Every finding on record at Queens Center for Rehabilitation and Nursing

Based on observation, record review, and staff interviews during the Recertification survey, the facility did not conduct an annual review of the water management plan and did not complete an annual risk assessment form. The findings are: A record review of the Legionella Management Plan, revealed a risk assessment form, dated 6/19/2019. Item #6 of the policy is The Water Management Program will be reviewed at least once a year, or sooner. A record review of the policy and procedure on Legionella revealed that it was last reviewed in 3/2019. Meeting agendas, minutes, or documentation of Program Team meetings were not provided at the time of the survey. In an interview on January 31, 2025, at approximately 10:00 AM, the Facilities Maintenance Coordinator stated that he had not participated in an annual review in the past year. On January 31, 2025, at approximately 2:00 PM, during the exit interview, the Administrator stated the water management plan was not reviewed in the previous 12 months. When asked why it was not done, the Administrator did not respond. 415.19(a)(1-3)

Based on observations, record review and interviews conducted during the Recertification Survey from 01/26/2026 to 01/31/2025, the facility did not ensure a safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. Specifically, the facility failed to exercise reasonable care for the protection of the resident's property from loss or theft. This was evident for 1 resident investigated for personal property out of 38 residents sample investigated, (Resident # 30). The findings are: The facility policy and procedure for Personal Property dated 01/2023, last revised 01/2025 documented that The resident's personal belongings and clothing shall be inventoried and documented upon admission and as such items are replenished. The facility will promptly investigate any complaints of misappropriation or mistreatment of resident property. On 01/26/25 at 10:44 AM during the initial pool process, Resident #30's Spouse was interviewed and stated that resident keeps on missing blankets brought from home, it has been reported to the staff who say they sent them to a place for laundry and they never came back. Resident's spouse stated that they make sure that all the items are labeled with resident's name when they brought them. Resident's spouse also stated that the golden color blanket that is used to keep the resident warm has been missing for over 4 weeks. Resident was admitted to the facility 08/23/2023, with diagnoses that included Cancer, Anemia, Cerebrovascular Accident (CVA). The Quarterly Minimum Data Set (MDS) dated [DATE] documented the resident had severe impairment in cognition and requires Substantial/maximal assistance of staff for most activities of daily living. Minimum Data Set also documented that Resident and resident's family participated in Assessment and Goal Setting. The Comprehensive Care Plan (CCP) for Abuse dated 3/15/23 documented that Resident is at risk for potential abuse, neglect related to cognitive impairment, dependence on others for Activity of Daily Living care with the goals including Resident will not experience any form of abuse or neglect through review date, with interventions Assess resident for sign/symptoms of abuse and / or neglect (example psychosocial status) and report to appropriate resources; Investigate all allegations of abuse and neglect promptly; Provide support and ensure resident is free from abuse. Facility's Grievances/Complaint dated 01/31/25 9:30 am documented that Resident #30's spouse stated that one of the two resident's blankets was missing. Housekeeping staff interviewed claimed that the missing blanket was sent to the outside laundry company a few weeks ago but failed to notify the supervisor of the resident's missing blanket. On 01/30/25 at 09:13 AM, Certified Nursing Assistant #3 was interviewed and stated that Resident #30's dirty clothing is placed in the bin, the laundry staff comes twice a week to take down the dirty clothing for washing and return clean clothing Mondays and Wednesdays. Certified Nursing Assistant #3 stated that the family sometimes reported that resident's blanket was missing which was believed to have been sent down for laundry and they thought the blanket has been returned from laundry. Certified Nursing Assistant #3 stated that they did not know that resident is still missing the blanket and would have reported it to the charge nurse. On 01/31/25 at 08:48 AM, Laundry staff was interviewed and stated that when Resident #30 was transferred to the hospital, resident's belonging is packed and taken down to the trailer, and the belongings were returned to the resident's current room when resident was readmitted . Laundry staff was unable to recall if the missing blanket was among the clothing returned when resident was readmitted and is not able to explain the last time that resident's blanket was sent to the laundry. On 01/31/25 at 09:00 AM, Registered Nurse/Unit Manager, (Registered Nurse #1) was interviewed and stated that they are not aware that Resident #30 is missing a blanket but will investigate from the laundry department to find out if any of the resident's clothing sent down for laundry that have not been returned included the resident's blanket. Registered Nurse #1 was not able to explain when Resident #30 was transferred/readmitted to the unit. On 01/31/25 at 09:10 AM, the Housekeeping Director was interviewed and stated that they are not aware that resident has been missing a blanket. Housekeeping Director stated that they will check and investigate if resident has the blanket that have not been returned after laundry. Housekeeping Director further stated that Outside laundry company was contacted when they were informed of the resident's missing blanket this morning, but they are yet to hear any response from any of the company's staff. On 01/31/25 at 10:05 AM, the Director of Nursing was interviewed and stated that they have started investigation by interviewing the Certified Nursing Assistants and Housekeeping staff to find out how resident's blankets got missing and when they were made aware of the missing blanket. On 01/31/25 at 11:49 AM, the Assistant Director of Nursing was interviewed and stated that upon investigation, it was found that when the family brought the blanket on which resident's name was written, it was placed in the resident's closet, and sent to the laundry with other resident's dirty clothing, the Laundry staff acknowledged sending out the resident's blanket to the outside company about 3 weeks ago and stated that the blanket never returned. Assistant Director of Nursing stated that they were informed that resident's family reported the missing blanket to the staff, and has been asking the laundry staff about the missing blanket anytime resident's laundry was delivered to resident's room, but laundry staff failed to report the missing blanket to the Housekeeping Director for the facility to have addressed it immediately. 10 NYCRR415.5(h)(2).

Based on observation, record review and staff interview during the Recertification /Complaint survey (NY00347053) conducted between 01/26/2025 and 01/31/2025, the facility did not ensure that all alleged violations involving abuse and injury of unknown origin were reported immediately to the New York State Department of Health, but not later than 2 hours after the allegation of abuse was reported. Specifically, the facility did not report within 2 hours when a resident (Resident #94) alleged that another resident (Resident #83) touched their breast. This was evident in 2 out of 37 residents sampled for Abuse. The findings are: The facility's policy titled Abuse - Prohibition Protocol, Types of Abuse, Response/Reporting, last reviewed 1/25, documented that it is the policy of the Grand Rehabilitation and Nursing Center that every resident has the right to be free from abuse, mistreatment, neglect and misappropriation of property. The facility's policy titled, Accident and Incident, Investigating and Reporting-Resident last reviewed 1/25, documented that the facility will report allegations and results of the investigations of alleged violations involving mistreatment, neglect or abuse. The facility investigation report dated that at 6/30/24 at 9:15PM, documented that Resident #94 stated that Resident #83 allegedly touched their breasts. Investigation revealed that on 6/30/24 at approximately 9:15PM, Resident #94 reported to the charge nurse, who notified the Registered Nurse Supervisor, that a resident who was identified as Resident #83, was passing by the hallway. Resident #94 was standing by the sink when Resident #83 allegedly touched their breast. The investigation also documented, that Resident #94 will be seen by the Psychiatrist and Psychologist to follow up on any behavioral changes, and that Resident #94 had a prior history of unfounded accusatory allegation against a staff member, which was investigated and ruled out. The Incident reporting to the New York State Department of Health Intake #NY0047053, documented that the incident occurred on 06/30/24 at 9:15PM, and was reported by the Administrator on 07/01/24 at 2:13PM. The investigation revealed that upon review of camera video on that side of the hallway, it was noted that around 6:35 PM, Resident #83 was wheeling themselves in the hallway and passed by Resident #94's room. From the camera angle, they appeared to shake /held hands for few seconds then upon wheeling back, Resident #83 again held hands with Resident #94. 1) Resident #83 was admitted to the facility with diagnoses that include Cancer, Neurogenic Bladder and Paraplegia. The Annual Minimum Dats Set dated 06/01/24, documented that Resident #83's cognition as intact, Brief Interview of Mental Status of 14, no behaviors and impairment on both sides to lower extremities. The Comprehensive Care Plan focus titled Resident is at risk for potential abuse, neglect related to dependence on others for activities of daily living care, language barrier, created 2/15/23. Goals include Resident #83 will not experience any form of abuse or neglect through review date, 6/20/24. Interventions include Investigate all allegations of abuse and neglect promptly, assess resident for signs and symptoms of abuse and / or neglect and report to appropriate resources. A Nursing Note dated 06/30/24 documented that as per Resident #94, complained that Resident #83 allegedly touched their breast. Resident #94 stated they did not touch Resident #94's breast, but that they touched Resident #94's hand like 'Hi five', as per interpreter. A Nursing Note dated 07/01/24 documented that Resident #83 was moved to another unit to prevent further interaction, family in agreement with plan of care. A Physician's Note dated 7/1/24 documented Resident #83 was alleged by Resident #94, that they touched Resident #94's breasts while they were in their room. Resident #83 said they never touched nor went into Resident #94's room, Resident #83 was wheeling only in the hallway and was blindly accused by Resident #94. Will order Psychiatry and Psychologist evaluation. 2) Resident # 94 was admitted to the facility on [DATE] with diagnoses that include Depression, Bipolar Disorder, and Schizophrenia. The Annual Minimum Data Set, dated dated dated [DATE] documented resident's cognition as intact, Brief Interview of Mental Status of 13, no behaviors, no impairments, that Resident #94 participates in assessment and goal setting. The Comprehensive Care Plan created on 7/3/24 documented Resident #94 is at risk for abuse related to diagnosis of Major Depressive and Bipolar Disorder. Goals include Resident will not experience any form of abuse or neglect through review date, 7/16/24. Interventions include assess resident for signs and symptoms of abuse and report to appropriate resources. The Comprehensive Care Plan created 1/16/24, documented Resident #94 exhibits behavior symptoms such as accusatory behavior. Goals include Resident #94 will verbalize understanding of need to control inappropriate behavior through the review date, 7/16/24. Interventions include to provide resident an opportunity to express themselves. A Nursing Note dated 6/30/24, documented that Registered Nurse Supervisor was called to assess Resident #94 by unit nurse that resident who was in wheelchair by nursing station that Resident #94 alleged another male resident touched their breast. Resident #94 had fully dressed up with shirt and pant. A Physician's Progress Note dated 7/1/24, documented nurse reported Resident #94 alleged that they were touched by Resident #83. Upon examination, there were no signs of bruises or scratches over the body and denies any pain over the body. The note documented that Resident #94 will be seen by Psychiatrist and Psychologist. On 01/30/25 at 10:32 AM the Director of Nursing was interviewed and stated that they were not employed at the facility at the time of the incident. On 01/30/25 at 10:34 AM, the Administrator was interviewed and stated that they were made aware on 06/30/24 that the allegation occurred, and once they were able to gain access in the Health Commerce System, they submitted the incident to the New York State Department of Health, later in the afternoon on 7/1/24. The Administrator also stated that they were not able to say why the previous Director of Nursing did not submit the investigation within the 2 hours, but that they were aware that an allegation of any abuse is supposed to be submitted within 2 hours. 10 NYCRR 415.4 (b)(2)

