Every finding on record at Queen Of Peace Residence

Based on record review and staff interviews conducted during the Recertification survey, the facility did not ensure a performance review of every nurse's aide was conducted at least once every 12 months and that regular in-service education was provided based on the outcome of these reviews. This was evident for all Certified Nursing Assistants reviewed for nurse aides' training requirements.The findings are:The facility did not provide a policy and procedure regarding certified nursing aides yearly performance reviewsOn 09/26/2025, Certified Nursing Assistants records were reviewed, and there was no documented evidence a performance review was conducted for any of the Certified Nursing Assistants.On 09/26/2025 at 4:42 PM, the Director of Nursing was interviewed and stated the facility does not have a policy and procedure for Certified Nursing Assistants performance review and subsequent regular in-service based on the performance review.On 09/29/2025 at 2:11 PM, the Administrator was interviewed and stated since the In-service Coordinator passed away, it was hard to find someone to replace them. The Administrator also stated the performance review and required in-service for Certified Nursing Assistants was not done. The Administrator further stated they are aware the performance review must be done first and then training provided for the Certified Nursing Assistants, however this was not done. 10 NYCRR 415.26(d)(8)(i)

Based on record review and interviews conducted during the Recertification survey, the facility did not ensure that training requirements were met. This was evident for all certified nurse's aides. Specifically, there was no documented evidence certified nurse aides received no less than 12 hours per year of in-service training.The findings are:The facility did not provide a policy and procedure on nurse's aide training.On 09/26/2025 certified nurse's aides records were reviewed. There were no inservice records or lesson plans provided that certified nurse's aides received 12 hours in-service education in the past year. On 9/26/2025 at 4:42 PM, the Director of Nursing was interviewed and stated they have provided episodic in-service when problems occurred since they started working in the facility in December 2024. The Director of Nursing also stated the In-service Coordinator passed away suddenly in December 2024 and the position had not yet been filled. The Director of Nursing further stated they provided in-service on the Health Insurance Portability and Accountability Act, Quality Assurance, infection prevention, antibiotic stewardship, workplace violence, harassment, corporate compliance and fire safety only.On 9/29/2025 at 2:11 PM, the Administrator was interviewed and stated it has been hard to find someone to replace the in-service coordinator. The Administrator also stated they have had in-service with all staff but the required mandatory in-service trainings for certified nurse aides were not done.10 NYCRR 415.26(d)8(vi)

Based on observations, record review, and interviews conducted during the Recertification survey, the facility did not ensure residents were provided the proper treatment and assistive devices to maintain vision abilities. This was evident for 1 (Resident #16) of 1 resident reviewed for Communication-Sensory, out of a sample of 16 residents. Specifically, there was no documented evidence a follow up Ophthalmology consult was done for Resident #16 who had high intraocular pressure. The findings are:The facility did not have a policy related to following up on residents' medical consults.Resident #16 had diagnosis of Bilateral Ocular Hypertension, Dry Eye Syndrome of Bilateral Lacrimal Glands, and Hypertension.The Quarterly Minimum Data Set 3.0 assessment dated [DATE] documented Resident #16 had intact cognition, impaired vision, and used corrective lenses.On 09/24/2025 at 10:21 AM, Resident #16 was interviewed and stated they have not seen an eye doctor since the COVID-19 pandemic, and they cannot see well with their eyeglasses.The Comprehensive Care Plan related to Vision dated 07/27/2017 and last reviewed 08/02/2025 documented increased bilateral intraocular pressure (rule out Glaucoma). The goals included Resident #16 will verbalize ability to see adequately thru next review. Interventions included instruct Resident #16 to notify staff if having difficulty seeing, monitor for further signs of poor vision, and provide eye appointments as per physician orders.An Ophthalmology consult dated 08/28/2024 documented intraocular pressure too high. Begin Timolol eye drops both eyes every morning. Recommendations to return in 2 months for intraocular check.A nursing progress note written by the Assistant Director of Nursing dated 08/28/2024 documented Resident #16 returned from an outside eye doctor appointment. Consult documented intraocular pressure high, follow up in 2 months for intraocular pressure check. Physician will review eye doctor's consult tomorrow morning on 08/29/2024.A physician's progress note dated 08/29/2024 documented status post ophthalmology. To begin Timolol eye drops and follow up with Ophthalmology.The Physician's Orders with active order date of 11/05/2024 documented Ophthalmology consult and as needed follow up.The Physician's Order dated 12/29/2024 with active orders date of 11/05/2024 documented Timoptic Ophthalmic Solution 0.5 % (Timolol Maleate Ophthalmic) Instill 1 drop in both eyes one time a day for lower intraocular pressure. Hold for apical pulse under 55.There was no documented evidence that a follow up Ophthalmology consult was done.On 09/29/2025 at 11:13 AM, the Assistant Director of Nursing was interviewed and stated Resident #16 has not been back to the Ophthalmologist since their last consult on 08/24/2024. The Assistant Director of Nursing also stated it was an oversight Resident #16 did not return for a follow up visit.On 09/30/2025 at 12:36 PM, the Director of Nursing was interviewed and stated when the physician orders a consult the Assistant Director of Nursing starts the process by filling out the heading on a consult form then gives this form to the Medical Secretary. The Medical Secretary calls the doctor's office and makes the appointment, and arrangements are made for transportation to the appointment. The Director of Nursing also stated they are unable to explain why Resident #16 did not have their follow up Ophthalmology consult as they were not working in the facility at that time.10 NYCRR 415.12

Based on observations, interviews, and record review conducted during the Recertification survey, the facility did not ensure that the results of the most recent health survey were posted in a place readily accessible to residents, visitors, or legal representatives of residents. Specifically, upon review of the survey binders on the 1st and 2nd floor, the facility did not have the health survey results for the Recertification Survey conducted from 06/13/2023 to 06/20/2023 included in the survey binder. The findings are:The facility did not have a policy related to posting the most recent health survey results.During multiple observations during the survey, the survey binders were observed by the reception area and in the 2nd floor library. The binders contained Recertification Life Safety survey results for 11/22/2021 and 6/20/2023, and Recertification Health Survey results for 11/22/2021 only.On 09/25/2025 at 10:00 AM, twelve (12) members of the Resident Council were interviewed and stated they had not personally observed or read the survey results in the facility. Resident #23 stated there is a notice on the main floor which is posted in a glass case by the gift shop on where to locate survey results.On 09/29/2025 at 3:29 PM, the Recreation Director was interviewed and stated they were not aware the 2023 health survey results were not in the binders. The Recreation Director also stated the Social Worker, or the Administrator is responsible for posting the survey results. On 09/29/2025 at 3:56 PM, the Social Worker was interviewed and stated the Administrator is responsible for putting survey results in the binder.On 9/30/25 at 2:19 PM, the Administrator was interviewed and stated they were not aware the 06/13/2023 to 06/20/2023 survey results were not in the binders. The Administrator further stated it was an oversight that the results were not posted within the facility.10 NYCRR 415.3(d)(1)(vi)

Based on interviews and record review conducted during the recertification survey from 6/13/23 to 6/20/23, the facility did not ensure a resident or their designated representative was provided with a Skilled Nursing Facility (SNF) Advanced Beneficiary Notice of Non-coverage (ABN) at the termination of Medicare Part A benefits. This was evident for 2 (Residents # 12 and # 21) of 2 residents reviewed for Beneficiary Notification of a total sample of 13 residents. Specifically, 1) Resident #12 and their designated representative were not provided with a SNFABN once Resident #12 was terminated from skilled rehabilitation services and remained in the facility, and 2) Resident #21 and their designated representative were not provided with a SNFABN once Resident #21 was terminated from skilled rehabilitation services and remained in the facility. The findings are: The facility policy titled Expedited Appeal Process, Termination of Medicare Services dated August 2022 documented it is the policy of the Nursing and Financial Department to provide timely notification to a Resident or their Responsible Party when Skilled Services are no longer indicated. 1) Resident # 12 had diagnoses of dementia and osteoarthritis. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #12 was severely cognitively impaired and only Resident #12 participated in the assessment. The SNF Beneficiary Protection Notification Review form documented skilled nursing services for Resident #12 began 1/19/23 and the last Medicare Part A covered day was 3/17/23. A Notice of Medicare Non-Coverage (NOMNC) form was signed by Resident #12 on 3/15/32. There was no documented evidence Resident #12 or their designated representative was provided with a SNFABN. 2) Resident #21 had diagnoses of cerebral infarction and dementia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #21 was moderately cognitively impaired and only Resident #21 participated in the assessment. The SNF Beneficiary Protection Notification Review form documented skilled services for Resident #21 began 3/10/23 and the last Medicare Part A covered day was 5/5/23. A Notice of Medicare Non-Coverage (NOMNC) was signed by Resident #21 on 5/3/23. There was no documented evidence Resident #21 or their designated representative was provided with a SNFABN. On 06/20/23 at 12:37 PM, the MDS Coordinator (MDSC) was interviewed and stated they were not aware the SNFABN had to be provided to the residents and/or their designated representatives when the residents were discharged from Medicare Part A and remained in the facility. The MDSC also stated they worked at the facility for about 5 to 6 years. On 06/20/23 at 12:42 PM, the Administrator was interviewed and stated the MDSC was responsible for providing forms to residents and/or designated representatives to review and sign before discharging them from Medicare Part A. The Administrator also stated they were not familiar with the forms residents and their designated representatives were required to sign. 415.3(g)(2)(i)

Based on observation, record review, and interviews conducted during the Recertification survey from 06/13/23 to 06/20/23, the facility did not ensure a person-centered Comprehensive Care Plan (CCP) was developed and implemented to meet the resident needs. This was evident for 1 (Resident #41) of 2 residents reviewed for Urinary Catheter of 13 total sampled residents. Specifically, a CCP related to Resident #41's Foley catheter (FC) use was not developed. The findings are: The facility's policy titled 'Resident Care Planning' dated 03/20/23 documented the CCP will be developed within 21 days of admission and reviewed and revised on a quarterly basis. Resident #41 had diagnoses of urinary retention and anxiety disorder. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #41 was moderately cognitively impaired and had an indwelling catheter. The Physician Orders last renewed 05/22/23 documented Resident #41 had a FC for urinary retention and was ordered to receive FC care twice daily and have their FC changed as needed if leaking or blocked. The CCP related to Resident #41's potential for alteration in urinary elimination initiated 7/27/21 documented to assess Resident #41's urine for color, odor, clarity, frequency, and amount as needed. The CCP also documented to monitor for signs/symptoms of dehydration, such as thirst, infrequent urination, dry skin, lightheadedness, or dark urine. There was no documented evidence a CCP related to Resident #41's FC use was developed. On 06/20/23 at 10:58 AM, the MDS Coordinator (MDSC) was interviewed and stated every morning the MDSC reviews the morning report to see if there are any changes with the residents. The MDSC compares the MDS assessments to ensure CCPs address all resident areas. The MDSC stated they manage and review the care plans quarterly and when a change happens with a resident. The MDSC does not know what happened in the case of Resident #41's FC CCP. It is a glitch in the computer system because there was one initially and the CCP had certainly been reviewed prior. Resident #41's CCP has now been updated to reflect FC use. On 06/20/23 at 3:00PM, the Director of Nursing (DNS) was interviewed and stated the MDSC updates the CCPs quarterly and if there is any change in condition with the resident. The DNS stated Resident #41 previously had a CCP related to FC use but somehow the CCP was discontinued and no one realized. The DNS has been working at the facility for less than a month and intends to look at these areas to prevent reoccurrence. 415.11(c)(1)

