Every finding on record at Rockville Skilled Nursing & Rehabilitation Center,

Based on observation, record review, and interviews during the Recertification Survey initiated on 6/23/2025 and completed on 6/27/2025, the facility did not ensure services provided or arranged by the facility, as outlined by the comprehensive care plan, met professional standards of quality. This was identified for one (Resident #58) of four residents observed during Medication Administration. Specifically, Resident #58 had a Physician's order for 150 milligrams of Topiramate (a medication to treat migraine headaches) daily. From 6/4/2024 to 6/25/2024, multiple medication nurses did not ensure the resident received the correct dosage of Topiramate 150 milligrams. Multiple nurses administered 100 milligrams and inaccurately documented that they administered 150 milligrams of Topiramate, 1.5 tablets. The finding is: The facility's policy titled Medication Administration and Documentation-General, dated 1/2024, documented that medication administration and documentation shall occur in a timely and accurate manner. The nurse assesses all medications that are due for administration at the assigned hour according to the electronic medication administration record. The nurse assures the 5 rights: Compares the medication name, strength, route, and dosage schedule on the medication administration record against the prescription label. Resident #58 was admitted with diagnoses including Migraine Headaches, Anxiety Disorder, and Displaced Bimalleolar Fracture (an ankle injury where both parts of the ankle bone are fractured and shifted out of normal alignment). The 6/6/2025 admission Minimum Data Set assessment documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. A Physician's order dated 6/3/2025 at 2:48 PM documented Topiramate Tablet 100 milligram, give one tablet by mouth one time a day for Migraines. This order was discontinued on 6/3/2025 at 3:40 PM. A Physician's order dated 6/3/2025 at 3:40 PM documented Topiramate 100 milligram tablet, give 1.5 tablets (150 milligrams) by mouth one time a day for headaches. During a Medication Pass observation on 6/24/2025 at 9:16 AM, Licensed Practical Nurse #1 prepared medications to be administered to Resident #58. Licensed Practical Nurse #1 stated they were not regularly assigned to Resident #58's unit and had not administered medications to Resident #58 before today. Licensed Practical Nurse #1 retrieved a medication blister from the medication cart and stated the blister pack label read, Topiramate 100 milligram tablet, give one tablet by mouth one time a day for Migraines. The date on the blister pack was 6/3/2025 [date delivered from the pharmacy]. Licensed Practical Nurse #1 stated the tablets in the blister pack were not scored (which refers to a pill or tablet that has a line or indentation on its surface to facilitate splitting the tablet into smaller doses), and therefore, they could not administer the 1.5 tablets per the current Physician's order. Licensed Practical Nurse #1 stated they were not sure how the previous medication nurses were providing the 1.5 tablets of Topiramate as per the physician's order and would refer this matter to their supervisor. Licensed Practical Nurse #1 was unable to find the blister pack for Topiramate 1.5 tablets (150 milligrams). During an interview on 6/24/2025 at 9:25 AM, Resident #58 stated that at home, they were taking Topiramate 150 milligrams for migraine headaches. Resident #58 stated they did not know how much Topiramate they were getting at the facility. During an interview on 6/24/2025 at 10:57 AM, Pharmacist #1 stated the pharmacy delivered Topiramate 100 milligrams blister pack to the facility on 6/3/2025. Another Topiramate order for Topiramate 150 milligrams, 1.5 tablets was received about an hour after the original order on 6/3/2025; however, the pharmacy did not fill the order for Topiramate 150 milligrams, 1.5 tablets. Review of the June 2025 Medication Administration Record revealed that from 6/4/2024 until 6/23/2024, the medication administration nurses documented that they had administered Topiramate 150 milligrams (1.5 tablets) to the resident. A new physician order dated 6/24/2024 at 9:37 AM documented Topamax (Topiramate) 100 milligram tablet, give one tablet by mouth, one time only, for migraines until 6/24/2025 at 3:59 PM. During an interview on 6/24/2025 at 2:38 PM, Licensed Practical Nurse #2 (who had administered one tablet of the 100 milligram Topiramate but signed the medication administration record 14 times, indicating they administered 150 milligrams, 1.5 tablets) stated, I just gave one tablet of the Topiramate. I do not recall seeing the order for the 1.5 tablets. During a re-interview on 6/24/2025 at 3:00 PM, Pharmacist #1 stated the pharmacy should have dispensed the 1.5 tablet Topiramate order (150 milligram); the order was mis-assessed by the pharmacy's billing department. The pharmacy only sent the 100-milligram dose; this was an oversight. Pharmacist #1 further stated that the facility staff did not call to inquire why the Topiramate 1.5 tablet, 150 milligram order was not delivered by the pharmacy. During an interview on 6/25/2025 at 10:58 AM, Licensed Practical Nurse #3 (who had administered one tablet of the 100 milligram Topiramate but signed the medication administration record two times that they administered 1.5 tablets) stated, I do not recall the medication pass for this resident [#58]. During an interview on 6/25/2025 at 1:15 PM, the Director of Nursing Services stated that the medication nurses made a medication error by giving the wrong dosage of Topiramate to Resident #58. Nurses are supposed to check the Physician's orders against the blister pack to ensure correct medication and dose are being administered to the resident. The Director of Nursing Services stated they initiated a medication error investigation, and the pharmacy would also be checking all facility orders for medication errors. The Director of Nursing Services stated the nurses should have followed up with the pharmacy to inquire why the Topiramate 1.5 tablet (150 milligram) order was not delivered to the facility. [10 NYCRR 415.11 (C)(3)(i)]