Based on record review, observation, and interviews conducted during the Recertification Survey from 2/27/2023 to 3/6/2023, the facility did not ensure that a resident's Minimum Data Set (MDS) assessment accurately reflected the resident's status. This was evident for 1 of 2 residents (Resident #49) investigated for Respiratory Care out of a sample of 36 residents. Specifically, the MDS assessment did not document the use of oxygen by Resident #49. The findings are: The facility policy and procedure titled Oxygen Administration last reviewed 1/2023, documented that prior to administering oxygen, staff should review the physician's orders as well as the resident's care plans. The policy further documented that after administering oxygen, staff would document details of the procedure in the resident's medical record. Resident #49 was admitted to the facility with diagnoses which included dementia, depression, and hypertensive heart failure. The Annual Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #49 had severe cognitive impairment and was totally dependent on staff for activities of daily living. The assessment further documented Resident #49 had not received oxygen or any special treatments or procedures within the previous 14 days. The Quarterly MDS dated [DATE] also documented that Resident #49 had not received oxygen or any special treatments or procedures within the previous 14 days. On 02/27/23 at 09:53 AM, Resident #49 was observed sleeping in their bed with a nasal cannula. The cannula was connected to an O2 concentrator which was providing oxygen at a rate of 3 LPM. On 02/28/23 at 09:45 AM, Resident #49 was observed in their room, sitting in a wheelchair. Again, the resident was receiving oxygen via nasal cannula at a rate of 2.5 LPM, through an oxygen concentrator. On 03/02/23 at 12:26 PM and at 03:42 PM, Resident #49 was observed in the dining room, sitting in a wheelchair. Resident was receiving oxygen via nasal cannula, at a rate of 2 LPM, from a portable oxygen tank hanging from the wheelchair. The Order Summary Report dated [DATE], listed active orders as of 02/01/2023. Orders included a physician order dated 10/21/22 which documented resident was to receive Oxygen at 2L/M via nasal cannula for shortness of breath as needed. The Weights and Vitals summary for February 2023 documented Resident #49 received O2 via nasal cannula daily, except on 2/4/23 and 2/26/23. On 03/02/23 at 12:58 PM, Certified Nursing Assistant (CNA) #3 was interviewed and stated Resident #49 had been using oxygen for a while. On 03/03/23 at 11:04 AM, Licensed Practical Nurse (LPN) #1 was interviewed and stated Resident #49 receives oxygen on an as-needed basis. On 03/03/23 at 12:26 PM, RN #2 was interviewed and stated Resident #49 uses oxygen as needed. On 03/06/23 at 12:50 PM, an interview was conducted with the Director of Nursing (DNS). The DNS stated that the doctors and nurses assess the resident to decide if they need to receive Oxygen (O2) treatment. Nurses monitor the O2 saturation both on oxygen and at room air. Oxygen administration is documented on the MAR/TAR or sometimes they document it on the vital signs. The DNS also stated there should be a care plan for O2 use, regardless of the order being prn or continuous and if a resident is receiving O2, it should be coded on the MDS assessment. On 03/06/23 at 01:07 PM, the MDS Coordinator (MDSC) was interviewed and stated that if they see the resident is on O2, they code it on the MDS. If residents do not have O2 on at the time of the assessment but there is an order, the vital signs, MAR/TAR, and progress notes should be checked to confirm the use of O2. The MDSC also stated that for Resident #49, oxygen should have been coded in the MDS and this MDS had been completed by another MDS assessor. 415.11(b)

Based on record review and staff interviews conducted during a Recertification/Complaint Survey from 2/27/2023 to 3/6/2023, the facility did not ensure that the resident and their representative were provided with a written summary of the baseline care plan. This was evident for 2 of 3 residents reviewed for Care Plan out of 36 sampled residents. (Residents #140 and Resident #29) The findings are: The facility policy titled Care Plans - Baseline with effective date 8/17 and last review date of 1/2023 documented that the resident and their representative will be provided a summary of the baseline care plan that includes but is not limited to any services and treatments to be administered by the facility and personal acting on behalf of the facility. 1. Resident #140 was admitted to the facility on [DATE] with diagnoses that included Osteomyelitis, unspecified; Cellulitis, unspecified; and Other lack of coordination. On 02/27/23 at 10:42 AM, Resident #140 was interviewed and stated they had been admitted to the facility about five months ago and made decisions for themselves. Resident #140 also stated they did not recall being provided a copy of baseline care plan. Resident #140 further stated they did not have any family members but a roommate in the community. The Admission Minimum Data Set (MDS) dated [DATE] documented Resident #140 was cognitively intact and Resident #140 and the representative participated in the assessment. The Admission/Readmission Evaluation - V 12 documented the baseline care plan (BCP) for Resident #140 was created on 7/26/22 and completed on 7/27/22. There was no documentation that Resident #140 or the representative signature had signed the BCP or otherwise acknowledged receipt of the BCP. The Progress notes dated from 7/26/22 to 8/11/22 had no documented evidence that Resident # 140 or representative was provided a copy of the Baseline Care plan (BCP). The hard copy medical chart had no documented evidence that a copy of the BCP was provided to Resident # 140 or representative. On 03/02/23 at 11:48 AM, Registered Nurse (RN) #1 was interviewed and stated the admission nurse or the nurse supervisor on the unit created and completed the baseline care plan (BCP) within 2 days after a resident was admitted to the facility. RN #1 also stated the nurse's responsibilities included printing out a copy of the BCP and providing it to the resident or the representative and documenting it in the medical chart. RN #1 further stated they were unable to find any documented evidence that Resident #140 or the representative was provided a copy of BCP and was not able to explain why this was not done. On 03/02/23 at 02:18 PM, the Director of Nursing Services (DON) was interviewed and stated the nurse supervisor reviewed and completed the BCP on the 2nd day of admission. The DON also stated the nurse supervisor provided a copy of BCP to the resident or the representative after it was completed. The DON further stated the nurse supervisor should document in the medical record that a copy of the BCP was provided to the resident or the representative. The DON was not able to locate any documented evidence that a BCP was provided to Resident #140 or the representative and was not able to explain what has occurred. 45349 2. Resident #29 was admitted on [DATE] with diagnoses that included Cerebral Vascular Accident, non-Alzheimer's dementia, Seizure Disorder, and Depression. The Admission Minimum Data Set (MDS) dated [DATE] documented that resident was moderately cognitively impaired with a Brief Interview of Mental Status score of 8 out of 15. The MDS also documented that Resident #29 sometimes makes themself-understood and sometimes understands. In addition, the MDS documented that family or significant other participated in the assessment. The LN: Admission/Readmission Evaluation Baseline care plan section was dated 1/19/2023. A Nursing note dated 2/1/2023 indicated that a Care Plan Meeting was held on that day, with the resident, nursing, social services, recreation, therapy, and the resident's child (on phone conference). Items reviewed included care plans, face sheet, allergies, Kardex and tasks. There was no documented evidence that a written summary of the baseline care plan was provided to either the resident or their representative. An interview was conducted on 3/2/23 at 10:37 AM with Registered Nurse Supervisor (RNS) #2, who stated that the admitting nurse will initiate the baseline on admission. RNS #2 also stated that the baseline care plan is part of the nursing admission form and a copy of the baseline is given to the resident or family by the RNS. RNS #2 looked in the electronic medical record and could not find a note that a written summary of the baseline care plan was provided to the resident or their representative. An interview was conducted on 3/2/23 at 10:44 AM with the Director of Social Work (DSW), who stated that the baseline care plan is done upon admission and it is started by the nurse. The Social Worker updates the baseline for the social work section and then initiate other care plans, like advance directives, mood, and discharge. The DSW also stated that Nursing staff provide a copy of the baseline care plan to the resident and their family. An interview was conducted on 3/2/23 at 11:11 AM with the MDS Coordinator (MDSC), who stated that the admitting nurse initiates the baseline care plan and the Unit Manager is responsible for doing the care plans, but they will also contribute. The MDSC further stated that the unit manager is responsible for giving copy of baseline to the resident/family. An interview was conducted on 3/2/23 at 11:33 AM via telephone, with Resident #29's representative who stated that they could not recall if they received the document or not. 415.11(c)

Based on observation, record reviews and staff interviews conducted during the Recertification survey from 2/27/2023 to 3/6/2023, the facility did not ensure that a person-centered Comprehensive Care Plan (CCP) was developed and implemented to address the resident's medical, physical, mental, and psychosocial needs. Specifically, a CCP was not developed and implemented for a resident receiving Oxygen daily. This was evident for 1 of 2 residents investigated for Respiratory Care (Resident #49) out of a sample of 36 residents. The findings are: The facility policy and procedure titled Resident Participation - Assessment/Care Plans effective 8/2017 with a revision date of 1/2023, states the care planning process will include an assessment of the resident's strengths and his or her needs and incorporate the resident's personal and cultural preferences in establishing goals of care. A Comprehensive Care Plan is developed within seven days of completing the resident assessment. Resident #49 was admitted to the facility with diagnoses which included dementia, depression, and hypertensive heart failure. The Annual Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #49 had severe cognitive impairment and was totally dependent on staff for activities of daily living. The assessment further documented Resident #49 had not received oxygen or any special treatments or procedures within the previous 14 days. On 02/27/23 at 09:53 AM Resident #49 was observed sleeping in their bed with a nasal cannula. The cannula was connected to an O2 concentrator at a rate of 3 LPM. On 02/28/23 at 09:45 AM, Resident #49 was observed in their room, sitting in a wheelchair. Again, the resident was receiving oxygen via nasal cannula at a rate of 2.5 LPM, through an oxygen concentrator. On 03/02/23 at 12:26 PM and at 03:42 PM, resident #49 was observed in the dining room, sitting in a wheelchair. Resident was receiving oxygen via nasal cannula, at a rate of 2 LPM, from a portable oxygen tank hanging from the wheelchair. The Order Summary Report dated [DATE], listed active orders as of 02/01/2023. Orders included a physician order dated 10/21/22 which documented resident was to receive Oxygen at 2L/M via nasal cannula for shortness of breath as needed. The Weights and Vitals summary for February 2023 documented Resident #49 received O2 via nasal cannula daily, except for 2/4/23 and 2/26/23. There was no documented evidence that a care plan addressing O2 use had been created prior to start of survey on 2/27/23. On 03/02/23 at 12:58 PM, Certified Nursing Assistant (CNA) #3 was interviewed and stated Resident #49 had been using O2 for a while. CNA #3 further stated that nurses are in charge of administering the O2. On 03/03/23 at 12:26 PM, Registered Nurse #2 was interviewed and stated Resident #49 uses O2 as needed and that should be documented in the medical record. RN #2 also stated they are responsible for developing the care plans and the care plan was re-started on 2-28-23 after they observed the resident was still receiving oxygen. On 03/06/23 at 12:50 PM, an interview was conducted with the Director of Nursing (DNS). The DNS stated that the doctors and nurses assess the resident to decide if they need to receive O2 treatment. Nurses monitor the O2 saturation both on oxygen and at room air. Oxygen administration is documented on the MAR/TAR or sometimes they document it on the vital signs. There should be a care plan for O2 use, regardless of the order being prn or continuous. The nurses create the care plans. 415.11(c)(1)

Based on record reviews and interviews the facility did not ensure that the MDS (Minimum Data Set) acurately reflects residenst current medical status for the use of medications. Specifically, 1)The MDS for Resident (#15) coded that they received anticoagulant medications, when they received [MEDICATION NAME] generic name ([MEDICATION NAME]); 2) Resident #133 received antipsychotic medication, but was coded on the MDS as receiving antipsychotic medications; 3)Resident #325 was coded as receiving insulin. This was evident for 3 out of Residents reviewed for assessments. Residents #15, #133, and #325. 1) Resident # 15 is [AGE] years old and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. CMS RAI Version 3.0 Manual documented NO4110E, Anticoagulants as [MEDICATION NAME], or Low Molecular weight [MEDICATION NAME]. It instructs: do not code antiplatelet medications such as aspirin/extended release, [MEDICATION NAME], or [MEDICATION NAME] here. On 02/07/2020 at 12:11 PM a review of Annual MDS Section N0410 dated 10/31/19 documented resident received anticoagulant 7 out of 7 days. Review of the Medication Administration Record [REDACTED]. On 2/10/2020 at 10:09 AM, an interview was conducted with RN#3 who reported that she started working as the MDS Coordinator at this facility on 2/3/2020. RN#3 checked the MDS to see who completed it, she went on to state that the individual is no longer with the facility. RN#3 reviewed the resident's chart to find the anticoagulant that the resident received during the look back period (7 days) and stated that the resident received [MEDICATION NAME] during the lookback period. RN#3 conducted an internet search for [MEDICATION NAME] and corroborated that the generic name is [MEDICATION NAME] which is an antiplatelet medicine, or blood thinner, not an anticoagulant. RN#3 reported that she received MDS training in 2009, completed the course, and have done MDS before. RN#3 stated that she is currently in training(MDS) since beginning working at this facility in the capacity of MDS Coordinator on 2/3/2020. At 11:45am, RN#3 followed up and reported that she reviewed coding of the anticoagulant and did a review of the MAR indicated [REDACTED]. She stated that [MEDICATION NAME] should not be on the MDS as an anticoagulant and that the individual who completed the MDS is no longer with the facility. RN#3 stated that she is aware that this is an error. 2) Resident #133 had [DIAGNOSES REDACTED]. The CMS RAI version 3.0 manual dated 10/19 provided to the SA by the MDS director documented steps for assessment and coding instructions as review the Resident's medical record for documentation that any of these medications were received by the Resident during the 7 day look back period. coding instructions N0410A, antipsychotic: record the number of days an antipsychotic medication was received by the Resident at any time during the 7-day look-back period. The Minimun Data Set (MDS) completed with the dates of 10/22/19 and 1/9/20 were reviewed and assessed the Resident with a Bims of 3, requiring total care, and has [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The Psychiatrist consults reviewed from 9/19 to 1/24/20 documented that the Resident is recommended to continue the use of the medication aripiprazole due to behaviors of agitation, anxiety, irritability, and [DIAGNOSES REDACTED]. The pharmacist Drug regimen review dated 12/19/19 documented that the Resident #33 receives aripiprazole ([MEDICATION NAME]) an antipsychotic, and further documented the black box warning of increased mortality in elderly pts with dementia receiving the antipsychotic. The Medication Administration Records dated september 2019 to february 2020 reviewed documented that the Resident received the medication ariprinazole ([MEDICATION NAME]). On 02/10/20 at 12:57 PM the Director of Nursing was interviewed and stated the MDS coordinator completes the N section of the MDS. She further stated that the coordinator should be reviewing the Medication Administration Record [REDACTED]. On 02/10/20 at 1:54 PM the Registered Nurse (RN #2) MDS Corporate Director was interviewed and stated that the MDS Coordinator RN#1 has been completing the MDS for the facility since more than 5 years. The MDS coordinator is responsible to complete the N section of the MDS book. The MDS coordinators have to check the physician order [REDACTED]. Before (MONTH) 2019 a review of MDS and coding was done for all MDS nurses and a list of med clasifications were given including the medication [MEDICATION NAME]. The number 0 that was coded in the MDS should have been coded as 7 for the number days in use. On 02/10/20 at 2:11 PM the RN#4 (Corporate Clinical MDS Nurse) was interviewed and stated the RN#1 completed the assessment and did not code the section for antipsychotic med received correctly. She further stated she is responsible to do spot check/audit on her assessments and have done so but have not done a comprehensive review of her assessments. 3) On 02/10/20 Resident #325 was interviewed and stated that he never received Insulin, only [MEDICATION NAME] (anti-coagulant) in this facility. A record review of the MDS dated [DATE] in Section N (Medications) documented that the resident received an Insulin injection on one day and there was one day the Physician changed the residents Insulin orders during the last 7 days or since admission/entry or reentry. The physician's orders [REDACTED]. On 02/10/20 at approximately 02:44 PM RN#2 MDS Director was interviewed. She reviewed the resident's Medication Administration Record [REDACTED]. She continuted to state that the MDS was coded by MDS coordinator who works the evening shift. She coded it incorrectly and she is responsible to ascertain accuracy of the data. This MDS was not further reviewed by MDS Director for accuracy. 415.11(b)