Based on observation, record review, and interviews conducted during the Recertification survey from 6/13/23 to 6/20/23, the facility did not ensure psychotropic medication was prescribed to treat a diagnosed condition and behavioral interventions were used in an effort to discontinue these drugs. This was evident in 2 (Resident #28 and #40) of 5 residents reviewed for Unnecessary Medication of 13 total sampled residents. Specifically, 1) Resident #28 was prescribed an Seroquel to treat dementia without documented use of non-pharmacological interventions to address behavior, and 2) Resident #40 had a diagnosis of dementia and was prescribed Seroquel for depression with psychotic features without documented non-pharmacological interventions used to address behavior. The findings are: The facility policy titled Psychotropic Drugs dated 11/18/21 documented psychotropic drugs shall be ordered to treat a specific documented condition, and after possible alternative methods for treating the condition or symptoms have been tried and have failed. Psychotropic medications may be used only for the treatment of specific medical and/or psychiatric conditions. 1) Resident #28 had diagnoses of non-Alzheimer's dementia and macular degeneration. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #28 had moderately impaired cognition, had a behavior of hitting or screaming towards others, and did not receive antipsychotic medication. There were multiple observations of Resident #28 alert, calm, and out of bed from 6/14/23 at 11:10 AM to 6/16/23 at 1:35 PM. A Comprehensive Care Plan (CCP) relate to psychotropic medication initiated 4/26/23 documented Resident #28 used antipsychotic medication for a diagnosis of dementia with agitation/psychotic disturbance. Interventions documented increases to Resident #28's Seroquel on 4/26/23, 6/5/23, and 6/13/23. A CCP related to aggressive behavior documented Resident #28 struck their husband on 10/19/22 and held a knife to their husband's throat 5/16/23. Interventions included psychiatric evaluation, transfer resident to the hospital for psychiatric evaluation, approach Resident #28 in a clam manner, encourage the resident to express their feelings, remove the stimulus, and report to the nurse and physician. The CCP related to threatening/abusive behavior towards staff documented to administer medications to Resident #28 as ordered by the physician. A Medical Doctor Order (MDO) dated 5/5/23 documented Resident #28 receive Seroquel 25mg in the morning and 25 mg at bedtime for psychosis. A Psychiatry Consult dated 5/2/23 documented Resident #28 returned from the hospital on 4/26/23 on Seroquel. Current psychotropic medications included Seroquel 25mg at bedtime for dementia/psychotic disorder. Resident #28 experienced an acute deterioration when Seroquel was decreased upon readmission to the facility and was observed restless and pacing in their room. The Psychiatrist recommended increasing Seroquel to 12.5 mg in the morning and 25 mg at bedtime for psychosis. A Nursing Note (NN) dated 5/4/23 documented Resident #28 had increased confusion and was at high risk for fall due to frequent wandering. NN dated 5/11/23 documented Resident #28 has anxiety, agitation, and confusion in the afternoon after supper. Seroquel in progress. NN dated 5/16/23 documented Resident #28 held a knife to their husband's throat and was transferred and admitted to the hospital's dementia unit. MDO dated 5/22/23 documented Resident #28 was readmitted to the facility with an order for Seroquel 12.5 mg daily and Seroquel 50 mg at bedtime for dementia with psychotic disturbance. A Psychiatry Consult dated 5/30/23 documented Resident #28 had a diagnosis of senile dementia with psychotic disturbance and was currently prescribed Seroquel 12.5mg in the morning and 50mg at bedtime for dementia with psychotic disturbance. Resident #28 improved since Seroquel was increased and was smiling. The Psychiatry Consult also documented Resident #28 fell twice since their return from the hospital. Reduction of dosage was not recommended as Seroquel was required for the treatment of dementia. Interim Physician's Order dated 6/5/23 documented Resident #28's Seroquel order was changed to 25 mg three times daily. A Psychiatry Consult dated 6/13/23 documented Resident #28 was currently prescribed Seroquel 25mg three times daily for psychosis. Resident #28 was agitated, yelling/hitting staff has increased, and could not be redirected. The Psychiatrist recommended to increase Resident #28's Seroquel to 100mg once daily for dementia with psychotic features. Will increase Seroquel to 25mg by mouth in the morning, 50 mg at 1:30 PM, and 25 mg at bedtime for the treatment of psychotic symptoms with behavioral disturbances. A Nurse's Progress Note dated 6/13/23 documented the Psychiatrist was informed about Resident #28's behaviors and agitation. The Psychiatrist saw Resident #28 and ordered Seroquel 25mg at 9:30 AM, 50mg at 2 PM, and 25 mg at bedtime. A Interim Physician's Order dated 6/13/23 documented to increase Resident #28's Seroquel order to 25mg in the morning, 50 mg at 1:30 PM, and 25 mg at bedtime. The Medication Administration Record from 5/1/23 through 6/20/23 documented Resident #28 received Seroquel according to MDO. There was no documented evidence non-pharmacological interventions were used to address Resident #28's behavior. On 06/16/23 at 10:14 AM, an interview was conducted with Certified Nursing Assistant (CNA) #2 who stated Resident #28 was confused and always asks for their children and spouse. Resident #28 was aggressive in the past but has not been aggressive lately. At times, Resident #28 will swing their arm and yells at the staff. On 6/16/23 at 2:12 PM, CNA #3 was interviewed and stated Resident #28 has sundown features and usually exhibits behaviors of yelling and being combative in the evening. On 06/20/23 11:52 AM, an interview was conducted with the Registered Nurse (RN) #2 who stated that Resident # 28 is on Seroquel because the resident gets aggressive at times. Seroquel keep the resident calm and quiet. On 06/20/23 at 12:21 PM, an interview was conducted with the Assistant Director of Nursing (ADNS) who stated Resident #28 returned from the hospital on 4/26/23 on Seroquel, the Attending Physician decreased the dose, the Psychiatrist saw the resident on 5/2/23, and the Seroquel dose was increased due to resident's symptoms. Resident #28 was seen by the Attending Physician on 6/5/23 and 6/13/23 and Seroquel was increased. A dose reduction was tried but the symptoms were not improving. Resident #28 receives Seroquel for dementia, anxiety, mood disturbance, and psychotic disturbance. On 06/16/23 at 2:33 PM, an interview was conducted with the Attending Physician/Medical Director (MD) who stated that Resident #28 is on Seroquel for dementia with behavior Disturbances. The resident had an increase in agitation and psychotic behavior. The MD knows the black box warning but Seroquel can be used off-label for psychotic behaviors. As per the Psychiatrist, Seroquel is being used for behaviors with psychotic symptoms. On 06/20/23 12:01 PM an interview was conducted with the Psychiatrist who stated Resident #28 was in the hospital recently and they started the resident on Seroquel and has been threatening towards their spouse, also another resident. Resident #28 is on Seroquel for psychotic features and it is good for the resident. They do not have bipolar disorder or schizophrenia. Resident #28's psychosis is secondary to the dementia diagnosis. The Psychiatrist is left with nothing else to treat Resident #28 except for Seroquel. There is a black box warning alert but there is no other alternative. 44843 2) Resident #40 had diagnoses of dementia with other behavioral disturbance and major depressive disorder (MDD), recurrent, severe with psychotic symptoms. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #40 was cognitively intact, had hallucinations, and received antipsychotic medication 7 of 7 days prior to the assessment. The last gradual dose reduction (GDR) was attempted on 1/24/23 and the physician documented GDR was clinically contraindicated on 2/21/23. On 06/13/23 at 11:33 AM, Resident # 40 was interviewed and stated someone was coming to their room and stealing their soda occasionally. On 06/15/23 at 11:47 AM, 06/16/23 at 10:08 AM, and 06/20/23 at 10:24 AM, Resident # 40 was observed sitting in the chair and quietly in their room. A comprehensive care plan (CCP) related to behavioral problems initiated 11/17/21 and last updated 4/3/23 documented Resident # 40 exhibited hallucinations and delusions by talking about other things not existing. A CCP related to the use of antipsychotic medication initiated 3/1/22 and last updated 6/14/23 documented Resident #40 was receiving Seroquel medication related to diagnosis of MDD with psychotic symptoms. Interventions included be aware of adverse reactions related to use of Seroquel and provide Psychiatrist consultation/evaluation as ordered by physician. The Psychiatry Consult dated 1/24/23 documented resident #40 had a diagnosis of senile dementia and major depressive disorder with psychosis. Seroquel was prescribed for psychosis and Remeron was prescribed for depression. Resident #40 had been quiet and the Psychiatrist recommended decreasing the Seroquel from 25mg daily to 12.5mg daily. Nursing Note (NN) dated 2/8/23 documented Resident #40 asked for a corn muffin and coffee and cursed and screamed when the nursing assistant told the resident the items were not in the kitchen. The Medical Doctor (MD) Orders dated 2/9/23 documented Resident #40 was ordered to receive Seroquel 25mg once daily for MDD with severe psychotic symptoms. Nursing Note dated 2/9/23 documented Resident #40 was anxious when demanded food was not available right away and refused to go for a knee MRI. Resident #40 will follow up with the Psychiatrist. The MD increased Resident #40's Seroquel to 25mg once daily. NN dated 2/11/23 documented Resident #40 was very needy and had multiple somatic complaints. The Psychiatry Consult dated 2/21/23 documented negative behavior returned since Resident #40's dose reduction on 1/24/23. Resident #40 was demanding different foods and refused to go for an MRI. Seroquel was increased from 12.5 mg to 25mg once daily on 2/9/23 and was required to treat psychosis. NN dated 2/22/23 documented Resident #40 stated their cousin was coming into their room and punching and hurting them. Resident #40 was reoriented with little effect. NN dated 2/23/23 and Social Work (SW) Note dated 3/6/23 documented Resident #40 had hallucinations of their cousin. SW Note dated 3/23/23 documented Resident #40 continues to report their cousin visits them and does not appear to be in any distress o fear when they speak of the hallucination of their cousin visiting. NN dated 4/11/23 documented Resident #40 reported hallucination of snakes and crocodiles in their room. SW Note dated 4/24/23 documented Resident #40 was upset about soda. The Psychiatry Consult dated 5/2/23 documented Resident #40's obsession with sods a was starting again with some hallucinations. SW Note dated 5/2/23 documented Resident #40 was noted with periods of agitation and visual hallucinations and was seen by the Psychiatrist. NN dated 5/14/23 documented Resident #40 had increased verbal and physical aggression towards staff, constantly ringing the call bell, demanding an ice box to store their soda, and complaining the food tastes like sand. Note sent to medical. The Psychiatry Consult dated 5/16/23 documented Resident #40 had an increase in hallucinations and appeared annoyed by staff presence. The psychiatrist recommended increasing Seroquel to 25mg in the morning and 12.5mg in the afternoon. SW Note dated 5/16/23 documented Resident #40 displayed an increase in behaviors, was demanding, and used verbally abusive negative language. The MD Order documented Resident #40 was ordered to receive an increase in Seroquel to 12.5mg in the afternoon and 25mg in the morning. NN dated 5/20/23 and 5/21/23 documented Resident #40 used derogatory language towards staff and continued on increased dose of Seroquel. SW Note dated 5/31/23 documented Resident #40 reported it was peaceful now that their Health Care Proxy (HCP got rid of the hallucination of their cousin. SW Note dated 6/12/23 documented Resident #40 was very angry because someone stealing their soda. Resident #40 requested an ice box in their room to keep their soda safe and settled for a cabinet that the resident can lock. The Medication Administration Record (MAR) from 5/1/23 through 6/17/23 documented Resident #40 was administered Seroquel daily according to the MD Order. There was no documented evidence non-pharmacological interventions were used to address Resident #40's behavior. On 06/15/23 at 01:51 PM, the Certified Nursing Assistant (CNA) # 1 was interviewed and stated Resident # 40 was alert, had mood swing, and was verbally and physically abusive to staff. CNA # 1 also stated Resident # 40 had visual hallucination once a while, did not interact with anyone, and stayed in their room watching TV all the time. On 06/20/23 at 10:55 AM, the Pharmacy Consultant was interviewed and stated they checked the psychiatrist consult in record, verified the med order with the psychiatrist, reviewed if the tapering of antipsychotic medication was done, and recommended the gradual dose reduction (GDR) to the MD for antipsychotic medication when performing the monthly medication regimen review. The psychiatrist consult documented Resident # 40 had MDD with severe psychotic symptoms and it was an appropriate indication to prescribe Seroquel. The Pharmacy Consultant stated they did not recommend that the MD check if Resident # 40 had diagnoses of schizophrenia and bipolar disorder before the MD prescribes Seroquel because Resident # 40 was diagnosed with psychotic symptoms. On 06/16/23 at 10:48 AM, the Psychiatrist was interviewed and stated they were aware of the black box warning regarding the use of Seroquel which is indicated to treat schizophrenia, bipolar disorder, and depression with psychotic symptoms. Seroquel was prescribed to treat Resident #40's psychotic symptoms related to MDD. On 06/16/23 at 02:23 PM, the Attending Physician/Medical Director (MD) was interviewed and stated they discussed recommended medications with the Psychiatrist after the Psychiatrist visits with residents. The MD is aware of the black box warning related to Seroquel and uses their clinical judgement to see if the resident benefits from the medication. Seroquel was prescribed to treat Resident #40's hallucinations and other abusive behavior. 415.12(1)(2)(i)