Based on observation, record review, and interviews during the Recertification Survey initiated on 6/23/2025 and completed on 6/27/2025, the facility did not ensure it provided pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. This was identified for one (Resident #58 of four residents reviewed for Medication Administration. Specifically, on 6/3/2024, Resident #58 had a new Physician's order for Topiramate 100 milligram tablet, give 1.5 tablet (for 150 milligrams) one time a day for a diagnosis of headaches. During the medication pass observation on 6/24/2024, it was revealed that the Topiramate 1.5 tablet (150 milligrams) order was never delivered by the pharmacy, and the resident continued to receive the discontinued dose of 100 milligrams of Topiramate for approximately 20 days. The finding is: The facility policy titled Provider Pharmacy Requirements, dated 8/2020, documented that regular and reliable pharmaceutical service is available to provide residents with prescription and non-prescription medications, services, and related equipment and supplies. The provider pharmacy agrees to perform all of, but not only, the following pharmaceutical services: Accurately dispensing prescriptions based on authorized prescriber orders. Resident #58 was admitted with diagnoses including Migraine Headaches, Anxiety Disorder, and Displaced Bimalleolar Fracture (an ankle injury where both parts of the ankle bone are fractured and shifted out of normal alignment). The 6/6/2025 admission Minimum Data Set assessment documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. A Physician's order dated 6/3/2025 at 2:48 PM documented Topiramate Tablet 100 milligram, give one tablet by mouth one time a day for Migraines. This order was discontinued on 6/3/2025 at 3:40 PM. A Physician's order dated 6/3/2025 at 3:40 PM documented Topiramate 100 milligram tablet, give 1.5 tablets (150 mg) by mouth one time a day for headaches. During a Medication Pass observation on 6/24/2025 at 9:16 AM, Licensed Practical Nurse #1 prepared medications to be administered to Resident #58. Licensed Practical Nurse #1 stated they were not regularly assigned to Resident #58's unit and had not administered medications to Resident #58 before today. Licensed Practical Nurse #1 retrieved a medication blister from the medication cart and stated the blister pack label read, Topiramate 100 milligram tablet, give one tablet by mouth one time a day for Migraines. The date on the blister pack was 6/3/2025 [date delivered from the pharmacy]. Licensed Practical Nurse #1 stated the tablets in the blister pack were not scored (which refers to a pill or tablet that has a line or indentation on its surface to facilitate splitting the tablet into smaller doses), and therefore, they could not administer the 1.5 tablets per the current Physician's order. Licensed Practical Nurse #1 stated they were not sure how the previous medication nurses were providing the 1.5 tablets of Topiramate as per the physician's order and would refer this matter to their supervisor. Licensed Practical Nurse #1 was unable to find the blister pack for Topiramate 1.5 tablets (150 milligrams). During an interview on 6/24/2025 at 9:25 AM, Resident #58 stated that at home, they were taking Topiramate 150 milligrams for migraine headaches. Resident #58 stated they did not know how much Topiramate they were getting at the facility. During an interview on 6/24/2025 at 10:57 AM, Pharmacist #1 stated the pharmacy delivered Topiramate 100 milligrams blister pack to the facility on 6/3/2025. Another Topiramate order for Topiramate 150 milligrams, 1.5 tablets was received about an hour after the original order on 6/3/2025; however, the pharmacy did not fill the order for Topiramate 150 milligrams, 1.5 tablets. Review of the June 2025 Medication Administration Record revealed that from 6/4/2024 to 6/23/2024, the medication administration nurses documented that they had administered Topiramate 150 milligrams (1.5 tablets) to the resident. During a re-interview on 6/24/2025 at 3:00 PM, Pharmacist #1 stated the pharmacy should have dispensed the 1.5 tablet Topiramate order (150 milligram); the order was mis-assessed by the pharmacy's billing department. The pharmacy only sent the 100-milligram dose; this was an oversight. Pharmacist #1 further stated that the facility staff did not call to inquire why the Topiramate 1.5 tablet, 150 milligram order was not delivered by the pharmacy. During an interview on 6/25/2025 at 1:15 PM, the Director of Nursing Services stated the pharmacy delivered the original order of Topiramate 100 milligram tablets, but did not deliver the new order for Topiramate 1.5 tablets (150 milligrams) that was also ordered on 6/3/2025. The Director of Nursing Services stated the nurses should have also followed up with the pharmacy to inquire why the Topramate 1.5 tablet (150 milligram) order was not delivered to the facility. 10 NYCRR415.12 (l)(1)

