Every finding on record at Resort Nursing Home

Based on observation, record review, and interviews during the survey, the facility failed to ensure that residents received adequate supervision to prevent elopement. This was evident in one out of five residents sampled (Resident #1). Specifically, on 07/15/2026 at 1:51 PM, the facility's video surveillance footage showed Resident #1, who was severely cognitively impaired, and identified as being at risk for elopement, exited the facility grounds without supervision. As Resident #1 exited through the front entrance door, the secure bracelet alarm was activated. Front Desk Receptionist #1 deactivated the alarm and buzzed the exit door, and allowed Resident #1to leave the facility. At 5:15 PM, the facility's staff became aware that Resident #1 was not in the building. At 9:10 PM, Resident #1 was found by police detectives and returned to the facility. Resident #1 was assessed by Registered Nurse Supervisor #1 no injuries were identified. Resident #1 was sent to the hospital for evaluation and did not return to the facility.The findings include:The facility's policy and procedure titled Assessment, Identification, Prevention and Care Planning for Unsafe Wandering and Elopement, dated 10/2025 documented all residents will be assessed for their potential risk for unsafe wandering and elopement at the time of admission, readmission, quarterly, annually and with significant changes. The purpose is to maintain safety to the highest degree possible by ensuring that the risk for unsafe wandering or elopement is care planned for individualized underlying causes and triggers. The licensed nurse initiates half hourly-hourly monitoring for residents identified as high elopement risk.The facility's policy and procedure titled Elopement Risk Assessment Form, dated 10/2025 documented the Elopement Risk Assessment is initiated by the Registered Nurse and serves as a tool to ensure residents at risk for elopement are assessed appropriately and corresponding care plans are developed and revised as necessary. The Registered Nurse completes Elopement Risk Assessment on admission, readmission, quarterly, annually, with significant changes, attempted elopement, actual elopement and as clinically indicated. The facility's policy and procedure titled Reception Desk/Front Desk Monitoring Policy and Procedure, dated 10/2025 documented the facility maintain continuous monitoring of the reception/front desk to promote the safety and security of residents, visitors, staff, and the building. The reception desk serves as the primary point of entry and exit and plays a critical role in preventing unauthorized access, resident elopement, and ensuring visitor accountability. Resident #1 was admitted to the facility with diagnoses including dementia (decline in cognitive function), chronic kidney disease (kidney gradually loose function over time), and anemia (blood not having enough healthy red blood cells).The Minimum Data Set (a resident assessment tool) dated 06/30/2026, identified Resident #1 as severely impaired cognition and ambulated independently.An Elopement Risk assessment dated [DATE] documented Resident #1 was identified as at risk for elopement. A review of Resident #1's at Risk for Elopement Care Plan, last reviewed on 06/05/2026 documented interventions to apply secure care bracelet as needed, use orange chart, orange armband, half hourly check, include Resident #1 in three times per shift monitoring, and secure care bracelet check daily for presence/function and replace as needed. A review of Physician Orders from 09/19/2025 through 06/30/2026 revealed, Resident #1 was ordered Elopement Risk with half hourly monitoring due to wandering behavior every day during the 7:00 AM to 3:00 PM shift, 3:00 PM to 11:00 PM shift and the 11:00 PM-7:00 AM shift. A review of the 7:00 AM to 3:00 PM shift and 3:00 PM to 11:00 PM shift Half Hour Check Room sheet dated 07/15/2026 revealed Resident #1 was on 30 minutes monitoring. On 07/15/2026 Certified Nursing Assistant #1 signed from 2:00 PM until 11:00 PM as evidenced by their initials that the check was done. A review of the Resident Monitoring Sheet (used to indicate the unit and location that each resident is seen) dated 07/15/2026 at 2:45 PM, Certified Nursing Assistant #2 documented Resident #1 was located in the hallway.A review of the Resident Monitoring Sheet dated 07/15/2026 at 3:00 PM, 7:00 PM and 10:45 PM, Certified Nursing Assistant #3 documented at 3:00 PM Resident #1 was located in the main dining room (MDR). At 7:00 PM Resident #1 was located in resident room (RR) and 10:45 PM documented Resident #1 was in the room.The facility's video surveillance was reviewed with the Director of Nursing on 07/30/2026. The video surveillance dated 07/15/2026 at 1:51 PM revealed Resident #1 who was wearing a hat, eyeglass, wearing a white sweatshirt and dark pants. Resident #1 was ambulating in the lobby using a single point cane device towards the facility entrance front door, looked at the Front Desk Receptionist #1 and touched their hat (appeared acknowledged the Front Desk Receptionist#1) and Front Desk Receptionist #1 observed buzzed out Resident #1 and Resident #1 exited the front entrance door. Front Desk Receptionist #1 observed stood up and deactivated the alarm. The facility's Summary of Investigation dated 07/21/2026 documented during dinner service on 07/15/2026 at 5:15 PM, Licensed Practical Nurse # 1 was unable to locate Resident #1 on the unit. A unit search was conducted immediately. An Orange Alert (elopement protocol) was activated at 5:20 PM. The facility staff conducted a comprehensive search of the entire building, other units, common areas, surrounding grounds and premises. The facility reviewed their video surveillance footage and confirmed Resident #1 exited the facility on 07/15/2026 at 1:51 PM. 911 was contacted to assist with the search, family and Medical Doctor were notified. Nearby hospitals were contacted. At 9:10 PM, Resident #1 was safely returned to the facility by two detectives. Resident #1 was assessed by Registered Nurse Supervisor #1 and there was no injury or distress. The facility's investigation determined that there was no abuse, neglect or mistreatment occurred. The findings revealed that Resident #1 exited the facility through the front door. The secure care bracelet alarm activated, however, believing the individual was a visitor rather than a resident, Front Desk Receptionist #1 opened the front door and silenced the alarm. A Nursing Progress Note dated 07/16/2026 at 12:20 AM by Licensed Practical Nurse #1 documented that Resident #1 cannot be found at dinner time and food was still on the table untouched. Started looking for Resident #1 in the unit but nowhere to be found. Expanded searched to the ground floor where recreation area is but negative outcome. According to staff, Resident #1 went down after lunch, and it was dinner time and did not come back. Registered Nurse Supervisor #1 was notified. Code Orange Alert was initiated and widened search but Resident #1 was not in the building. An attempt was made to contact Front Desk Receptionist #1 multiple times but was unsuccessful. A letter was sent via certified mail on 08/10/2026. A review of the Front Desk Receptionist #1 statement dated 07/15/2026 documented they observed Resident #1 leaving and recalled the alarm went off and they turned it off without checking the individual. The footage from the facility showed Resident #1 left at 1:51 PM. They did not realize that they were a resident. During a telephone interview on 08/03/2026 at 10:15 AM, Certified Nursing Assistant #1 stated they worked on 07/15/2026 during the 7:00 AM- 3:00 PM and 3:00 PM to 11:00 PM shift. Certified Nursing Assistant #1 stated that Resident #1 was regularly assigned to them. Certified Nursing Assistant #1 stated Resident #1's routine after lunch they go downstairs (first floor) in the recreation activity in the main dining room approximately 1:30 PM to 2:00 PM. The recreation team picked up Resident #1 or Resident #1 go by himself in the activity room. Certified Nursing Assistant #1 stated they were aware that Resident #1 was on 30-minute monitoring for elopement risk. Certified Nursing Assistant #1 stated they documented in the monitoring log that that Resident #1 was visually checked from 2:00 PM through 11:00 PM. Certified Nursing Assistant #1 stated they made a mistake in pre-signing the document. Certified Nursing Assistant #1 stated they should visually see Resident #1 before signing which they did not do. During a telephone interview on 08/03/2026 at 10:28 AM, Certified Nursing Assistant #2 stated they worked on 07/15/2026 during the 7:00 AM-3:00 PM shift. Certified Nursing Assistant #2 stated they were responsible in monitoring the whole residents in the unit three times in their shift. Certified Nursing Assistant #2 stated they know that Resident #1 was in the main dining room on the first floor for recreation activity. Certified Nursing Assistant #2 stated they did not visually check the location of Resident #1 at 2:45 PM and documented that Resident #1 was in the hallway. Certified Nursing Assistant #2 stated they should have gone to the main dining room to check before documenting and regretted it happened. During a telephone interview on 08/04/2026 at 9:55 AM, Certified Nursing Assistant #3 stated they worked on 07/15/2026 during the 3:00 PM-11: 00 PM shift. Certified Nursing Assistant #3 stated they were responsible for monitoring all residents' location three times in their shift between the times of 3:00 PM, 7:00 PM and 10:45 PM. Certified Nursing Assistant #3 stated during their rounds they did not observe Resident #1 in the unit. Certified Nursing Assistant #3 stated they did not notify the unit nurse and they believed Resident #1 was in the main dining room on the first floor for recreation activity. Certified Nursing Assistant #3 stated they signed monitoring sheet. Certified Nursing Assistant #3 stated they should not have signed the sheet until Resident #1 was located. During an interview on 07/30/2026 at 11:25 AM, Licensed Practical Nurse #1 stated they worked on 07/15/2026 during 3:00 PM-11:00 PM shift. Licensed Practical Nurse #1 stated they did their rounds and did not see Resident #1 on the unit. Licensed Practical Nurse #1 stated the Certified Nursing Assistant #1 told them that Resident #1 went to the recreation activity after lunch. Licensed Practical Nurse #1 stated they have a staff assigned to Resident #1 to do 30-minute monitoring, and also a staff assigned to all residents to document their location three times in their shift. Licensed Practical Nurse #1 stated at dinner time around 4:30 PM to 5:00 PM, they did their rounds and did not observe Resident #1 on the unit. Licensed Practical Nurse #1 stated them and staff immediately searched Resident #1 in the unit and went downstairs. Licensed Practical Nurse #1 stated they notified the Registered Nurse Supervisor #1 and they initiated code orange for missing resident. During an interview on 07/30/2026 at 3:51 PM, Registered Nurse Supervisor #1 stated Licensed Practical Nurse #1 called them approximately 5:00 PM and reported that Resident #1 did not come back from activity. Registered Nurse Supervisor #1 stated they immediately went to the unit to search again and asked the other staff to go to the other units. Registered Nurse Supervisor #1 stated they notified the Administrator who was still in the building and activated the Code Orange. Registered Nurse Supervisor #1 stated they confirmed that Resident #1 was missing in the facility at approximately 5:30 PM. Registered Nurse Supervisor #1 stated 911 was notified and responded. Registered Nurse Supervisor #1 stated they notified the family and Director of Nursing. Registered Nurse Supervisor #1 stated they immediately checked the two monitoring sheets and found out that the assigned Certified Nursing Assistants were responsible for checking the location of Resident #1 in the morning shift and evening shift signed the monitoring log from 2:00 PM to 11:00 PM that Resident #1 was checked and located. Registered Nurse Supervisor #1 stated they immediately provided re-education to all staff. Registered Nurse Supervisor #1 stated staff should not pre-sign the time of monitoring and they should physically see Resident #1's location prior to signing the sheet. Registered Nurse Supervisor #1 stated when Resident #1 returned to the facility together with the detectives, they assessed Resident #1 and there were no signs of injury or change in mental status. Registered Nurse Supervisor #1 stated they sent Resident #1 to hospital for further evaluation.During an interview on 07/30/2026 at 1:38 PM, the Director of Nursing stated Resident #1 was high risk for elopement and the Elopement Risk Assessment must be updated quarterly by the Registered Nurse. The Director of Nursing stated they were called by the Administrator at approximately 5:15 PM that Resident #1 could not be located during dinner time by staff and they activated the Code Orange at approximately 5:20 PM. The Director of Nursing stated they expanded the search to neighboring areas and facilities and contacted multiple neighboring hospitals but Resident #1 were not found. The Director of Nursing stated they were two police officers and two detectives responded and they provided demographics of Resident #1. The Director of Nursing stated that the video surveillance footage was reviewed by the Administrator and confirmed Resident #1 exited the facility at the front door on 07/15/2026 at 1:51 PM after the Front Desk Receptionist #1 buzzed them out and observed them deactivated the alarm. The Director of Nursing stated Resident #1 was found by two detectives at 9:10 PM in stable condition. The Director of Nursing stated they immediately provided facility wide re-education on elopement protocol, secure care bracelet check, identification of individual attempting to exit through exit door and accurate documentation. The Director of Nursing stated they conducted a Quality Assurance Performance Improvement meeting on 07/16/2026 to identify the root cause and established a plan for correction. The Director of Nursing stated the Front Desk Receptionist #1 was terminated for allowing Resident #1 to exit the building without identifying the individual and deactivated the alarm. The Director of Nursing stated further investigation revealed Certified Nursing Assistants #1, #2 and #3 documented they pre-signed in the monitoring log that they located Resident #1 during 2:00 PM to 11:00 PM where in Resident #1 exited at the facility 1:51 PM. The Director of Nursing stated the staff should visually check Resident #1's location prior to signing the half-hour check form and the Resident Monitoring Sheet. During an interview on 07/30/2026 at 2:42 PM, the Administrator stated they were in the facility when incident happened on 07/15/2026 at 5:15 PM. The Administrator stated they initiated the Code Orange Alert and accounted for all residents. The Administrator stated they reviewed the video surveillance footage approximately at 6:00 PM and determined that Resident #1 exited the facility front door entrance at 1:51 PM without supervision after the Front Desk Receptionist #1 buzzed them to open the door and observed the Front Desk Receptionist #1 turned off the alarm without identifying if they were a visitor or resident. The Administrator stated they and other staff drove around neighborhood, contacted local hospitals and they were in communication with the police and detectives. The Administrator stated they received a call from two detectives that Resident #1 was found at approximately 9:00 PM and returned to the facility in good spirits. The Administrator stated Resident #1 was on half hour check monitoring and the Certified Nursing Assistants who signed despite Resident #1 leaving the building were suspended pending investigation outcome and the Front Desk Receptionist #1 was terminated. Based on the following corrective actions taken, there was sufficient evidence that the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement prior to surveyors' s onsite visit on 07/31/2026. A Plan of Correction is not required for this citation.10 New York Codes, Rules, and Regulations 415.12(h)(2)The facility took immediate corrective actions and was found to be in substantial compliance on 07/30/2026.Immediate Corrective Actions:On 07/15/2026 at 5:15 PM, the unit staff immediately initiated a search upon discovering that Resident #1 was missing.On 07/15/2026 at 5:20 PM, the facility's Code Orange Alert/Elopement protocol activated. All residents were accounted for at 5:30 PM.On 07/15/2026 at 5:20 PM, a comprehensive search of the facility and surrounding grounds was immediately conducted. On 07/15/2026 at 5:20 PM, video surveillance footage was reviewed to determine Resident #1's last known location.On 07/15/2026 at 6:48 PM, 911 was contacted and Resident #1's information and picture were given to the local police and detectives. At 7:16 PM the Medical Doctor notified. At 7:30 PM the family was notified. At 8:45 PM, the nearby hospitals were contacted to determine whether Resident #1 had been presented for evaluation. On 07/15/2026, immediate in-service/re-education commenced to reception staff and all other staff during the 3-11 PM shift regarding Elopement Policy and Procedure, secure care bracelet alarms and the requirement to verify the identity of any individual attempting to exit through the door. The in-service continued until all facility staff completed the mandatory in-service training. On 07/15/2026 at 9:10 PM, Resident #1 returned to the facility and assessed by Registered Nurse Supervisor #1. On 07/15/2026, a review of all residents identified as risk for elopement was conducted by the Risk Manager. The Elopement Risk list was reviewed and updated, including residents' photographs to ensure accurate identification. No other residents were affected by this incident.On 07/15/2026, all exit doors were inspected and verified in proper order.On 07/15/2026, all other half hourly monitoring forms for other residents were reviewed. No erroneous signatures were identified. On 07/15/2026, the Director of Nursing and Administrator reviewed the Elopement Policy and Procedures with no revision.On 07/15 2026 an audit tool was created to monitor the staff (Certified Nursing Assistant) compliance with half hourly monitoring/Resident Monitoring Sheet documentation signed by the unit nurse and reviewed by Registered Nurse Supervisors.On 07/15/2026 through 07/30/2026, reviewed a Secure Care Bracelet check continued on day and night shift to ensure proper placement and functioning.On 07/15/2026 and 07/16/2026 an Elopement Drill was conducted. On 07/16/2026, a Termination of Employment letter documented the Front Desk Receptionist #1 was terminated.On 07/16/2026, an Employee Warning Notice documented Certified Nursing Assistants #1 and #3 were taken off the schedule pending investigation outcome.On 07/16/2026, a lesson plan and in-service on Accurate and Timely Documentation were given by RNS, ADON and In- Service Coordinator to Certified Nursing Assistants was reviewed.On 07/16/2026 at 9:30 AM, a Quality Assurance meeting was held to review the incident, identify immediate corrective actions and implement facility wide interventions.From 07/15/2026 to 07/20/2026 - a lesson plan and facility wide reeducation on elopement prevention. Attendance reviewed. The facility wide reeducation: Total staff = 251= 91 percent: Staff on vacation will be re-educated upon return and before providing care to residents. Completed % Complete Administrator 1 100%Director of Nursing 1 100%Assistant Director of Nursing 1 100%Nursing Supervisors 8 100%MDS Nurses 4 100%Rehab Nurse 1 100%Inservice Coordinator 1 100%Medical Record Coordinator 1 100%admission Coordinators 2 100%Office Staff 5 100% Front Desk/Receptionist 5 100%Nursing Secretary 2 66% (1 on vacation)Dieticians 2 100%Dietary staff 21 91% ( 2 on vacation)Rehabilitation 11 100%Human Resources 1 100%Escorts 6 100%Housekeeping 23 92% (2 on vacation)Recreation 14 93% (1 on vacation)Social Services 3 100%Registered Nurses 22 81.5% (5 on vacation)Licensed Practical Nurses 4 80% (1 on vacation)Certified Nursing Assistants 90 90% (6 on vacation) total 229