Based on record review and staff interview during the Recertification survey, the facility did not ensure infection prevention control practices were maintained to help prevent the spread, development, and transmission of communicable diseases and infections. Specifically, the facility was missing a Legionella sampling plan based on the facility's risk assessment. Finding is: Record review revealed the Facility Risk Assessment lacked a Legionella sampling plan that identified specific locations where Legionella and other opportunistic waterborne pathogens (e.g., Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system. On 11/17/2021 at approximately 1:10PM, the Director of Maintenance was interviewed and stated that water samples for Legionella tests were collected from distal, end-sampling points that were facilitated by an outside contracted laboratory. They were unable to provide documentation that identified specific sampling locations within the facility's water management plan based on the facility environmental risk assessment, and further stated that they were unaware of the requirement. On 11/17/2021 at approximately 1:20PM, the Director of Nursing was interviewed and stated that they were the responsible person for maintaining the water management plan, and was unaware of the requirement for sampling plan locations to be based on the facility's completed environmental risk assessment. Documentation of a Legionella sampling plan was not available for review during the survey. The facility provided documentation via email on 11/23/2021, one day after exit. 415.19(a) (1-3)

Based on interviews and record review, the facility did not ensure that residents were free from neglect. The facility did not ensure that it's employees provided necessary services to a resident to avoid physical pain, mental anguish or emotional distress. Specifically, Resident #7 was left unattended for 1 1/2 hours on a commode which was located in the resident's room in an area where the resident's call bell was not within reach. This was evident for one (1) resident out of a sample of 19 residents, Resident #7. The facility's policy: Resident Abuse, neglect, Mistreatment and Misappropriation of Resident Property Policy dated November, (YEAR) documents: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The finding is: Resident #7 is approximately [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Safety Data Set ((MDS) dated [DATE] documented that Resident #7 has intact cognition. Care plans documented that the resident is at risk for falls with interventions: place call bell within easy reach (12/17/17). The facility's Accident or Incident Report dated 1/10/18 was reviewed. It documented the date of the incident: 1/10/18, the resident's condition before the incident as normal & alert. Describe Injuries: no apparent injuries, however, a potential for impairment of skin integrity is possible. Disposition and remarks: no visible injury or any skin impairment noted. But, at risk for impairment. Three (3) signatures were present: Medical Director, signature of the person completing the form and the Administrator. Statements were taken from the staff involved, all data reviewed and completed on 1/10/18. Section completed by nurse on duty (LPN #1): Date of report: 1/10/18. Time that Accident occurred or Incident was found: 12:30PM. How did the accident happen: was toileted. Where did the accident happen: resident's room. The resident involved is alert and oriented. The resident's statement: resident stated she was left on the toilet for one (1) hour and (1/2) a half. +LPN #1 signature was present on this section. CNA Day Shift: (CNA#1) documented the she gave care to the resident during the shift: 6:30-2:30. She assisted with transfer and toileting. The CNA who assisted her was CNA #2. She (CNA #1) did not notice an injury during care. The resident did not do anything unusual during her shift. The resident was not agitated or restless or uncooperative during her shift. a lift was used during care, type: full body. An alarm was ordered, in place and working. She reported the incident to RN #1 and LPN #1 and signed her name. CNA Day Shift: CNA #2. documented that she gave care to the resident during the shift: 7-3. The care she gave or assisted with: I assisted with transfer. The CNA who assisted her was CNA #3. She (CNA #2) documented: There was no injury. The resident did not do anything unusual during her shift. The resident's behavior during her shift was documented as : She was a little angry. A lift was used during care. Type: full body. An alarm was ordered , it was in place and working. CNA #2 reported the incident to RN #1. CNA Day Shift: CNA #3. documented that she gave care to the resident during the shift: between 6:30AM & 2:30PM. The care she gave or assisted with: Total care. The CNA who assisted her was CNA #2 and #1. She (CNA #3) documented: There was no injury. The resident did not do anything unusual during her shift. The resident's behavior during her shift was documented as : She was a bit angry. A lift was used during care. Type: full body. An alarm was ordered, it was in place and working. CNA #3 reported the incident to RN #1. Section completed by the Supervisor: RN #2 documented: Medical, Psychological or Behavioral factors to consider in the investigation: Spinal stenosis, chronic recurrent UTI. Currently ill with URI (upper respiratory infection). Conclusion: 1. resident was placed on the commode over by the window without her call light. She is alert enough to call and does want privacy. However, due to post fall staff need to make frequent checks. 2. One aide, CNA #3, went on break and the other CNA #2 did not check on her. CNA #1 did not check on her on return to the unit, thinking that they probably took her off and she(Resident #7) requested to go to back on the commode or that her son was visiting and that was why she had the door closed. 3. Resident was upset but not injured-no bruising or skin breakdown noted. Neglect did occur but was it was not willful and CNA #3 is a seasoned aide who gives impeccable care to the residents. She did not use good judgment at the moment and realized her error. CNA #2 is new and still adapting to the Home. CNA #1 was involved in getting the resident OOB (out of bed) in the AM and to assist with care. She was not on that side when the resident was placed on the commode and was unaware until she was called to assist the other CNA to get her off. Plan-education given to all 3rd floor staff re: lifts and personal assistance. Interviewed CNA #1 who was unaware that resident was on the commode. she failed to check the residetn and just started bringing everyone to mass. She was not involved in placing her on the commode and when she saw the door closed she assumed that resident's son was there saying Mass. CNA #2 is at fault in other areas: 1. call bell. 2. communication. 3. failure to check her resident. No harm came to the resident except that she was upset. Employees involved did not need to be separated from resident. They were honest, forthright about what occurred. Resident usually is content with their care. They were careless but there was no intent to do harm. No evidence of abuse, mistreatment but some actions were neglectful. Signed by RN #2. On 3/12/2018 at approximately 10:15 AM Resident #7 was interviewed. She stated that she does not have any concerns or problems with any staff members on any shift. She denies having any problems with her care. She further stated that she is very well cared for and everyone is wonderful to her. Also, she did not recall any incident in January, (YEAR) regarding toileting. She attends daily Mass and activities that suit her interests. She was interviewed again on 3/15/18 at approximately 9:38 AM and asked how she calls for help. She pointed the call bell out: it was hanging over her commode. She stated that she can wheel herself over to the call bell and press the button (she is approximately 2 feet away from call bell). She then self propelled in her wheelchair to the call bell, held it and said See? She stated that her care from the staff is very good; when she calls for help they come. All of her needs are met, no problem with any staff on any shift. On 3/14/18 at approximately 2:37 PM LPN#1 was interviewed and she stated that her Certified Nursing Assistants (CNA) work from 6:30AM to 2:30 PM. The residents on this unit require two (2) person assist. If a resident is toileted, the CNAs stay outside the door in order to assist the resident. She is aware of the incident with Resident #7 but was on her break during the time. She was not present when the resident was found on her commode. When she returned from her break she was told what happened and to make an occurrence report. The LPN #1 further stated that she makes rounds on the unit, checking rooms. She knows which residents attend Mass and go to various activities on and off the unit. She assists the CNAs taking residents from the Chapel after Mass either to their rooms or to the Dining Room for lunch. She continued and stated that she saw Resident #7 on 1/10/18 and the resident denied having pain. Lastly, she stated that she attends scheduled annual in-service education on recognizing and preventing abuse/neglect of the residents provided by the facility; Education Day is scheduled for this week for all of the staff. And, in-services are given to staff on the units when any incidents occur throughout the year. The last one was following this incident with Resident #7 in January, (YEAR). On 3/16/18 at approximately 11:19 AM, LPN #1 was interviewed and stated she is aware that the resident was left unattended on the commode. She stated that she does not leave residents unattended; staff will also stay by the door with the door cracked and monitor Resident #7. She continued to state that she makes her rounds in the morning, before and after Mass, meals and activities. Residents are on fall precautions and hourly rounds. The residents who stay in their rooms are checked during Mass also. On 3/15/18 at approximately 12:58 PM CNA #1 was interviewed. She stated that she knows Resident #7 well. On 1/10/18 she went on her break 10:15-10:30 AM. Her