Every finding on record at Penn Yan Manor Nursing Home Inc

Based on interviews and record review conducted during the Recertification Survey the facility did not ensure that the completion of a discharge summary that included a recapitulation of the residents stay, a final summary of the resident's status and a post-discharge plan was completed for one (Resident #40) of one resident reviewed. Specifically, the resident was discharged without a complete discharge summary to ensure the facility communicated the necessary information to the resident, the continuing care provided and the resident representative (if applicable) at the time of discharge. The finding is: The undated policy and procedure Discharge Summary and Plan provided by the Administrator, documented when a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed. The discharge summary will include a recapitulation of the resident's stay at the facility and a final summary of the resident's status at the time of discharge. A post-discharge plan will be developed by the care planning/interdisciplinary team with the assistance of the resident. Resident #40 had diagnoses including diabetes mellitus, anemia, and atrial fibrillation (abnormal heart rhythm). The Minimum Data Set (MDS - a resident assessment tool) dated 1/8/24 documented the resident was cognitively intact and wanted to be asked on all assessments about returning to the community. Resident #40 current Comprehensive Care Plan documented no discharge planning focus areas or discharge planning interventions. The discharge planning visit dated 1/30/24 completed by Physician #1 documented Resident #40 was stable for discharge to home on 1/31/24 with the support of family/others. The Social Work Discharge Summary Note dated 1/31/24 completed by Social Worker #1 documented Resident #40 was discharged to home with family. The Voluntary Discharge form dated 1/31/24 and signed by Resident #40, Social Worker #1, and Registered Nurse Manager #1 documented a list of current medications and primary care provider follow-up appointment was provided to the resident. Additionally, prescriptions were sent to their pharmacy. Review of the electronic medical record and the paper medical record revealed no documentation that a discharge summary including a recapitulation of the resident's stay at the facility, a final summary of their status, and a post-discharge plan of care was completed for Resident #40. During an interview on 4/23/24 at 7:43 AM Registered Nurse Manager #1 stated they provide a list of current medications and administration times to residents when they are discharged from the facility. During an interview on 4/24/24 at 8:11 AM Social Worker #1 stated the Voluntary Discharge form (which includes follow-up appointments, outpatient services if needed, and whether prescriptions were sent to pharmacy) is provided to the resident and/or responsible party upon discharge from the facility. During an interview on 4/24/24 at 8:23 AM Occupational Therapist #1 stated they verbally review any discharge instructions with the resident, but do not provide any written discharge instructions upon discharge from the facility. During an interview on 4/24/24 at 8:25 AM Physical Therapist #1 stated they verbally review any discharge instructions with the resident, but do not provide any written discharge instructions upon discharge from the facility. During an interview on 4/24/24 at 8:45 AM Registered Dietician #1 stated they do not provide any written discharge to residents upon discharge from the facility. During an interview on 4/25/24 at 8:12 AM the Director of Nursing stated residents should receive an interdisciplinary team discharge summary, with a written summary and directions from each discipline, upon discharge from the facility. During an interview on 4/25/24 at 8:15 AM the Administrator stated residents should be discharged from the facility with the instructions to provide the care needed at home. 10 NYCRR 415.11 (d)(1)(2)(3)

Based on interview and record reviews conducted during the Recertification Survey completed on 8/5/22, it was determined that the facility did not implement written policies and procedures to prevent abuse, neglect, exploitation, and misappropriation of resident property related to screening prospective employees. Specifically, a Nurse Aide Registry (NAR) abuse screening was not completed prior to hire for four out of five employee files reviewed. The findings are: 1. On 8/4/22 from 10:34 a.m. to 11:45 a.m. the surveyor was provided documentation related to five newly hired employees. The files included Employees #1, #4 and #5 were hired as: Certified Nurse Assistants (CNAs) and Employee #2, was hired as a Housekeeper. The files also included hire dates of 6/17/22, 6/23/22, 4/4/22, and 4/17/22 for Employees #1, #2, #4 and #5, respectively. The documentation provided did not include a NAR abuse screen for employee #4, and the NAR abuse screen for employees #1, #2, and #5 were run on 8/4/22 (after hire). 2. During an interview on 8/4/22 at 10:39 a.m., the Human Resources Director (HRD) stated that they were not aware that the non-CNAs (housekeeper) had to be run through the NAR. Additionally, the HRD stated that the procedure was for the Director of Nursing (DON) to run the NAR screen for CNAs and pass the forms to the HRD. The HRD also stated that they believed the NAR checks were completed for the CNAs prior to hire but could not find the documentation in the former DON's office. 3. Review of the facility policy, effective November 13, 2017, titled: Penn [NAME] Manor Nursing Home Policy & Procedure: Abuse, Neglect, Mistreatment, Exploitation, and Misappropiation of Resident Property revealed; It is the policy of this facility to screen employees and volunteers prior to working with residents. Screening components include verification of references, certification and verification of license and criminal background check. Further review of this policy revealed it did not include provisions to run all prospective employees through the New York State NAR for findings concerning abuse, neglect, exploitation, mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] 10 NYCRR: 415.4(b)

Based on observations, interviews, and record reviews conducted during the Recertification Survey completed on 8/5/22, it was determined that for one of one kitchen the facility failed to dispose of garbage and refuse properly. Specifically, the garbage dumpster outside the facility was not equipped with a tight-fitting lid, door, or cover. This is evidenced by the following: Observations during the follow-up kitchen tour on 8/4/22 at approximately 11:55 a.m., revealed a large rectangular open-top roll-off garbage dumpster outside the facility located outside the nearby hospital kitchen where the facility meals are prepared. There were garbage bags accumulating in the dumpster and with no cover, which could create a potential feeding and harborage area for pests. During an interview on 8/4/22 at 11:55 a.m., the Kitchen Supervisor stated that the garbage dumpster had been in place for one year and was emptied twice a week. The Kitchen Supervisor stated there was never a tight-fitting lid, cover, or door on the dumpster. During an interview on 8/4/22 at 12:17 p.m., the Director of Nutritional Services stated that they were aware that the garbage dumpster stored outside the facility should have had a tight-fitting lid and they were working on obtaining a solution. 10 NYCRR: 415.14 (h), Subpart 14-1.150(c)