Based on record review and interviews conducted during an abbreviated survey (Incident # 2581915), the facility failed to prevent further potential abuse, neglect, exploitation, or mistreatment while an investigation was in progress. This was evident for one (1) out of three (3) residents (Resident #1) sampled for abuse. Specifically, on 08/05/2025 at 1:59 PM Certified Nursing Assistant #1 reported to Registered Nurse #1 that Resident #1 slapped Clinical Transportation Aide #1, who was providing 1:1 supervision to Resident #1, and Clinical Transportation Aide #1 in return slapped Resident #1 while they were assisting them with repositioning the resident in their wheelchair. Registered Nurse #1 did not protect Resident #1 from further potential abuse; Clinical Transportation Aide #1 was left by themself in the room with Resident #1 until Registered Nurse Supervisor #1 came to the unit at 2:00 PM and removed Clinical Transportation Aide #1 from the unit and schedule. Resident #1 was assessed by both Registered Nurse #1 and Registered Nurse Supervisor #1 and there were no visible signs of injuries. The findings are:The facility's policy titled Abuse Prohibition Program dated 06/20/2025 documented that residents/patients have a right to remain free form verbal, sexual, physical, mental abuse, involuntary seclusion, misappropriation of property, mistreatment and neglect and exploitation. The facility will protect all residents during any investigation by reassigning staff and/or providing counseling to resident. Resident #1 was admitted to the facility with diagnoses included Non-Alzheimer's Dementia, Anxiety Disorder and Depression. The Minimum Data Set Assessment (an assessment tool) dated 07/18/2025 documented Resident #1 had severe cognitive impairment. A nursing note dated 08/05/2025 at 2:35 PM by Registered Nurse #1 documented at approximately 1:59 PM Resident #1's assigned Certified Nursing Assistant #1 reported that Resident #1 allegedly slapped Clinical Transportation Aide #1, and Clinical Transportation Aide #1 might have retaliated. Registered Nurse #1 immediately approached Resident #1 to assess and verify the incident. Registered Nurse #1 documented that Clinical Transportation Aide #1 confirmed that they were slapped by Resident #1 while attempting to reposition Resident #1 in their wheelchair to prevent a fall. However, Clinical Transportation Aide #1 strongly denied slapping Resident #1 in return. Registered Nurse #1 documented Resident #1 denied any complaints of pain or discomfort during the assessment. There was no documented evidence that Clinical Transportation Aide #1 was immediately removed from Resident #1's care. The Report of Accident/Incident dated 08/05/2025 at 1:59 PM documented that Certified Nursing Assistant #1 reported that Clinical Transportation Aide #1 allegedly slapped Resident #1 while being repositioned in their wheelchair inside their room. Resident #1 was assessed by Registered Nurse #1 and there was no visible injuries, redness or complaints of pain. Registered Nurse Supervisor #1 was notified and responded immediately to unit and removed Clinical Transportation Aide #1 from Resident #1. The Medical Doctor and family notified. The facility's undated summary of investigation concluded that there was insufficient evidence to confirm that abuse occurred. Resident #1 was assessed with no visible injuries and Clinical Transportation Aide #1 has a positive interaction and has maintained a good rapport throughout. Clinical Transport Aide #1 has no allegations or disciplinary actions on file. No other staff witnessed the alleged incident. During an interview on 08/12/2025 at 10:47 AM, Registered Nurse #1 stated that the Clinical Transportation Aide #1 informed them (unsure of time), while they were wheeling Resident #1 in the hallway, that Resident #1 slapped them on the left side of their face. Registered Nurse #1 stated that they instructed Clinical Transport Aide #1 to take Resident #1 back to their room. Registered Nurse #1 stated at approximately 1:59 PM on 08/05/2025 while they were at the nursing station, Certified Nursing Assistant #1 reported to them that Resident #1 slapped Clinical Transportation Aide #1 and Clinical Transportation Aide #1 in return slapped Resident #1. Registered Nurse #1 stated that they went to Resident #1's room and observed Resident #1 hugging Clinical Transport Aide #1. Registered Nurse #1 stated that Resident #1 was not fearful of Clinical Transport Aide #1 and had no emotional distress. Registered Nurse #1 stated that they assessed Resident #1 and there was no discoloration, redness, swelling, and Resident #1 did not exhibit any signs of pain. Registered Nurse #1 stated that they reported the allegation to Registered Nurse Supervisor #1 who responded to the unit at 2:00 PM. During a follow up interview on 08/15/2025 at 1:55 PM, Registered Nurse #1 stated that they did not remove Clinical Transport Aide #1 from Resident #1's care because Resident #1 showed no signs of aggression towards Clinical Transportation Aide #1. Registered Nurse #1 stated that they observed Resident #1's behavior with Clinical Transportation Aide #1 to be same as if nothing happened. During an interview on 08/12/2025 at 11:13 AM, Registered Nurse Supervisor #1 stated that they responded to Resident #1's unit at approximately 2:00 PM and observed that Clinical Transportation Aide #1 was in Resident #1's room with Resident #1. Registered Nurse Supervisor #1 stated that they reassessed Resident #1 and there was no visible injury. Registered Nurse Supervisor #1 stated that they immediately removed Clinical Transportation Aide #1 (unsure of time) from the unit and schedule. Registered Nurse Supervisor #1 stated that they notified the Director of Nursing, Medical Doctor, and Resident #1's family. Registered Nurse Supervisor #1 stated that they did not interview any other residents because Clinical Transportation Aide #1 has been providing 1:1 supervision to Resident #1 since 11/2024. During a follow up interview on 08/20/2025 at 11:30 AM, the Director of Nursing stated Resident #1 was left unsupervised in their room with Clinical Transportation Aide #1 when Registered Nurse #1 notified Registered Nurse Supervisor #1. The Director of Nursing stated that Registered Nurse #1 should have removed the Clinical Transportation Aide #1 when there was an allegation of abuse. The Director of Nursing stated that Registered Nurse #1 did not immediately remove the Clinical Transportation Aide #1 from the room because they did not observe any signs of trauma or fear of Resident #1 towards the Clinical Transportation Aide #1. The Director of Nursing stated that one of the processes of investigating abuse allegation is that when a staff is involved, the staff must be removed immediately from the resident and schedule pending investigation outcome. 10NYCRR 415.4(b)(1)(ii)