partner, CNA #3 was scheduled to go on break at 10:30 AM. At 10:30 AM CNA#1's responsibility is to cover the floor, make sure all residents go to Mass in the Chapel for 11 AM. Residents who do not attend daily mass are put in TV room and her responsibility is to stay with these residents. There are three (3) residents who are watching TV and they are non-ambulatory. CNA#1 stated that Resident #7 had a cold and was supposed to stay on room rest for the day. Normally, her son will come and say Mass with her and the door will be closed. She stated that her mistake was that she did not knock on the door to check on Resident #7 and see if she was in her room. She saw her partner, CNA #3 at 10:30 AM but CNA #3 did not tell her that she put the resident on her commode. When CNA#3 brought lunch to the resident's room and saw her sitting on the commode. CNA #3 got CNA #1 and used the hoyer lift to take her off the commode, cleaned her and apologized to the resident and explained what happened. CNA#1 went to get RN #1 and explained what happened to the resident. CNA #1 stated regarding her training for toileting a resident who is designated a 2 person assist using a hoyer lift is as follows: put the resident on the commode via the hoyer lift, give her the call bell and place pull alarm on her shirt. Return in 3-5 minutes if she is not done. If the resident is not ready, we stand outside the door and give her 2-3 minutes. CNA #1 stated that she would not leave the resident until there is another CNA to cover her. Changes made since the incident: we put the commode near the call bell, give her privacy and stand outside the door: do not leave the resident. On 3/15/18 at approximately 1:25 PM: CNA #2 stated that has worked with Resident #7 for past six (6) months and the commode would be placed by the bathroom door. On 1/10/18 her assignment was float to 3 North for 15 minutes to assist with toileting. CNA #2 and CNA #3 used the hoyer lift and put the resident on the commode next to the bathroom door. Assured she was safe, they left the room to give her privacy. They looked in after 5 minutes and the resident was not ready to come off the commode. CNA #2 stated she left to return to 3 South as her 15 minutes was up and CNA #3 was standing by the Nurse's station on 3 North. CNA #2 stated that CNA #1 would be working with CNA #3. Regarding her training: give resident the care that they need and leave when 15 minutes is completed on that side. She would wait outside the door for resident to call her through the door. If after 5 minutes passed, she would open the door and check on her. Then, if she must leave, CNA # 3 would be there and CNA #1 would be assisting to take Resident #7 off the commode. Since the incident, new procedures in place: the call bell is within reach of the commode. The CNAs do not leave the door until the resident is fully toileted and safely in wheelchair. On 3/15/18 at approximately 2:40 PM, CNA #3 was interviewed. She stated that she knows the residents. Resident #7 wanted to go to the bathroom and called via call bell for toileting. She is a two (2) person assist and she did not see CNA #1 so she called CNA #2 to assist. Together they used the hoyer lift and put her on the commode. The call bell was by her bed and too short for the resident to reach it. CNA #3 stated that she realized this but since the resident was set-up she didn't want to move her again. She stated that she thought CNA #2 would look for CNA #1 and she (CNA #2) would be there outside the door for the resident. The standard of care: two (2) people have to use the hoyer lift. She stated that she told CNA #2 she was going on her break. CNA #2 wanted to leave and go for the laundry. CNA #3 stated that she told CNA #2 that the laundry is not open today as it is closed on Wednesday. CNA #3 stated that she goes on her break for 45 minutes at approximately 10:35 AM and Resident #7 was on the commode at that time. When CNA #3 returned from her break she stated that she knows she has to cover both sides (3 North and 3 South) with CNA #2. CNA#3 stated that she went to the South side to check to see if everything is okay-both CNAs cover both sides. CNA #2 was on 3 North making rounds for residents who are in their room. While CNA#3 was on the South side, she heard CNA #2 calling her saying she was on 3 North. CNA#3 continues to explain that she is going room to room checking the residents. When she got to Resident #7's room she saw that Resident #7 was on the commode. She apologized and consoled the resident and went to get assistance. CNA #1 was located and was immediately informed that the resident was found on the commode. Together CNA #1 and #3 went into the resident's room and took her off the commode. She (CNA#3) found RN#1 and informed her of the incident. The resident was checked by RN#1 and RN#2. A meeting was held afterwards with the three (3) CNAs, RN#1 and RN#2 and the CNAs explained to the RNs what they did wrong. Pre-incident: CNA #3 stated that they would put the resident on commode, leave her a few minutes and go back and keep checking on her. New procedure: stay in the room with the resident, put the call bell in her hand. Regarding education on how to recognize, report and prevent abuse/neglect of the residents: she has received in-service education when she was hired. She stated that she attends scheduled annual in-service education on recognizing and preventing abuse/neglect of the residents provided by the facility; Education Day is scheduled for this week and next week for all staff. Also, in-services are given to staff on the units when any incidents occur throughout the year. The last one was following this incident with Resident #7 in January, (YEAR). On 03/16/18 at approximately 10:18 AM interview with RN#1 was conducted. She stated that she was working on 1/10/18. However, she was not on floor as she was in Care Planning meetings. RN #1 saw Resident #7 after breakfast; she was coughing due to a cold and stayed in her room on room rest. RN#1 returned to the floor at approximately 11:45 AM and went to the Dining Room. CNA #1 came to her in DR and reported that the resident was left on toilet for a long time. RN#1 spoke to Resident #7 and examined her skin for breakdown-none noted. RN #1 saw that there was moderate redness noted to buttocks. The CNAs did not report any breakdown to her. Resident #7 wanted to eat lunch in her room. One CNA stayed with her for lunch. Following lunch: the resident's vital signs were taken, an accident report by LPN #1 was initiated. RN #1 informed RN #2 regarding the incident. RN #1 checked with LPN #1 regarding the resident's vital signs and saw the resident again. Education of the three (3) involved CNAs regarding what happened. Specifically, what did the staff not do and what will staff do going forward. RN #1 spoke with the resident's son regarding the incident over the phone. RN #1 stated that the changes made following this incident included: move the position of the commode closer to bed, keep call bell within her reach and check that it works. The CNAs need to be outside the room or inside the room if resident will permit. All staff and all shifts educated re: checking on residents, placement of the commode near call bell, call bell in reach of residents. It is everyone's responsibility re: safety of resident. Regarding making rounds on the floor: all staff this includes the nurses and the CNAs on all shifts: Check on the residents before Mass and knock on doors that are closed, and before leaving for the day. On 03/16/18 at approximately 10:54 AM an interview was conducted with CNA #4. She stated that she was not working on the North side day of incident. She stated that she works alternating months on each unit. She was educated by RN #2 that a resident is not to be left alone during toileting, the call bell must always be in their reach and the CNA must check that it works. As soon as she comes on unit: she goes to all of the resident's rooms to visualize and check on the residents. She continued to state that staff education is done annually and PRN (as necessary) for Abuse, neglect, mistreatment. Education Day began yesterday, is in progress today and continues into next week. 03/16/18 12:41 PM Interview with the resident's son was attempted. He was called on his cell phone and a message was left for him to return my call at the facility. As of 3:15 PM he did not return the call. On 3/16/18 at approximately 1:16 PM and interview was conducted with RN #2, the Director of Nursing (DON). She stated that she was informed by RN #1 about the incident involving Resident #7 and the CNAs #1,#2 and #3 on 1/10/18. She informed the Chief Executive Officer about the incident. She stated that the plan for all staff on the 3rd floor was education on placing call bell in the resident's hand, communication between staff members, checking on the residents who are on the commode, use of lifts and personal assistance to the residents. She stated that she conducted individual interviews with the staff involved, completed the facility's Accident/Incident Investigation form and notified the New York State Department of Health of this reportable incident via HERDS (Higher Education Research and Development Survey). Nursing progress Notes: 1/10/18-1/11/18 were reviewed. 1/10/18, 12:30 PM: Assessed after being left on toilet. Redness noted to buttocks and upper thighs. Skin is intact. 2:40 PM: checked resident again, skin intact to buttocks, no further redness noted. 3-11 PM: resident is alert and oriented times three (person, place and time). Call bell within easy reach and resident denied pain /discomfort during tour. Frequent rounds provided and resident needs anticipated. 11 PM-7 AM: No visible signs of injuries observed. No complaints voiced. 1/11/18: resident denies pain; being toileted and taken off commode appropriately. Call bell within reach. No redness or discoloration to buttocks. 11 PM-7 AM: Resident is alert and oriented x 3. Able to make all needs known. No visible signs of injuries observed after incident. The Universal Progress Notes on 1/10/18 was reviewed and the Physician documented: left on toilet x 90 minutes-no injury. VSS(vital signs stable). 415.4(b)(1)(i)