Based on observations, interviews, and record review conducted during the Recertification Survey completed on 8/5/22, it was determined that for one (Resident #13) of five residents reviewed during dining, the facility did not ensure that the resident received care in a respectful and dignified manner during meals. Specifically, Resident #13 did not receive timely assistance with eating. This is evidenced by the following: Resident #13 had diagnoses including dementia with behavioral disturbances, [CONDITION(S)], dysphagia (difficulty swallowing), and anxiety. The Minimum Data Set Assessment, dated 5/19/22, documented that Resident #13 had severe impairment of cognitive skills and was totally dependent on staff for eating. Review of current physician orders revealed that Resident #13 was ordered a regular diet, with puree texture and nectar thick fluid consistency. The current comprehensive care plan (CCP) and current Certified Nursing Assistant (CNA) care card (used by CNAs for daily care) included that Resident #13 was at risk for aspiration and was not allowed to be fed by their spouse (also a resident). Interventions included no straws, pureed consistency foods and nectar thick liquids. The CCP also included that Resident #13, was to be brought to the dining room for lunch and dinner, required physical assistance with meal set up, close staff supervision throughout and that Resident #13 should sit up at 90 degrees for meals to assist with swallowing. During an observation on 8/2/22, Resident #13 was sitting at the dining room table. Their lunch was delivered to the table at 12:18 p.m., but the resident was not assisted until 12:39 p.m. During an observation on 8/3/22, Resident #13 was observed sitting in a lounge chair at a dining room table awaiting lunch with their spouse who was sitting at the same table. Resident #13's lunch tray was delivered to their table at 12:13 p.m. A staff member removed the resident's face mask but did not uncover or setup the resident's lunch. At 12:18 p.m., Resident #13's spouse's lunch tray was delivered and they began eating, while Resident #13 remained unassisted with their plate still covered. At 12:20 p.m., a staff member called to Resident #13 from across the room, You haven't started eating yet? At 12:33 p.m., the resident's spouse asked the surveyor when someone would assist their spouse. At 12:34 p.m., Resident #13's spouse asked why no one was feeding their spouse and a staff member began feeding Resident #13 at 12:38 p.m. (25 minutes after the meal tray was set in front of Resident #13). During an interview with the Resident #13's spouse (identified by facility documentation as severely impaired cognitively) on 8/3/22 at 12:50 p.m., Resident #13's spouse stated that staff do help Resident #13 eat but that staff do not get to it while the food is still hot. During an interview on 8/4/22 at 1:24 p.m., the CNA stated that that when the food trays arrive in the dining room, there are no specific residents that receive their trays first. The CNA stated that residents who need assistance with eating are identified by a green dot on the food tray ticket. The CNA said that the aides and nurses assist with feeding residents, and if food is too cold, the microwave is an available option to reheat food. During an interview on 8/4/22 at 1:36 p.m., the Licensed Practical Nurse (LPN) stated that food trays for dining room residents are delivered first, but in no particular order. The LPN said that one nurse is required to be in the dining room, while another nurse needs to be out on the floor, and the aides fill in where needed. The LPN said that food trays are not immediately set up when delivered for residents needing assistance and the lids are left on, so the food does not get cold. The LPN stated that staff try to deliver Resident #13's and their spouse's trays last since the resident's spouse has been observed feeding Resident #13 foods from the trays. The LPN said that Resident #13 required assistance with eating but has at times fed themselves. During an interview on 8/4/22 at 1:55 p.m., the Registered Nurse / Charge Nurse stated the expectation is that when a food tray is delivered to a resident who requires assist, staff should immediately start feeding the resident. [NYCRR 415.5(a)]

Based on observations, interviews, and record reviews conducted during the Recertification Survey, completed on 8/5/22, it was determined that for 3 (Residents #29, #17 and #19) of 13 residents reviewed, the facility did not ensure that the resident's right to request, refuse, and/or discontinue treatment, and to formulate an advance directive would be honored. Specifically, the color-coded name plates at the entrance of the residents' rooms did not match the wishes documented on the residents' Medical Orders for Life Sustaining Treatment (MOLST). Review of the undated facility policy Advance Directives, indicated; if a resident has executed an advance directive, it will be displayed prominently in the medical record and reflected in the resident's care plan. 1. Resident #27 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) Assessment, dated 6/27/22, included that the resident had severe cognitive impairment. Review of the MOLST form, dated 3/19/21, documented Resident #27's wishes as Do Not Resuscitate (DNR) and Do Not Intubate (DNI). During an interview on 8/3/22 at 8:45 a.m., LPN#1 stated the color-coded name plates on resident room doors indicate the residents' code status. LPN#1 stated that a green resident name plate indicates that the resident is a full code, while a white resident name plate indicates that the resident is a DNR/DNI. LPN #1 stated that they would look at the pink MOLST form for the resident's code status, which should be in the front of the resident's paper chart. During an observation on 8/3/22 at 9:33 a.m., the name plate on Resident #27's door had a green background. During an interview and observation on 8/3/22 at 1:33 p.m., the Charge Registered Nurse (RN) stated that Resident #27's code status was DNR/DNI and that the green name plate on the door was not displaying their code status correctly. 2. Resident #17 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Assessment, dated 6/3/22, included the resident had moderately impaired cognition. Review of the MOLST form dated 1/28/22, indicated the resident's wishes were DNR, DNI, and Comfort Measures. When observed on 8/3/22 at 1:37 p.m, and 2: 34 p.m, the name plate outside of Resident #17's room door had a green background. During an interview on 8/3/22 at 8:44 a.m., the Charge RN stated that the resident was originally a full code when admitted and changes had been made to the resident's code status. 3. Resident #19 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Assessment, dated 6/9/22, included the resident had severe cognitive impairment. The current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 8/03/22 at 1:38 p.m, the name tag outside of room door had a green background with the resident's name in black writing. During an interview on 8/3/22 at 9:09 a.m., LPN #2's stated that it was their practice to check the resident's MOLST in the paper chart to identify a resident's code status. During an interview on 8/3/22 at 9:10 a.m., CNA #1 stated that to identify a resident's code status, reviewing the green books at the front desk (resident paper charts) or looking at the resident's care card in the resident's closet door would be the fastest way. During a joint interview with the Charge RN and the Nurse Practitioner (NP) on 8/3/22 at 11:57 a.m., the Charge RN stated that residents code status is verified by reviewing the resident's MOLST (if applicable) in the paper chart and an order is placed in the Electroni Medical Record. The door name plates are color-coded based on the resident's code status, with a white name plate indicating DNR and a green name plate indicating a full code. The Charge RN also stated that any resident brought into the facility without a MOLST form is a full code. 10 NYCRR 415.3 (e)(1)(ii)