Based on observation, record review, and interviews during the Recertification Survey initiated on 6/23/2025 and completed on 6/27/2025, the facility did not ensure that it maintained all patient care equipment in a safe operating condition. This was identified for one (Resident #161) of two residents reviewed for Pressure Ulcers. Specifically, Resident #161 had a Stage 3 pressure ulcer (full-thickness skin loss, where the damage extends into the subcutaneous tissue) and had a care plan intervention for the use of an air mattress. There were multiple observations of the low-pressure light flashing on the air mattress pump before the facility staff replaced the air mattress. The finding is: The facility's undated policy titled Use of Low Air Loss Systems/Air Mattress documented that low air loss systems are medical devices designed to prevent and manage pressure ulcers by providing air circulation to reduce pressure and moisture on the skin. Low-air-loss systems should be installed according to the manufacturer's guidelines and checked by facility staff for compliance with safety standards. The mattress or overlay must be adjusted for proper pressure distribution, ensuring that the patient's body is adequately supported. Any malfunctions, patient injuries, or adverse events related to the use of low-air-loss systems must be reported immediately to Risk Management/Director of Nursing/Wound Nurse. Resident #161 was admitted with diagnoses including Parkinson's Disease, Malnutrition, and Hypertension. The 6/2/2025 admission Minimum Data Set assessment documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact, was at risk for pressure ulcer development, and had one Stage 3 pressure ulcer (full-thickness skin loss, where the wound extends into the subcutaneous tissue, but not to underlying bone, tendon, or muscle). A wound care note dated 5/28/2025 documented that the resident had a sacral stage 3 pressure ulcer and recommended continuing to maintain a pressure-relieving mattress with correct settings. A Comprehensive Care Plan titled, Actual Skin Impairment, Sacral Stage 3 pressure ulcer, initiated 5/28/2025, documented an intervention for pressure reducing air mattress. The resident's most recent weight, as of 6/23/2025, was 168.0 pounds. During an observation on 6/23/25 at 10:37 AM, Resident #161 was in bed. The air mattress pump's red low-pressure light was flashing, and the weight setting was set at 600-750 pounds. During an observation on 6/24/2025 at 08:21 AM, Resident #161 was in bed. The air mattress pump's red low-pressure light was still flashing, and the weight setting was set at 220 pounds. The air mattress manufacturer's manual documented when abnormal pressure occurs, the low-pressure indicator will come on. During an interview on 6/24/2025 at 2:08 PM, Licensed Practical Nurse #4 (unit medication/treatment nurse) stated they had observed the flashing low-pressure light on Resident #161's air mattress pump; they were not sure what the flashing low-pressure light meant, and were not sure what the next step should be. During an observation and interview on 6/25/2025 at 8:30 AM, Resident #161 was observed in bed. The resident's bed had a different air mattress in place. Licensed Practical Nurse #4 stated that after the surveyor brought the low-pressure light to the nurses' attention, the Director of the Maintenance Department had changed the air mattress because the Director of the Maintenance Department was not sure if there was an air pressure leak. During an interview on 6/25/2025 at 9:10 AM, Maintenance Director #1 stated they were alerted about the low air pressure light on the air mattress yesterday (6/24/2025). Maintenance Director #1 stated they replaced the mattress because they were not sure what was causing the low-pressure light to flash. Maintenance Director #1 stated yesterday afternoon was the first time they were alerted that Resident #161's mattress was not functioning properly, and that there were no prior maintenance requests. During an interview on 6/26/2025 at 1:25 PM, the Director of Nursing Services stated that nurses or certified nursing assistants should inform the maintenance department when a low-pressure light on the resident's air mattress pump is flashing. 10 NYCRR 415.29

Based on record review and interviews during the Recertification and Abbreviated Survey (Complaint #NY00326729) initiated on 12/19/2023 and completed on 12/22/2023, the facility did not ensure each resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing. This was identified for one (Resident #68) of three residents reviewed for Pressure Ulcers. Specifically, Resident #68 was assessed to be at a moderate risk for developing pressure ulcers. On 8/26/2023 the resident's Physician ordered a wheelchair gel cushion as a pressure relieving device. There was no documented evidence that the resident received the gel cushion until 10/19/2023. The resident was identified to have a Stage 2 sacral pressure ulcer on 10/19/2023. The finding is: The facility's policy titled, Pressure Ulcer Prevention and Treatment dated January 2022 and last revised January 2023, documented that new pressure-relieving devices/measures