Based on observation, record reviews and interviews, the facility did not ensure that infection control practices were followed, Specifically an RN used a contaminated glove to smear ointment on a resident's wound. This was evident for 1 of 2 residents observed for pressure ulcer care out of a sample of 19 residents. Resident #42 The finding is: Resident #42 is admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The annual MDS dated [DATE] documented that the resident is assessed as cognitively intact with a BIMS of 15. It further documented that she is at risk for Pressure Ulcer development and has a Moisture Associated Skin Damage which is an incontinence-associated [MEDICAL CONDITION] (IAD) to the buttocks and is on application of ointment as a treatment. The care plan dated 2/12/18 documented a problem of Actual/Potential for skin breakdown related to frequently incontinence and impaired mobility. a superficial abrasions on 2/12/18. Sacral stage 2 Pressure Ulcer noted 1/8/18 with a goal of resident will have superficial abrasions to buttocks healed with 6 weeks. The intervention is to apply [MEDICATION NAME] ointment, [MEDICATION NAME] ointment and Bacitricin ointment to the affected areas of the buttocks The physician order [REDACTED]. Apply [MEDICATION NAME] ointment twice daily, do not cover. On 3/14/18 2:30 PM, the treatment registered Nurse (RN) was observed doing the treatment to resident's buttocks. She washed her hands, donned gloves. Put Domeboro in normal saline and mixed them together. Soaked the area with the solution on an abdominal pad for 15 minutes. Patted dry. Washed hands, donned gloves. RN applied [MEDICATION NAME] to the right buttock, [MEDICATION NAME] ointment to both buttocks and [MEDICATION NAME] to the inner area of the buttocks. The RN held the tubes with the right hand, and used the same right hand to smear the creams on the resident's buttocks. The Dermatologist consult notes were reviewed from 12/4/17 to 2/12/18 documented the followings 12/4/17 Followed up for irritant an irritant [MEDICAL CONDITION] of the buttocks. Recent bacteria culture to rule out secondary staff infection was negative. She grew multiple gram negative bacteria but no significant pathogen 1/12/18 Resident is being reevaluated today because the problem seems to be getting worse. 2/12/18 The plan is to continue with the Domeboro compresses and follow with the ointments. On 3/16/ 18 at 12:31 PM, the DON was interviewed and stated that we have inservice here every six months. We are trying to do inservice more often. On Friday (MONTH) 16, (YEAR) at 10:05 AM, the treatment RN was interviewed. The RN stated that she used the wrong technique. She stated that it was wrong to apply the ointment on the resident's buttocks after contamination of the glove. The RN stated that she needed improvement in applying treatments. 415.19(b)(4) Pressure Ulcer/Injury

Based on observation and staff interview the facility did not ensure that food was stored under sanitary conditions. Specifically, during the initial tour there were several food items in the dry storage area that were expired. This deficient practice had the potential to affect the entire facility. The findings is: During the initial tour of the kitchen area expired food items were observed in the dry storage area. The following things were expired: 1. 2 jars of lemon curd expired [DATE] 2. liquid marble chocolate 12.5 lbs. dated 10/12 3. 1 large tub of peach filling with date of 4/15 4. 3 kernel paste 45 lbs. dated 10/12 5. 2 raspberry peach spread 45 lbs. dated expired Feb/24/14 6. 2 fudge ice base 15 lbs. dated 10/12 7. 1 apricot cookie filling 45 lbs. dated 10/12 8.1 raspberry filling 50 lbs. best by [DATE] 7. 1 apple filling 18 lbs. use by 1/11/15 8. 2 raspberry peach spread 45 lbs. use by 5/26/13 and 5/3/15 9. 1 strawberry filling 20 lbs. dated 10/22/14 An interview with the food service supervisor was conducted on 11/17/15 at 9:30 am. The Food service supervisor stated that they regularly check the store room every week but does not document items or expiration date. The Food Service Supervisor stated that the expired items following items are donations and are not regularly used or checked. The facility does not have a designated person assigned to the store room who checks stocked items. The FSD (food service director) was interviewed on 11/17/15 at 10:00 AM who stated that the FS supervisor checks the inventory once a month and they have a food service worker who checks the inventory when they initially receive the donations and then once a month. The FSD stated that food is purchased through a contractor. The FSD further stated that one of the Sisters of the order also goes out to the farmers markets and wholesale stores to receive donated foods. When asked the FSD how does she ensure that food items that are donated are from procured and approved satisfactory sources the FSD stated from her discussion with the Sister that the Sister obtains food items from wholesale stores that sell to small stores and the wholesalers are licensed. On 11/17/15 an interview with the facility baker was conducted her role and responsibility is to check inventory. When asked how often do you check the inventory? The baker stated once a month. When asked where is the inventory documented the baker stated on the inventory log. The baker also stated that if something expired bring to FSD. The baker stated she was under the impression that you could not get rid of those items because they were donated. Those items were items that we don't use. The last time she checked the inventory was approximately three weeks ago and the FSD was not in so she was not able to show the FSD the items expired. The baker stated that it slipped her mind to bring it up to the FSD attention because these are items they really dont use. On the inventory log the baker dates it and signs off or initial that check the inventory of the food storage. When initially get donations the baker checks the donated expiration dates and does not document it anywhere. The FSD stated on 11/17/15 at 11:25 AM that when they check the dry storage donation log which last documented on 11/6/15 that if the worker observes anything expired they bring out and would show it to FSD and supervisor on duty. Then they would discard the items. On 11/18/15 at 9:15 AM an interview with the Sister responsible for getting donated items was conducted. The Sister stated that she goes to Hunts Point Market it is a wholesale produce market, they get from different countries different produce from Europe and United States. There are government inspectors at the market they oversee the quality. If the see any discrepancies or below standards they call they government inspectors to check the food items out. The FSD gives the sister the list by Sunday night of items they need from the market. The sister goes to Fish Market every month and they would donate part of of the items or giving it for half the price. This is also under government regulations and have high standards. The sister stated the items that were discarded were items she purchased, not donated. These were items that she purchased years ago for the previous FSD to use. Another interview was conducted with the FSD on 11/18/15 at 2:15 PM that the Sister stated the expired items were not donated. When asked, how does the facility identify items that are donated and do they have vouchers for those items? The FSD stated that anything that they do not buy goes into donation. The food items were not purchased by the contract vendor so that them place them in the donated section in the dry store room and still it is our responsibility to ensure those products are not expired. Certain things are not bought and may not have a voucher for them and/or receipts. The FSD will make a copy of any vouchers or receipts she has for those items. The Policy On Donated Food Items revised on January 2015 documents, 1. All donated foods are screened and inspected upon receipt by a designated Begging Sister', with the assistance of the Dining Services Department. 2. All food, perishable or shelf stable items are refused or discarded if: a. The source of the donation is not known or reputable. b. The food temperature is not acceptable based upon the type of product aka temperature danger zone. c. The physical condition of the original container show signs of time, temperature or physical abuse. d. Expiration or use by dates are not valid. e. If the source is known but if we are able to determine if it has been maintained at proper temperatures it is has been maintained at proper temperatures it is discarded. 415.14(h)

Based on observation, record reviews, and staff interviews, the facility did not ensure that infection control practices were maintained. Specifically, the Registered Nurse did not remove her gloves after cleansing a residents sacral pressure ulcer. This was evident for 1 resident reviewed for Pressure Ulcers. (Resident # 16). This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. The findings is: Resident #16 was admitted to the facility with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented: Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition, extensive assistance of one person for personal hygiene, toileting, dressing and transfers. The MDS further documented the presence of two stage 2 and stage 3 pressure ulcers. A wound care observation was conducted on 12/19/13 at 9:45 am with the unit Registered Nurse (RN). The RN was observed cleansing the residents right buttock pressure ulcer with a gauze pre-moistened with normal saline. After cleansing the wound the RN did not remove her gloves, wash her hands and don clean gloves before proceeding with the remainder of the wound care. Physician orders [REDACTED]. Diagnosis: [REDACTED]. An interview was conducted with the Registered Nurse (who performed the dressing change) on 12/13/13 at 3:10 pm. The RN stated that she was aware that she should have removed her gloves, washed her hands and donned clean gloves after cleansing the wound, and had just forgotten to do so. 415.19(a)(1-3)

Based on record review and resident and staff interview during the recertification survey, the facility did not ensure that 1) one of twenty-four sampled residents had a timely physician's orders [REDACTED]. Specifically, Resident #59 had documents in his/her clinical record revealing that there should have been a Do Not Resuscitate Order (DNR) in the chart since 1/4/12, however the physician's orders [REDACTED]. In addition, 2) the facility did not ensure that there was documented evidence that the Resident Council Representative was informed of her right (and given information on how) to formally complain to the State about the care she and other residents are receiving. This lack of knowledge has the potential to affect other residents in the facility. This resulted in no actual harm with the potential for more than minimal harm that was not immediate jeopardy. The findings are: 1) Resident #59 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Advanced Directive Section of the resident's medical record revealed that papers were signed for this resident to have a DNR Order in place on 1/4/12. Resident #59's medical record was reviewed with the Social Worker (SW) on 1/31/12 at 9:20 AM. The SW's Note dated 1/4/12 documented that admission policies and procedures were reviewed with the resident's son who was the resident's Health Care Proxy (HCP). In keeping with the resident's wishes, a DNR was signed. The SW stated that the DNR document is then left in the Physician's mail box for the Physician to sign. The SW further stated that there was no phone call placed to the Physician to obtain an Interim Order for the DNR. The Interim physician's orders [REDACTED]. On 1/31/12 at 9:30 AM the Director of Nursing (DON) was interviewed and stated that five days was too long to wait for the Physician to write a DNR order. The facility's current policy on Do Not Resuscitate dated 6/2007 documented that once DNR papers are completed, it was the Physician's responsibility to write a DNR order. 2) The Resident Council Representative (Resident #18) was interviewed on 1/26/12 at 3:05 PM and stated that she and the other members of the Resident Council were never told about a State hotline number. Review of Resident Council Meeting minutes dated 11/5/10 to the most current minutes dated 9/6/11 revealed no documented evidence that the State hotline number had been discussed with the residents. The Director of Activities was interviewed on 1/31/12 at 12:40 PM and stated that the State hotline number is discussed with the residents once a year when Resident Rights are discussed, but she has never documented that in the Resident Council Meeting minutes. 415.3(e)(2)(iii) 415.3(c)(2)(i)(b)

Based on resident and staff interview and record review during the recertification survey, the facility did not ensure that there was documented evidence that the Resident Council Representative was informed of where to find the results of the State survey inspection. This lack of knowledge has the potential to affect other residents in the facility. This resulted in no actual harm with the potential for no more than minimal harm. The finding is: An interview with the Resident Council President (Resident #18) on 1/26/12 at 3:00 PM revealed that no one had ever told her about the State inspection report or where to find it. Review of Resident Council Meeting minutes dated 11/5/10 to the most current minutes dated 9/6/11 revealed no documented evidence that the residents were told where to find the results of the State inspection. The Director of Recreation was interviewed on 1/31/12 at 12:30 PM and stated that the residents are told about the State inspection report after a survey (the last survey was dated 11/19/10), but she has never documented that in Resident Council Meeting minutes. 415.3(c)(1)(v)