Based on record review and interviews conducted during the re-certification survey, the facility did not ensure Minimum Data Set (MDS) 3.0 assessment was completed in a timely manner. Specifically, the Annual MDS assessment was not completed within 14 calendar days from the Assessment Reference (ARD) Date. This was evident for 1 of 1 resident reviewed for the Resident Assessment Facility Task (Resident #3) The findings are: The CMS RAI Version 3.0 Manual (Dated (MONTH) (YEAR)), Chapter 5 titled Submission and Correction of the MDS Assessments documented the MDS completion date must be no later than 14 days after the assessment reference date (ARD) for all non-admission, OBRA, and PPS assessments. The MDS completion date must be no later than 13 days after the entry date for admission assessments. Comprehensive assessments must be transmitted electronically within 14 days of the care plan completion date. All other MDS assessments must be submitted within 14 days of the MDS completion date. The MDS assessment for Resident #3 was reviewed. The verification page revealed that the assessment was completed late (more than 14 days after the ARD date). The verification page of the MDS revealed that the Annual MDS assessment had an ARD date of 01/05/20, the completion due date was 01/19/2020; the assessment wasn't completed until 02/05/2020. On 02/06/20 at 11:37 AM an interview was conducted with MDS coordinator (RN#1). She stated that she has been working in the facility for [AGE] years. She stated that she had a training this past year when they started a new book. She also stated that she's the only person who does the assessment, but has staff who assist on a per diem basis. who help out if needed. she said she s responsible for most MDS assessments in the facility, but the cooperate MDS Rita is responsible to submit MDS's. When asked [NAME] Rose Massa to explain the MDS assessment protocol as per the deadlines for completion and submission of assessment, she stated that the MDS assessment suppose to be completed within 7 days from the ARD dates. she then asked the state agency (SA) to wait to clarify the deadlines from the cooperate director. she then came right back and informed the SA that she was unable to give accounts of deadlines as per when to complete and submit the assessment. She referred the surveyor to the Corporate MDS director. During an interview with the MDS Corporate Director (RN#2) on 02/06/20 at 11:55 AM, it was stated that she comes to the facility on ce a week , and she monitors the completion and submission of the MDSs. She also stated that she assess the resident records remotely. The director explained that the MDS have to be completed within 7 days of ARD date .then they have 14 to 21 days to care plan and 7 days to submit the MDS. She further stated that the facility hasn't had problems in completing and submitting the MDS on time, but was unable to explain why the MDS for resident # 3 was not completed in a timely manner 415.11(a)(3)(iii)

Based on observation, record review, and interviews, the facility did not ensure that a resident was free from unnecessary medications. Specifically, a resident received antipsychotic and antidepressant medications for over a year without an attempted dose reduction and in absence of documented evidence justifying the continued use/and or dosage, or clinical indication for use. This was evident in 1 of 5 sample residents reviewed for unnecessary medications (Resident #87). The finding is: Resident #87 is an [AGE] year old female with [DIAGNOSES REDACTED]. Multiple observations were made from 11/28/16 at 12:24 PM to 12/2/16 at 9:57 AM where resident was calm and quiet. The Minimum Data Set 3.0 (MDS) Admission assessment dated [DATE], and Quarterly assessment dated [DATE] documented resident with severely impaired cognition; no [MEDICAL CONDITION], mood, or behaviors; and received seven days of antipsychotic and antidepressant medications. The Comprehensive Care Plans (CCP) were reviewed for the following: 1. Alteration in Behavior dated 11/21/16 documented the following interventions, .assess response to medications . 2. Drug related complications dated 11/21/16 documented the following interventions, .medications are reviewed by Medical Doctor on admission, readmission, and as needed; psychiatry follow up consult to evaluate for possible dose reduction and/or discontinuation . The physican's ordered documented the following orders for anipsychotic and antidepressant medications: [REDACTED] 1. [MEDICATION NAME] Sodium Tablet Delayed Release 250 milligram (mg) by mouth PO three times daily (TID) for [MEDICAL CONDITION] dated 1/12/15 to 2/11/16. 2. [MEDICATION NAME] Sodium Tablet Delayed Release 250 mg PO every 8 hours for [MEDICAL CONDITION] dated 3/15/16 to 4/26/16. 3. [MEDICATION NAME] Sodium Tablet Delayed Release 250 mg PO twice daily (BID) for [MEDICAL CONDITION] dated 4/26/16 to 8/31/16. 4. [MEDICATION NAME] Sodium Tablet Delayed Release 500 mg PO BID for [MEDICAL CONDITION] dated 9/1/16 to 9/5/16. 5. [MEDICATION NAME] Sodium Tablet Delayed Release 750 mg PO BID for [MEDICAL CONDITION] dated 9/6/16. 6. [MEDICATION NAME] Tablet 2.5 mg, half tablet PO Daily for [MEDICAL CONDITION] dated 1/13/15 to 2/11/16. 7. [MEDICATION NAME] Tablet 2.5 mg, 1 tablet PO at Bedtime for [MEDICAL CONDITION] dated 3/15/16. 8. [MEDICATION NAME] 15 mg Tablet PO at Bedtime for Depression dated 7/21/15 to 2/11/16. 9. [MEDICATION NAME] Tablet 15 mg PO at Bedtime for Depression dated 3/15/16. There is no documented evidence in the medical record of the resident exhibiting behaviors to justify the continue use of the antipsychotic and antidepressant medications. The resident's admission record documented the admission history for the past year. The resident was hosptalized on [DATE] for abnormal Kidney, Ureter, and Bladder (KUB). The residend was readmitted to the skilled nursing facility on 3/14/16 with [DIAGNOSES REDACTED]. The most recent psychiatric consultation report was dated 9/4/16. It documented that the resident was diagnosed with [REDACTED]. It further documented that a dosage reduction was not attempted because the resident was symptomatic. The consult did not provide documented evidence of the resident presenting with behaviors attributed to depression or [MEDICAL CONDITION]. Previous psychiatric consultations also did not provide such documented evidence. Psychoactive Medication Monthly assessments completed by nursing were reviewed from 6/9/16 to 11/30/16 and documented the following. 1. 6/9/16- .calm and cooperative no behavior episodes . 2. 7/9/16- No behaviors documented. 3. 8/9/16- .calm and cooperative no behavior episodes .resident is calm and cooperative .no signs of abnormal behaviors . 4. 9/9/16- .calm and cooperative no behavior episodes resident is calm and cooperative .no signs of abnormal behaviors . 5. 10/13/16- No behaviors documented. 6. 11/30/16- .calm and cooperative, free of negative behavior .free of negative behavior (screaming/yelling) . The Physician Monthly Progress assessments were reviewed from January 2016 to November 2016 which documented the following. 1. 1/8/16- No behaviors documented. Medication regime and [MEDICAL CONDITION] section incomplete. 2. 2/5/16- No behaviors documented. Medication regime section incomplete. 3. 4/12/16- No behaviors documented. Medication regime section incomplete. 4. 5/10/16- No behaviors documented. Medication regime section incomplete. [MEDICAL CONDITION] section completed as no. 5. 6/7/16- No behaviors documented. Medication regime section incomplete. [MEDICAL CONDITION] section completed as no. 6. 8/2/16- No behaviors documented. Medication regime and [MEDICAL CONDITION] section incomplete. .Clinically this resident is remarkably well. No changes at present. 7. 8/30/16- No behaviors documented. [MEDICAL CONDITION] section completed as no. .Clinically appears stable . 8. 9/27/16- No behaviors documented. .Clinically appears stable . 9. 10/25/16- No behaviors documented. .Continue with current Rx for now . 10. 11/22/16- No behaviors documented. Nursing progress notes from 11/12/15 to 11/23/16 did not provide documented evidence of the resident presenting with behavioral episodes. Pharmacy reviews were completed on 4/14/16, 5/20/16, 7/20/16, 9/20/16, 10/13/16, and 11/11/16 where there were no reported irregularities. On 8/11/16, report was made to physician. There was no review completed for June 2016. On 12/01/16 at 11:13 AM, the Certified Nursing Assistant (CNA) stated she has been caring for resident for the past 7 months and resident does not have any negative behaviors such as refusing care or yelling and cursing. She further stated resident is able to make her needs known and is talkative with her. On 12/01/16 at 11:26 AM, the Licensed Practical Nurse (LPN) stated resident is verbal, able to make needs known, and have not seen major outbursts. The LPN further stated that if resident has any behaviors he would report it to the supervisor and physician and document it on the CCP, and general clinical notes. On 12/01/16 at 11:38 AM, the Registered Nurse Supervisor (RN) stated resident has no negative behaviors that he has seen or was any reported to him. He further stated that behaviors are documented in nursing notes and the supervisor and physician are notified. On 12/01/16 at 12:37 PM, the covering Psychiatrist (Psych #1) was interviewed. He stated that residents need to have a valid [DIAGNOSES REDACTED]. Antipsychotic medications are not given to patients with dementia and [MEDICAL CONDITION]. He then stated once a resident is started on medication, an attempt to taper it at least every three months is made. On 12/01/16 at 2:18 PM, the facility Psychiatrist (Psych #2) was interviewed. He stated he completes his assessments based on resident observations and interview and nursing report. Resident is being treated for [REDACTED]. He then stated resident is on [MEDICATION NAME] to prevent [MEDICAL CONDITION] from recurring, [MEDICATION NAME] for depression and anxiety, and resident is on a small dose of [MEDICATION NAME] to help boost [MEDICATION NAME] as additional reasons for not completing a dose reduction. On 12/01/16 at 2:52 PM, the Physician stated he has not observed resident with aggressive behaviors the past few months. Resident is on [MEDICATION NAME], and [MEDICATION NAME] for [MEDICAL CONDITION] and depression. He further stated that resident is maintained on these medications due to resident improving. On 12/02/16 at 10:55 AM, the Pharmacy Supervisor was interviewed. He stated the attending pharmacist is expected to review each patient monthly by reviewing the medications, labs, consults, if nurse is administering medication per physician order, if physician is monitoring medication, and if physician are reviewing consult recommendations. Specifically for [MEDICAL CONDITION] medications, the pharmacist is required to see if physician referred patient to see the psychiatrist, a psychiatrist consult is completed every 3 to 6 months, if a dose reduction can be done. Upon completion of review of chart, the pharmacist documents on the log sheet where they sign, date, and check off the box for irregularities or not. If there are irregularities, it will be reported and written to the Director of Nursing Services (DNS). If there are no irregularities, it is checked off on log sheet. He further stated he does not check after the pharmacist if monthly reviews are completed. Instead, he completes quarterly reports for the facility regarding the pharmacist findings. On 12/2/16 at 11:21 AM and 11:47 AM, the facility Pharmacist stated she reviews the resident's orders, labs, consults, behavior notes, and check to see if a dose reduction was completed. She further stated if a resident has dementia and [MEDICAL CONDITION], she would notify the psychiatrist of the black box warning for antipsychotics for residents with dementia where there is an increase risk for mortality. The pharmacist stated for June 2016 review she might've missed it. On 12/02/16 at 12:45 PM, the Medical Director was interviewed. He stated that physicians should be reviewing psychiatric consults, monthly medications, pharmacy reviews, and discuss with nursing in order to attempt a dose reduction. Dose reductions should be attempted quarterly and/or place resident on the lowest dose. The facility Antipsychotic Drug Protocol policy and procedure documented the following. .consistent monitoring should be done to assess the risk/benefit relationship of [MEDICAL CONDITION] drug therapy, including appropriateness of drug selection and dosage .monitoring for efficacy .document the reason for the medication on the physician order [REDACTED].g. biting scratching, kicking, hitting, etc.) .specific behavioral problems should be tracked and documented as to the number of episodes on an ongoing basis . The facility Monthly Drug Regimen Review policy and procedure documented the following. .pharmacist shall review the drug regiment of each resident at least monthly and report any irregularity to the medical director, the director of nursing, and the attending physician .'irregularity' is any drug when used .without adequate indications for its use . 415.12(l)(1)