Based on interview and record review during the Recertification and Complaint Survey (NY00331563) from 05/21/2024 through 05/29/2024, the facility failed to ensure that residents were free of significant medication errors. This was evident for 1 (Resident #126) of 1 resident reviewed for medication administration. Specifically, Resident #126 had a physician's order for 12 tablets of Methadone 10 milligram by oral route once daily. On 01/13/2024, the Resident was administered 12 tablets of Percocet 10-325 milligrams instead of Methadone. Cross Reference: F658 - Services Meet Professional Standards The findings include: The facility policy titled Medication Administration with a revision date of 10/2023 documented the purpose of the policy was to ensure safe administration of medication for residents. The policy stated that medication and strength are verified with physician's order as transcribed on the medication administration record. Controlled substance record is signed immediately after a narcotic has been administered. During an interview on 05/29/2024 at 1:00 PM, Registered Nurse #3 stated they gave Resident #126 12 tablets of Percocet instead of the prescribed 12 tablets of Methadone. They stated they discovered their error when they were counting the controlled drugs before the end of their shift. They stated they immediately reported the incident to the nursing supervisor, and they were told not to come back to work while investigation was in progress. During an interview on 05/29/2024 at 2:10 PM, the Director of Nursing stated they completed the investigation of the incident, and that Registered Nurse #3 committed a medication error and was immediately terminated. During an interview on 05/29/2024 at 3:11 PM, the Administrator stated the medication error incident was a big shock to the facility and had not happened before. 415.12(m)(2)

Based on interviews and record review conducted during the Recertification and Complaint Survey (NY00331563) from 05/21/2024 to 05/29/2024 the facility did not ensure that services provided by the facility as outlined by the comprehensive care plan, met professional standards of quality. This was evident for 1 (Resident #126) of 1 resident reviewed for medication administration. Specifically, Resident #126 had a physician's order for 12 tablets of Methadone 10 milligram by oral route once daily. On 01/13/2024, Registered Nurse #3 administered 12 tablets of Percocet 10-325 milligrams instead of Methadone. The findings include: The facility policy titled Medication Administration with a revision date of 10/2023 documented the purpose of the policy was to ensure safe administration of medication for residents. The policy stated that medication and strength are verified with physician's order as transcribed on the medication administration record. Controlled substance record is signed immediately after a narcotic has been administered. The facility policy titled Professional Standards with a revision date of 10/2023 documented that all staff must perform their duties competently, effectively, and in accordance with the facility's expectations and industry standards. Resident #126 had diagnoses of Traumatic Spine Injury with Quadriplegia, prior Opioid Abuse, and Bipolar Disorder. The Minimum Data Set assessment dated [DATE] documented Resident #126 had intact cognition. A care plan for alteration in comfort related to spinal cord injury with fracture was initiated on 02/25/2022. The facility interventions include to monitor and assess for pain, and Methadone oral tablet 10 milligrams 12 tablets by mouth every day. A physician's order dated 12/11/2023 documented give 12 tablets of Methadone 10 milligram by oral route once daily for pain. A review of Resident #126's Medication Administration Record showed that Methadone was signed for by Registered Nurse #3. A review of Resident #126's Individual Controlled Medication Record for Methadone revealed that Methadone was not administered on 01/13/2024 and that the Methadone count was the same for all shifts on 01/13/2024. An Individual Controlled Medication Record for Percocet 10-325 milligrams that was prescribed for a different resident documented on 01/13/2024 3:00 PM, 12 tablets inadvertently given to Resident #126. A Medication Incident Report dated 01/13/2024 documented the medication nurse reported they accidentally gave Resident #126 12 tablets of Percocet 10-325 milligram instead of the prescribed 12 tablets of Methadone 10 milligrams. Resident was immediately assessed and was sent to the emergency room to check for toxicity. A written statement emailed by Registered Nurse #3 to the Director of Nursing documented they worked on 01/13/2024 on the day shift and that towards the end of their shift, they noticed the Methadone count was the same as the beginning of the shift. Upon checking another resident's medication, they noticed there were 12 tablets taken from this resident's Percocet blister, and realized they gave the Percocet to Resident #126. A nurse's progress notes dated 01/13/2024 at 6:38 pm documented Registered Nurse #3 came to the nursing office towards the end of shift and reported the medication error. Immediate assessment was made, no sign of adverse reaction, no lethargy, and no changes in mental status. The hospital discharge summary dated 01/14/2024 documented no adverse reaction from the medication error that occurred at the Nursing Home. The drug toxicity level was negative, and Resident #126 can return to the facility. During an interview on 05/22/2024 at 2:34 AM, Resident #126 stated they were sent to the hospital because they were given the wrong medication. During an interview on 05/29/2024 at 1:00 PM, Registered Nurse #3 stated they gave Resident #126 12 tablets of Percocet instead of 12 tablets of Methadone. They stated they discovered the error when they were counting the controlled drugs before the end of their shift. They stated they immediately reported the incident to the nursing supervisor, and they were told not to come back to work while investigation was in progress. During an interview on 05/29/2024 at 2:10 PM, the Director of Nursing stated they completed the investigation of the incident, and that Registered Nurse #3 committed a medication error and was immediately terminated. 10 NYCRR 415.11(c)(3)(i)