Based on record review and staff interviews during the recertification survey, the facility did not ensure that Accident/Incidents (A/I) were thoroughly investigated for 2 sampled residents and 2 out of sample residents reviewed for A/I's in a total of 13 records reviewed (Residents #4, #5, #18 and #19). Specifically, 1) Resident #4 had three A/I's documenting a bruise, a blister and an old wound on the lower leg without statements obtained from all staff assigned to the resident; 2) Resident #5 had documentation of a swollen painful wrist in the medical record without an A/I developed; 3) Resident #18 had a bruised area to the lower leg without statements from assigned staff; and, 4) Resident #19 had an ecchymotic area identified to the right rib cage on 11/8/10 and there were no staff statements obtained in the investigation completed to rule out abuse, neglect or mistreatment. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The findings include but are not limited to: 1) Resident #4 has a [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had modified independence in cognitive skills for daily decision making with short term memory problems. The MDS also documented that the resident required two person physical assistance for transferring and ambulating. The A/I Report dated 10/8/10 at 7:30 AM documented that the resident had a black and blue area on the left upper arm, that looked new, a 2.0 x 2.0 inch red ecchymotic area to the resident's left upper arm, a black and blue ecchymosis on the resident's right lower arm and scattered small ecchymotic areas to both knees. There were no documented statements from the 2 CNA's that had assisted with the resident's care on the 3:00-11:00 PM shift or the 11:00 PM- 7:00 AM shift prior to the identification of the ecchymotic areas. The A/I Report dated 10/11/10 at 9:00 AM documented that the resident had a blackened area on the right middle finger. There were no documented statements from the direct care staff that assisted with the resident's care during the past 24 hours. The A/I Report dated 10/25/10 at 11:00 AM documented that the resident had an old looking wound on the right lower leg. There were no documented statements from the direct care staff that assisted with the resident's care during the past 24 hours. 2) Resident # 5 had [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] documented the resident's cognition as independent. A Nurse's note dated 2/16/10 documented that the resident's left hand and wrist were swollen and painful. There was no documented A/I report developed for this finding. There was no subsequent nurse's note for the resident documented until 3/4/10. This note had no reference to the left hand and wrist. A physician progress notes [REDACTED]. 3) Resident #18 had [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] documented the resident's cognition as moderately impaired. The MDS also documented that the resident required 2 person physical assistance with all Activities of Daily Living (ADLs). An A/I report dated 5/29/10 at 7:00 AM documented that the resident was identified with a bruised area on the right lower forearm. There were no documented statements from staff who had been assigned to the resident in the previous 24 hours of the observation. The Director of Nursing was interviewed on 11/18/10 at 10:00 AM. The DNS stated that statements should have been obtained for these resident's at the time the findings were made. A policy titled Medical and Nursing Service Policies and Procedure Reporting Accidents and Incidents dated 11/15/08 was reviewed. The policy contained no documentation pertaining to obtaining staff statements. 415.4(b)(l)(ii)

Based on record review and staff interview during the recertification survey, the facility did not ensure that all residents received the necessary care and services to maintain their highest practicable physical, mental and psychosocial well-being in accordance with their Comprehensive Assessment and Plan Of Care. This was evident for 3 of 11 residents reviewed for pain in a total of 13 sampled residents. Specifically, 1) Resident #1 had multiple documented episodes of not having Bowel Movements (BM) for greater than 3 days without documented Abdominal Assessments, Physician notification and/or medication administration as per physician's orders [REDACTED].#8 was administered multiple doses of pain medication, as needed (PRN) without documented reassessments of the effectiveness of the medication; 4) Resident #1 was readmitted to the facility on [DATE] with a new [DIAGNOSES REDACTED]. The findings include, but are not limited to: 1) Resident #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessments dated 11/11/09 through 9/8/10 documented that the resident was independent with cognitive skills for daily decision making and had no long or short-term memory problems. The MDSs documented that the resident was continent of bowel and occasionally incontinent of bladder. The MDSs documented that the resident required two person physical assist for transferring. A CCP titled Continence - Prone to Constipation dated 11/18/09 documented goals including: resident will have a Bowel Movement (BM) every 1-3 days. Interventions on the CCP included: administer laxatives/stool softeners As Needed (PRN) as ordered; monitor and record BMs; and, minimize constipation by encouraging fluids and fiber in diet. The physician's orders [REDACTED]. The Resident Care Accountability Record (RCAR) dated 11/27/09 through 12/3/09 documented that Resident #1 did not have a BM for 19 shifts (approximately 6 days). The MARs dated 11/27/09 through 12/3/10 documented that the resident did not receive the PRN MOM as ordered after three days of no BMs on 12/1/09 through 12/3/09. A Nurse's Note dated 11/30/09 documented that the resident had not had a BM in three days and refused PRN MOM. The note further documented that the resident stated that she would take the MOM tomorrow night if no BM by then. There was no follow-up regarding the resident's BM status or administration of MOM documented on 12/1/09. A Nurse's Note dated 12/2/09 documented that the resident took 30 ml of MOM at 8:30 PM. There was no documented evidence in the note that the physician had been notified that the resident had not had a BM in the past 4 days. A Subsequent Nurse's Note and physician's orders [REDACTED]. The physician's orders [REDACTED]. A Nurse's Note dated 12/4/09 during the 7:00 AM - 3:00 PM shift documented that the resident had a BM. A physician's orders [REDACTED]. The RCAR dated 1/2/10 through 1/6/10 documented that Resident #1 did not have a bowel movement for 14 shifts (greater than 4 days). The MAR indicated [REDACTED]. A Nurse's Note dated 1/6/10 during the 7:00 AM - 3:00 PM shift documented that the resident complained of not being able to move her bowels (for 11 shifts as per the RCAR). The note documented that the resident's abdomen was distended. There was no documented evidence that the resident's Physician had been notified of the resident's abdominal distention or ineffectiveness of the laxative medications administered. The RCAR dated 1/28/10 through 2/4/10 documented that Resident #1 did not have a bowel movement for 23 shifts (greater than 7 days). The Nurse's Note dated 2/1/10 at 6:00 AM (after 9 documented shifts of no BMs on the RCAR) documented that Resident #1 appeared to have dyspnea affiliated with exertion when bathing, dressing and toileting. A Nurse's Note dated 2/3/10 during the 7:00 AM - 3:00 PM shift documented that the resident stated "I'm too sick to eat". The MAR indicated [REDACTED]. The Nurse's Note dated 2/4/10 completed during the 3:00 PM - 11:00 PM shift documented that MOM had been administered for constipation. There was no documented evidence in the note of any results from the MOM administered, that the Physician had been notified or that an assessment of the resident's abdomen had been conducted . The Physicians Orders dated 2/4/10 documented no changes in medications for constipation for Resident #1 and the following meds continued: [MEDICATION NAME] Softgel 24 mcg one capsule daily; [MEDICATION NAME] 300 mg at bedtime; [MEDICATION NAME] 30 cc two times daily; Calcium Polycarbophil 635 mg tablet two tablets daily; and, Milk of MOM 45 ml by mouth at bedtime as needed if no bowel movement in 3 days. A Nurse's Note dated 2/5/10 completed during the 7:00 AM - 3:00 PM shift and the RCAR dated 2/5/10 documented that Resident #1 had a BM (23 shifts and approximately 8 days after the last documented BM on the RCAR). The RCAR dated from the 11:00 PM - 7:00 AM shift on 2/5/10 through the 11:00 PM - 7:00 AM shift on 2/10/10 documented that Resident #1 did not have a BM for 16 shifts (greater than 5 days). The MAR indicated [REDACTED]. The Nurse's Notes dated 2/5/10 during the 3:00 PM - 11:00 AM shift through 2/9/10 during the 11:00 PM - 7:00 AM shift revealed no documented evidence that the Physician had been notified or that an assessment of the resident's abdomen had been conducted. A Nurse's Note dated 2/9/10 during the 3:00 PM - 11:00 PM shift documented that the resident complained of constipation and that MOM had been administered along with [MEDICATION NAME] and that at 4:00 PM "awaiting BM". There was no documented assessment of the resident's abdomen or documentation that the Physician had been notified. A subsequent Nurse's Note dated 2/10/10 during the 3:00 PM - 11:00 PM shift documented that the resident had not had a BM in 6 days, that MOM given, [MEDICATION NAME] given, abdomen distended, medical aware and will see the resident in the morning. A Nurse's Note dated 2/11/10 documented that Resident #1 had a large BM at 6:00 AM (5 days after the last documented BM on the RCAR). A review of Resident #1's Dietary Notes dated 11/18/09 through 9/22/10 and Nutrition Status CCP dated 11/7/09 revealed no documented evidence that the resident had been identified with, constipation or assessed for and provided with nutritional interventions to prevent constipation. A Medical & Nursing Service Policy & Procedure dated 6/15/05 documented a goal to treat constipation in a timely and effective manner. The procedure documented that if a resident does not have a BM in 3 days the following will be completed: (1) Assess the resident for abdominal distention, tenderness, bowel sounds and for nausea and vomiting; (2) Encourage the resident to drink extra fluids if not contraindicated; and, (3) Administer laxatives, suppository or enema as ordered by the Physician. The procedure further documented that if no BM by the fourth day that medications will be administered as ordered and if no BM in 6 hours, call MD. An interview was conducted on 11/17/09 at 1:25 PM with the facility's Registered Dietitian (RD). The RD stated that she does not provide or assure that specific juices or increases in fiber are provided for residents with constipation because the resident's get to choose their foods at meal time. An interview was conducted with the Director of Nursing Services (DNS) on 11/19/10 at 10:12 AM. The DNS stated that if a resident does not have a BM for 3 days the Physician should be notified for recommendations. The DNS stated that the 3:00 PM - 11:00 PM nurse is responsible to review the bowel records for all the residents on their prospective units. An interview was conducted with the Medical Director on 11/19/10 at 11:30 AM. The Director stated that the medical team should be notified when a resident does not have a BM after 3 days. The Director further stated that nutritional interventions could be incorporated into dietary assessments to assist in preventing constipation. An interview was conducted on 11/19/10 at 1:35 PM with the 3:00 PM - 11:00 PM RN responsible for Resident #1. The RN stated that she checks the bowel records for all her assigned residents. The RN could not recall what had been done on the specific dates when constipation greater than 3 days had been documented for Resident #1. The RN stated that if a resident does not have a BM for 3 or more days, she will give prune juice and Laxatives and/or call the nursing supervisor. The RN further stated that if no BM is noted after the third day that the nursing staff must act and that medical would be notified for new orders. 2) Resident #5 was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] documented the resident's cognition as independent. An initial Pain Screening/Assessment form dated 11/10/09 documented a pain scale of 8. (A score above 5 indicated that a Comprehensive Assessment was needed) There was no documented evidence in the medical record that a Pain Assessment had been completed. Subsequent Pain Screens were documented as completed on 3/16/10 and 6/11/10. The scores were 7 and 8 respectively, and again no Comprehensive Pain Assessment had been completed. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. A Nurse's Note dated 6/18/10 documented that the resident stated that her hips had been "killing" her for the past few days. The Physician was notified and ordered [MEDICATION NAME] ([MEDICATION NAME]) (anti-[MEDICAL CONDITION]) 200 mg tablet, 2 tablets by mouth = 400mg every 6 hours PRN for hip pain times five days. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated some" relief from the [MEDICATION NAME] for 12 administrations and was relieved on only 2 occasions. The MAR indicated [REDACTED]. The MAR indicated some" relief for 9 administrations and "good" relief on 2 occasions. A physician's orders [REDACTED]. The Nurse's Notes dated 7/8/10 through 7/13/10 revealed no documented evidence of an assessment of the effectiveness of the [MEDICATION NAME] administered. A physician's orders [REDACTED]. Between 7/14/10 and 7/30/10 the MAR indicated some" relief documented on 6 administrations. The MAR indicated [REDACTED]. The MAR indicated some" or "little" relief for each administration. There was no documented evidence in the medical record that the Physician had been notified of the effectiveness of the pain medication administered to the resident and that it resulted in only some or little pain relief. There was also no documented evidence that a pain scale had been utilized to determine how great the degree of discomfort was prior to the administration of the pain medication to insure that appropriate relief was obtained. 3) Resident # 8 has [DIAGNOSES REDACTED]. The resident was readmitted to the facility from a hospital stay on 7/30/10 status [REDACTED]. The Quarterly MDS assessment dated [DATE] documented that the resident had moderately impaired cognitive skills for daily decision making. The Physician's Readmission orders [REDACTED]. A CCP titled Pain Management dated 7/30/10 documented that the resident's potential for pain was related to [MEDICAL CONDITION] and Hemorrhoids. Interventions documented on the CCP included to monitor the resident's response to pain management and refer to the Medical Doctor accordingly. There were no updates to the Pain CCP. A Significant Change MDS assessment dated [DATE] documented that the resident was experiencing moderate pain symptoms on a daily basis. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The back of the MAR indicated [REDACTED]. Seven of the 22 doses of Tylenol were documented as providing "some relief"; twelve of the twenty-two doses documented "little" or "no relief"; and three were documented as being effective. A review of the Nurse's Notes for 8/1/10 through 8/30/10 documented that Tylenol PRN was given to the resident with some, little or no relief on 8/4/10 (3:00PM-11:00PM Shift), 8/6/10 (3:00 PM-11:00PM Shift), 8/8/10 (3:00 PM-11:00PM Shift), 8/10/10 (7:00 PM), 8/11/10 (3:00 PM-11:00 PM Shift). There was no documented evidence that the Physician was notified of the ineffectiveness of the Tylenol and [MEDICATION NAME] in relieving the resident's pain. A Nurse's Note dated 8/30/10 7:00 AM-3:00 PM Shift documented that the resident stated that on a scale of 1 to 10 the pain in both legs was an 8. The Nurse's Note documented that the resident was given Tylenol with "some" relief. There was no further follow-up documented. A facility Pain Screening/Assessment Form dated 8/12/10 documented a Total Pain Score of 13 (a score of 5 or greater indicates a Comprehensive Assessment is needed). The Comprehensive Pain Assessment documented that the resident had intermittent pain and effects of the pain included Sleep Disturbances and effects on the resident's Mood/Behavior. The plan included that the resident continue to get the medication prescribed. There was no documented evidence that the Physician was notified of the results of the Pain Assessment and no update to the Pain CCP. The Nurse's Note dated 9/3/10 documented that the resident's pain was "still at level of 8" and that the resident would continue to be monitored. The Physician's Monthly Orders dated 9/6/10 documented no changes to the resident's pain regime. The MAR indicated [REDACTED]. There were no pain levels documented as part of the pain assessment. The results documented that 14 doses provided "some" relief; 3 doses had "no or little effect" and, 4 were effective. The Nurse's Note dated 9/14/10 on the 7:00 AM-3:00 PM Shift documented that it was reported to the Medical Supervisor that the resident continued to request Tylenol for leg pain and that the legs were large and hard to the touch. A physician's orders [REDACTED]. A Nurse's Note dated 9/22/10 on the 7:00 AM-3:00 PM Shift documented that the resident does not complain of leg pain anymore and that the resident was satisfied with the new regime. The Director of Nursing Services (DNS) was interviewed on 11/19/10 at 2:00 PM. The DNS stated that the Medical Supervisor should have been notified regarding the ineffectiveness of the pain medication being administered for Residents #5 and #8. The DNS further stated that the resident's pain should have been measured on a scale of 0-10. The DNS stated that the ineffectiveness of the pain medication should have been reassessed. The DNS further stated that Comprehensive Pain Assessments should have been completed for Resident #1 and Resident #5. The facility's Pain policy and procedure dated August 2003 and reviewed August 2007 documented that ". . .between quarterly screens a resident's pain is evaluated on an ongoing basis by the charge nurse and reflected on the Universal Progress Notes. . ." 415.12