Based on observation, record review, and interviews, the facility did not ensure the physician reviewed a resident's total plan of care. Specifically, the physician did not evaluate a resident's condition to indicate continued appropriateness of an antipsychotic and antidepressant medication. This was evident in 1 of 5 residents reviewed for unnecessary medications (Resident #87). The finding is: Resident #87 is an [AGE] year old female with [DIAGNOSES REDACTED]. Multiple observations were made from 11/28/16 at 12:24 PM to 12/2/16 at 9:57 AM where resident was calm and quiet. The Minimum Data Set 3.0 (MDS) Admission assessment dated [DATE], and Quarterly assessment dated [DATE] documented resident with severely impaired cognition; no [MEDICAL CONDITION], mood, or behaviors; and received seven days of antipsychotic and antidepressant medications. The Comprehensive Care Plans (CCP) were reviewed for the following: 1. Alteration in Behavior dated 11/21/16 documented the following interventions, .assess response to medications . 2. Drug related complications dated 11/21/16 documented the following interventions, .medications are reviewed by Medical Doctor on admission, readmission, and as needed; psychiatry follow up consult to evaluate for possible dose reduction and/or discontinuation . Doctor orders revealed the following: 1. [MEDICATION NAME] Sodium Tablet Delayed Release 250 milligram (mg) by mouth PO three times daily (TID) for [MEDICAL CONDITION] dated 1/12/15 to 2/11/16. 2. [MEDICATION NAME] Sodium Tablet Delayed Release 250 mg PO every 8 hours for [MEDICAL CONDITION] dated 3/15/16 to 4/26/16. 3. [MEDICATION NAME] Sodium Tablet Delayed Release 250 mg PO twice daily (BID) for [MEDICAL CONDITION] dated 4/26/16 to 8/31/16. 4. [MEDICATION NAME] Sodium Tablet Delayed Release 500 mg PO BID for [MEDICAL CONDITION] dated 9/1/16 to 9/5/16. 5. [MEDICATION NAME] Sodium Tablet Delayed Release 750 mg PO BID for [MEDICAL CONDITION] dated 9/6/16. 6. [MEDICATION NAME] Tablet 2.5 mg, half tablet PO Daily for [MEDICAL CONDITION] dated 1/13/15 to 2/11/16. 7. [MEDICATION NAME] Tablet 2.5 mg, 1 tablet PO at Bedtime for [MEDICAL CONDITION] dated 3/15/16. 8. [MEDICATION NAME] 15 mg Tablet PO at Bedtime for Depression dated 7/21/15 to 2/11/16. 9. [MEDICATION NAME] Tablet 15 mg PO at Bedtime for Depression dated 3/15/16. There is no documented evidence of resident with behavioral episodes. Resident admission history for the past year reveals resident was hospitalized [DATE] for abnormal Kidney, Ureter, and Bladder (KUB) and was readmitted to skilled nursing facility on 3/14/16 with [DIAGNOSES REDACTED]. Psychiatric consults were reviewed from 3/19/16 to 9/4/16. The most recent consult dated 9/4/16 documented resident with psychiatric [DIAGNOSES REDACTED]. There were no documented evidence of resident with behavioral episodes on the consults. Psychoactive Medication Monthly assessments completed by nursing were reviewed from 6/9/16 to 11/30/16 and documented the following. 1. 6/9/16- .calm and cooperative no behavior episodes . 2. 7/9/16- No behaviors documented. 3. 8/9/16- .calm and cooperative no behavior episodes .resident is calm and cooperative .no signs of abnormal behaviors . 4. 9/9/16- .calm and cooperative no behavior episodes resident is calm and cooperative .no signs of abnormal behaviors . 5. 10/13/16- No behaviors documented. 6. 11/30/16- .calm and cooperative, free of negative behavior .free of negative behavior (screaming/yelling) . The Physician Monthly Progress assessments were reviewed from January 2016 to November 2016 which documented the following. 1. 1/8/16- No behaviors documented. Medication regime and [MEDICAL CONDITION] section incomplete. 2. 2/5/16- No behaviors documented. Medication regime section incomplete. 3. 4/12/16- No behaviors documented. Medication regime section incomplete. 4. 5/10/16- No behaviors documented. Medication regime section incomplete. [MEDICAL CONDITION] section completed as no. 5. 6/7/16- No behaviors documented. Medication regime section incomplete. [MEDICAL CONDITION] section completed as no. 6. 8/2/16- No behaviors documented. Medication regime and [MEDICAL CONDITION] section incomplete. .Clinically this resident is remarkably well. No changes at present. 7. 8/30/16- No behaviors documented. [MEDICAL CONDITION] section completed as no. .Clinically appears stable . 8. 9/27/16- No behaviors documented. .Clinically appears stable . 9. 10/25/16- No behaviors documented. .Continue with current Rx for now . 10. 11/22/16- No behaviors documented. Nursing progress notes were reviewed from 11/12/15 to 11/23/16 and there were no documented evidence of resident with behavioral episodes. Pharmacy reviews were completed on 4/14/16, 5/20/16, 7/20/16, 9/20/16, 10/13/16, and 11/11/16 where there were no reported irregularities. On 8/11/16, report was made to physician. There was no review completed for June 2016. On 12/01/16 at 11:13 AM, the Certified Nursing Assistant (CNA) stated she has been caring for resident for the past 7 months and resident does not have any negative behaviors such as refusing care or yelling and cursing. She further stated resident is able to make her needs known and is talkative with her. On 12/01/16 at 11:26 AM, the Licensed Practical Nurse (LPN) stated resident is verbal, able to make needs known, and have not seen major outbursts. The LPN further stated that if resident has any behaviors he would report it to the supervisor and physician and document it on the CCP, and general clinical notes. On 12/01/16 at 11:38 AM, the Registered Nurse Supervisor (RN) stated resident has no negative behaviors that he has seen or was any reported to him. He further stated that behaviors are documented in nursing notes and the supervisor and physician are notified. On 12/01/16 at 12:37 PM, the covering Psychiatrist (Psych #1) was interviewed. He stated that residents need to have a valid [DIAGNOSES REDACTED]. Antipsychotic medications are not given to patients with dementia and [MEDICAL CONDITION]. He then stated once a resident is started on medication, an attempt to taper it at least every three months is made. On 12/01/16 at 2:18 PM, the facility Psychiatrist (Psych #2) was interviewed. He stated he completes his assessments based on resident observations and interview and nursing report. Resident is being treated for [REDACTED]. He then stated resident is on [MEDICATION NAME] to prevent [MEDICAL CONDITION] from recurring, [MEDICATION NAME] for depression and anxiety, and resident is on a small dose of [MEDICATION NAME] to help boost [MEDICATION NAME] as additional reasons for not completing a dose reduction. On 12/01/16 at 2:52 PM, the Physician stated he has not observed resident with aggressive behaviors the past few months. Resident is on [MEDICATION NAME], and [MEDICATION NAME] for [MEDICAL CONDITION] and depression. He further stated that resident is maintained on these medications due to resident improving. On 12/02/16 at 10:55 AM, the Pharmacy Supervisor was interviewed. He stated that the attending pharmacist is expected to review each patient monthly by reviewing the medications, labs, consults, if nurse is administering medication per physician order, if physician is monitoring medication, and if physician are reviewing consult recommendations. Specifically for [MEDICAL CONDITION] medications, the pharmacist is required to see if physician referred patient to see the psychiatrist, a psychiatrist consult is completed every 3 to 6 months, if a dose reduction can be done. Upon completion of review of chart, the pharmacist documents on the log sheet where they sign, date, and check off the box for irregularities or not. If there are irregularities, it will be reported and written to the Director of Nursing Services (DNS). If there are no irregularities, it is checked off on log sheet. He further stated he does not check after the pharmacist if monthly reviews are completed. Instead, he completes quarterly reports for the facility regarding the pharmacist findings. On 12/2/16 at 11:21 AM and 11:47 AM, the facility Pharmacist stated she reviews the resident's orders, labs, consults, behavior notes, and check to see if a dose reduction was completed. She further stated if a resident has dementia and [MEDICAL CONDITION], she would notify the psychiatrist of the black box warning for antipsychotics for residents with dementia where there is an increase risk for mortality. The pharmacist stated for June 2016 review she might've missed it. On 12/02/16 at 12:45 PM, the Medical Director was interviewed. He stated that physicians should be reviewing psychiatric consults, monthly medications, pharmacy reviews, and discuss with nursing in order to attempt a dose reduction. Dose reductions should be attempted quarterly and/or place resident on the lowest dose. The facility Antipsychotic Drug Protocol policy and procedure documented the following. .consistent monitoring should be done to assess the risk/benefit relationship of [MEDICAL CONDITION] drug therapy, including appropriateness of drug selection and dosage .monitoring for efficacy .document the reason for the medication on the physician order for [REDACTED].g. biting scratching, kicking, hitting, etc.) .specific behavioral problems should be tracked and documented as to the number of episodes on an ongoing basis . The facility Monthly Drug Regimen Review policy and procedure documented the following. .pharmacist shall review the drug regiment of each resident at least monthly and report any irregularity to the medical director, the director of nursing, and the attending physician .'irregularity' is any drug when used .without adequate indications for its use . 415.15(b)(2)(iii)