Based on record reviews and interviews conducted during the Recertification survey, completed 8/5/22, it was determined that for 1 (Resident #27) of 13 residents reviewed, the facility did not ensure that each resident was screened for a mental disorder (MD) or intellectual disability (ID) prior to admission to the facility and that individuals identified with MD or ID were evaluated and received care and services in the most integrated setting to meet their needs. Specifically, there was no evidence that a Pre-Admission Screening and Resident Review (PASARR) was completed for Resident #27, who had been admitted to the facility with a significant MD diagnosis. This is evidenced by the following: Resident #27 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) Assessment, dated 6/27/22, indicated the resident had severe cognitive impairment. Review of the Electronic Medical Record (EMR) and the paper record for Resident #27 did not reveal any evidence that a PASARR was completed prior to admission. During an interview on 8/4/22 at 8:59 a.m., and 10:01 a.m., the Director of Nursing (DON) stated that all residents were required to have a PASARR completed prior to admission. The DON stated that Resident #27 came from another state and a PASARR review was not completed prior to admission to the facility. During an interview on 8/4/22 at 9:46 a.m., a Human Resources staff stated that at the time of Resident #27's admission, Social Work would have completed the admission process. During an interview on 8/4/22 at 10:01 a.m., the DON stated there was not a specific person to complete all the admission paperwork. The DON stated that there was no one on staff that was certified to complete screens. The DON stated that they were aware all residents required a PASARR screening prior to admission. The DON stated that Resident #27 displayed behaviors and received psychiatric services. 10NYCRR415.11(e)

Based on interviews and record reviews during a COVID-19 Focused Infection Control Survey on 1/20/21, the facility did not inform residents, their representatives, and families of suspected or confirmed COVID-19 cases in the facility along with mitigating actions in a timely manner for three of three residents reviewed. Specifically, the facility did not provide verbal or written notification to Resident #1, #6 and #7 by 5:00 p.m., the next calendar day following the occurrence of confirmed COVID-19 infections in the facility. This is evidenced by the following: The policy provided by the facility Guidance for Resident and Family Communicating in Adult Care Facilities and Nursing Homes, dated 4/4/2020, included best practices to consider when creating a communication protocol that included the same day a facility learns of a suspected or confirmed case of COVID-19, communicate to the resident when an individual who has been in the facility is suspected of having or has been diagnosed with [REDACTED]. The Centers for Medicare and Medicaid Services guidance Interim Final Rule Updating Requirements for Notification of Confirmed and Suspected COVID-19 Cases Among Residents and Staff in Nursing Homes, dated May 6, 2020, included that as part of a skilled nursing facility's COVID-19 reporting requirements, facilities must inform residents, their representatives, and families of those residing in facilities by 5:00 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other. Review of the facility report of positive COVID-19 cases revealed that on 1/6/21 there were 9 new positive cases and on 1/13/21 there were 15 new positive cases. 1. Resident #1 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 12/16/20, included the resident was cognitively intact. Review of interdisciplinary progress notes dated 1/6/21 through 1/20/2021 revealed no documented evidence that Resident #1 was notified of any new COVID-19 positive cases. In an interview on 1/20/21 at 10:00 a.m., Resident #1 stated they were aware there was COVID-19 in the facility but had not been told anything by the facility. 2. Resident #6 had [DIAGNOSES REDACTED]. The MDS Assessment, dated 10/22/20, revealed the resident was cognitively intact. Review of interdisciplinary progress notes, dated1/6/21 through 1/19/21, revealed no documented evidence that Resident #6 was notified of new COVID-19 positive cases. In an interview on 1/20/21 at 1:40 p.m., Resident #6 stated the facility does not tell them about positive COVID-19 cases in the facility. 3. Resident #7 had [DIAGNOSES REDACTED]. The MDS Assessment, dated 11/6/20, revealed the resident was cognitively intact Review of interdisciplinary progress notes, dated 1/6/21 through 1/19/21, revealed no documented evidence that Resident #6 was notified of any new COVID-19 positive cases. When interviewed on 1/20/21 at 1:45 p.m. Resident #7 stated that the facility does not tell them about positive COVID-19 cases in the facility. In an interview on 1/20/21 at 12:45 p.m. the Social Worker (SW) stated that family's and residents were notified within 24 hours of identifying positive COVID-19 cases in residents and staff. The SW said families were notified within 24 hours of any COVID-19 related deaths and that documentation of the notifications to residents and families should be in the medical record. When interviewed on 1/20/21 at 1:00 p.m. the Registered Nurse Manager (RNM) stated that no one notified the residents of positive COVID-19 cases. The RNM identified residents that were alert and oriented which included Residents' #1, #6, and #7. The RNM stated she did not know who was responsible for notifying residents of positive COVID-19 cases. In an interview on 1/20/21 at 1:20 p.m. with the the Director of Nursing (DON) and the Administrator, the DON stated if the resident can understand they would provide them with the letter that the Administrator sends to the families. The Administrator stated the facility was notifying resident's families or responsible parties within 24 hours of positive cases but said he had not provided the weekly letter to the residents. The Administrator stated we dropped the ball with notifying the residents. 10 NYCRR 400.2 10NYCRR 415.9

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of one resident reviewed for activities, the facility did not develop a person-centered care plan that included measurable goals and interventions to meet the resident's medical, nursing, and psychosocial needs. Specifically, Resident #13 did not have an activities care plan. This is evidenced by the following: Resident #13 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 8/22/19, revealed the resident was cognitively intact. The Admission Activity Assessment, dated 8/14/19, revealed that books and local newspapers were very important to the resident. The resident liked cards, was Presbyterian, and liked small and large group activities. Review of the Comprehensive Care Plan and Closet Care Plan (care plan used by Certified Nursing Assistants - CNA) revealed that neither care plan included activities. When interviewed on 11/7/19 at 3:36 p.m., CNA #1 stated she was not sure what activities the resident liked. CNA #1 said she would have to ask the Activities Director. When interviewed on 11/8/19 at 2:10 p.m., CNA #2 stated the resident was offered activities every day based on what was being provided on the activity calendar. During an interview on 11/12/19 at 8:42 a.m., the resident stated she liked to read Good Housekeeping and the Finger Lakes Times. She stated occasionally she was offered a magazine or newspaper. When interviewed on 11/12/19 at 12:00 p.m., the Interim Recreation Director stated that the resident liked to read magazines but she did not know the resident's preferences for reading materials. She said the resident's activity preferences should be addressed in the Comprehensive Care Plan. (10 NYCRR 415.11(c)(1))