or changes to pressure-relieving devices/measures will be noted in the 24-hour report and the CNA accountability record. Rehabilitation responsibilities include assessment of residents for appropriate pressure relieving devices and measures (to include cushions, splints, booties, mattresses, turning and positioning schedules) and ensuring implementation as needed. Resident #68 was admitted with diagnoses including Cerebral Infarction, Hemiplegia, and Hemiparesis affecting the Left Non-Dominant Side, and Type 2 Diabetes Mellitus. The admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident had intact cognition. The resident had no pressure ulcers and was at risk for developing pressure ulcers. The MDS documented the resident was dependent on staff for transfers, used a wheelchair, and had limitations in range of motion on one side of the upper and lower extremities. The Nursing Admission assessment dated [DATE] documented the resident's Braden Scale score (a scale for predicting pressure ulcer risk) was 13 indicating the resident was at a moderate risk for pressure ulcer development. A Physician's Order dated 8/26/2023 documented to utilize a gel foam cushion in the wheelchair. A Comprehensive Care Plan (CCP) titled, The Resident has Potential for Impairment to Skin Integrity due to Decreased Mobility dated 8/28/2023 documented interventions to provide education, keep skin clean and dry, and to use lotion on dry skin. The interventions did not include the use of a gel foam wheelchair cushion. A Physiatrist's Consultation Note dated 9/19/2023 documented a recommendation for a cushion to be used in the resident's wheelchair for offloading purposes and pressure relief. The Resident Nursing Instructions (care instructions provided to the Certified Nursing Assistants) for August 2023, September 2023, and October 2023 revealed no instructions for the use of a gel cushion until 10/19/2023. A Nursing Progress Note dated 10/19/2023 documented the resident complained of sacral pain. An evaluation by the Nursing Supervisor revealed a Stage 2 sacral ulcer. The resident's Physician was notified and orders for Silvadene (topical antimicrobial cream) and a dry protective dressing were obtained. A Physician's Order dated 10/19/2023 documented instructions to apply Silver Sulfadiazine (Silvadene) Cream 1% to sacrum topically one time a day for wound healing. The wound care assessment dated [DATE] documented the wound site as an in house acquired Stage 2 pressure wound that measured as 0.6 centimeters in length x 0.6 centimeters in width x 0.1 centimeters in depth. A Rehabilitation Therapy Note dated 10/19/2023 documented that an Equagel cushion was provided for the resident's wheelchair on 10/19/2023. A CCP titled, Actual Skin Impairment effective 10/19/2023 documented that the pressure-reducing gel cushion in the wheelchair was first initiated on 10/19/2023. The Director of Rehabilitation was interviewed on 12/22/2023 at 10:19 AM and stated that orders by Physicians for pressure relieving devices, such as gel cushions, are presented at morning meetings and the devices are provided by the Rehabilitation Department. The Director of Rehabilitation was unable to provide any documented evidence of the provision or implementation of the gel cushion that was ordered for Resident #68 on 8/26/2023. Licensed Practical Nurse #2 was interviewed on 12/22/2023 at 1:20 PM and stated that interventions ordered by the Physician are documented on the CCPs and automatically populate in the Resident Nursing Instructions. Licensed Practical Nurse #2 was not able to recall if the resident had a wheelchair cushion in use during their stay on the unit. Licensed Practical Nurse #2 stated they expected that interventions ordered by the Physician should be documented on both the Comprehensive Care Plans and the Resident Nursing Instructions. Licensed Practical Nurse #2 stated that the nursing supervisor would be the person responsible to update the care plans to include new interventions. Primary Physician #3, who is also the facility's Medical Director, was interviewed on 12/22/2023 at 2:30 PM and stated they (Physician #3) expected facility staff to follow the physician orders and expected that Resident #68 was provided with the pressure relieving chair cushion for offloading. Physician #3 stated they rely on Nursing and Rehabilitation Staff to follow their (Physician #3) orders. The Director of Nursing Services (DNS) was interviewed on 12/22/2023 at 3:00 PM and stated that the gel cushion should have been added as an intervention on the Resident Nursing Instructions and the Comprehensive Care Plan for Resident #68. The Director of Nursing Services stated Resident #68's Electronic Medical Record (EMR) did not have any documentation related to implementation of the pressure relieving cushion ordered on 8/26/2023. 10 NYCRR 415.12(c)(2)