Based on observation, record review, and interviews, the facility did not ensure the pharmacist identified and reported irregularities to the attending physician. Specifically, a gradual dose reduction was not recommended for a resident receiving an antipsychotic and antidepressant medication. This was evident in 1 of 5 residents reviewed for unnecessary medications (Resident #87). The finding is: Resident #87 is an [AGE] year old female with [DIAGNOSES REDACTED]. Multiple observations were made from 11/28/16 at 12:24 PM to 12/2/16 at 9:57 AM where resident was calm and quiet. The Minimum Data Set 3.0 (MDS) Admission assessment dated [DATE], and Quarterly assessment dated [DATE] documented resident with severely impaired cognition; no delirium, mood, or behaviors; and received seven days of antipsychotic and antidepressant medications. The Comprehensive Care Plans (CCP) were reviewed for the following: 1. Alteration in Behavior dated 11/21/16 documented the following interventions, .assess response to medications . 2. Drug related complications dated 11/21/16 documented the following interventions, .medications are reviewed by Medical Doctor on admission, readmission, and as needed; psychiatry follow up consult to evaluate for possible dose reduction and/or discontinuation . Doctor orders revealed the following: 1. Divalproex Sodium Tablet Delayed Release 250 milligram (mg) by mouth PO three times daily (TID) for Psychosis dated 1/12/15 to 2/11/16. 2. Divalproex Sodium Tablet Delayed Release 250 mg PO every 8 hours for Psychosis dated 3/15/16 to 4/26/16. 3. Divalproex Sodium Tablet Delayed Release 250 mg PO twice daily (BID) for Psychosis dated 4/26/16 to 8/31/16. 4. Divalproex Sodium Tablet Delayed Release 500 mg PO BID for Psychosis dated 9/1/16 to 9/5/16. 5. Divalproex Sodium Tablet Delayed Release 750 mg PO BID for Psychosis dated 9/6/16. 6. Olanzapine Tablet 2.5 mg, half tablet PO Daily for Psychosis dated 1/13/15 to 2/11/16. 7. Olanzapine Tablet 2.5 mg, 1 tablet PO at Bedtime for Psychosis dated 3/15/16. 8. Remeron 15 mg Tablet PO at Bedtime for Depression dated 7/21/15 to 2/11/16. 9. Mirtazapine Tablet 15 mg PO at Bedtime for Depression dated 3/15/16. There is no documented evidence of resident with behavioral episodes. Resident admission history for the past year reveals resident was hospitalized [DATE] for abnormal Kidney, Ureter, and Bladder (KUB) and was readmitted to skilled nursing facility on 3/14/16 with [DIAGNOSES REDACTED]. Psychiatric consults were reviewed from 3/19/16 to 9/4/16. The most recent consult dated 9/4/16 documented resident with psychiatric [DIAGNOSES REDACTED]. There were no documented evidence of resident with behavioral episodes on the consults. Psychoactive Medication Monthly assessments completed by nursing were reviewed from 6/9/16 to 11/30/16 and documented the following. 1. 6/9/16- .calm and cooperative no behavior episodes . 2. 7/9/16- No behaviors documented. 3. 8/9/16- .calm and cooperative no behavior episodes .resident is calm and cooperative .no signs of abnormal behaviors . 4. 9/9/16- .calm and cooperative no behavior episodes resident is calm and cooperative .no signs of abnormal behaviors . 5. 10/13/16- No behaviors documented. 6. 11/30/16- .calm and cooperative, free of negative behavior .free of negative behavior (screaming/yelling) . The Physician Monthly Progress assessments were reviewed from January 2016 to November 2016 which documented the following. 1. 1/8/16- No behaviors documented. Medication regime and psychotropics section incomplete. 2. 2/5/16- No behaviors documented. Medication regime section incomplete. 3. 4/12/16- No behaviors documented. Medication regime section incomplete. 4. 5/10/16- No behaviors documented. Medication regime section incomplete. Psychotropics section completed as no. 5. 6/7/16- No behaviors documented. Medication regime section incomplete. Psychotropics section completed as no. 6. 8/2/16- No behaviors documented. Medication regime and psychotropics section incomplete. .Clinically this resident is remarkably well. No changes at present. 7. 8/30/16- No behaviors documented. Psychotropics section completed as no. .Clinically appears stable . 8. 9/27/16- No behaviors documented. .Clinically appears stable . 9. 10/25/16- No behaviors documented. .Continue with current Rx for now . 10. 11/22/16- No behaviors documented. Nursing progress notes were reviewed from 11/12/15 to 11/23/16 and there were no documented evidence of resident with behavioral episodes. Pharmacy reviews were completed on 4/14/16, 5/20/16, 7/20/16, 9/20/16, 10/13/16, and 11/11/16 where there were no reported irregularities. On 8/11/16, report was made to physician. There was no review completed for June 2016. On 12/01/16 at 11:13 AM, the Certified Nursing Assistant (CNA) stated she has been caring for resident for the past 7 months and resident does not have any negative behaviors such as refusing care or yelling and cursing. She further stated resident is able to make her needs known and is talkative with her. On 12/01/16 at 11:26 AM, the Licensed Practical Nurse (LPN) stated resident is verbal, able to make needs known, and have not seen major outbursts. The LPN further stated that if resident has any behaviors he would report it to the supervisor and physician and document it on the CCP, and general clinical notes. On 12/01/16 at 11:38 AM, the Registered Nurse Supervisor (RN) stated resident has no negative behaviors that he has seen or was any reported to him. He further stated that behaviors are documented in nursing notes and the supervisor and physician are notified. On 12/01/16 at 12:37 PM, the covering Psychiatrist (Psych #1) was interviewed. He stated that residents need to have a valid [DIAGNOSES REDACTED]. Antipsychotic medications are not given to patients with dementia and psychosis. He then stated once a resident is started on medication, an attempt to taper it at least every three months is made. On 12/01/16 at 2:18 PM, the facility Psychiatrist (Psych #2) was interviewed. He stated he completes his assessments based on resident observations and interview and nursing report. Resident is being treated for [REDACTED]. He then stated resident is on Depakote to prevent seizures from recurring, Remeron for depression and anxiety, and resident is on a small dose of olanzapine to help boost Remeron as additional reasons for not completing a dose reduction. On 12/01/16 at 2:52 PM, the Physician stated he has not observed resident with aggressive behaviors the past few months. Resident is on Depakote, Zyprexa, and Remeron for psychosis and depression. He further stated that resident is maintained on these medications due to resident improving. On 12/02/16 at 10:55 AM, the Pharmacy Supervisor was interviewed. He stated that the attending pharmacist is expected to review each patient monthly by reviewing the medications, labs, consults, if nurse is administering medication per physician order, if physician is monitoring medication, and if physician are reviewing consult recommendations. Specifically for psychotropic medications, the pharmacist is required to see if physician referred patient to see the psychiatrist, a psychiatrist consult is completed every 3 to 6 months, if a dose reduction can be done. Upon completion of review of chart, the pharmacist documents on the log sheet where they sign, date, and check off the box for irregularities or not. If there are irregularities, it will be reported and written to the Director of Nursing Services (DNS). If there are no irregularities, it is checked off on log sheet. He further stated he does not check after the pharmacist if monthly reviews are completed. Instead, he completes quarterly reports for the facility regarding the pharmacist findings. On 12/2/16 at 11:21 AM and 11:47 AM, the facility Pharmacist stated she reviews the resident's orders, labs, consults, behavior notes, and check to see if a dose reduction was completed. She further stated if a resident has dementia and psychosis, she would notify the psychiatrist of the black box warning for antipsychotics for residents with dementia where there is an increase risk for mortality. The pharmacist stated for June 2016 review she might've missed it. On 12/02/16 at 12:45 PM, the Medical Director was interviewed. He stated that physicians should be reviewing psychiatric consults, monthly medications, pharmacy reviews, and discuss with nursing in order to attempt a dose reduction. Dose reductions should be attempted quarterly and/or place resident on the lowest dose. The facility Antipsychotic Drug Protocol policy and procedure documented the following. .consistent monitoring should be done to assess the risk/benefit relationship of psychotropic drug therapy, including appropriateness of drug selection and dosage .monitoring for efficacy .document the reason for the medication on the physician order [REDACTED].g. biting, scratching, kicking, hitting, etc.) .specific behavioral problems should be tracked and documented as to the number of episodes on an ongoing basis . The facility Monthly Drug Regimen Review policy and procedure documented the following. .pharmacist shall review the drug regiment of each resident at least monthly and report any irregularity to the medical director, the director of nursing, and the attending physician .'irregularity' is any drug when used .without adequate indications for its use . 415.18(c)(l)

Based on observation, record review, and staff interviews during the recertification survey the facility did not ensure that the Comprehensive Care Plan, (CCP) was updated to include specific interventions to manage each resident's behavior. This was evident for one of five residents reviewed for Unnecessary Drugs, in a total Stage 2 sample of 24 residents (Resident #297). Specifically, Resident # 297 received the antipsychotic medication [MEDICATION NAME]. The CCP did not document specific interventions used to redirect the resident's behavior. The findings is: Resident #297 has [DIAGNOSES REDACTED]. The Admission Minimum Data Set Assessment ((MDS) dated [DATE] documented that Resident #297 could understand and be understood. The resident's Brief Interview for Mental Status (BIMS) Score was 6, which indicated that the resident was severely cognitively impaired. The MDS also documented that the residents Mood Interview score was 2, identifying that the resident felt down, depressed or hopeless and that the resident felt tired with little energy. The Mood Score indicated that Resident #297 had minimal depression. The MDS documented that the resident received antipsychotic medications for 7 days during the assessment period. Physician order [REDACTED]. Additionally, [MEDICATION NAME] was ordered as follows: 6/11/15 Halperidol tablet 1 mg 1 tablet by mouth one time only for agitation. 8/18/15 [MEDICATION NAME] 5 mg x 1 for agitation 8/27/15 [MEDICATION NAME] 5 mg/ml (milliliters) inject 1 ml one time only for agitation. Review of the Medication Administration Record [REDACTED]. Review of the Nursing Progress Notes for [MEDICATION NAME] administration dated 5/1/15 through 9/23/15 included but was not limited to: On 5/22/1 the resident was noted with agitation, crying, cursing. I want to go home. Emotional support provided but not successful. MD (medical doctor) on unit and ordered [MEDICATION NAME] 2 mg IM stat (immediately). On 6/11/15 Physician ordered [MEDICATION NAME] 1 mg x 1 dose at 1:00 PM prior to 2:00 PM MD appointment. On 6/25/15 at 4:00 PM resident was observed with some agitation stating going home. Verbally redirected and comfort care provided. Unit nurses closely monitored residents need and safety precautions maintained. On 6/25/15 Resident was continuously agitated. At 5:00 PM [MEDICATION NAME] (IM) 0.2 ml as prn order given to left deltoid. On 7/4/15 there was no documented NPN. On 7/11/15 3:00 PM resident has increased agitation, redirected several times but unsuccessful. Attempt to hit staff with duffle bag. Resident crying, screaming and using profanity toward staff. [MEDICATION NAME] 1 mg IM given. On 7/22/15 1:00 PM resident yelling and offending roommate and calling her a liar. Resident taken out of room and provided with peaceful atmosphere. Resident returned to room and started blaming roommate for water on the floor. Floor checked by staff, dry and clean. On 7/22/15 3:00 PM resident continued to be agitated and to pace hallways yelling. Resident stated she would punch room mate. [MEDICATION NAME] 1 mg IM in right deltoid given. On 8/18/15 resident appears to be very agitated . Resident to go OP (out on pass) with son to see the Opthomologist. MD ordered [MEDICATION NAME] 1 mg IM, given to (l) forearm, no reaction. Resident left unit via wheelchair accompanied by son. No distress noted. On 8/27/15 8:00 AM resident alert and responsive new orders obtained to by MD. Give [MEDICATION NAME] 5 mg/1 ml one time only today for agitation The Comprehensive Care Plan dated 5/1/15 titled Alteration in Behavior last updated 9/5/15 was reviewed. Interventions included but not limited to: administer meds as per MD orders, assess response to medication, monitor side effects, encourage verbalization of feelings, calm environment, redirect negative behavior, encourage family support and Psychiatric Consultation. The Evaluation page documented that on 5/22/15 the resident had increased agitation and restlessness. The page documented that the resident was crying and screaming I want to go home. The MD on unit ordered [MEDICATION NAME] 2 mg IM stat (immediately). The evaluation page documented on 6/11/15 the resident was observed with increased agitation. [MEDICATION NAME] 1 mg PO (by mouth) administered prior to leaving for medical appointment. The Pharmacy review report dated 8/17/15 recommended to the physician to discontinue the [MEDICATION NAME], and that [MEDICATION NAME] was not recommended on Dementia patients. The resident was observed on 5 days of the survey at various times: On 9/27/15 at 10:00 AM sleeping soundly in her bed. At 11:30 AM the resident was still noted to be sleeping. The resident was observed on 9/28/15 at 9:30 AM sleeping in her bed and at 10:15 AM the resident was observed to be sleeping. On 9/29/15 at 10:20 AM, resident ambulating independently to nursing desk, asking to call son to take her home. An interview was conducted with Resident #297 on 09/29/2015 10:55 AM . The resident stated that she feels well but is frightened to have cataract surgery tomorrow. The resident stated she cannot see out of her right eye and that the left is poor. The resident was not sure which eye was being operated on. The Registered Nurse (RN) unit charge nurse was interviewed on 9/29/15 at 11:05 PM and stated that many interventions were attempted by the staff prior to administering [MEDICATION NAME]. The RN stated that the resident enjoys listening to Spanish music, taking walks off the unit (escorted by staff), enjoys visiting staff on the first floor, and going out onto the patio. The RN stated that the resident's son was very involved and never minded when the staff would call him to intervene. The RN stated that the CCP should have the specific interventions documented on the CCP. The (RN) Unit Manager was interviewed on 9/29/15 at 11:15 AM and stated that the resident would get agitated and the staff would attempt multiple interventions, including calling the residents son and one daughter, prior to administering [MEDICATION NAME]. The Unit Manager stated that the interventions should be listed in the CCP. 415.11(c)(2)(iii)