Based on interviews and record reviews conducted during the Recertification Survey and complaint investigation (#NY 354), it was determined that for one of two residents reviewed for accidents, the facility did not ensure that residents received adequate supervision to avoid potential accidents. Specifically, Resident #2 eloped from the facility undetected and fell while outside the building, and the resident's care plan was not revised to include an actual elopement. This is evidenced by the following: Resident #2 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 7/29/19, revealed the resident had severely impaired cognition and wandered four to six days but less than daily. The current Comprehensive Care Plan revealed the resident's behavior symptoms included wandering as evidenced by exit seeking behaviors since admission, and wandering in and out of other's rooms. Exit seeking attempts occurred on 1/24/19, 3/27/19, 5/10/19, 9/12/19, and 10/8/19. There were no actual elopements included in the care plan. The Incident and Accident Report and Investigation Summary, dated 8/31/19, revealed that the resident had attempted to exit the South hall door setting off the alarm. Staff interceded and reset the alarm at the door. However, a nurse had turned off the alarm at the nurses' station thereby cancelling the reset. At 5:58 p.m., the resident walked out of the dining room and up and down the halls. Eventually, the resident went down the South hall where she pushed on the bar on the door long enough to open the door and exited the facility undetected at 6:08 p.m. The alarm did not sound. At 6:58 p.m., a staff person from a neighboring facility brought the resident back to the facility. The resident was found sitting on her buttocks behind the outdoor gazebo. The resident had grass in their hair and dirt near their forehead. Interviews conducted on 11/12/19 included the following: a. At 10:26 a.m., a Licensed Practical Nurse stated she thought she was resetting the alarm at the nurses' station when she turned it off. She said 45 minutes later the front door alarm was ringing and staff from next door were returning the resident to the facility. b. At 10:33 a.m., the Certified Nursing Assistant (CNA) stated that on 8/31/19 before dinner, the resident was down the North hall by the exit door. She requested that the resident follow her, which she did. The CNA said she then went into the dining room and that was the last time she saw the resident. c. At 1:31 p.m., the Director of Nursing (DON) said that staff are always around and complete rounds every two to four hours to check on residents' whereabouts. The DON stated the resident's Comprehensive Care Plan had not been revised to reflect the actual elopement and or interventions. (10 NYCRR 415.12(h)(2))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #44) of one resident reviewed for an indwelling urinary catheter (a tubing inserted into the bladder to drain urine into a bag), the facility did not ensure that a resident who entered the facility with an indwelling urinary catheter was assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrated that the indwelling catheter was the only option. This is evidenced by the following: Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 10/28/19, included that the resident had moderately impaired cognition, had a urinary catheter, and required extensive assistance from staff for personal hygiene. The Current Comprehensive Care Plan included that the resident has an indwelling urinary catheter with a goal that the resident does not have any further urinary tract infection. Interventions included, but were not limited to, urology consults as needed. During observations and interviews on 11/06/19 at 12:13 p.m. and again on 11/12/19 at 10:24 a.m., the resident had a urinary catheter that was secured with a strap and attached to a leg bag. When interviewed at that time, the resident said that they did not know when the catheter was going to be removed. Review of the medical record revealed the following: a. A urology consult, prior to admission and dated 3/14/19, revealed that the resident was seen for hematuria (blood in the urine) and several urinary tract infections. A cystoscopy was done that revealed LUTS (lower urinary tract symptoms) including retention and leaking and options were discussed. The plan at that time included for the resident to straight catheterize their self two to three times a day and to keep a diary. b. A hospital discharge summary, dated 4/16/19, included the resident was admitted with an acute urinary tract infection and was being transferred to the skilled nursing facility with a urinary catheter. Recommendations included to follow up with the resident's urologist for further evaluation and recommendations (i.e.: previous recommendation of a suprapubic catheter). c. An emergency room visit summary, dated 6/1/19, revealed the resident was being seen for a catheter associated urinary tract infection, was started on antibiotics, and transferred back to the facility. d. Facility orders, dated 10/22/19, revealed the resident had antibiotics ordered for a urinary tract infection. e. A routine medical progress note, dated 10/28/19, revealed that the resident had a chronic indwelling urinary catheter. There was no documented plan for the removal or continued use of the catheter, the resident's frequent urinary infections, or urology follow up. Review of a note from the resident's urologist, dated 11/9/19, obtained at the surveyor's request, revealed that the resident had an appointment scheduled on 7/11/19 and 7/22/19 that were cancelled by the resident's representative. The representative stated the appointment was no longer needed as the resident now lives at the facility and was doing well. In an interview on 11/8/19 at 10:12 a.m., the Registered Nurse stated that there were no urology appointments scheduled for the resident. She said that she was not aware of any plan. In an interview on 11/12/19 at 10:06 a.m., the Nurse Practitioner (NP) stated that the plan was to have the physician say it was time to take the catheter out. She said there was some miscommunication when the urology office called the representative instead of the facility to confirm an appointment, and the representative cancelled the appointment because she could not transport the resident. The NP said the plan was to remove the catheter but the resident needs to be seen by Urology. She said the resident gets very anxious and pulls on the catheter. She said the staff changes the bag several times a day and that could contribute to the infections. When interviewed on 11/12/19 at 4:01 p.m., the Director of Nursing stated she could not find any documentation that continuing with the catheter or other options were discussed with the resident or representative. (10 NYCRR 415.12(d)(2))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #36) of one resident reviewed for Preadmission Screening and Resident Review (PASARR- a screen used to determine developmental disability and/or mental health needs), the facility did not ensure the resident received the necessary behavioral health 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. The issues included lack of behavioral health services to ensure the resident's behavioral health needs were met as identified in the comprehensive assessment. This is evidenced by the following: Resident #36 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 10/12/19, revealed the resident was cognitively intact, had occasional feelings of depression, and required assistance of staff for all activities of daily living. Under behaviors, the MDS Assessment revealed that the resident had verbal behaviors, physical behaviors, other types of behaviors not directed at others (i.e.: hitting self, pacing, disruptive sounds), and rejection of care. The annual MDS Assessment, dated 4/11/19, under PASARR, the MDS was coded 'no,' which means the resident does not have a serious mental illness. The current Comprehensive Care Plan included impaired decision making, impaired judgement, altered mood (as evidenced by sadness, reduced social interaction, and unpleasantness), anxiety (as evidenced by motor tension, apprehensiveness, hypervigilance), depression (as evidenced by outbursts of crying, anger, and