnecessary medication in a total of twenty four Stage 2 sampled residents. Specifically, Resident #34 has order for [MEDICATION NAME] 0.5 mg two time daily without an appropriate indication for the use of the medication or documented evidence that a Gradual Dose Reduction (GDR) was attempted. The finding is: Resident #34 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The resident was observed on 11/18/15 at 11:00 AM in an activity program and again on 11/20/15 at 10:00 AM in the main dining room. There were no signs of behavior observed. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) Score as (14) which indicates intact cognition. The resident has mood symptoms but no behavior symptoms. The resident required limited to extensive assist of one staff for all areas of Activities of Daily Living (ADL) and is frequently incontinent of urine. A Comprehensive Care Plan (CCP) dated 9/22/15 for [MEDICAL CONDITION] drug use documented the resident is prescribed [MEDICATION NAME] for [DIAGNOSES REDACTED]. Interventions include periodic review of drug and dose reduction as indicated. A physician's orders [REDACTED]. A Psychiatry consult dated 5/27/15 documented the resident is an [AGE] year old female with prior history of hallucinations. The resident also has a history of Stroke with visual field deficit. The resident was referred for sad mood and slow mentation. [MEDICATION NAME] is ordered for visual disturbance but no recent GDR. The resident is not suicidal or combative and no hallucination now. The Psychiatrist recommended to reduce [MEDICATION NAME] to 0.25 mg every morning and keep 0.50 mg every hour of sleep for [MEDICAL CONDITION]. A review of the medical record was conducted on 11/20/15 and there no documented evidence that a GDR was attempted. A Neurologist Review dated 5/29/15 was reviewed. The Neurologist documented the resident developed visual hallucination one to two days after an occipital infarct in early August 2011. The Neurologist documented the hallucination became very frightening in 2012 and that the resident was started on [MEDICATION NAME] and the hallucination completely resolved. The Neurologist stated that she was ok with the GDR from [MEDICATION NAME] 0.5 mg to 0.25 mg every morning. However if the resident has break through frightening hallucination during the day she recommend going back up to [MEDICATION NAME] 0.5 mg in the morning. A Consultant Pharmacy review dated 9/23/15 documented the resident has an order for [REDACTED]. The review further documented [MEDICATION NAME] does not have an FDA approved indication for Visual Disturbance. In the Physician response section, the Physician checked the options to continue the [MEDICATION NAME] with current indication, for behavioral symptoms of pacing and inappropriate response to verbal communication. An interview was conducted on 11/20/15 at 10:24 AM with the Neurologist who stated that she started the resident on [MEDICATION NAME] in 2012 due to visual hallucination related to [MEDICAL CONDITION]. The Neurologist stated that in the past the resident developed very frightening hallucination right after an Occipital Infarct. The Neurologist stated that the hallucinations was resolved however she was in agreement with the reduction of the morning dose of [MEDICATION NAME] from 0.5 mg to 0.25 mg. The Neurologist stated that she did not know why the reduction was not attempted. An interview was conducted on 11/20/15 at 11:34 AM with the resident's Physician. The Physician stated that the resident was on [MEDICATION NAME] for visual hallucination. The Physician stated that a GDR was not attempted secondary to the Neurologist recommendation and that she refers to the Neurologist for all recommendation regarding the [MEDICATION NAME]. When the Physician was questioned regarding the Neurologist Review dated 5/29/15 the Physician stated that she was not aware of the Neurologist agreement with the recommendation to reduce the [MEDICATION NAME]. The Physician further stated had she seen the review that she would have attempted the reduction. 415.12(1)(1)

Based on record review and staff interview during the recertification survey, the facility did not ensure that the Comprehensive Care Plan (CCP) was reviewed and revised after a decline in the resident's urinary status. This was evident for one of one resident reviewed for urinary incontinence in a total of 26 stage 2 sampled residents. Specifically, Resident #24 had a decline in urinary status from occasionally incontinent to frequently incontinent and there was no documented evidence in the CCP reflecting the decline. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The finding is: Resident #24 has [DIAGNOSES REDACTED]. A 5-Day Minimum Data Set (MDS) assessment dated [DATE] documented the resident was occasionally incontinent of urine, required extensive assist of two staff for transfer and extensive assist of one staff for toileting. A Quarterly MDS assessment dated [DATE] documented the resident's cognition was moderately impaired. The resident required extensive assist of two staff for transfer, extensive assist of one staff for toileting and was frequently incontinent of urine. A CCP for Urinary Continence/Indwelling catheter dated 6/18/13 documented the resident was continent of bowel and bladder and needed help with toileting. The goals is that the resident will remain continent of bowel and bladder with staff assist of staff. On 9/20/13 the CCP was updated to say that the goals were met and to continue present plan of care. There was no documentation in the CCP regarding the resident's decline in urinary status. An interview was conducted on 11/1/13 at 10:21 with the day shift Certified Nursing Assistant (CNA). The CNA stated that the resident was continent of both bowel and bladder however since the decline in the resident's condition there has been a change in the resident urinary status. The CNA stated that for the past two months the resident has frequent episodes of urinary incontinence and wears a brief. An interview was conducted on 11/1/13 at 11:05 AM with the Director of Nursing Services (DNS). The DNS stated that the MDS Coordinator was responsible for updating the CCP and that the CCP should have been updated to reflect the resident change in urinary status. The MDS Coordinator was not available for interview. 415.11(c)(2)(i-iii)