Based on observation, record reviews, and staff interviews the facility did not ensure that treatment and services were provided to prevent the development of a sacral pressure ulcer. Specifically, a resident at risk for pressure ulcer development was not monitored prior to the development of an unstageable pressure ulcer. This was evident for 1 of 2 sampled residents reviewed for pressure ulcers. (Resident #11). This resulted in actual harm that is not immediate jeopardy. The findings are: Resident #11 is a [AGE] year old with [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) 3.0 dated 3/2/12 documents the resident has unclear speech, rarely/never understands, and cognitive skills for daily decision making are severely impaired. The MDS further documents the resident requires extensive assistance for bed mobility, transfers, dressing, bathing and is always incontinent of bowel and bladder. The MDS further documents the resident is at risk of developing pressure ulcers and had no healed or unhealed pressure ulcers. The MDS further documented skin and ulcer treatments were pressure reducing devices for the chair and bed. The " Braden Risk Assessment Scale For Ulcers" dated 3/2/12 documents a total score of 13. The form further documents " A score of 16 or less indicates high risk for pressure sore development." As such the resident was identified as a high risk for the development of pressure ulcers. An observation of the sacral pressure ulcer dressing change was conducted on 7/6/12 at 9:30 AM. The observation revealed a full thickness open wound with approximately 50% darkened eschar, 50% granulation tissue. The approximate measurements of the wound were 5 cm (centimeters) in length and 5 cm in diameter. There was no evident measurable depth. The surrounding skin was reddened with a moderate amount of bloody drainage. The Comprehensive Care Plan ( CCP) for " Skin Impairment-Potential" dated 3/2/12 documented "Potential for alteration in skin integrity as evidenced by limited OOB (out of bed), fragile skin and incontinence. Team Interventions- provide incontinence care q (every) 2-4 H (hours) and PRN (as needed)...Assess skin condition daily during care..." The CCP intervention for "Turn and position as scheduled" was not checked as an intervention. The "CNA Assignment/ Accountability Record" dated 5/2012 documents " Corrective/ Supportive Devices...Wedge seat cushion, sit straight cushion, gel water cushion, Roho cushion. The space on the sheet after each device was left blank. The CCP further documents a nursing "Evaluation" dated 6/2/12 Quarterly review- No skin impairment." The " Braden Risk Assessment Scale For Ulcers" dated 6/2/12 documents a total score of 13- high risk for pressure ulcer development. The nurse's note dated 6/11/12 and timed at 6:50 AM documented that resident was in bed when the nurse (LPN) was called to observe a black area on the coccyx. The note further documented that the supervisor was called and to follow-up with the physician. At 10: 30 AM it was documented in the nurse's note: "Cleanse bilateral coccyx area with normal saline pat dry apply [MEDICATION NAME] with DPD (dry protective dressing) until healed. Dx Excoriation BID (twice daily). Will continue to monitor and check Q (every) shift". The Physician's Progress note dated 6/11/12 documented that the resident had an unstageable sacral pressure ulcer. The physician's orders [REDACTED]. This order was discontinued on 6/19/12. A new order read, "cleanse sacrum to encompass with normal saline pat dry and apply [MEDICATION NAME] to open area (mid sacrum) zinc oxide to surrounding tissue apply dry protective dressing QD (daily) and prn (as needed)". There were no further physician's notes documenting the assessment or care of the ulcer, or skin . The "CNA Assignment/ Accountability Record" dated 6/12 documents" "Corrective/ Supportive Devices...The form further documents "Roho cushion to w/c (wheelchair) (with a check mark) dated 6/12/12 and the addition of an "air mattress." There was no documented evidence that the Roho cushion or air mattress was in place prior to 6/12/12. The "CNA (Certified Nurse Assistant) Assignment/ Accountability Record" dated 6/2012 documents " Skin Observation (+) Okay...(-) Problem-Nurse Notified...Skin Checks 11-7, 7-3 and 3-11. The form further documents (+) okay entries from 6/1/12 to 6/30/12. The " Weekly Status" form dated 6/12/12 documented the " Location of Wound: Sacrum- stage N/A (not applicable) Type of Wound: Pressure...Nosocomial - Unstageable- Size-length 5.5 cm (centimeters) Width 5.5 cm." The form further documents no measurable depth, drainage or granulation tissue. The CCP " Skin Impairment - Potential" further documents another "Evaluation" dated 6/21/12 Quarterly review-unstageable to sacrum area tx (treatment) continues..." There was no documented evidence in the medical record that ongoing monitoring of the residents skin had been provided after the resident was assessed as high risk for pressure ulcer development on the Braden Risk Assessments dated 6/2/12 and prior to the development of the unstageable sacral pressure ulcer on 6/11/12. The medical record contained a document titled: "Bi-weekly Skin Observation and Discharge Data Skin Collection Tool". The document was to be completed on each shower day by the LPN (Licensed Practical Nurse) on the dates: 6/2, 6/6, 6/9, 6/13, and 6/20/12. Review of the form revealed no nurses signatures for the documented dates. The weekly wound care tracking sheet dated 7/3/12 documented that the wound was unstageable, eschar included yellow slough, 50% necrotic material, measuring 5.5 cm x 5.0 cm x 0.3 cm, drainage with sero-sanguanous, with granulation of the wound bed, no odor, surrounding skin was blanchable, treated with [MEDICATION NAME] DPD QD (daily) and PRN with a care plan in place. The "Bi-weekly Skin Observation and Discharge Data Skin Collection Tool "dated 7/4/12 documented, "Description / Comments: Stage IV to sacral area." On 7/6/12 at 10:10 AM the Wound Care Nurse RN (Registered Nurse) was interviewed and stated that she does the wound care but does not usually document the status of the wound in the medical record. On 7/11/12 at 10:30 AM, the LPN (Licensed practical Nurse) responsible for completing the "Bi-weekly Skin Observation form " on 6/6/12, 6/9/12, 6/13/12, and 6/20/12 was interviewed and stated that he is normally called in to the shower room to check the resident's skin condition on shower days. The LPN further stated that on the above referenced dates he did not check the status of the resident's skin, because he was not called in to the shower room by the CNA. This is why the pages on the skin observation form are blank. He stated that he should have alerted the CNAs to tell him when the resident is being showered. He also stated that the LPNs are responsible for checking that the CNA entries on the "CNA Assignment / Accountability Record " are documented accurately. He stated that he had not checked that the Skin Observation checks were accurate. He stated that it is the LPN ' s responsibility to report any skin changes, redness, or increased redness to the Nursing Supervisor. He stated that he did not report changes because he had not checked the resident's skin on the dates referenced. (6/9/12, 6/13/12 and 6/20/2012). On 7/11/12 at 12:30 PM, the RN/WCC (Registered Nurse/Wound Care Coordinator) was interviewed. She stated that she only does wound rounds on residents with pressure ulcers. She documents the staging and description of the wound on the weekly wound tracking sheets and also updates the care plan titled: " Skin Impairment - Actual ". The RN also stated that she reviews all sections of the medical record thoroughly before updating the care plans and speaks to the wound care nurse and the LPNs regularly regarding the wounds. The RN further stated that she was not aware the LPN had documented the wound as a stage IV sacral ulcer on the "Bi-weekly Skin Observation" form dated 7/4/12, because she had not checked the Bi-weekly Skin Observation forms or the nursing progress notes. The RN/WCC also stated that the forms are completed by the LPN's. It is the responsibility of the RN supervisors to review the forms for completion and accuracy. On 7/11/12 at 2 PM, the CNA was interviewed and stated that the resident was able to turn himself on his back in bed, but needed the assistance of the staff to reposition himself from side to side to relieve pressure to his back and sacral areas. On 7/11/12 at 3:40 PM, the RNS (Registered Nurse Supervisor) was interviewed and stated that she is responsible for wound tracking and skin care for the resident. She stated that she updated the care plans, and that each new skin breakdown should be documented on the existing skin integrity care plan and had no explanation for why there was no monitoring of the residents skin from 6/2/12 to 6/11/12 when the unstageable ulcer was noted. The RNS further stated that it is her responsibility to check the documentation of the CNA's and LPNs regularly and did not have any explanation as to why the LPNs did not document in the progress notes or on the Bi-weekly Skin Observation section for the month of June, 2012 and added that this should not have happened. On 7/11/12 at 6:10 PM, the resident ' s Physician was interviewed and stated that the resident was at high risk for pressure ulcer development since his admission due to incontinence and immobility. He stated that the wound began as a skin excoriation in the coccygeal area and then quickly progressed to an unstageable ulcer in early June 2012. He stated that he was unaware of the development of the pressure ulcer prior to June 11, 2012. The Physician further stated that frequent skin observations and close monitoring were necessary to prevent the development of a pressure ulcer in this resident. The revised Policy and Procedure for, "Pressure Sore, Ulcer Prevention and Intervention Program " dated 7/11/12 documented, "Upon admission, weekly for four weeks, re-admission, change of condition, the resident will be assessed for pressure sore prevention / intervention ...2. The progress of the Comprehensive Care Plan will be evaluated on an ongoing basis and revised as needed ....3. Pressure Sore Intervention: (d) Nursing ...will monitor the progress of pressure sore / ulcer treatment and document accordingly. All residents who develop pressure sores / ulcers will have their Comprehensive Care Plans revised to reflect the current needs of the resident." The undated Policy and Procedure for the "Body Audit Flow Sheet" documented that the facility uses this form to monitor skin integrity and ensure early detection of skin impairment. It instructs that the body audit form is to be completed when the resident is given a shower. It further stated that the licensed nurse reviews the flow sheet and is responsible for reporting findings as necessary." 415.12(c)(1)