Based on record reviews and interviews, during the Recertification and Complaint Survey (NY00331563) from 05/21/2024 to 05/29/2024, the facility did not ensure that all alleged violations involving abuse and neglect, were reported immediately, but not later than 2 hours after the allegation was made to the State Survey Agency. Additionally, the facility did not ensure the results of all investigations were reported to the State Survey Agency within 5 working days of the incident. This was evident for 3 (Resident #126, #136, and #195) of 7 residents reviewed for Abuse out of 36 sampled residents. Specifically, 1.) On 01/13/2024 at approximately 2:30 PM, the facility was made aware that Registered Nurse #3 administered the wrong medication to Resident #126. An initial report was made to the New York State Department of Health on 01/14/2024 at 9:01 AM. A Follow-up Investigation Report was not submitted by the facility within 5 working days of the incident. 2.) On 05/06/2024, Resident #136 had a physical altercation with Resident #195 that was not reported to the New York State Department of Health. The findings include: The facility policy titled Abuse Prohibition dated 12/2023 documented all alleged or suspected incidents of abuse, neglect, or mistreatment will be thoroughly investigated. Any case in which abuse, neglect, or mistreatment has been identified via the investigation will be reported promptly to the New York State Department of Health. A Dear Nursing Home Administrator Letter (DAL: NH 22-20) dated 10/18/2022 regarding Facility Incident Reporting System stated that the notice was to inform the Administrator of changes in reporting of nursing home facility incidents as detailed in QSO-22-19-NH and effective on 10/24/2022. The guidance stated that in addition to an initial facility incident report that must be submitted following reporting timelines, nursing homes must submit to the New York State Department of Health the results of the facility investigation. Within 5 business days of the incident, the facility must provide, in its report, sufficient information to describe the results of the investigation, and must indicate any corrective action(s) taken if the allegation was verified. The facility should include any updates to information provided in the initial report and the following additional information, including, but are not limited to, the following: 1. Additional/Updated information related to the reported incident, 2. Steps taken to investigate the allegation, 3. A conclusion, 4. Corrective action(s) taken, and 5. The name of the facility investigator. 1. Resident #126 had diagnoses of Traumatic Spine Injury with Quadriplegia, prior Opioid Abuse, and Bipolar Disorder. The Minimum Data Set assessment dated [DATE] documented Resident #126 had intact cognition. A Report of Accident / Incident form with date of occurrence 01/13/2024 at 3:00 PM documented that towards the end of the shift, the medication nurse reported they accidentally gave 12 tablets of Percocet 10-325 milligrams to Resident #126 instead of 12 tablets of Methadone 10 milligrams. The facility summary of investigation dated 01/13/2024 documented the incident as medication error. The summary of investigation documented that the medication nurse discovered their own medication error when they were completing the narcotic count. The nurse immediately reported the error to the Registered Nurse Supervisor. Resident #126 was transferred to the hospital to rule out Tylenol toxicity and returned to the facility without signs and symptoms of adverse effects. The summary documented the investigation revealed no evidence of narcotic diversion. A Nursing Home Facility Incident Report documented that the incident report was submitted to the New York State Department of Health on 01/14/2024 at 9:01 AM. During an interview on 05/29/2024 at 2:10 PM, the Director of Nursing stated they completed the investigation of the medication error. The Director of Nursing stated they do not have to report the medication error incident within 2 hours and that they have 5 days to report the incident. They stated it was an error on their part for not complying with the 2 hour time frame for reporting. During an interview on 05/29/2024 at 3:11 PM, the Administrator stated they were not aware that the incident was not reported to the State Agency within the required time frame which was no later than 2 hours. 44864 2. Resident #136 was admitted to the facility with diagnoses of Non-Alzheimer's Dementia, Impulse Disorder, and Hyperlipidemia. The Minimum Data Set assessment dated [DATE] documented Resident #136 had intact cognition and had no behavior symptoms. Resident #195 was admitted to the facility with diagnoses of Alzheimer's Disease and Difficulty Walking. The Minimum Data Set assessment dated [DATE] documented Resident #195 had severely impaired cognition and had no behaviors. A staff statement by a Certified Nursing Assistant dated 05/06/2024 documented that they heard 4 loud bangs on the wall and heard a loud argument coming from Residents #136 and #195's room. Resident #136 had Resident #195 against the wall. Resident #136's both hands were wrapped around Resident #195's shirt, while Resident #195's hand was holding onto Resident #136's shirt. The Certified Nursing Assistant separated the residents. The Accident Investigation Report dated 05/07/2024 documented that on 05/06/2024 at around 10:00 AM, the staff heard shouting and yelling coming from Residents #136 and #195's room. The staff immediately responded and noted Resident #136 was grabbing Resident #195's shirt. Both were separated. Resident #136 continued to curse as they were redirected outside of their room. The facility summary of investigation concluded that abuse had not occurred because the plan of care was followed, and safety interventions were in place. There was no documented evidence that the resident to resident physical abuse involving Resident #136 and Resident #195 that occurred on 05/06/24 was reported to the New York Department of Health. During an interview on 05/28/2024 at 3:43 PM, the Director of Nursing stated the incident was not reported because the residents did not sustain any injury as a result of the altercation. The Director of Nursing stated there was no need to report the incident since there was no harm and the residents were immediately separated. During an interview on 05/29/2024 at 2:37 PM, the Administrator stated they did not feel that there was a need to report the incident because there was no harm on either residents. 10 NYCRR 415.4(b) (2)

Based on observation and interview conducted during the Recertification Survey from 05/21/2024 to 05/29/2024 , the facility did not ensure that the nurse staffing information was posted in a prominent place readily accessible to residents and visitors. Specifically, there was no available posting of daily nurse staffing information. The findings are: The facility did not have a policy on Posting Daily Nurse Staffing Information. During observations conducted on 05/21/2024, 05/22/2024, 05/23/2024, and 05/24/2024, the State Surveyor was unable to locate the postings of the daily nurse staffing levels for each shift or any signage instructing residents or visitors where it was located. On 05/24/2024 at 3:45 PM , the State Surveyor asked the Director of Nursing where the staffing information was located and was shown the staffing schedule for the day. During an interview on 05/24/2024 at 2:45 PM, the Director of Nursing stated they do not have the daily nursing staffing posted and they had no policy for it. They stated they read the guidelines and saw that the daily nursing staffing posting was required and they started posting it. 10 NYCRR 415.13

Based on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure the garbage and refuse were disposed of properly. This was evident during observation of the Kitchen. Specifically, the garbage compactor (GC) was observed open on more than one occasion. The findings are: The facility policy titled GC Area revised 4/2022 documented the garbage compactor door will be closed after each use to prevent pests, cross contamination and to maintain a clean environment. On 04/26/22 at 09:28 AM, the GC used by the Kitchen was observed with its door open. The Food Services Director (FSD) was present during the observation and stated the GC door is functional and able to close. On 04/29/22 at 09:23 AM, a Food Service Worker (FSW) was observed removing an uncovered garbage can from the kitchen by wheeling the can to the GC. FSW threw garbage bags in the GC, turned the GC on, and left the GC door open. On 04/29/22 at 03:24 PM the FSD was interviewed and stated the GC door is not closed after each use because staff use the GC often to dispose of garbage throughout the day. FSD stated the dietary department did not have a policy on garbage disposal because the Director of Environmental Services (DES) managed the garbage disposal area. On 04/29/22 at 03:44 PM the DES was interviewed and stated the GC door stays open throughout the day and the evening shift closes it after the last meal service has been completed. The facility does not have a policy regarding garbage disposal. The DES was unaware the garbage compactor door should remain closed to promote proper garbage disposal. 415.14 (h)