informing staff she is leaving the facility), sleep pattern disturbances, and falls due to psychosocial factors such as putting herself on the floor to get attention from staff. Multiple interventions for all of the above issues included appropriate psychological services and psychiatric consults as needed. The current Certified Nursing Assistant (CNA) Care Plan included behaviors such as verbally abusive, repetitive health complaints, repetitive anxious complaints, yelling, screaming, crying, [MEDICAL CONDITION], and resisting care. The CNA Care Plan did not include interventions for CNAs to utilize to address the specific behaviors. The current physician orders [REDACTED]. Review of an undated behavior care plan posted at the nurses' station included seven different behaviors and goals but no specific interventions for staff to utilize. During multiple observations, from 11/6/19 through 11/8/19 on the day shift, the resident was alert and oriented talking to the surveyor but it was difficult to remain on a subject. The resident repeatedly focused on her life prior to being admitted to the facility, past injuries, and asking repetitive questions about who the surveyors were. The resident required continual reassurances from staff. Review of the medical record revealed the following: a. Psychotherapy notes, signed by the Nurse Practitioner (NP) and dated 6/25/19 through 8/21/19, revealed that the resident was being seen weekly to every other week for behavioral outbursts, mood swings, and inability to control her temper with a focus on developing a behavioral intervention plan. On 8/21/19, it was documented that the resident would be assigned a new therapist who would follow up in two weeks. There were no further psychotherapy notes in the medical record after 8/21/19. b. Psychiatric progress notes, dated10/15/19, 10/31/19, and 11/11/19, included that the resident was having increased mood swings and [MEDICAL CONDITION] and medication changes were made. None of the notes included any behavior modification or psychotherapy. c. Review of interdisciplinary progress notes, from 10/28/19 through 11/11/19, revealed 18 notes regarding resident behaviors such as being verbally abusive, socially inappropriate, physically abusive, crying, and refusing to eat. Several notes included interventions such as providing a calm environment, redirecting and engaging in diversional activities, but did not include specific or an evaluation of the interventions. When interviewed on 11/6/19 at approximately 11:00 a.m., CNA #1 stated that the resident was afraid that they personally were being inspected. She said that the resident was concerned that surveyors would find fault and requested staff to clean out all their drawers and closets immediately despite reassurances. In an interview on 11/7/19 at 2:29 p.m., the Social Worker stated the resident was working with a psychiatric NP on a regular basis and received psychotherapy but she left at the end of August. She said the resident was now seeing the psychiatrist every three to four weeks. When asked about behavior modification therapy, the SW said that the resident gets some from the psychiatrist regarding medications. Interviews conducted on 11/12/19 included the following: a. At 8:27 a.m., CNA #2 stated that the resident has paranoid behaviors, really dwells on things, and does a lot of yelling. She said the resident recently hit a staff member for no reason. CNA #2 said that when the resident has behaviors staff just walk away. She said sometimes that helps and sometimes the resident just follows staff down the hall screaming at them. b. At 12:26 p.m., the Registered Nurse stated that the resident was not receiving psychotherapy at that time as the psychiatric NP had not been replaced. She said CNAs use the behavior care plan posted at the desk but they are really struggling on how to respond to the resident behaviors. After review of the behavior plan at that time, the RN said that the care plan did not really include specific interventions. She said that the resident sees the psychiatrist but the visits only include medication recommendations. (10 NYCRR 415.12(f)(1))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that the facility did not ensure that it was free of a medication error rate of 5 percent or greater for 2 of 11 residents observed for medication administration resulting in a 6 percent error rate. Specifically, Resident #37's eye drops were administered in both eyes instead of one eye, and Resident #30 had a medication ordered after meals that was given over an hour before meals. This is evidenced by the following: 1. Resident #37 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Current physician orders [REDACTED]. During observation of medication administration on 11/7/19 at 9:39 a.m., Licensed Practical Nurse (LPN) #1 instilled one drop of [MEDICATION NAME] eye drops in both the right and the left eye. When interviewed on 11/7/19 at 9:55 a.m. and again on 11/12/19 at 9:08 a.m., LPN #1 stated that she accidently administered the eye drops in both eyes. She said the drops were ordered for the right. She later said that she filled out a medication error report and notified medical who instructed her to wash out the resident's left eye. 2. Resident #30 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Current physician orders [REDACTED]. During observation of medication administration on 11/7/19 at 3:51 p.m., LPN #2 administered the Vitamin C. There was no snack given at that time and dinner trays were approximately 1.5 to 2 hours from being served. Interviews conducted on 11/12/19 included the following: a. At 8:49 a.m., the Registered Nurse stated that the administration times were entered in the computer by the physician and were too early. She said the dinner trays do not arrive until at least 5:30 p.m. to almost 6:00 p.m. at times. She said the nurse reconciling the order should have contacted the physician for clarification. b. At 11:00 a.m., the Nurse Practitioner stated that Vitamin C was an acid and can cause stomach upset so it should be given after meals. (10 NYCRR 415.12(m)(1))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #15) of one resident reviewed for hospitalization , the facility did not ensure the resident or the resident's representative received a written Transfer or Discharge Notice when the resident was transferred to the hospital. This is evidenced by the following: Resident #156 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 8/25/19, revealed the resident usually comprehends most conversations. The facility policy, Transfer and Discharge from the Facility, dated 10/19/17, revealed the resident and representative will receive timely notification, adequate preparation and information to make transfers as orderly and safe as possible. The notice contains information about the transfer and the resident's rights to appeal. A copy of the Discharge/Transfer Notice will be kept in the medical record A nursing progress note, dated 11/2/19, revealed the resident was transferred to the hospital at 6:30 p.m. The facility was notified at 10:30 p.m. that the resident was admitted to the hospital. Review of the medical record revealed there was no documented evidence that the resident's representative was notified in writing of the resident's transfer to the hospital. During an interview on 11/12/19 at 3:15 p.m., the Director of Nursing stated that when a resident was sent to the hospital the family was notified verbally via phone of the reason for transfer. She said that she was not aware that a written Transfer/Discharge Notice should be provided. (10 NYCRR 415.3(h)(iii)(a))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #15) of one resident reviewed for hospitalization , the facility did not ensure a written notification, which specifies the duration of the bedhold policy, was provided to the resident or the resident's representative at