Based on observation, staff interview, and record review during the recertification survey, the facility did not prepare, store and serve food under safe and sanitary conditions to prevent food borne illnesses. Reference is made to the following: 1) Food items, and partially used food items in storage that were not dated/labeled as per the facility ' s policy and procedure. 2) Food contact utensils that were not properly stored to prevent potential cross contamination. 3) Food contact equipment and contact surfaces that were not maintained clean. 4) The general kitchen environment and a food storage area that were not maintained clean and in good repair. The findings are: During the kitchen inspection on 07/03/12 between 9:15am and 10:30am, and an inspection of the resident " cafeteria " between 11:45am and 12:00pm the following was noted: 1). Food items were not dated while in storage in accordance with the facility ' s policy and procedure. Examples include but are not limited to the following: Dairy walk-in refrigerator: - 1 tray of individually poured containers of apple juice. - 1 bottle of partially used spring water. - Partially used plastic containers each of " raisin oat bran " and " beans banana nut " cookie batter. Meat walk-in refrigerator: - Partially used containers each of " mustard " , " mayonnaise " , " BBQ sauce " and " pickle cucumber " Dry goods storage room: - Canned goods of " tapioca pudding " , " butter scotch pudding " , " vanilla pudding " , and " sliced apples " . - 2 plastic containers of " mayonnaise " - 5 plastic containers of " honey " - 3 partially used five gallon containers of " beef " and " chicken " base. Chef ' s refrigerator in the resident Cafeteria: - Mushrooms, lettuce, sliced peppers, sliced onions and wraps. In an interview on the same day at approximately 9:30am, the Food Service Director stated that all the food items in storage are supposed to be dated when initially placed in storage and when initially opened for usage as per policy. She further stated that the stock person and dietary employees may have missed dating some of the identified food items and that she would in-service them on following the facility ' s policy and procedure. She immediately contacted a dietary employee to remove and discard all the partially used food items and stated that all the other undated food items would be checked for expiration dates before being dated. A review of the facility ' s policy for food storage revealed that " food should be dated as it is placed on the shelves " . 2) Food contact utensils were not properly stored to prevent potential cross contamination as follows: a) A meat plate warmer was noted kept in close proximity to the meat sink and was noted with one stack of clean plates that was not covered or protected to prevent potential cross contamination. b) A dairy plate warmer was noted making direct contact with an uncovered garbage can near the steam table. The plate warmer was noted with two stacks of clean plates that were not covered or protected to prevent potential contamination. 3) Food contact equipment and contact surfaces were not maintained clean in that food debris and splash stains were noted on portions of the surfaces of the meat and dairy plate warmers, the griddle, on a blender rubber guard, on the surfaces of the steam table, and on a food preparation counter top near the meat sink. In an interview on the same day at approximately 9:50am, the Food Service Director stated that the stack of plates should have been covered since they are clean and not in use at the time. She further stated that a safe distance should be maintained between the plate warmers and unclean items to prevent potential cross contamination. She immediately contacted a dietary employee to wash all the stacks of uncovered plates, and stated that the stains would be cleaned. 4) The general kitchen environment was not maintained clean and in good repair. Reference is made to the following: a) An accumulation of lint was observed on the ceiling tiles and surfaces of the ventilation grilles in the vicinity of the meat walk-in refrigerator, by the meat preparation sink, and the meat dishwasher. In addition, approximately six ceiling tiles in the vicinity of the range hood were noted to be discolored (off-white) in appearance and noted with splash stains in some areas. b) An accumulation of a discolored (dark) fluid was observed on the floor surface beneath the dairy mixer and in front of the commercial gas range. Multiple observations were made of the fluid accumulation on the floor during the kitchen survey. c) The cart wash down area was noted in disrepair in that four wall tiles were missing, and the edges of the wall tiles by the entrance to the room was noted to be chipped and cracked. d) The meat side pot and pans storage area was noted with chipped and scratched paint surfaces on the top portion of the wall. e) The dry goods area was noted with condensation dripping from a condenser line onto the outer surface of a rice bin. In a separate interview on the same day at approximately 9:55am, the Food Service Director stated that the fluid accumulation on the floor resulted from a leaking steam line that is connected to the steam cooker. She stated that it leaked about one week ago and was fixed, and that it just started leaking again. She further stated that all the other identified areas would be addressed. The Food Service Director immediately removed the rice bin from beneath the condenser line and contacted a dietary employee to clean the bin. NYCRR 415.14(h) Chapter 1 SSC Subpart 14-1 Based on observation and staff interview, the facility did not ensure that food was stored, distributed, and served under sanitary conditions. Specifically, (1) Expired dairy drinks were observed on resident trays; (2) The pantry refrigerator on the 1st floor nursing unit had food items not labeled and dated properly.This was evident for 2 of 3 resident units (1st and 2nd floors) and the kitchen. This resulted in no actual harm with potential for more than minimal harm. The findings are: 1) On 7/3/12 at 10:00 AM, during the initial tour of the the 1st floor , the pantry refrigerator located in the 1st floor dining room had a container of "Philadelphia Cream Cheese" with a resident's name but was not dated and a container of fruit salad dated 6/29/12. The Registered Nurse Supervisor was present and was immediately interviewed. She stated that usually food is discarded after 48 hours from the date written on the item and that both dietary and nursing are responsible for throwing items out when they are expired. She further stated that the fruit salad should have been discarded but that the cream cheese is ok because it doesn't expire and is non-perishable. 2) On 7/3/12 at 12:25 PM, during a lunch observation on the the 2nd floor, three resident trays were observed with boxes of "Resource Vanilla Artificially Flavored Dairy Thick Honey Consistency" drinks with an expiration dated of March 24, 2012. The Registered Dietician was immediately interviewed and stated that she would immediately take the expired drinks off the trays and bring them to Food Service. On 7/3/12 at 12:35 PM, the Licensed Practical Nurse (LPN) feeding residents in the dining room was interviewed and stated that the staff on the unit does not always check the expiration dates of food that comes on the trays from dietary. On 7/3/12 at 2:23 PM, the Food Service Director was interviewed and stated that all persons are responsible for checking the expiration dates to ensure that expired food is discarded, including the staff maintaining the food storage rooms as well as the staff preparing the trays. On 7/3/12 at 2:46 PM, the Dietary Aide #1, assigned to maintain the storage room, was interviewed and stated that he checks all incoming food for expiration dates and also puts the arrival date on the case. He further stated that items are put into the stock room so that new items are put in the back or on the bottom, so that older items can be used first. Dietary Aide #1 stated that he checked the room this morning and did not see the expired Dairy Thick drinks in there. On 7/10/12 at 10:30 AM, the Dietary Aide #2 who prepared the lunch trays on 7/3/12 was interviewed and stated that he took the drinks from the storage room and put them in the refrigerator in preparation for the tray line. He further stated that he did check the dates and was shocked to learn that the drinks were expired. Dietary Aide #2 stated that expired items are removed from the storage room and the supervisor is informed. 415.14(h)

Based on observations, record review and interviews, the facility did not ensure that a resident's family member was notified of a change in resident's condition. Specifically, a resident's family member was not notified about a discoloration beneath the resident's eye. This was evident for 1 of 24 sampled residents. (Resident #15) This resulted in no actual harm with potential for more than minimal harm. The finding is: Resident #15 is a [AGE] year old male with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 dated 4/24/12 documented that resident's cognitive status is moderately impaired with short and long term memory loss. On 7/6/12 at approximately 11:30 AM, the resident's wife was observed walking towards the nursing station and stating to the staff at the desk; "What happened to my husband...he has a black eye...I was just hear the other day and he was fine". On 7/6/12 at approximately 11:40 AM, the resident was observed to have a black and bluish area approximately 2 centimeters (cm) under his right eye. The Medical Record was reviewed and there is no documented evidence that the resident's family member was notified of the resident's skin discoloration The resident's wife was interviewed on 7/6/12 at approximately 11:45 AM and stated that she normally visits everyday but had not visited her husband since Sunday because she was sick.She further stated that when she saw him last (4 days prior), he was fine,and now had a black eye. The residents wife further stated that she was not notified about what happened, and was upset because her husband can't speak for himself. The Certified Nursing Assistant (CNA) was interviewed on 7/6/12 at 11:50 AM and stated that she is not normally assigned to this resident but had noticed a bruise under his right eye when she was doing her rounds this morning around 7:10 AM. The Registered Nurse Supervisor was interviewed on 7/6/12 at approximately 12:15 PM and stated that she was not aware of any bruises or marks on this resident but that the resident's wife should have been notified of any changes in the resident's condition. 415.3(e)(2)(ii)(a)

Based on observations, record review and interviews, the facility did not ensure that a resident's confidentiality was maintained. Specifically, the unit physician was heard discussing confidential resident information at the nursing station in close proximity of other residents and family members. This was evident for 1 of 24 sampled residents. (Resident #9) This resulted in no actual harm with potential for more than minimal harm. The finding is: Resident #9 is a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 dated 5/17/12 documented that the resident is cognitively impaired and is sometimes understood/understands. On 7/10/12 at 12:50 PM, the resident's family member was observed approaching the nursing station to speak to the unit physician. The family member appeared upset about his mother's medical condition and started asking the physician about his mother and why the resident still had a [MEDICAL CONDITION]. The unit physician started discussing the resident's medical condition at length with the resident's son at the nursing station, directly across from the elevators. The unit physician was also observed to be talking in a loud volume and argumentive manner. During the conversation which lasted approximately 30 minutes, other residents and family members were present by the nursing station. The Physician observed discussing this resident was unavailable for interview. Another facility Unit Physician was interviewed on 7/11/12 at approximately 1:45 PM and stated that you can't talk in public about a resident's diagnosis, treatment plan or any resident information due to "HIPAA" (Health Insurance Portability and Accountability Act). He continued to state that you would either go to the resident's room or a private place, for example a conference room to discuss resident information and that you would not discuss this type of information in a public place. The Medical Director was interviewed by phone on 7/11/11 at approximately 2:00 PM and stated that when discussing resident information, he prefers to have a conversation face to face to ensure that the person he is talking to is the authorized designated representative listed on the resident's face sheet. He further stated that he would take them to a private location to discuss resident information. The Medical Director also stated that he would expect his staff to speak to residents and their families in a calm and respectful manner at all times. 415.3(d)(1)

Based on observations, record review and interviews, the facility did not ensure that an investigation was conducted for a resident with an injury of unknown origin. This was evident for 1 of 24 sampled residents. (Resident #15) This resulted in no actual harm with potential for more than minimal harm. The finding is: Resident #15 is a [AGE] year old male with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 dated 4/24/12 documented that the resident's cognitive status is moderately impaired with short and long term memory loss. On 7/6/12 at approximately 11:30 AM, the resident's wife was observed walking towards the nursing station and stating to the staff at the desk; "What happened to my husband...he has a black eye...I was just hear the other day and he was fine". On 7/6/12 at approximately 11:40 AM, the resident was observed to have a black and bluish area approximately 2 centimeters (cm) under his right eye. The Nursing Progress Notes dated January 1, 2012 through June 27, 2012 were reviewed. There was no documented evidence of any bruises or discolorations on resident's body or face for that time-frame. The "Skin Impairment-Actual" Comprehensive Care Plan (CCP) dated 2/2/12 through 5/30/12 was reviewed. There was no documented evidence in the care plans of any bruises or discolorations on resident's body or face. The "24 Hour Patient Care Record" dated 7/1 through 7/6/12 documented on 7/6/12 7 AM - 3 PM that resident was seen with a discoloration underneath right eye, MD (Medical Doctor) evaluated, no pain noted when touched, continue to monitor. The Registered Nurse Supervisor was interviewed on 7/6/12 at approximately 11:40 AM and stated that she was not aware of any bruises or marks on this resident. She further stated that this resident's regular Certified Nursing Assistant (CNA) was off today. The resident's wife was interviewed on 7/6/12 at approximately 11:45 AM and stated that she normally visits everyday but had not visited her husband since Sunday because she was sick.She further stated that when she saw him last (4 days prior), he was fine,and now had a black eye. The residents wife further stated that she was not notified about what happened, and was upset because her husband can't speak for himself. The Certified Nursing Assistant (CNA) was interviewed on 7/6/12 at 11:50 AM and stated that she is not normally assigned to this resident but that she noticed a bruise under this resident's right eye when she was doing her rounds this morning around 7:10 AM and forgot to tell the nurse. The Registered Nurse was interviewed on 7/6/12 at approximately 12:05 PM and stated that she was not aware of any changes in regards to this residents skin. The Licensed Practical Nurse (LPN) was interviewed on 7/6/12 at 12:50 PM and stated that he gave this resident medication at approximately 8:35 AM today and did not notice any discolorations to resident's face or body. He further stated that he did not become aware of the discoloration to the resident's face until after the SA (State Agency) started asking questions about this resident. The Physician was interviewed on 7/6/12 at approximately 2:50 PM and stated that this resident has history of [MEDICAL CONDITION] of the face and was seen by the dermatologist on 7/3/12 so that he figured that was why the nurse was notifying him about this resident's face. He further stated that this resident has dry eyes and tends to itch his eyes a lot so he also thought that the discoloration underneath the resident's eye was due to the resident rubbing his eyes to the point of creating a bruise. The Registered Nurse Supervisor was interviewed on 7/10/12 at 11:00 AM and stated that she had obtained statements from two CNA's on the 7 to 3 shift and the bruise was noticed on the 3 to 11 shift on 7/5/12 according to the statements she had gotten so far. She furthered stated that the investigation was just started and not yet complete. The CNA/Orderly regularly assigned to this resident was interviewed on 7/10/12 at approximately 11:55 AM on 7/10/12 and stated that it wasn't a bruise, it was a dark area and that he noticed it on Thursday, July 5th at approximately 9:00 AM. He further stated that he didn't tell anyone because the nurse was with him and also saw the mark on the resident's face. The Director of Nursing was interviewed on 7/10/12 at 12:20 PM and stated that no investigation was done because it wasn't a bruise it was a reddish purple mark and that this resident has history of Senile Purpura. She further stated that her nursing supervisor came to her on the 3 to 11 shift on 7/5/12 to report the discoloration and that they did an investigation but didn't write it up because it wasn't a case of abuse. 415.4(b)(1)(ii)