Based on record review and interviews conducted during the Recertification Survey, the facility did not ensure that a resident was invited to participate in comprehensive care planning (CCP). This was evident for 1 of 32 sampled residents (Resident #69). Specifically, Resident #69 was not invited to CCP meetings with the interdisciplinary team (IDT). The findings include: The facility policy titled IDT Care Plan Meetings dated 12/2021 documented that CCP meetings with the IDT will be held initially within 21 days of admission, quarterly, upon significant change and upon request. Residents are invited to attend the IDT meetings. Resident #69 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) 02/25/2022 documented Resident #69 was cognitively intact. On 04/26/22 at 11:06 AM, Resident #69 was interviewed and stated they could not recall the last time they were invited to a CCP meeting with the IDT team. CCP Meeting attendance records documented CCP meetings for Resident #69 were held on 10/12/2021, 12/28/2021, 3/8/2022, and 4/19/2022. There was no documented evidence Resident #69 was invited to or attended scheduled CCP Meetings with the IDT. On 04/28/22 at 12:47 PM, Registered Nurse (RNS) #1 was interviewed and stated residents are verbally invited by any of the Interdisciplinary Team (IDT) members. Resident notification is not documented in the medical record. Social Services keeps attendance of the IDT meetings. RNS #1 was unable to provide documented evidence Resident #69 was invited to CCP meetings. On 04/28/22 at 02:07 PM, the Director of Social Work (DSW) was interviewed and stated residents are invited to their admission, annual, significant changes, and quarterly CCP meetings. The Social Services staff do not document in the medical record when a cognitively intact resident is invited but does not attend. The DSW was unable to provide documented evidence Resident #69 was invited to the CCP meetings. 415.11(c)(2) (i-iii)

Based on observations, record review, and interviews conducted during the Recertification survey, the facility did not ensure infection prevention control practices were maintained. This was evident for 2 of 2 residents reviewed out of a sample of 32 residents (Resident #62 and #69). Specifically, respiratory equipment for Resident #62 and Resident #69 was observed on multiple occasions unprotected, unlabeled, and undated. The findings are: The facility policy titled Oxygen Therapy dated 12/2021 documented oxygen nasal cannulas (NC) and masks must be changed once a week and must be stored in plastic bags when left at bedside. 1) Resident #62 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) dated [DATE] documented the resident had moderate cognitive impairments and required extensive assistance of staff for activities of daily living. On 04/26/22 at 10:37 AM and 04/27/22 at 12:18 PM, Resident #62 was observed in bed with one end of an undated NC attached to an oxygen tank and the other end attached to Resident #62's nose. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 2) Resident #69 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented the Resident #69 was cognitively intact and required extensive assistance of staff for activities of daily living. On 04/26/22 at 11:06 AM, 04/27/22 at 09:18 AM, and 04/28/22 at 09:13 AM, Resident #69 was observed in bed. A Bilevel Positive Airway Pressure ([CONDITION(S)]) machine with uncovered and undated oxygen tubing and mask, and an uncovered IS (incentive spirometer) were on the overbed table. On 04/28/2022 at 09:15 AM, Resident #69 was interviewed and stated they could not recall the last time the oxygen tubing was changed by staff. Sometimes the staff will assist Resident #69 with placing the [CONDITION(S)] mask in a bag, but staff are not consistent with helping. The IS is used according to Physician orders, but staff have not provided a plastic bag or covering for the IS. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 04/28/22 at 10:31 AM, Certified Nursing Assistant (CNA) #1was interviewed and stated nurses administer oxygen to the residents. Resident #69 has the IS on their bedside to use at any time throughout the day. The oxygen mask and the IS are kept on resident's table for use at any time. On 04/28/22 at 12:08 PM, Registered Nurse (RN) #1 was interviewed and stated Resident #69 used the [CONDITION(S)] and IS according to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 04/28/22 at 12:20 PM, the Respiratory Therapist (RT) was interviewed and stated Resident #69 used the [CONDITION(S)] at night and when removed in the morning, the dated oxygen mask and NC tubing must be placed in a plastic bag. On 04/28/22 at 12:39 PM, RN Supervisor (RNS) was interviewed and stated the RT was responsible for ensuring the [CONDITION(S)] is properly stored and dated when removed from Resident #69 in the morning. The RNS makes rounds on the units to ensure resident care equipment is kept in hygienic condition. If the RNS observes an issue with the [CONDITION(S)] mask or tubing, the RT is contacted to change the tubing and mask. Oxygen tubing is supposed to be changed weekly and the RNS stated they unaware oxygen tubing, NC, and mask were undated and exposed for Resident #62 and Resident #69. On 04/29/22 at 12:20 PM, the Director of Nursing (DON) was interviewed and stated oxygen tubing not being used by the resident was dated and stored in a plastic bag to promote infection control. The IS for Resident #69 should not be left uncovered. All oxygen tubing was replaced every Sunday according to facility policy. practices .ng proper protocol regarding infection control. 415.19(a)(b) (1-3)

Based on observations and interviews during the Recertification/Complaint Survey, the facility did not ensure a resident was cared for in a manner that maintained. This was evident for 1 of 1 resident out of a sample of (Resident # 46). Specifically, Resident #46's stomach and gastrostomy tube were left uncovered and exposed to public view. The findings are: The facility's policy titled Abuse Prohibition revised December 2021 documented the staff was respectful of individual dignity. Resident # 46 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #46 was severely cognitively impaired and required extensive assistance for bed mobility and dressing. On 4/26/2022 at 10:08 AM, 4/26/2022 at 3:11 PM, 4/27/2022 at 10:26 AM, 4/27/2022 at 3:04 PM and 4/28/2022 at 12:54 PM, Resident # 46 was observed lying in bed in their room without the privacy curtain drawn. Resident #46's stomach was exposed with gastrostomy tube visible from the hallway. The Comprehensive Care Plan (CCP) related to inappropriate behavior and risk for abuse were initiated 5/2/2018 updated 2/10/2022 documented Resident # 46 will maintain dignity and self-esteem. On 5/2/2022 at 11:38 AM Certified Nursing Assistant (CNA) # 3 was interviewed stated Resident # 46 does not like their stomach to be covered. When CNA #3 covers Resident #46's stomach with a towel, Resident #46 will throw the towel on the floor. The charge nurse has been made are of the Resident #46's behavior. On 5/2/2022 at 11:42 AM Registered Nurse (RN) # 2 was interviewed and stated Resident# 46 is confused and removes the covering of their gastrostomy tube. RN #2 observed the Resident #46's exposed stomach and stated the resident's stomach must be covered to provide privacy and promote dignity. On 5/2/2022 at 1:28 PM, the Director of Nursing (DON) was interviewed and stated the dignity and privacy of Resident #46 must be maintained and Resident #46 may need a private room to address their behavior of removing the gastrostomy tube dressing. 415.5(a)

Based on observation, interview and record review during a recertification survey, the facility did not ensure the dishwasher was functioning properly to sanitize dinnerware and that food was stored under the proper temperatures. Specifically, 1) The facility dishwashing machine was not operating at the proper temperature to ensure proper sanitization of serving plates and utensils; and 2) The walk-in Freezer was not operating at the proper temperature to ensure that frozen foods remain frozen. The findings are: 1) The initial inspection of the kitchen was conducted on 6/6/19 at 9:45 AM. The facility dishwashing machine was inspected while in operation. The final rinse temperature was observed to reach a maximum operating temperature of 162 degrees Fahrenheit. The Food Service Director (FSD) was interviewed on 6/6/19 at 9:45 AM. He stated that he was aware of a problem with the hot water booster since the previous day. He stated that the booster was not operating properly and would fluctuate in operation, at times reaching 180 degrees and at other times not reaching 180 degrees Fahrenheit. He stated the morning dishes were being washed at the time of observation. He also stated that the morning's breakfast dishes were washed in the machine yesterday and utilized this morning despite being aware of an issue with the water booster not reaching 180 degrees Fahrenheit consistently. He stated that the dish washing machine did not utilize a supplemental chemical sanitizing system. The Food Service Director further stated that the repair company was called yesterday and the necessary parts for repair would not be available until the 6/7/19. The work order related to the repair visit on 6/5/19 was reviewed and documented that the hot water booster was checked and that parts would need to be replaced. The work order documented the service technician would be back with parts by 6/8/19. A letter was provided by the facility from the repair company dated 6/6/19, stating that the parts necessary for repair were on order and will be available by 6/7/19. The Food Service Director (FSD) was interviewed at on 6/6/19 at 12:45 PM. He stated that he was aware of the issue with the dishwasher yesterday afternoon and that it was neglectful of him not to use plastic serving utensils immediately instead of cleaning the dishes/utensils in the dishwasher in light of the fact that the dishwasher was not reaching adequate sanitizing temperature. He stated that plastic dishes/utensils would be used until the machine was repaired. A copy of the dishwashing machine operation manual for the AJ-64 Vision Series dishwashing machine documented the minimum rinse temperature needed to be 180 degrees Fahrenheit. The Administrator was interviewed at 2:00 PM on 6/6/19 and he stated he was made aware of the issue with the dishwasher since yesterday afternoon, and he understood that the repair company was called to address the issue. He provided a letter, dated 6/6/19, addressing plans to now use plastic serving supplies until the dishwasher was fixed. On 6/10/19 at 11:12 AM the dishwasher was observed to be operational at 190 degrees in the final rinse cycle. The Food Service Director was present at the time of observation. 2) At 10:00 AM on 6/6/19, the walk-in freezer, accessible from within a walk-in refrigerator unit, was inspected. The gauge of two thermometers situated in the walk-in freezer registered at 10 degrees Fahrenheit (F) at the point of entry and 20 degrees Fahrenheit immediately below the compressor. The temperature log of the freezer for the month of (MONTH) and (MONTH) 2019 was reviewed. The temperature log documented -6 Fahrenheit on all days but (MONTH) 31st when it was recorded to be -5 degrees Fahrenheit. The Food Service Director (FSD) was interviewed on 6/6/19 at 10:00 AM. He stated that the temperature of the freezer should be at 0 or below. He further stated that it was not unusual for the temperature to rise to the temperatures observed because of its thawing cycle every day at 10:00 AM. Following review of the temperature logs, the FSD stated that he was aware of the above temperatures, but no action was taken because the food was frozen solid. The log did not instruct the dietary staff members what to do if the temperature was not within the acceptable range. The dietary staff who recorded the temperatures was interviewed on the morning of 6/7/19 at 11:30 AM and stated that he records the temperature every morning at 5:00 AM. He stated that it was not unusual for the freezer to change sometimes because it goes into a thawing cycle. A review of service records for the freezer revealed that refrigerant was added to the compressor unit on 6/22/18. The refrigeration service was called by the facility and 3 pounds of refrigerant was added to the freezer unit again on 6/7/19. 415.14(h)