the time of transfer to the hospital. This is evidenced by the following: Resident #156 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 8/25/19, revealed the resident usually understands and comprehends most conversations. A nursing progress note, dated 11/2/19 at 6:02 p.m., revealed the resident was transferred to the hospital at 6:30 p.m. The facility was notified at 10:30 p.m. that the resident was admitted to the hospital. Review of the medical record revealed there was no documented evidence that the resident's representative was notified in writing of the facility bedhold policy following the resident's transfer to the hospital. Interviews conducted on 11/12/19 included the following: a. At 9:45 a.m., the Director of Nursing stated the Fiscal Manager provided the bedhold information. b. At 10:16 a.m., the Fiscal Manager stated she did not know who was responsible for providing the bedhold information to the resident or representative. c. At 1:00 p.m., the Administrator stated they did not have a bedhold policy. He said that all residents are brought back to the facility after a hospital stay. (10 NYCRR 415.3(h)(4)(i)(a))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for six (Residents #6, #12, #13, #15, #44, and #95) of eight residents reviewed for Baseline Care Plans, the facility did not consistently develop and implement a Baseline Care Plan within 48 hours of admission that included the minimum healthcare information necessary to properly care for the immediate needs of the resident and did not consistently review or provide the resident or representative a written summary. This is evidenced by, but not limited to, the following: 1. Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) Assessment, dated 4/28/19, revealed that the resident had severely impaired cognition. The Baseline Care Plan provided by the facility, dated 4/18/19, did not include the resident's medications, diet instructions, therapy services related to functional ability, or any information related to an indwelling urinary catheter. There was no documented evidence that a written summary of the Baseline Care Plan was reviewed with, or provided to, the resident or representative. 2. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission MDS Assessment, dated 5/3/19, revealed the resident had moderately impaired cognition. The Baseline Care Plan provided by the facility, dated 11/8/19 and titled interim care plan, did not include the resident's medications, diet instructions, therapy services or social services. There was no documented evidence that a written summary of the Baseline Care Plan was reviewed with, or provided to, the resident or representative. 3. Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission MDS Assessment, dated 3/11/19, revealed that the resident had moderately impaired cognition. The Baseline Care Plan provided by the facility, dated 4/22/19, did not include the resident's medications, diet orders, therapy instructions, or functional needs to prevent falls. There was no documented evidence that a written summary of the Baseline Care Plan was reviewed with, or provided to, the resident or representative. Interviews conducted on 11/7/19 included the following: a. At 11:54 a.m., the Registered Nurse stated that the interim care plan included the resident's activities of daily living and was documented in the progress notes. She said the Social Worker (SW) reviews the care plan with the resident. b. At 2:14 p.m., the SW stated that she usually reviews the information with the resident or representative but does not provide any copies to anyone. She said the Baseline Care Plans did not include medications, specific diet, or therapy recommendations. She said that she did not have any documentation that she reviewed the care plan with anyone. When interviewed on 11/8/19 at approximately 3:00 p.m., the Director of Nursing said she did not have documentation that the Baseline Care Plans were reviewed with Residents #6, #15, and #44 or their representative.

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #33) of three residents reviewed for skin conditions, the facility did not investigate an injury of unknown origin to rule out resident abuse, neglect, or mistreatment. The issue included abrasions that were not investigated. This is evidenced by the following: Resident #33 has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 4/21/17, revealed that the resident has severely impaired cognition. Observations made on 6/6/17, 6/7/17, and 6/8/17 revealed that the resident had one pencil eraser size abrasion between the index and middle finger and two smaller abrasions between the middle and ring finger. A review of the medical record revealed no documentation regarding the observed abrasions. The Comprehensive Care Plan did not include abrasions. A Progress Note, dated 6/1/17, revealed that a skin inspection had been completed with no new skin issues documented. The abrasions to the right hand were not documented on the 6/6/17 weekly skin assessment note. When interviewed on 6/7/17 at 2:02 p.m., Licensed Practical Nurse (LPN) #1 stated that she was not aware of abrasions on the resident's right hand. LPN #1 stated that the resident frequently digs in his drawer because his family puts his candy in there. She said the resident also self-propels in his wheelchair. Observations and interviews conducted on 6/8/17 included the following: a. At 1:32 p.m., the Nurse Manager (NM) stated that an investigation had not been started prior to surveyor intervention. The NM said that the resident cannot recall what happened. The NM added that the resident is known to self -propel in his wheelchair. She said that the resident also digs in his drawers for candy and other things that the family leaves for him. The NM said staff interviews revealed that no staff member had reported the abrasions. b. At 3:46 p.m., the surveyor and LPN #2 observed the resident's right hand. LPN #2 stated that the abrasions should have been reported. LPN #2 stated that skin checks are completed with every shower and any changes are documented. c. At 3:51 p.m., LPN #1 said that the area should have been reported. LPN #1 said that if she had observed the area, she would have started an investigation immediately. d. At 3:58 p.m., the NM said that during care between 6/6/17 and 6/7/17, staff should have noticed the areas and reported them to the nursing staff. (10 NYCRR 415.4(b)(1-4))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for 2 of 15 residents reviewed for Comprehensive Care Planning (CCP), the facility did not develop a CCP which included measurable objectives and timetables to meet a resident's medical and nursing needs that are identified in the comprehensive assessment. The issues involved the lack of a CCP for a resident at risk for pressure ulcers (Resident #3) and the use of an anticoagulant (blood thinner, Resident #23). This is evidenced by the following: 1. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 3/2/17, revealed the resident's cognition is moderately impaired and requires extensive assist for bed mobility, transfer, personal hygiene, and toileting. The Care Area Assessment Summary documented that the resident was at risk for skin breakdown and pressure ulcers and to proceed to care planning. The Admission Assessment, dated 2/17/17, identified the resident as a high risk for skin breakdown due to very limited mobility, very poor nutrition, and being chair fast. The Resident Nursing Instructions (Care Card), dated 2/17/17, did not identify the resident as a high risk for skin breakdown or include preventative measures. The Nursing Progress Notes included the following: a. On 3/8/17, it was documented that the resident had a purple area just above the crevice of the buttocks, suspected deep tissue injury. b. On 3/13/17, the same area was described as a Stage II pressure ulcer and the purple color was gone. The area was open with a shallow pink wound bed, no infection or drainage. c. On 3/15/17, it was documented that the resident had an unstageable pressure ulcer on the left heel measuring 2.9 centimeters (cm) x 1 cm and was oval shaped. Interviews conducted on 6/8/17 included the following: a. At 2:00 p.m., the Acting Director of Nursing (ADON) stated that she could not find an interim care plan for the resident. She said that when a problem is identified on admission, it should be added to the care plan. b. At 2:10 p.m., the Registered Nurse (RN) stated that if the resident was identified to be a high risk for skin breakdown on admission, then preventative measures should be documented on the Certfied Nursing Assistant (CNA) Care Plan. She said the measures should include frequent turning and repositioning, a pressure reducing mattress, a fel cushion for the wheelchair, and booties. 