Based on observation and staff interview, it was determined that the facility did not ensure that the resident environment remains as free of accident hazards as is possible in that windows in resident rooms on all units were of the double-hung variety and can be unlatched at the top of the window and tilted down. This configuration would leave an unrestricted window opening and would not prevent a possible fall. This was noted on three of five resident-use floors in the building. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. The findings are: On 11/16/10 between 8:30am- 2:00pm during the recertification survey, resident rooms and common use areas on floors 1, 2 & 3 were provided with windows noted to be of the double-hung variety and can be unlatched at the top of the window and tilted down. This feature was tested by and confirmed with the Director of Maintenance. The windows were not provided with security screens to prevent accidental falls. This situation would present a possible accident hazard as it would leave an unrestricted window opening. In an interview on 11/16/10 at approximately 11:00am, the Director of Maintenance stated that he would monitor the windows while installing devices to prevent them from opening in. 415.12(h)(1)

`Based on observation, record review and staff and resident interviews during the recertification survey, the facility did not ensure that each resident's drug regimen remained free from unnecessary drugs. This was evident for 4 of 11 residents reviewed for Psychoactive medications in a total of 13 records reviewed. Specifically, 1) Resident #3 was documented as receiving [MEDICATION NAME] (an [MEDICATION NAME]) for sleep without appropriate indication for its use. In addition, there were no non-pharmacological interventions documented as attempted prior to the use of the drug; 2) Resident #6 was receiving long term antipsychotic drug therapy without reassessment of the effectiveness of the [MEDICAL CONDITION] medication regime, or any attempts at gradual dose reduction. 3) Resident #9 received [MEDICATION NAME] (anxiety medication) for 8 dosages without documented evidence of non-pharmacological interventions attempted prior to administration; 4) Resident #1 had received a Hypnotic medication for 22 months without a documented Comprehensive Care Plan related to [MEDICAL CONDITION] or an attempted dose reduction. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The findings are: 1) Resident #3 has [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had no short and long term memory problems and was independent in cognitive skills for daily decision making. A Physicians Order Form (POF) dated [DATE] documented [MEDICATION NAME] 25 Milligrams (mg.) at hours of sleep PRN (as needed). A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A physician's orders [REDACTED]. A Pharmacist Review of Medication Therapy (Review) dated [DATE] documented to discontinue [MEDICATION NAME], as it was not recommended due to side effects. A Physician Response documented that the resident requests [MEDICATION NAME] and no change is indicated at this time. A Pharmacist Review dated [DATE] documented that there was a report generated for [MEDICATION NAME] utilized for [MEDICAL CONDITION]. The report dated [DATE] did not document further recommendations for [MEDICATION NAME]. There was no documented evidence in the medical record that a gradual reduction of dosage was attempted. The Director of Nurses (DNS) was interviewed on [DATE] at 10:00 AM. The DNS stated that when resident's receive PRN medications for sleep, there should be documented evidence of some interventions, such as a drink or snack prior to the administration of the medication. The Medical Director was interviewed via telephone on [DATE] at 12:30 PM. The Medical Director stated that an alternative intervention should be attempted and documented prior to the administration of PRN medications for sleep. 2) Resident #6 has [DIAGNOSES REDACTED]. The resident is [AGE] years old and was admitted to the facility on [DATE]. The MDS Assessments dated [DATE], [DATE] and [DATE] documented that the resident had independent cognitive skills for daily decision making with no long term memory problems. The three MDS's documented that the resident had periods of restlessness, not of recent onset and indicators of depression included sad, pained, worried, facial expressions with crying and tearfulness which were easily altered. The MDS documented that the resident was being administered antipsychotic medication and antidepressive medication daily. The Physician's Monthly Orders dated [DATE] documented [MEDICATION NAME] 25 mg tablet daily for [DIAGNOSES REDACTED]. The resident's Psychiatric/Mood CCP initiated [DATE] and updated [DATE] documented that the resident had mood indicators of Depression which included tearfulness and sad, pained look with no behavior issues. The CCP documented that the resident had periods of restlessness and limited attention related to nervousness. The CCP did not document a specific description of any agitated behaviors related to the resident's Psychiatric [DIAGNOSES REDACTED]. The medical record from [DATE] through [DATE] was reviewed. There was no documented evidence that the resident's medication regime was reviewed in conjunction with the Nurses Monthly Behavior Notes which documented that the [MEDICAL CONDITION] drug regime was ineffective for the indications documented from [DATE] through [DATE]. The Quarterly Psychiatry Progress Notes dated [DATE], [DATE], [DATE], and [DATE], all documented that the resident was anxious (at times) and restless with a [DIAGNOSES REDACTED]. . ." and continuation of the current medication regimen was recommended. A facility form titled Antipsychotic [DIAGNOSES REDACTED]. The Psychiatrist documented the specific behavior to be monitored to provide stability of mood and reduce acute agitation. There was no description of the agitation documented. There was no documented evidence or accurate description in the medical record reviewed from ,[DATE] through [DATE] of how the resident exhibited acute agitation. The Monthly Nursing Psychoactive Behavior Notes dated [DATE] through [DATE] documented symptoms of depressed mood throughout including statements by the resident of feeling helpless and depressed with behaviors which included restlessness and general anxiety. The behavior notes dated [DATE], [DATE] and [DATE] specifically documented that the resident had increased episodes of Depression. There was no documented evidence of Agitation or Psychoses in the Behavior Notes from, January through [DATE]. There were no reassessments of the psychoactive medication regime documented in relation to the increase in depressive behavior and ineffectiveness of the current medication regime. The Monthly Behavior Monitoring was not integrated with the Quarterly Psychiatry Assessments. The Nurses Notes dated [DATE] on the 7:00 AM-3:00 PM Shift documented that the resident's depressed mood persisted, the N/N dated [DATE] on the 3:00 PM-11:00 PM Shift documented that the resident was anxious and asking the staff to "Pray for me". The N/N dated [DATE] 7:00 AM-3:00PM documented that the resident stated that he was going to God and asked for prayer. There was no description of agitated behaviors documented. The Physician's Progress Note dated [DATE] documented that the resident was agitated and nervous. The resident's attending physician ordered an increase in the antipsychotic [MEDICATION NAME] to an additional 12.5 mg every morning. The CCP dated [DATE] was not updated to reflect the increase in the [MEDICATION NAME]. The Psychologist evaluated the resident on [DATE]. The Psychologist documented that the resident had a [DIAGNOSES REDACTED]. The Nurse's Monthly Behavior Notes dated [DATE] documented that the resident continued to express feelings of being depressed, was impatient and pacing. The resident was interviewed on [DATE] at 9:45 AM. He was alert and a good communicator. The resident stated that he attempts to attend the facility activities, sometimes he is anxious and prefers not to. When he wants to be alone he stays in his room. The resident stated he was satisfied with the care he was receiving at the residence and very blessed to be there. The Psychiatrist was interviewed on [DATE] at 11:15 AM. The Psychiatrist stated that the resident had a history of [REDACTED]. 3) Resident #9 has [DIAGNOSES REDACTED]. The MDS dated [DATE] documented that the resident had short and long term memory problems and moderately impaired cognitive skills for daily decision making. POF's dated [DATE] through [DATE] documented [MEDICATION NAME] (a sedative-hypnotic) 0.25 mg every four hours as needed for agitation. Psychoactive Drug Nurse Evaluation Notes dated June through [DATE] documented that the resident calls out for deceased sister and becomes disruptive on bath days. Notes further document that resident enjoys activities and is quiet when kept busy. A review of the MAR from [DATE] through [DATE] documented that Resident #9 received [MEDICATION NAME] 8 times for agitation and there was no documented evidence in the MAR indicated [REDACTED]. The Director of Nurses (DNS) was interviewed on [DATE] at 10:00 AM. The DNS stated that when residents receive PRN medications for agitation, there should be documented evidence of some interventions, such as a diversional activity prior to the administration of the medication. The Medical Director was interviewed via telephone on [DATE] at 12:30 PM. The Director stated that if a Physician uses a medication that is known to be contraindicated, the physician must document the rationale for use in their notes. The Director stated that a resident's request for medication is not sufficient justification for use alone. An undated facility policy titled Anti-Psychotic Medication Guidelines documented that . . .#6-the physician will document the effectiveness of the medication at the time of monthly/bi-monthly review. If antipsychotic medications are used outside the guidelines, but in the best interest of the resident, the resident's clinical record shall include documentation of evidence to support justification of the reasons why this is clinically appropriate. . . 415.12(1)(1)