Based on observation, record review and interviews during the recertification survey, the facility did not ensure that each resident who displays or is diagnosed with [REDACTED]. This was identified for 7 (Resident #38, #72, #64, #154, #177, #111 and #454) of 7 residents reviewed for Dementia care. Specifically, the facility did not develop person-centered care plans to reflect individualized approaches to care with measurable goals, timetables, and specific interventions, nor identify effective non-pharmacologic interventions to maintain the highest psychosocial wellbeing for these residents. Additionally, an intervention to provide Russian speaking staff to interpret the needs and wants was in place for residents who did not speak Russian (Resident #38, #72, and #64). The findings include but are not limited to: 1) Resident #38 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #38 could not complete the Brief Interview for Mental Status (BIMS) assessment. The language portion of Section A in the MDS documented that Resident #64's preferred language was Spanish. The MDS documented that Resident #38 received Antipsychotic and Antidepressant Medication 7 out 7 days in the MDS review period. The Comprehensive Care Plan (CCP) for Potential for exhibiting inappropriate behavior and signs and symptoms of Depression related to Dementia with Behavioral Disturbances dated 3/6/2018 documented a goal that Resident #38 will not show altered behavior daily in 3 months as evidenced by agitation, altercation with another resident, Activities of Daily Living (ADL) refusals, verbal/physical aggression, restlessness and delusional episodes. The interventions did not specify what diversional activities would be appropriate for Resident #38. Additionally, the interventions included providing Resident #38 with Russian speaking staff to interpret needs and wants, although the resident speaks Spanish. Resident #38 was observed sitting by the elevator attempting to wheel off the unit on 6/6/19 at 11:53 AM. Resident #38 was speaking Spanish and was asking to see her father and stated that he was waiting for her to have lunch outside. The Registered Nurse (RN #1) called for a translator. RN #1 stated that she did not speak Spanish and could not understand what Resident #38 was saying. At 11:56 AM on 6/6/19, a staff member who spoke Spanish came to the unit and attempted to redirect Resident #38 to the dining room. The staff member repeatedly told Resident #38 that she could not leave and had to go to the dining room for lunch and proceeded to wheel her to the dining room. Resident responded by yelling louder that she had to go to her home. The Psychiatrist was interviewed on 6/12/19 at 1:47 PM. The Psychiatrist stated the nursing staff should document all the non-pharmacologic interventions attempted prior to involving Psychiatry. The Psychiatrist stated that he does not know what specific non-pharmacologic interventions the staff attempted with Resident #38. He further stated that the nursing staff have a general list of non-pharmacologic interventions to try prior to administering pharmacologic interventions. RN #1 from 7 AM-3 PM shift was interviewed on 6/12/19 at 1:54 PM. RN #1 stated the nurses request Psychiatry interventions when residents do not respond to the general interventions outlined in the care plan for Dementia Care. The RN stated the interventions on the care plan are generalized to all residents with the Dementia [DIAGNOSES REDACTED]. The attempted interventions are usually documented in the evaluation notes and in the progress notes. RN #1 stated that she generally applies the interventions of redirection, anticipation of needs, and involvement in recreation groups for Resident #38. RN #1 stated that she did not know what the underlying causes for Resident #38's behaviors were. 2) Resident #72 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #72 had a BIMS Score of 11 indicating moderately impaired cognition. The language portion of Section A in the MDS documented that Resident #72 did not need an interpreter and did not specify a preferred language. The CCP for Potential for exhibiting inappropriate behavior and signs and symptoms of Depression related to Dementia with Behavioral Disturbances dated 12/28/2017 documented a goal that Resident #64 will not show altered behavior daily in 3 months as evidenced by agitation, altercation with another resident, Activities of Daily Living (ADL) refusals, verbal/physical aggression, restlessness and delusional episodes. The interventions were not individualized and specific to address targeted behaviors. The interventions included providing Resident #72 with Russian speaking staff to interpret needs and wants. Resident #72 was interviewed on 6/6/19 at 11:32 AM and began crying when being interviewed. The interview was concluded. RN #1 was interviewed on 6/11/19 at 12:01 PM. She stated that Resident #72 is often confused and references past events. RN #1 stated that Resident #72's primary language is English. 3) Resident #64 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #64 could not be understood and could not complete the Brief Interview for Mental Status (BIMS) assessment The language portion of Section A in the MDS documented that Resident #64's preferred language was Spanish. The CCP for Potential for exhibiting inappropriate behavior and signs and symptoms of Depression related to Dementia with Behavioral Disturbances dated 11/28/2017 documented a goal that Resident #64 will not show altered behavior daily in 3 months as evidenced by agitation, altercation with another resident, Activities of Daily Living (ADL) Refusals, verbal/physical aggression, restlessness and delusional episodes. The interventions were not individualized and specific to address targeted behaviors. Additionally, the interventions included providing Resident #64 with Russian speaking staff to interpret needs and wants. Resident #64 was observed watching television in her bed as she was receiving a tube feeding on 6/6/19 at 9:45 AM. The MDS Coordinator was interviewed on 6/12/19 at 1:02 PM. The MDS Coordinator stated she oversees the development of care plans at the facility and that all residents with a Dementia [DIAGNOSES REDACTED]. She further stated that interventions are decided upon as behaviors occur episodically. The specific interventions applied for the residents should be documented in the evaluation notes. The care plan is developed to address the [DIAGNOSES REDACTED]. The team conducts an ad hoc (impromptu) meeting to discuss ways to address behaviors after they occur. The MDS Coordinator stated that the meetings should be documented in the evaluation notes. The MDS Coordinator reviewed the evaluation notes for Resident #38. She stated that on 5/9/2018 it was documented that staff continue to provide redirection such as offering snacks, toileting needs, check for manifestations of pain or discomfort, hunger or thirst. The notes further documented that Resident #38 is encouraged to attend recreational activities. On 8/1/18, 10/10/18, 1/2/2019 and 3/20/2019 it was documented the resident had continued verbal disruption, yelling, screaming and non-stop incoherent monologue despite encouragement and redirection by staff. The MDS Coordinator stated that the evaluation notes documented that the goals and plan of care continues quarterly and explained that the care plans are continued because they are not specific to the individual. The MDS Coordinator read the care plans for Resident #38, #72 and #64 and stated that they each contained an intervention to provide the resident with Russian Speaking staff to interpret needs and wants. The MDS Coordinator stated that Resident #38 speaks Spanish, Resident #72 speaks English, and Resident #64's native language is Spanish. The MDS Coordinator stated the 6th floor of the facility has predominately Russian Speaking residents and the intervention on the CCP was added to address the language barrier on the 6th floor. The MDS Coordinator stated Resident #38 and #72 live on the 4th floor and Resident #64 lives on the 3rd floor so it is not applicable to them. 415.12