Based on observations, record review, and staff interviews during the Recertification Survey initiated on 12/19/2023 and completed on 12/22/2023, the facility did not ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice. This was identified for one (Resident # 317) of four residents reviewed for Respiratory Care. Specifically, Resident #317 was administered oxygen therapy without a Physician's order since the resident's admission to the facility on [DATE] until 12/19/2023. The finding is: The facility's policy and procedure titled, Oxygen Administration, last revised on 10/20/2023 documented that oxygen use must be documented in the medical record. Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and /or nasal catheter. Before administering oxygen. While the resident is receiving oxygen therapy, an assessment must be documented for signs or symptoms of hypoxia and cyanosis. Resident#317 was admitted with Diagnoses of Atrial Fibrillation, Chronic Obstructive Pulmonary Disease (COPD), and Congestive Heart Failure (CHF). The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) score was 7 which indicated severely impaired cognition. The MDS documented the resident utilized oxygen therapy. The hospital History and Physical dated 9/21/2023 documented that the resident was making sounds during breathing and was put on oxygen at 2 Liters via nasal cannula. The Patient Review Instrument (PRI, a tool used in the healthcare field to assess the functional status and needs of individuals who are receiving long-term care services) dated 9/28/203 documented that Resident #317 needed oxygen therapy as a medical treatment. The Admission Physician's Order dated 9/28/2023 did not include an order for oxygen therapy. A Comprehensive Care Plan (CCP) titled Pt [patient] referred to respiratory rehab [rehabilitation] skilled services for experiencing SOD [shortness of breath] while lying flat and diagnosis of COPD dated 10/31/2023 documented interventions including to keep the Head of bed (HOB) elevated, administer Oxygen, Positioning, Pulmonary Rehabilitation, and Respiratory Muscle Training. Resident #317 was observed on 12/19/2023 at 11:00 AM in bed receiving oxygen from an oxygen concentrator 1.5 liters per minute via a nasal cannula. An oxygen tank was attached to the resident's wheelchair. A Physician's order dated 12/19/2023 entered at 11:00 PM documented to administer oxygen at 2 Liters per minute via nasal cannula as needed. During a subsequent observation on 12/20/2023 at 8:34 AM, Resident #317 was observed in bed receiving oxygen from the oxygen concentrator at 2 Liters per minute via a nasal cannula. Certified Nursing Assistant (CNA) #2 was interviewed on 12/20/2023 at 1:45 PM and stated that Resident # 317 needed oxygen because Resident #317 gets short of breath without it. Certified Nursing Assistant #2 stated that the staff, both nurses and nurses aides, always put the oxygen on for Resident #317 when the resident is in bed or in a wheelchair. Licensed Practical Nurse (LPN) #1 was interviewed on 12/20/2023 at 2:00 PM and stated that Resident # 317 has been using oxygen therapy on an as-needed basis since September 28, 2023 when they (Resident #317) were admitted to the facility. Licensed Practical Nurse #1 stated a physician order is required when a resident is receiving oxygen therapy. Licensed Practical Nurse #1 stated they did not know why there was not a Physician's order for the use of oxygen for Resident # 317. An interview was conducted with Registered Nurse #2, who was the Unit Supervisor, on 12/20/2023 at 2:30 PM. Registered Nurse #2 stated that a physician order must be in the Electronic Medical Records (EMR) system before the start of a treatment or medication. Registered Nurse #2 further stated that Resident # 317 should have a physician's order for oxygen therapy. Registered Nurse #I was interviewed on 12/20/2023 at 2:45 PM and acknowledged that the oxygen orders were obtained for the oxygen therapy for Resident #317 on 12/19/2023 at 11:00 PM after the resident was observed receiving supplemental oxygen by the surveyor on 12/19/2023. The Director of Nursing Services was interviewed on 12/21/2023 at 2:23 PM and stated that there should have been an order for the use of oxygen for Resident #317. The Director of Nursing Services stated it was an oversight that no one picked up that the oxygen therapy was part of the resident's respiratory treatment regimen and that no one obtained the physician's orders for the use of the oxygen. Medical Doctor #1 was interviewed on 12/21/2023 at 8:40 AM and stated that it was an oversight that an order for oxygen use was not documented in the Physician's Orders. Oxygen is a part of the resident's management of symptoms and should have been included as an order. Medical Doctor #1 further stated that they added the order for oxygen for Resident #317 on 12/19/2023 at 11:00 PM. NYCRR 415.12(k)(6)

Based on observation, record review, and staff interviews during the Recertification Survey initiated on 12/19/2023 and completed on 12/22/2023, the facility did not ensure that a physician, physician's assistant, nurse practitioner or clinical nurse specialist provide orders for each resident's immediate care and needs. This was identified for one (Resident #318) of seven residents reviewed during the Medication Administration task. Specifically, Resident #318 had a Physician's Order to administer Midodrine (medication used to treat low blood pressure); however, the order did not include blood pressure parameters regarding when to hold the medication and when to call a Physician. The finding is: The facility's policy and procedure titled, Medication Administration/Physician Orders, last revised on 7/24/2023 documented that vital signs are recorded in the Electronic Medication Administration Record (eMAR). The eMAR shall serve as the source from which all medications are documented and to use prudent professional judgment by informing the Physician in a timely manner when medications are held, refused, or otherwise