Based on record review and staff interviews during the standard survey the facility did not ensure that non pharmacological interventions were attempted prior to the increase of an Antipsychotic medication. This was evident for one of five residents reviewed for unnecessary medications. (Resident #37) This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The finding is: Resident #37 is an [AGE] year old resident with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 9 ( cognition impaired). The MDS also documented that the resident had no behavior concerns and received 7 antipsychotic medications. A Psychiatry Progress Note (PPN) dated 10/9/13 documented to continue [MEDICATION NAME] 25 milligrams (mg) two times a day and that the resident is stable. The PPN also documented to do a gradual dose reduction on the Antidepressant medication. Nursing Progress Notes (NPN) dated 10/15/13 through 10/23/13 had no documented behavior concerns. A NPN dated 10/24/13 at 9:42 PM documented that the Registered Nurse (RN) received a phone call from the resident's husband that the resident had a change in behavior and that she struck her private aide during care. A NPN dated 10/25/13 documented that the resident has been more irritable in the evening when her husband visited. The NPN also documented that the resident's daughter believes that it is because the antidepressant medication dose was reduced. The NPN also documented that the daughter wants the antidepressant medication dose restored. A Physician order [REDACTED]. A NPN dated 10/25/13 documented that the resident had an increase in [MEDICATION NAME] to 50 mg two times a day due to aggressive behavior. There is no documented evidence in the medical record that the facility provided non pharmacological interventions prior to the increase of the antipsychotic medication [MEDICATION NAME]. An interview was held with the Assistant Director of Nurses (ADNS) on 11/1/13 at 10:15 AM. The ADNS reviewed the medical record and stated there is no documented evidence that non pharmacological interventions were attempted prior to the increase of the antipsychotic medication but that the family requested the medication. 415.12(1)(1)

Based on record review and staff interviews during the standard survey the facility did not ensure that a resident, that was admitted to the facility without an order for [REDACTED]. Specifically, Resident #47 was admitted to the facility on [DATE] and was given an [MEDICAL CONDITION] medication without documented evidence that non pharmacological interventions were attempted. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The finding is: Resident # 47 is a [AGE] year old resident who was admitted to the facility on [DATE] for long term care with [DIAGNOSES REDACTED]. A Patient Review Instrument (PRI) (a patient evaluation prior to admission to a long term care facility) dated 7/30/12 had no documented evidence that the resident was receiving [MEDICAL CONDITION] medication or had a history of [REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 7 (severely impaired). The MDS also documented that the resident had [DIAGNOSES REDACTED]. The MDS further documented that the resident had no behavior concerns and received antipsychotic medications. A Progress Note (PN) dated 8/22/12 at 7:18 PM documented that the resident was attempting to ambulate with a walker and that the resident was attempting to go back to his apartment upstairs located in the same building. The PN also documented that the resident was evaluated by the Psychiatrist and that [MEDICATION NAME] 25 milligrams (mg) at 12:00 PM and at bedtime was ordered. A Psychiatrist Consultation Report (PCR) dated 8/22/12 documented that the resident was upset about being here, trying to elope and was anxious. The PCR also documented to initiate [MEDICATION NAME] 25 mg twice a day. A physician's orders [REDACTED]. A Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There is no documented evidence in the medical record that the facility provided non pharmacological interventions prior to the initiation of an antipsychotic medication. An interview was held with the Certified Nursing Assistant (CNA) on 9/18/12 at 9:30 AM. The CNA stated that the resident has not displayed any physical behavior concerns. The CNA also stated that the resident is cooperative with care. An interview was held with the Assistant Director of Nurses (ADNS) on 9/18/12 at 10:15 AM. The ADNS reviewed the medical record and stated there is no documented evidence that non pharmacological interventions were attempted prior to the initiation of the antipsychotic medication. 415.13(1)(1)