Based on observations, record review, and interviews during the recertification survey, the facility did not ensure that each resident receive reasonable accommodation of needs by ensuring each resident's call bell was within reach. This was identified for 9 (Residents #160, #20, #68, #108, #175, #40, #195, #155, and #165) of 38 sampled residents. Specifically, 1) The call bell for Residents #160, #20, #68, and #108 was observed with the wire of the call bell wound, tied, and hung on the wall near the head of bed (HOB). 2) Resident #175 was observed with his call bell placed on top of the overhead lighting fixture above the HOB. 3) The call bell for Residents #155, #195, #40, and #165 was observed on the floor. The findings include but are not limited to: The facility's policy and procedure dated 10/2018 titled Use of Call [NAME]s documented . 1. Explain use of call bell and place within easy reach . 1) Resident #160 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 9 indicating the resident was moderately impaired in cognition. The MDS documented no impairment in functional range of motion of both upper and lower extremities. On 6/6/19 at 9:20 AM and at 10:45 AM, the resident's call bell was observed wound, tied, and hung on the wall near the head of bed (HOB). An interview with CNA #1 was conducted on 6/6/19 at 10:50 AM. CNA#1 stated the resident could use her call bell and that the call bell should be clipped at the resident's bedside so she could reach the call bell. CNA #1 stated that the call bell should not be hanging on the wall. An interview with the Unit RN Manager was conducted on 6/6/19 at 10:53 AM. The RN stated the resident is able to use the call bell and the call bell should be placed at her bedside, not hanging on the wall. 2) Resident # 175 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Quarterly MDS assessment dated [DATE] documented the resident's BIMS score was 8 indicating the resident was moderately impaired in cognition for daily decision making. The MDS documented no impairment in functional range of motion of both upper and lower extremities. On 6/6/19 at 9:23 AM and at 10:55 AM, the resident's call bell was observed placed up on top of the overhead light fixture above the HOB. An interview with CNA #1 was conducted on 6/6/19 at 10:48 AM. CNA#1 stated the resident could use his call bell and that the call bell should be clipped at the resident's bedside so he could reach the call bell. CNA #1 stated that the call bell should not be placed on top of the light fixture. An interview with the Unit RN Manager was conducted on 6/6/19 at 10:52 AM. The RN stated that the resident is able to use the call bell and the call bell should be placed at his bedside, not on top of the overhead light fixture. 3) Resident #155 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Admission MDS assessment dated [DATE] documented the resident's BIMS score was 12 indicating the resident was moderately impaired in daily decision making. The MDS documented no impairment in functional range of motion of both upper and lower extremities. On 6/6/19 at 9:22 AM and at 10:35 AM, the resident's call bell was observed on the floor, out of reach of the resident. An interview with CNA #1 was conducted on 6/6/19 at 10:50 AM. CNA#1 stated that the resident could use her call bell and the call bell should be clipped at the resident's bedside so she could reach the call bell. An interview with the Unit RN Manager was conducted on 6/6/19 at 10:52 AM. The RN stated the resident is able to use the call bell and the call bell should be placed at her bedside. 415.5(e)(1)

Based on observation, record review, and interviews during the recertification survey, the facility did not implement a comprehensive person-centered care plan for each resident. This was identified for 1 (Resident # 64) of 1 resident reviewed for Range of Motion (ROM). Specifically, Resident # 64's Comprehensive Care Plan (CCP) developed for the Development of the Functional Limitation in ROM included an intervention to use an Abductor pillow. The Physician ordered Abductor pillow was not observed in place on two separate occasions. The finding is: The Facility's Comprehensive Care Plan (CCP) policy dated 2/2018 documented that the Care Plan guides the care and treatment provided to each resident. The CCP addresses the resident's medical, functional, and severity of the resident's condition. Resident #64 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #64 could not be understood and could not complete the Brief Interview for Mental Status (BIMS). The MDS documented Resident #64 was totally dependent on two people for Bed Mobility, Transfer, Personal Hygiene and Toilet Use. The MDS also documented Resident #64 had impairment in functional range of motion on both sides of the upper and lower extremities. The At Risk for Development of Functional Limitation in Range in Motion CCP dated 3/19/19 documented a goal that Resident #64 will not develop further functional limitation in ROM for 3 months. The interventions included Therapeutic Devices, including an abductor pillow to be worn in and out of bed to prevent abduction/scissoring of the lower extremities. The physician's orders [REDACTED].#64 required the use of an abductor pillow in and out of bed to prevent abduction/scissoring of the Lower Extremities. Resident #64 was observed resting in bed on 6/6/19 at 9:45 AM without an abductor pillow in place. The abductor pillow was observed on the chair by the bedroom window. Resident #64 was also observed on 6/10/19 at 10:46 AM in bed without abductor pillow in place. The abductor pillow was observed on the nightstand on the right side of the bed. The daytime Certified Nursing Assistant (CNA) from the 7 AM-3 PM shift was interviewed on 6/12/19 at 12:29 PM. The CNA stated Resident #64 does not use the abductor pillow in the bed. She stated the physician order [REDACTED].#64 is out of the bed. The CNA further stated that she regularly sees Resident #64 in bed without the abductor pillow when she arrives to work on the 7 AM-3 PM shift. The CNA reviewed the CNA Accountability Record and stated the instruction was that the abductor pillow was to be worn in and out of bed. The RN Supervisor for the 7 AM-3 PM shift was interviewed on 6/12/19 at 12:32 PM. The RN Supervisor stated the physician order [REDACTED].#64 is out of bed. The RN Supervisor stated that she thought the abductor pillow was important to help prevent scissoring and contracture development of the legs. The RN Supervisor reviewed the medical record and stated that the physician order [REDACTED]. The Physical Therapist (PT) was interviewed on 6/12/19 at 2:37 PM. The PT stated that Resident #64 requires the abductor pillow in place at all times except when performing hygiene and care. Resident #64 has muscle tone tightness in her legs which puts her at risk for permanent scissoring of the legs, worsening contractures, poor positioning in her chair and bed, and difficulty performing hygiene care. The abductor pillow places Residents #64 legs into a resting position and prevents complications from muscle tone tightness. The evening CNA (3 PM - 11 PM shift) was interviewed on 6/12/19 at 3:15 PM. The CNA stated that she is not the regular evening CNA for Resident #64 and she is a floating CNA at the facility. She stated that she was just told today during the shift rotation that Resident #64 requires the abductor pillow in place 24 hrs and that she did not provide care for Resident #64 from 6/6/19 to 6/11/2019. 415.11(c)(1)

Based on record reviews and staff interviews during the recertification survey, the facility did not ensure that medical records were maintained in accordance with accepted professional standards and practices that are complete and accurately documented. This was identified for 1 (Resident #40) of 3 residents reviewed for anticoagulant medication and 1 (Resident #155) of 3 residents reviewed for advance directives a total of 38 sampled residents. Specifically, 1) Resident #40 has a physician's orders [REDACTED]. The physician's orders [REDACTED]. 2) Resident #155 had a) physician's orders [REDACTED]. Additionally, Comprehensive Care Plans were developed for both Occupational and Physical Therapy. b) The nurse did not document she notified the Physician of the resident's diastolic blood pressure level of 49 as indicated in the physician's orders [REDACTED].>The findings are: The facility's policy and procedure dated 8/28/18 titled Administration of a [MEDICATION NAME] Injection documented . 9. Administer [MEDICATION NAME] subcutaneously . 1) Resident #40 has [DIAGNOSES REDACTED]. The resident was re-admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 11 indicating the resident was moderately impaired in cognition. The MDS documented the resident received 7 days of injections of any type and 7 days of anticoagulant medication during the last 7 days of the MDS review period. The physician's orders [REDACTED]. The Comprehensive Care Plan (CCP) developed for potential bleeding dated 3/20/19 documented to rotate injection site and to administer medications as ordered. The Medication Administration Record [REDACTED]. The physician's orders [REDACTED]. An interview with the Unit Medication Registered Nurse (RN) was conducted on 6/12/19 at 8:30 AM. The RN stated the [MEDICATION NAME] injections were given via subcutaneous injection. An interview with the Director of Nursing Services (DNS) was conducted on 6/12/19 at 8:40 AM. The DNS stated that the [MEDICATION NAME] order should document that [MEDICATION NAME] was to be administered subcutaneously. 2a) Resident #155 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. The Admission MDS assessment dated [DATE] documented the resident's BIMS score of 12 indicating the resident had moderately impaired cognition for daily decision making. The physician's orders [REDACTED]. The physician's orders [REDACTED]. An interview with the DNS was conducted on 6/13/19 at 9:04 AM. The DNS stated the 5/6/19 order for PT/OT was an error. It should have been for a screening by the OT/PT department. The DNS stated that the MDS Nurse created the CCP in error. An interview with the MDS Nurse was conducted on 6/13/19 at 9:27 AM. The MDS Nurse stated the CCP she developed for rehabilitation treatment was an error. An interview with the Director of Rehabilitation Department was conducted on 6/13/19 at 9:33 AM. The Director stated the resident was automatically screened by PT/OT upon admission and he recommended to continue rehabilitation nursing program twice daily as tolerated. 2b) The physician's orders [REDACTED]. Review of the MAR for (MONTH) 2019 documented that on 6/1/19 at 5:00PM, the resident's blood pressure was 113/49. Losartan was held. There was no documented evidence in the medical record that the Physician was notified of the low diastolic blood pressure level. An interview with the RN Medication Nurse was conducted on 6/12/19 at 11:00 AM. The RN stated that he forgot to document that he informed the physician. He stated that there were no new orders by the Physician. He stated he withheld Losartan as ordered. 415.22(a)(1-4)