unavailable for administration. Resident #318 was admitted on [DATE] with diagnoses including Orthostatic Hypotension ( a form of low blood pressure that occurs when standing up after sitting or lying down that can cause dizziness, lightheadedness, fainting or confusion), Essential Hypertension, and Personal History of Traumatic Brain Injury. The Minimum Data Set (MDS) assessment was not available as the resident was newly admitted to the facility. A Physician's Order dated 12/18/2023 documented to administer Midodrine Hydrochloride (HCL) tablets 2.5 milligrams (mg), one tablet by mouth three times a day for Hypotension, and to monitor vital signs every shift. The order did not include blood pressure parameters and guidance regarding when to hold the medication and or when to call the resident's Physician. The Baseline Care Plan dated 12/19/2023 documented the resident was alert and oriented to time, place, and person; was cognitively intact, and could communicate with staff. A Medication Administration Observation task was conducted on 12/20/2023 at 8:16 AM with Licensed Practical Nurse #1. Licensed Practical Nurse #1 obtained Resident #318's blood pressure and heart rate. The resident's blood pressure reading was 124/62 millimeters of mercury (mmHg), and their heart rate was 73 beats per minute. Licensed Practical Nurse #1 then administered Midodrine medication as per the Physician's Order. Licensed Practical Nurse #1 was interviewed on 12/20/2023 at 8:22 AM and stated that they (Licensed Practical Nurse #1) do not call the Physician with any vital sign results because the Physician's Order did not indicate when to call a Physician. A review of the Medication Administration Record (MAR) from 12/18/2023 to 12/20/2023 documented the following vital signs: -On 12/18/2023 the resident's blood pressure was 145/63 millimeters of mercury (mmHg) (normal range 120/80) and their heart rate was 85 beats per minute (normal range 72-80 beats per minute). The resident was administered Midodrine as per the Physician's Order. -On 12/19/2023 the resident's blood pressure was 132/68 mmHg, and their heart rate was 80 beats per minute. The resident was administered Midodrine as per the Physician's Order. -On 12/20/2023 the resident's blood pressure was 130/74 mmHg, and their heart rate was 74 beats per minute. The resident was administered Midodrine as per the Physician's Order. A Physician's Order dated 12/21/2023 documented to hold Midodrine HCL 2.5 milligrams if the systolic blood pressure (BP) is above 110 millimeters of mercury (mmHg) as per the MD every shift for Midodrine Protocol. The Director of Nursing Services was interviewed on 12/21/2023 at 1:57 PM and stated the resident's Physician has a team that enters all orders for a new admission. The facility has the ultimate responsibility of checking those orders for accuracy. It was an oversight on the facility's part that they did not check for those parameters or to clarify the vitals sign orders. The Director of Nursing Services further stated the unit supervisors should have checked the accuracy of the orders and the nurses who administer the medication should have brought up that there were no parameters for such significant medication to the attention of the nursing Supervisors. Physician #2, who is the primary care physician for Resident #318 and who signed the medication orders, was interviewed on 12/21/2023 at 4:00 PM. Physician #2 stated that they (Physician #2) would only document an order for parameters if the resident was on Dialysis. When asked why the Midodrine medication had an indicated parameter as of 12/21/2023, after the medication administration observation of 12/20/2023 and not at the time of admission, Physician #2 stated the Medical Director ordered the parameters on 12/21/2023. The Medical Director was interviewed on 12/22/2023 at 3:06 PM and stated that the standard of practice for the medication Midodrine would be to monitor the resident's Blood Pressure (BP) for a week and to hold the medication if the resident's Blood Pressure was above 110 millimeters of mercury (mmHg) because a high blood pressure can cause dizziness or blurred vision that can lead to a fall. The Medical Director stated that the Physician would then decide if the medication should be discontinued, or the order should be changed to a lower dose or frequency. According to Drugs.com, last reviewed 2/6/2023, Midodrine is used to treat low blood pressure that causes severe dizziness or a light-headed feeling. Blood pressure will need to be checked before and during treatment with Midodrine. NYCRR 415.15(b)(1)(i)(ii)

Based on record review and staff interviews during the Recertification Survey and the Abbreviated Survey (Complaint # NY 362) completed on 12/9/2021 the facility did not consult with the resident's Physician when there was a significant change in the resident's physical or mental status for one (Resident #205) of one resident reviewed for Choices. Specifically, Resident #205 had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 7/23/2020 the resident's BP was documented as 83/46 mmHg and there was no documentation in the resident's medical record that the resident's Physician was made aware of the resident's low BP. The finding is: Resident #205 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 6 which indicated that the resident had severely impaired cognitive skills. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order included to call the Physician for Systolic BP less than 90 mmHg or greater than 140 mmHg. The July 2020 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's Electronic Medical Record (EMR) revealed no documented evidence that the resident was assessed or that the resident's Physician was notified of the resident's low BP. The Director of Nursing Services (DNS) was interviewed on 12/9/2021 at 1:10 PM and stated that the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Physician, who is also the facility's Medical Director, was interviewed on 12/9/2021 at 1:25 PM and stated that they (Physician) would definitely expect the nurse to call them when the resident had an abnormal blood pressure. The Physician stated that the nurse would usually call them, and they (Physician) would ask the nurse to recheck the BP because it could be an error. The Physician stated that they would also ask the nurse if the resident was symptomatic for [CONDITION(S)] such as dizziness, weakness, lightheadedness, nauseous, or had a change in mental status from baseline. The Physician stated that if the resident was symptomatic, they would start intravenous (IV) fluids and hold the BP medications if the resident was receiving any. 415.3(e)(2)(ii)(b)

Based on observation, record review and interviews during the Recertification Survey and the Abbreviated Survey (Complaint # NY 243) completed on 12/9/2021, the facility did not implement a comprehensive person-centered care plan for each resident to meet a resident's medical and nursing needs that are identified in the comprehensive assessment for one (Resident #105) of one resident reviewed for Pain and one (Resident #158) of two residents reviewed for Pressure Ulcers. Specifically, 1) Resident #105 was admitted to the facility on [DATE] and had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #105 did not receive [MEDICATION(S)] until 8/22/2019 (7 days after being ordered). Additionally, Resident #105 did not receive [MEDICATION(S)] on 8/27/2019 and 8/28/2019 when the [MEDICATION(S)] supply for Resident #105 ran out. 2) On 12/6/2021, during the observation of Resident #158 wound care, Licensed Practical Nurse (LPN) #1 did not cleanse the left heel Pressure Ulcer with Normal Saline (NS) as ordered by the Physician. The findings are: 1) The facility's policy titled Controlled Substances - Ordering dated August 2017 documented that a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The prescription is faxed to the pharmacy and the medication is then delivered to the facility. While the medication is in route, the facility may utilize the emergency narcotic medication supply. The facility's policy titled Medication Administration and Documentation-General, last reviewed 8/1/2021, documented that medications are to be administered within a two-hour time frame (i.e. one hour before or after the medication order time). It is the responsibility of the Licensed Nurse to immediately notify the nursing supervisor if medication is unavailable for administration. Resident #105 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14 which indicated that the resident was cognitively intact. The MDS documented Resident #105 had occasional pain in the last 5 days and rated the worst pain level as a 4 on a scale of 1-10. The Pain Management/Pain Risk Comprehensive Care Plan (CCP) dated 8/16/2019 documented to administer pain medications as ordered by the MD. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was discontinued on 8/17/2019 and a clarification order was requested. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was discontinued on 8/19/2019 and another clarification order was requested. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was discontinued on 9/2/2019 when the resident was discharged to the hospital. The August 2019 EMAR documented the following for [MEDICATION(S)] ([MEDICATION(S)]) 10 mg tablet - give 2 tablets (20 mg) by oral route once daily: 8/16/2019 9:00 AM - Awaiting delivery (from the Pharmacy). 8/18/2019 9:00 AM - Awaiting delivery (from the Pharmacy). 8/20/2019 9:00 AM - Awaiting Rx. MD notified. Will administer when available. 8/21/2019 9:00 AM - Awaiting delivery (from the Pharmacy). 8/27/2019 9:00 AM - Awaiting delivery (from the Pharmacy). MD made aware. 8/28/2019 9:00 AM - Awaiting delivery (from the Pharmacy). MD made aware. The Director of Quality from the facility's Pharmacy was interviewed on 12/7/2021 at 9:45 AM and stated that [MEDICATION(S)] was not sent to the facility when first ordered because the pharmacy did not receive the required prescription from the ordering Physician. The initial order for [MEDICATION(S)] was received by the pharmacy on 8/15/2019. The Pharmacy delivered 10 tablets, a five-day supply, to the facility on [DATE]. The Director of Quality from the facility's Pharmacy further stated that a valid eRx was received from the Physician on 8/28/2019 however, the prescription did not include a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Director of Nursing Services (DNS) was interviewed on 12/7/2021 at 1:45 PM and stated that once an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DNS stated the Resident did not receive the pain medication [MEDICATION(S)] because the Physician did not sign the required prescription. The facility's Medical Director was interviewed on 12/7/2021 at 3:00 PM and stated that the resident's Physician only worked at the facility for a short