2. Resident #23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 2/26/17, revealed that the resident's cognition is moderately impaired and uses an anticoagulant. The 2/26/17 CCP and the current CNA Assignment Summary Sheet do not include that the resident is on [MEDICATION NAME] (blood thinner) or the side effects to monitor. The 5/22/17 physician orders [REDACTED]. Interviews conducted on 6/9/17 included the following: a. At 9:03 a.m., the ADON stated that there should be a CCP for [MEDICATION NAME]. She said she is responsible for the care plans and is not sure why she did not include one. She said that taking [MEDICATION NAME] puts the resident at a high risk of bleeding. She said staff should be aware so they are careful, know what foods to avoid, monitor lab work, and report bruising and other skin issues. b. At 9:13 a.m., the Administrator said that she expects every resident's CCP to be up to date. The Administrator stated that every resident on [MEDICATION NAME] should have a care plan so that staff are aware. She said [MEDICATION NAME] is a blood thinner and staff need to monitor bloodwork and watch for bruising and bleeding. The facility policy, Resident Assessment Instrument (RAI)/MDS Policy, dated 8/25/10, included that an interim care plan is to be implemented within 24 hours of the resident's admission to the facility. The CCP is to be completed within seven days of the MDS Assessment completion date. (10 NYCRR 415.11(c)(2)(i)(ii))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for two (Residents #16 and #44) of five residents reviewed for unnecessary medications, the facility did not ensure that each resident's drug regime is free of unnecessary medications. The issue involved the lack of an attempted gradual dose reduction (GDR) for residents receiving antipsychotics. This is evidenced by the following: 1. Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 3/26/17, revealed that the resident's cognition is severely impaired, no hallulcinations or behaviors, and uses an antidepressant and antipsychotic. The following documentation was found in the medical record: a. A physician order, dated 4/29/16, included [MEDICATION NAME] (an antipsychotic) 25 milligrams (mg) every day at bedtime for one week, then 50 mg every day at bedtime for dementia with hallucinations and paranoia. b. The physician note, dated 6/19/16, documented that the resident's hallucinations had resolved. c. The pharmacy consultant recommendation, dated 9/22/16, included to consider a taper attempt of [MEDICATION NAME], and if contraindicated at that time, to update progress notes to support this. For the taper to be contraindicated there must be an axis 1 [DIAGNOSES REDACTED]. The pharmacist also documented to implement resident centered nonpharmacological interventions with the care plan for the use of this medication as a substitute for the reduction of the medication. The Nurse Practitioner (NP) documented that she disagreed and will continue the medication as the resident is still exhibiting episodes of paranoid thoughts and delusions. d. Review of the progress notes, from 3/1/16 to the present, revealed no documented paranoid thoughts and/or delusions. e. The Comprehensive Care Plan (CCP), dated 1/15/17, revealed that the resident is on [MEDICATION NAME] for paranoid behavior. It is noted that the resident was started on [MEDICATION NAME] in April. Since that time, there is a decrease in the frequency of his paranoia and delusions about people spying on him. The CCP refers to a paranoid behavior note on 1/12/17. There are no resident centered nonpharmacological interventions. f. The pharmacist consult recommendation, dated 2/27/17, revealed the same recommendations as the 9/22/16 consult. The pharmacist documented [MEDICAL CONDITION] symptoms have a dose dependent relationship to [MEDICATION NAME] medications ([MEDICATION NAME]) used to treat [MEDICAL CONDITION]. The NP response revealed that a psychiatric recommendation will be requested. g. The NP note, dated 4/19/17, documented that the pharmacy consult recommendation was reviewed for a [MEDICATION NAME] taper and a psychiatric consult recommendation will be requested. A physician order [REDACTED]. h. A Social Worker (SW) note, dated 4/25/17, documented that the resident was to be seen by a psychologist for behaviors of paranoia and weepiness, especially when he talks to family. i. Physician orders, dated 5/18/17, included [MEDICATION NAME] 50 mg once a day. j. The physician note, dated 5/22/17, documented no recent hallucinations since [MEDICATION NAME] dose reduction and to consider a [MEDICATION NAME] GDR. During an observation of the resident on 6/7/17 at 11:09 a.m., the resident was sitting quietly in his room with his eyes closed. At 1:41 p.m., the resident was self-propelling his wheelchair in the hallway. Interviews conducted on 6/7/17 included the following: a. At 1:46 p.m., Certified Nursing Assistant (CNA) #1 stated the resident did not hallucinate or have any other behaviors. b. At 2:08 p.m., Licensed Practical Nurse (LPN) #1 stated that the SW schedules psychiatric evaluations. c. At 2:15 p.m., the SW stated a psychologist is not the same as a psychiatrist. The SW said that she made the mistake of scheduling the psychologist. After surveyor intervention, a psychiatric evaluation was scheduled for 6/10/17. Interviews conducted on 6/8/17 included the following: a. At 11:16 a.m., CNA #2 stated she was not aware of the resident hallucinating. b. At 11:28 a.m., the Acting Director of Nursing (ADON) stated the pharmacy recommendations should be addressed by medical within a week. She stated there is no documentation regarding hallucintions and/or paranoid behavior. The ADON stated there is no reason a GDR should not be attempted. 2. Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 5/16/17, included that the resident's cognition is severely impaired, that the Resident has no acute onset mental status changes, signs and symptoms of [MEDICAL CONDITION], hallucinations, or delusions, and does have behaviors not directed towards others (such as pacing, disrobing in public, disruptive sounds, etc.), rejection of care, and wandering. Physician orders, dated 5/11/17, include [MEDICATION NAME] (antipsychotic medication) 2mg daily at bedtime and 1mg daily in the morning. The order includes that the start date for both doses was 8/2/16. The CCP, dated 5/17/16, revealed that the resident's behaviors include wandering and resisting care. Interventions included redirecting negative behaviors, allowing time to de-escalate, and giving the resident tasks and jobs to keep her busy. Review of the 7/23/16 psychiatric consult revealed the resident exhibited behaviors including wandering, attempting to elope twice, disrobing in other residents' rooms, turning on the stove, and significant confabulation (fabricated, distorted, or misinterpreted memories about oneself or the world, without the conscious intention to deceive). A recommendation to adjust the [MEDICATION NAME] (antipsychotic) dosing to 1 