Based on observation, record review, and staff and resident interviews during the Recertification Survey the facility did not develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. This was identified for 1 of 3 residents reviewed for the Communication-Sensory care area. Specifically, Resident #110 was assessed to have difficulty with hearing; however, a person-centered care plan with the resident's input was not developed to specifically address whether the resident requested to be referred to an Audiologist or could benefit from an Audiologist referral. The finding is: The facility's policy titled Consultations, dated May 2014, documented that all consultations are ordered for a resident as deemed necessary by the attending physician. Resident #110 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 11/27/2017 Quarterly Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 10, indicating the resident had moderate cognitive impairment. The MDS documented the resident had minimal difficulty hearing in some environments and that there was no hearing aid used. A Comprehensive Care Plan (CCP) dated 10/11/2017 and titled, Alteration in Ability to be Understood and to Understand, documented that the resident had minimal difficulty in hearing. Interventions included maintain eye contact, use short, simple language, stand where resident can visualize your face, speak slowly and clearly, and speech evaluation as needed. There were no interventions regarding evaluation by Audiology and whether the resident should be assessed for a hearing aid. Resident #110 was interviewed on 1/22/2018 at 10:15 AM. The resident was observed to be hard-of-hearing (HOH) in his left ear. There was no hearing aid in place. The resident had to turn his head so that his right ear was closer to the surveyor, and the resident often asked for words to be repeated. The resident said that he had not been evaluated for a hearing aid. The resident stated that he would be interested if a hearing aid could benefit him. Resident #110's Certified Nursing Assistant (CNA) was interviewed on 1/24/2018 at 2:07 PM. She stated that the resident does not have a hearing aid. She stated, He always says I do not hear you. The Registered Nurse (RN) Unit Supervisor was interviewed on 1/25/2018 at 10:04 AM and stated that an Audiology consult was not recommended by the Physician because the resident does not have any problem communicating. The RN MDS Director was interviewed on 1/25/18 at 12:04 PM. She stated that the MDS coordinators develop the care plans. She stated that this resident's hearing deficit is addressed in the Alteration in Ability to be Understood and to Understand care plan through the documented interventions. She further stated audiology was not in the care plan because the resident did not have any problem communicating, so there was no need for audiology. The Attending Physician was interviewed on 1/25/2018 at 12:28 PM and stated that as long as you stand in front of him you can have a normal conversation with him. He stated that the hearing loss did not affect his care, so audiology was not considered. The Director of Nursing Services (DNS) was interviewed on 1/26/2018 at 12:04 PM. She stated that if the need arises that he needs a hearing aid, it will be reflected in the care plan. Resident #110's Social Worker (SW) was interviewed on 1/26/2018 at 1:00 PM. She stated that she had just spoken to the resident and the resident expressed interest in getting a hearing aid if it would benefit him. The SW said that the Physician will be contacted to get an order for [REDACTED].>415.11(c)(1)

Based on record review and staff interview during the recertification survey, the facility did not ensure that Accident/Incident (A/I) Reports were thoroughly investigated to rule out neglect. Specifically, Resident #142 was assessed for being at risk for falls, had multiple falls, and was found on the floor with no documentation if the resident used the call bell or had the call bell in reach to request for help. The finding is: Resident #142 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident with a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. The resident required limited assistance of 1 staff member to transfer out of bed, was non-ambulatory and required extensive assistance of 1 person for dressing and hygiene. Under section G0300-A Moving from seating to standing position- the resident was not steady and was only able to stabilize with staff assistance. The resident was always continent of bowel and bladder. The MDS also documented the resident had two or more falls without injuries since the last assessment. The 9/28/17 Comprehensive Care Plan (CCP) interventions included keep call bell and frequently used items within easy reach and remind resident to request for assistance at all times. On 11/13/2017 at 7:18 AM, a nurse's note, written by the RN Supervisor, documented that at 6:55 AM she was notified by a CNA (Certified Nursing Assistant) that the resident was on the floor sitting on the right side of the bed. On arrival to unit resident is settled in bed alert, responsive to verbal commands. The resident mouthed she was okay, refusing to give details of what happened and shaking her head. The A/I dated 11/13/17 did not have documented evidence if an investigation was conducted to determine whether a call bell was within reach and/or if a call bell was used by the resident prior to the incident to request assistance. On 1/26/18 at 3:08 PM, the RN MDS Coordinator was interviewed and stated that the resident has a behavior problem and this is reflected in the MDS and the CCP. The resident is non-compliant and reminded to use the call bell. The RN further stated that all incidents should determine if the call bell was in reach and if the call bell was used. On 1/26/18 at 3:12 PM the Assistant Director of Nursing (ADNS) was interviewed and stated there should have been documentation and an investigation to determine if the resident used the call bell prior to the fall. On 01/26/18 at 3:34 PM the RN Supervisor was interviewed and stated the incident should have documented and investigated whether the call bell was used and whether it was in reach. 415.4(b)(1)(ii)

Based on record review and interviews during the recertification survey, the facility did not provide a quarterly statement in writing to the resident's representative. This was evident for one resident reviewed for Resident Finances. Specifically, Resident #151's representative was unaware that the resident had a personal account, was unaware of the balance and had never received a quarterly Financial Statement. The finding is: Resident #151 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had severely impaired cognition. During the interview with the resident's responsible party on 1/23/18 at 10:15 AM the resident's representative was not aware of the resident's personal funds balance. In addition, the representative stated that Financial Statements were never received. A review of Resident #151's Financial Statement revealed that the resident had a current personal account balance. The Business Office Assistant (BOA) who is responsible for providing the Financial Statements to the residents and/or representatives was interviewed on 1/23/18 at 2:40 PM. The BOA stated that Resident #151's Financial Statement had been given to the Recreation Director who is responsible to deliver the statements to all the facility's residents. The BOA stated that the Recreation Director returns statements to him for mailing to the representatives when the residents are not able to understand the statements. The BOA stated that he had no recall if he mailed statements to Resident #151's representative and he does not maintain a log book to keep track of who he sends Financial Statements to. The Recreation Director was interviewed on 01/26/18 at 2:12 PM and stated that Financial Statements are given to her from the BOA and then she delivers them to the residents. The RD stated that when it is not appropriate to leave the statements with the resident, she hands those statements back to the BOA. The Recreation Director stated that she had no recall about returning Resident #151's Financial Statement to the BOA for mailing. 415.26(h)(5)(i)

Based on observation and staff interview during the recertification survey the facility did not ensure that resident care equipment was clean and in good repair on 3 out of 5 nursing units. Specifically, there were wheelchairs that had torn arm rests and seat backs on the 3rd floor and 6th floor, there was a soiled wheelchair on the 6th floor, and there was a geri-chair with various tears on the 2nd floor. The findings are: On 11/3/2015 at 9:15 AM Resident #192's (2nd floor) geri-chair was observed to have various tears in different locations. On 11/5/2015 at 9:45 AM Resident #132's (3rd floor) wheelchair was observed to have a torn right arm rest. On 11/6/2015 at 11:10 AM Resident #79's (6th floor) wheelchair was observed to have tears to both arm rests. On 11/6/2015 at 11:15 AM Resident #17's (6th floor) wheelchair was observed to be soiled, especially the wheels and foot rests. On 11/9/2015 at 10:20 AM Resident #67's (3rd floor) wheelchair was observed to have a torn left arm rest and torn seat back. On 11/9/2015 at 10:50 AM the Registered Nurse (RN) Rehabilitation (rehab) Supervisor was interviewed regarding wheelchair maintenance. He stated that the rehab department does rounds with maintenance on a daily basis on each unit to identify needed repairs and that wheelchair cleaning takes place on Tuesday and Thursday nights. Repairs and cleaning are also done on an as needed basis after a problem is reported by the nursing staff. On 11/9/2015 at 11 AM Resident #132's and Resident 67's (3rd floor) wheelchairs were observed by the RN unit supervisor. She stated she would call maintenance. On 11/9/2015 at 11:05 AM Resident #192's (2nd floor) torn geri-chair was observed by the RN unit supervisor. She stated that new geri-chairs have been ordered. On 11/9/2015 at 11:10 AM resident #79's and resident #17's wheelchairs were observed by the MDS RN. She stated that she would report the wheelchairs to maintenance. On 11/9/2015 at 11:35 AM the RN rehab supervisor stated that all of the torn wheelchair arm rests have been replaced, a new wheelchair is being ordered for Resident #67, and the wheelchair for Resident #17 will be cleaned. The facility's policy on Wheel Chair Maintenance, dated 1/2013, states that all wheelchairs are checked quarterly for damage and adjustments to ensure that residents have a safe, clean wheelchair for their use. 415.5(h)(2)

Based on record review, staff and resident interview during the recertification survey, the facility did not provide notification of a change in the resident's medication regime to an alert and oriented resident. This was evident for one of six residents reviewed for Unnecessary Drugs in a total Stage 2 sample of 33 residents. Specifically, there was no documented evidence that Resident # 169 was notified or aware of the psychoactive medications that were being administered and included in the medication regime. The finding is: Resident # 169 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE] status [REDACTED]. The follow up Psychiatric Consultation dated 6/25/15 documented to start [MEDICATION NAME] XL (an antidepressant medication) for [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented that the resident has a Brief Interview for Mental Status (BIMS) Score of 15, indicating that the resident is cognitively intact. The resident always understands and is always understood. The MDS also documented that the resident had no symptoms of Depression. On 11/9/15 at 9:15 AM the resident stated that he had been put on an Antidepressant medication without notification that it had been ordered for him. In addition, the resident stated that he had noticed that there was new medication being administered to him and when he asked the nurse what it was he was told about the addition of the antidepressant medication. The resident stated that he was refusing the medication. Review of the Nursing Notes and [MEDICAL CONDITION] Drug Care Plan did not document the 6/25/15 Psychiatric Consultation and the addition of the antidepressant. There was no documentation that the the resident had been notified. The Psychiatrist/MD was interviewed on 11/09/2015 at 12:20 PM. The Psychiatrist stated that any medication recommendations would have been discussed with the resident, however, he was told by the resident that he was not depressed and did not want any medication. The Registered Nurse/Supervisor (RN) was interviewed on 11/9/15 at 12:30 PM. The RN stated that it was the responsibility of the physician to discuss any medication orders with the resident. The RN also stated that the Psychiatrists consult and the notification to the resident or family should have been documented in the Nurse's Note and updated on the plan of care. 415.3(e)(2)(ii)(c)