Based on record review and staff interviews during the recertification survey, the facility failed to accurately document and assess the fluids provided via Gastrostomy Tube (GT) for one resident reviewed for GT in a total sample of 13 residents reviewed. Specifically, Resident #2 received GT feedings with no documented evidence that the Dietitian had assessed the GT feedings provided to determine if they met estimated nutrient needs. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The finding is: Resident #2 has [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] and a Significant Change MDS dated [DATE] documented that the resident received 76% to 100% of total calories and 2001 or more cubic centimeters (cc) of fluids on average via a feeding tube in the past seven days. The MDS dated [DATE] further documented that the resident had a significant weight gain of 5% or more in the last 30 days or 10% or more in the last 180 days. A physician's orders [REDACTED]. ml at end. A POF dated 7/21/10 documented that the GT feeding order reflected a change in the [MEDICATION NAME] feeding of 2 cans of [MEDICATION NAME] 1.0 to 1 can of [MEDICATION NAME] 1.0 with the same fluid flushes. A Laboratory Report dated 9/22/10 documented a Total Protein (TP) value of 5.5 grams/deciliter (g/dl) (normal TP = 6.4 - 8.9 g/dl) and a low [MEDICATION NAME] value of 2.99 g/dl (normal 3.5 - 5.7 g/dl). A physician's orders [REDACTED]. A Dietary Note dated 7/26/10 documented that the GT formula was changed to promote weight control. Further Dietary notes dated 8/25/10 through 11/8/10 documented that the resident had abnormal lab values and weight gains. The Note dated 9/1/10 documented that the resident's ideal body weight is 140-172 pounds, and the resident weighed 192 pounds. There was no documented evidence in the Dietician's notes that the nutrients provided via the G/T feeding prescribed by the Physician were calculated to determine if the GT feeding met the resident's estimated fluid needs. (The last Nutrition Assessment that evaluated and assessed the resident's nutrient needs compared to the GT feeding provided was dated 6/3/09) An interview was conducted with the Registered Dietitian (RD) on 11/17/10 at 12:30 PM. The RD stated that basal needs are calculated on an as needed basis, for example when the formula is changed or when a Significant Change Assessment is done but were not documented. The RD further stated that this should have been documented. A Policy titled Nutritional Care Planning dated 1/2008 documented that "Each resident shall be assessed and a plan of care developed outlining their nutritional needs, goals for care and approaches to meet those goals." 415.12(g)(2)

Based on record review and staff interviews during the recertification survey, the facility did not ensure that comprehensive nutritional assessments were completed for all residents. This was evident for 2 of 10 resident records reviewed for Nutrition in a total of 13 sampled residents. Specifically, Residents #5 and #1 were identified to have had significant weight losses and there was no documented evidence that comprehensive nutritional assessments were completed to ensure that the diets provided met the residents nutrient needs. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The findings are: 1) Resident #5 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition as independent. The MDS also documented that the resident weighed 131 pounds (lbs). The MDS Assessments dated 1/13/10 documented a weight of 135 lbs and 9/8/10 documented a weight of 13 lbs. The MDS documented under K3 that the resident had lost 5% or more weight in the last 30 days or 10% or more weight in the last 180 days. A review of the resident's weight record documented the following weights: July - 145-139lbs August - 136-130lbs September - 131lbs October - 129lbs November - 127lbs A Dietary Note dated 8/25/10 documented that the resident was spoken to regarding her poor appetite/intake. The note further documented that the resident had lost 9 lbs since July. There was no documented reassessment of what the resident was receiving or if her nutrient needs were being met by the resident's prescribed diet. A subsequent Dietary Note dated 8/30/10 documented that Ensure (supplement) 4 ounces daily had been added to the resident's diet. There was still no assessment of the nutrient needs for Resident #5 or if the prescribed diet was meeting the resident's estimated nutrient needs. On 9/22/10 the Dietitian documented that the resident's weight was 131 lbs and that the resident had gained 5 lbs since August 24th. However, the weight record documented that the resident lost 6 lbs in the month of August. There was no additional dietary documentation or completed assessments as of 11/19/10 for Resident #5 despite the resident's documented weight of 127 lbs in 11/2010. 2) Resident #1 has [DIAGNOSES REDACTED]. The MDS Assessments dated 12/30/09 and 6/9/10 documented that the resident was independent with cognitive skills for daily decision making. Both MDS Assessments documented that Resident #1 had a weight loss of 5% or more in the past month; or 10% or more in the last 180 days. The physician's orders [REDACTED].#1 was prescribed a Diabetic No Concentrated Sweets Diet and received a supplement of Glucerna 4 ounces (oz) by mouth Two Times Per Day (BID). A CCP dated 11/7/09 titled Nutritional Status related to medical conditions requiring therapeutic diet, altered blood glucose, finicky eater, poor condition of teeth was reviewed. The goals on the CCP documented that the resident will maintain weight of 103 lbs +/- 3 lbs and the resident will gain 3-5 lbs this quarter. Interventions included: allow preferences, encourage adequate fluid intake and, provide supplements as ordered. A Dietary Note dated 12/11/10 documented that the resident was readmitted to the facility with a 9.2 lb weight loss, weighed 96 lbs and had an ideal body weight of 131-161 lbs. The note documented that the resident continued on the same diet and supplement prior to the readmission. There was no documented evidence of a nutritional assessment of the residents diet and nutrient needs to determine if the resident was provided and consumed adequate calories, protein and fluids to meet the estimated needs. The note documented to monitor intake. A Dietary Note dated 6/22/10 documented that the resident's diet and supplementation remained unchanged. The note documented that the resident had lost 4 lbs since 5/2010 possibly secondary to illness. There was no documented evidence of a nutritional assessment of the resident's diet and nutrient needs to determine if the resident was provided and consumed adequate calories, protein and fluids to meet the estimated needs. A Dietary Note dated 9/22/10 documented that the resident'd diet and supplementation remained unchanged. The note documented that the resident had gained 1 lbs since last month and gained 8 lbs since 6/2010. There was no documented evidence of a nutritional assessment of the residents diet and nutrient needs to determine if the resident was provided and consumed adequate calories, protein and fluids to meet the estimated needs. A Policy titled Nutritional Care Planning dated 1/2008 documented that "Each resident shall be assessed and a plan of care developed outlining their nutritional needs, goals for care and approaches to meet those goals." An interview was conducted on 11/17/10 with the RD responsible for all the residents in the facility. The RD stated that she does not document what the prescribed diet provides for any resident. The RD stated that she does not calculate calorie or protein needs for any resident or compare the needs to what is being provided to determine if what is provided meets the needs. The RD stated that she assesses lab work and weights to ensure that residents' diets and intake are appropriate. An interview was conducted with the Medical Director on 11/19/10 at 11:30 AM. The Medical Director stated that he would expect that the Dietitian would assess, calculate and document that the diet being provided meets all resident's nutrient needs. 415.12 (i) (1)