Based on record reviews and staff interviews, the facility did not ensure that care plans were developed for a resident with multiple areas of altered skin integrity. This was evident for 1 of 2 residents reviewed for pressure ulcers (Resident #11). This resulted in no actual harm with potential for more than minimal harm. The findings are: Resident #11 is a [AGE] year old with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 dated 5/23/12 documents the resident's BIMS (Brief Interview for Mental Status) score is 3 (severely impaired cognition), rarely/never understood and sometime understands. The MDS further documents the resident is always incontinent of bowel and bladder. The MDS further documents the resident was at risk of developing pressure ulcer and had no unhealed ulcers. The " Braden Risk Assessment Scale For Ulcers" dated 3/22/12, 6/2/12 and 6/21/12, documented the resident with very limited sensory perception, moist skin, chairbound, very limited mobility and a problem with friction and shear. The total Braden scale score was 13- high risk for pressure ulcer development. The Comprehensive Care Plans for "Skin Impairment - Potential" dated 3/2/12 documented: " Problems / Strength - As evidence by: Limited oob...Fragile skin...related to: Dementia...Incontinence... Goals / Time Frame - Resident 's skin integrity will be maintained as evidenced by no skin breakdown... Team Interventions - Prompt incontinence care Q2-4H and PRN, Wash, dry, and lubricate perineal area and bony prominence after every incontinence episode, Assess skin condition daily during care, Keep skin dry and clean and well lubricated..." " Physician 's Interim Order(s) and Progress Note(s)" documented the following: "... 10/16/11- [MEDICATION NAME] cream to open ulcer at base of penis Bid x 2 weeks" "... 10/23/11- T/O (name of Doctor)...Cleansed Rt elbow open Purpura with NS pat dry Apply [MEDICATION NAME] oint leave open to air Q shift and PRN x 7 days. " "...11/22/11-Cleanse (with) NS (normal saline) + (plus) [MEDICATION NAME] oint (ointment) (with) bandaid daily + prn(as needed) x (times) 5 days (secondary) to opened small black mole (R) arm." "...12/13/11-Cleanse scrotal area with NS, pat dry and apply Myclog cream BID x 14 days Dx: Rash. " "...2/8/12 - [MEDICATION NAME] oint to scrotal abrasion BID x 2 weeks ... " "...3/12/12- Cleanse (with) NS to right upper thigh abrasion-apply [MEDICATION NAME] oint...qd (every day) + prn." "...4/28/12- Cleanse Open Skin to left shin with NS ....Dx open skin. " There was no documented evidence that comprehensive care plans were developed to address the care of the residents multiple areas of altered skin integrity. On 7/11/12at 3:40PM, the Nursing Supervisor was interviewed and stated that she is responsible for initiating an appropriate care plan for the resident ' s skin integrity as well as revising it to include any new interventions. She stated that the resident ' s care plan for Skin Integrity should be updated each time the resident has a new skin impairment . 415.11(c) (1)

Based on observations, record reviews, and staff interviews, the facility did not ensure that Physician's orders were followed. Specifically, during a wound care observation, there was no dressing in place for a resident 's sacral pressure ulcer. This was evident for 1 of 24 residents reviewed for provision of wound care (Resident #11). This is a repeat deficiency This resulted in no actual harm with potential for more than minimal harm. The findings is: 1) Resident #11 is a [AGE] year old with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 dated 5/23/12 documents the resident's BIMs (Brief Interview for Mental Status) score is 3 (severely impaired cognition), rarely/never understood and sometime understands. The MDS further documents the resident is always incontinent of bowel and bladder. The MDS further documents the resident was at risk of developing pressure ulcer and had no unhealed ulcers. The Comprehensive Care Plans for "Skin Impairment - Actual" dated 4/16/12 through 6/21/12 documented, " Problems ...Fragile skin, Impaired Mobility... Goals...pressure / stasis ulcer will be healed by: Time Frame x 90 days ....Team Interventions - Treatment to affected site as per MD orders, Monitor skin during daily care, Protective / Preventive Skin Care. " The Physician's Interim Order dated 6/19/12 documented, " Cleanse sacrum with Normal Saline, pat dry, apply [MEDICATION NAME] to open area (mid sacrum) Zinc oxide to surrounding DPD (dry protective dressing) OD (every day) and PRN (as needed) (PU). A sacral ulcer dressing observation was conducted on 7/6/2012 at 9:30A.M, the RN (Registered Nurse) Wound Care Nurse assisted by the CNA (Certified Nursing Assistant), removed the residents incontinent brief. On removal of the brief, the sacral wound was observed uncovered, without a dressing in place. The wound was in direct contact with the incontinent brief, with a moderate amount of bloody drainage and peripheral redness. On 7/6/12 at 10:15 AM the assigned CNA was interviewed regarding the absence of the resident ' s dressing. The CNA stated that 7:45AM she informed the LPN (Licensed Practical Nurse) that the resident was soiled and that she had provided incontinent care. The LPN stated that the Wound Care Nurse was coming later that morning, and would apply a dressing to the wound. On 7/6/12 at 10:20AM, the RN/Wound Care Nurse was interviewed and stated she did not know that the resident had been incontinent, and had not spoken to the CNA or LPN prior to the dressing change. The RN further stated that LPN should have put a clean dressing on the wound after the CNA informed him that the resident was incontinent. On 7/8/12 at 9AM the Nursing Supervisor was interviewed and stated that the CNA should inform the nurses immediately when the resident is incontinent and the dressing becomes soiled. The RN further stated that the wound should have been changed at 7:45AM after the CNA informed the nurse, and not later that morning. On 7/9/12 at approximately 10:30AM the LPN (Licensed Practical Nurse) was interviewed. He stated that he was giving out medication when the CNA had come to tell him that the resident was incontinent and that she was going to clean the resident.The LPN stated that he told the CNA that the Wound Care Nurse would be coming to do the wound care later that morning, and that he was busy giving medications at the time. 415.11(c)(3)(ii)

Based on record review and interviews, the facility did not ensure that the resident was provided with the necessary care and services to attain or maintain the highest practicable physical well-being in accordance with the comprehensive assessment and plan of care. Specifically, the facility did not monitor the urinary output of a resident with a [DIAGNOSES REDACTED]. This is evident for 1 of 30 sampled residents. (Resident #21) This result in actual harm that is not immediate jeopardy The findings is Resident #21 is a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Nursing Admission assessment dated [DATE] documented that the resident's short and long term memory was intact and had the capability to make decisions. This assessment further documented that the resident was incontinent of bowel and bladder, had dribbling and uses incontinent briefs. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Comprehensive care plan (CCP) for alteration in urinary elimination dated 4/17/12 documented that the resident had "episodes of incontinence" that is "daily, but some control (frequently)." The interventions documented that the resident required monitoring of bladder incontinence and to assess for a pattern. The comprehensive care plan dated 4/27/12 documented "Resident observed with suprapubic pain, suprapubic distention, and no urinary output for 24 hrs. (hours) Obtained MD (medical doctor) order for Straight Cath. (catheter)" No other interventions were noted in the care plan. The nurse's notes dated 4/21/12 at 2:30 PM documented: "c/o (complained of) generalized pain - [MEDICATION NAME] given w/ minimal relief. Res. (resident) stated that pain meds (medications) is not completely effective...". There is no documented evidence that the resident was assessed or monitored by the licensed nurse for elimination from 11:00 AM on 4/22/12 through 3:00 PM on 4/27/12. The nurse's note dated 4/27/2012 at 3:45 PM documented: "Observed resident with pelvic distention, pain upon palpation. Resident claimed to not have voided for close to 24 hours. The MD (Medical Doctor) was notified by telephone. Obtained order for: Straight Cath and if more than 200 cc urinary output leave Foley in. Foley care Q (every) shift change Foley Q month. Resident drained 300 cc. Catheter clamped and in place. Will continue to monitor." The physician telephone order dated 4/27/12 at PM documented "Straight Cath pt (patient) and if more than 200 cc urinary output leave Foley in Foley Care Q shift Change Foley Q Month." There was no documented evidence of a complete order for a Foley (no size or type noted) catheter, no order for clamping the Foley catheter at set intervals. The care plan was not updated to reflect the insertion of the Foley catheter or to indicate monitoring of the urinary output. The nurse's note dated 4/27/12 at 4:45 PM documented "Foley tube unclamped resident drained 500 cc. Reclamped Will continue to monitor. The nurse's note dated 4/27/12 at 6:00 PM documented "Foley tube unclamped 400 cc drained tube left unclamped. will continue to monitor." There is no documented evidence that the physician was notified that on 4/27/12 between 3:45 PM to 6:00 PM, the resident drained a total of 1200 cc of urine. The nurse's note dated 4/27/12 at 7:30 PM documented "500 cc drained Reclamped." There is no documented evidence that the physician was notified that on 4/27/12 at 7:30 PM the resident drained an additional 500 cc's of urine. The nurse's note dated 4/27/12 documented the following: "9:00 PM 500 cc drained re-clamp; at 9:30 PM 500 cc drained unclamped & left open 10:30 PM noted 300 cc in Foley bag- yellow in color. Dr. _____ notified of urinary output of 3000 cc this tour, v/s-96/65 Pulse 78. T/O (telephone order ) obtained for IVF (Intravenous fluids) 0.9% ns (normal saline) at 100cc/hr x 24 hour (hydration) sma7 in am". On 07/11/2012 the resident was interviewed and stated that prior to insertion of the Foley catheter her bladder was full like it was going to bust, and she had pain in the abdomen. The Resident stated that she could not remember how many hours she did not void, because her memory is not good. There was no documented evidence that the resident was assessed and monitored by nursing staff for urinary output prior to Foley catheter insertion. The tool that the CNAs were supposed to use to monitor output i.e., 'the hourly brief change monitoring sheet for incontinence" was not completed. An interview was conducted via telephone on 07/11/2011 with the assigned certified nurse aide (CNA #1) who was assigned to the resident on 04/27/2012 during the day (7 AM-3 PM) shift. She stated that at about 10:00 AM the resident told her she could not void and she felt pain, she reported the problem to the license practical nurse (LPN) immediately, that was in charge of the resident care. CNA #1 stated that during her shift the resident rang the call bell several times during the day complaining of pain. The resident stated that she needed to urinate, but could not. She stated that she reported the resident's complaints of discomfort and inability to urinate to the nurse about 5 to 6 times during the shift. She stated that she changed the resident about three (3) times and she had no urine, but she had two (2) BMs (bowel movements). CNA #1 stated that the last time she changed the resident was 2:30 PM. She had a BM, but no urine. She stated that at 2:50 PM she reported to the nurse that the resident was still complaining of pain and still had not urinated. The nurse told her it was 3 PM and to go home and that she would take care of it. The next day she was assigned to the resident to provide care. The resident had a Foley catheter in place. Although she stated that she reported the resident's inability to void, she did not document this on the brief change monitoring sheet. On 07/11/12 an interview was conducted with the assigned certified nurse aide (CAN#2) who was assigned to the resident on 04/27/2012-3-11 shift. She stated on 4/27/12, she was assigned to care for the resident. She stated that on 4/27/12 at 3:30 PM she asked the resident if she was ready to go back to bed. The resident stated yes. CNA #2 stated that as she was putting the resident back to bed she complained that she was having some discomfort in her abdomen. She asked the resident if she urinated at all that day. The resident stated that she drank a lot of fluids, but did not urinate. CNA #2 stated that when she asked her if she told anyone she said no. CNA #2 stated that she asked the resident if she had a bowel movement and she said no. When she checked her incontinent brief, she was dry. CNA #2 stated that she asked her the last time she was changed, she said about 1:30 PM. She then asked her if she was currently wet and she said no. She stated that she reported this to the immediately to the evening supervisor and charge nurse. She stated that both the supervisor and charge nurse went into the resident's room right away. She did not document this on the brief change monitoring sheet. There was no documented evidence that the resident was assessed and monitored by nursing staff for urinary output prior to Foley catheter insertion as evidenced by the brief change monitoring sheet for incontinence to be filled out every hour was not completed. There was no documented evidence that the resident was assessed for pain, or offered any intervention to address her repeated complaints of pain or discomfort. On 07/11/2012 an interview was conducted with the RN supervisor of the evening (3 PM-11 PM) shift. She stated on 04/27/2012 at approximately 3:30 PM, the assigned CNA came to the 1st floor desk and reported to the nurse in charge, RN that the resident complained of not voiding. She and the charge nurse went to assess the resident. The resident's abdomen was distended and she complained of abdominal discomfort. The charge nurse informed the medical doctor and he gave an order to straight catheterize the resident and if more than 200 cc urinary outputs leave Foley catheter in and provide Foley care every shift. The Foley catheter was inserted and drained 300 cc immediately. After that the Foley catheter was clamped and unclamped intermittently during the shift, resulting in 3000 cc urinary output. Medical Doctor was informed of urinary output and B/P=96/65, R=78 Medical Doctor ordered ( IV) intravenous fluid 0.9% ns@ 100 cc/hour x 24 hour (hydration), sma7 in am. She could not provide the order for the Foley or an order instructing the how frequent the clamping should have be done. An interview was conducted with the Director of Nursing on 07/11/2012. She stated on 04/28/2012, at 9:15 am, during morning report, RN manager reported that resident in room [ROOM NUMBER] b did not void during the 7-3 PM shift on 04/27/2012 and complained of abdominal discomfort. She stated that the resident had to be catheterized and a total of 3,000 cc was obtained over 6 ? hours and that it was done in increments i.e. clamping and releasing. She further stated that the resident was comfortable, the Foley remained in place and was draining adequate amount of urine. 415. 12.(d)(2)