mg in the morning and 2 mg at bedtime was ordered by the physician. Review of the progress notes by nursing and medical staff since 12/1/16 included behaviors of exit seeking, resisting cares, hitting staff, and frequent falls. The nonpharmacological interventions used included redirection and offering of snacks. There was no documentation about hallucinations or delusions found. The 12/22/16 pharmacy consultant recommendation included to consider a taper attempt on [MEDICATION NAME] and if contraindicated at that time, to update progress notes to support this. For the taper to be contraindicated there must be an Axis I [DIAGNOSES REDACTED]. The NP documented that she disagreed and will continue current dosage plan because the resident still has episodes of exit seeking and agitation. No GDR was found in the medical record. When observed on 6/7/17 at 11:17 a.m., the resident was sleeping in a recliner in her room. At 1:00 p.m. and on 6/8/17 at 8:15 a.m., the resident was observed sleeping in bed. Interviews conducted on 6/8/17 included the following: a. At 2:17 p.m., the regular day shift CNA #3 stated that the resident is sleeping more lately. She said that when the resident is awake she wanders into other residents' rooms but is easily redirected. She said the resident is cooperative with care and does not resist. She said she has never been aware of the resident hallucinating or having delusions. b. At 2:23 p.m., the regular day shift LPN #1 said the resident has some behaviors in the evening and overnight but she is no longer combative or exit seeking and is easily redirectable. LPN #1 said that she has not been aware of the resident being combative in five or six months. LPN #1 said the resident is very confused but she does not see any evidence of hallucinations or delusions. c. At 3:02 p.m., the physician stated that she could try a GDR for the [MEDICATION NAME] because the resident seems calmer and is not exit seeking. She stated that the resident is on [MEDICATION NAME] for behaviors of wandering, agitations, hallucinations, and confabulation. The physician said she has not been told the resident is hallucinating since last August after the medication timing was changed. The physician said that exit seeking and agitation are not reasons to be on [MEDICATION NAME], and those are the only symptoms and behaviors the resident is having. d. At 4:20 p.m., the evening shift CNAs #4 and #5 said that they have never known the resident to have hallucinations or delusions. They said the resident's behaviors are yelling while in the shower and wandering, both of which are easily redirected. e. At 4:30 p.m., the evening shift LPN #2 said the resident tends to follow staff, wander, and hit the exit doors to get out. She said the resident's attention span is short but she is easily redirected and sometimes can be distracted. LPN #2 stated that the resident has not hallucinated or had delusions recently. When interviewed on 6/9/17 at 9:13 a.m., the Administrator stated that the Quality Assurance committee has been auditing the records once a GDR is ordered. She said no audit activity is occurring on residents on antipsychotic medications until a GDR is ordered. The facility policy, Medication Monitoring and Management, dated February 2015, revealed the medication regime is re-evaluated (periodically/every quarter) to determine whether prolonged or indefinite use of a medication is indicated. When a resident's clinical condition has improved, or stabilized the underlying causes of the original target symptoms have resolved and or non-pharmacological interventions, including behavioral interventions, have been effective in reducing symptoms the resident is evaluated for a gradual dose reduction (GDR). If the facility initiates antipsychotic therapy, the facility must attempt a GDR in two separate quarters within the first year unless clinically contraindicated. (10 NYCRR 415.12(l)(1))

Based on interviews and record reviews, it was determined that for one of five residents reviewed for influenza and pneumococcal immunizations, the facility did not document the pneumococcal immunization, did not receive the pneumococcal immunization status, or obtain a vaccination history (Resident #38). This is evidenced by the following: Resident #38 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Assessment, dated 3/9/16, revealed the resident has severe cognitive impairments and that the pneumococcal vaccination (Pneumovac) is not up to date, offered and it was declined. Review of Immunizations Given to Resident logs, dated 9/3/15 and 10/20/15, do not include any documentation that Pneumovac was given, offered, or refused. Additionally, a Nursing Admission Assessment, dated 9/3/15, does not include any information regarding administration of the Pneumovac. A review of physician orders, dated 9/3/15 to current, did not include to administer Pneumovac to the resident. Additionally, a review of progress notes, dated 9/3/15 to 4/6/16, did not include any record of Pneumovac being offered, given, declined, or vaccination history. During an interview on 4/6/16 at 3:40 p.m., a Registered Nurse/Nurse Manager/Infection Control (RN/NM) looked through the medical record and said there was not any information regarding whether the Pneumovac had been given or refused. She said there was also no vaccination history and that information should have been put in the chart. The RN/NM said she may have called for vaccination records but could not really remember. When interviewed on 4/7/16 at 10:00 a.m., the RN/NM/Infection Control said that she expects the complete immunization record on newly admitted residents to be in the facility within one week. She said sometimes they are difficult to obtain but that it is important so the resident is not infected. She said that in March 2016 and April 2016 the facility had ten cases of influenza like illness (acute respiratory infection with flu-like symptoms) in residents, ten cases in staff, and three cases of pneumonia. Review of the facility's policy, Infection Control-Influenza and Pneumococcal Immunizations, dated July 2011, directs to assess each resident's pneumococcal immunization status upon admission and offer pneumococcal vaccination, unless medically contraindicated or the resident has already been immunized. (10 NYCRR 415.12)

Based on interviews and record reviews, it was determined that for 2 of 18 residents reviewed for Accuracy of the Minimum Data Set (MDS) Assessment, the facility did not accurately code the MDS Assessment to reflect the resident's status. The issues involved antipsychotic use (Resident #26), and urinary incontinence (Resident #7). This is evidenced by the following: 1. Resident #26 was admitted on [DATE] with [DIAGNOSES REDACTED]. Physician orders, dated 10/22/15 (admission orders [REDACTED]. The MDS Assessments, dated 10/26/15 and 1/26/16, are not coded for daily use of an antipsychotic. In a joint interview on 4/6/16 at 2:32 p.m., a Registered Nurse (RN)/MDS Coordinator said she had been on maternity leave during that time, but the use of Aripiprazole should have been coded as an antipsychotic. The RN Manager said she probably completed these MDS Assessments and did not code Aripiprazole as an antipsychotic because she did not recognize this medication as an antipsychotic, and this would be corrected. 2. Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 3/3/16 MDS Assessment revealed that the resident was frequently incontinent of urine. When interviewed on 4/7/16 at 11:34 a.m., the RN/MDS Coordinator said she uses the information that the Certified Nursing Assistants input into the computer as to whether or not the resident is incontinent. The surveyor and MDS Coordinator reviewed the information together. The MDS Coordinator stated that she miscoded the 3/3/16 MDS Assessment because she looked at more days than required for the look back period. (10 NYCRR 415.11(5)(b(2))