period of time The Physician did not come to the facility often, only came at night, and many times you could not get in touch with the Physician. The Medical Director stated that if the facility was unable to reach the resident's Physician, the facility staff could have called them (Medical Director) or called the Pharmacy. The Medical Director then could have called the pharmacy to approve an emergency supply of the medication for a maximum of 5 days. The facility does not carry [MEDICATION(S)] in the facility's emergency medication box. The Administrator was interviewed on 12/8/2021 at 11:00 AM and stated that the resident should not have been without [MEDICATION(S)] medication for a week. 2) The facility's policy, titled Pressure Ulcer-Prevention and Care, effective 5/1/2021, documented that aseptic technique is used for all dressing changes unless otherwise ordered. Resident #158 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission nursing assessment dated [DATE] documented that the resident had an unstageable left heel ulcer and a Stage 3 ulcer to the left lateral lower leg. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] During an observation of Resident #158's left heel wound care, performed by LPN #1, on 12/6/2021 at 10:08 AM LPN #1 placed a barrier under the left leg, removed the existing dressing from the left heel, and allowed the heel to rest directly on the barrier. The left heel was observed with an eschar (dead skin tissue). LPN #1 lifted the left leg and applied [MEDICATION(S)] solution to the left heel without first cleansing the heel ulcer with normal saline. LPN #1 was interviewed immediately after the observation and stated cleansing the wound with Normal Saline was not necessary. The Director of Nursing Services (DNS) was interviewed on 12/6/2021 at 11:14 AM and stated that LPN #1 should have cleaned the heel ulcer with Normal Saline as per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 415.11(c)(1)

Based on observation, record review, and interviews during the Recertification Survey completed on 12/9/2021 the facility did not ensure that each resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for one (Resident #158) of two residents reviewed for pressure ulcers. Specifically, Resident #158 had an unstageable pressure ulcer to the left heel and had a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, a wound consult recommended bilateral heel boots on 12/2/2021; however, the care plan and Certified Nursing Assistant (CNA) accountability record were not updated to include the heel boots until 12/6/2021. The finding is: The facility's policy titled Pressure Ulcer-Prevention and Care, effective 5/1/2021, documented that nursing interventions are added as needed to prevent pressure ulcers and to manage treatment; and that nursing interventions include discussing/evaluating, and initiating/implementing interventions with the health care team. Resident #158 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission nursing assessment dated [DATE] documented that the resident had an unstageable left heel ulcer and a Stage 3 ulcer to the left lateral lower leg. The Braden Scale (a scale to predict pressure sore risk), dated 11/30/2021 documented a score of 9, which equates to very high risk for pressure ulcer development. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A Comprehensive Care Plan (CCP) dated 12/1/2021 titled At Risk for Skin Breakdown/Pressure Ulcer included an intervention to offload the heels when in bed by using pillows. Resident #158 was observed in bed on 12/2/2021 at 2:55 PM. CNA #1 pulled back the sheet covering the resident's feet, revealing that the resident's heels were resting on a pillow and not offloaded. The left heel was observed with a dressing in place. On 12/2/2021 at 2:57 PM Licensed Practical Nurse (LPN) #1 observed Resident #158's feet, with the surveyor and CNA #1 present, and stated the resident's heels should be offloaded and not resting on the pillow. LPN #1 then adjusted the pillow under the resident's calves so that the heels were offloaded and not in contact with the pillow. Resident #158 was seen by the wound Physician on 12/2/2021. The wound consult documented an unstageable left heel pressure ulcer measuring 4 centimeters (cm) x 6 cm, with recommendations to apply [MEDICATION(S)], pad, protect, offload wound sites, and use bilateral heel booties. On 12/6/2021 at 8:22 AM Resident #158 was observed in bed having breakfast. CNA #1 was present. The resident's left heel had a heel bootie in place; however, there was no heel bootie on the right foot and the right heel was resting directly on the mattress. There was a pillow under the resident's right calf, but the pillow was not offloading the heel. Resident #158's left heel wound care, performed by LPN #1, was observed on 12/6/2021 at 10:08 AM. The resident had heel boots on both feet. LPN #1 stated they (LPN #1) got a boot for the right foot because the pillows did not seem to be working. The Director of Nursing Services (DNS) was interviewed on 12/6/2021 at 11:14 AM. The DNS stated that offloading means that the heel(s) should not be in direct contact with any surface to prevent friction. The wound care Physician was interviewed on 12/6/2021 at 12:19 PM and stated that offloading means removing all pressure from the heels through the use of pillows or heel boots. The wound care Physician stated if pillows are being used, the heels should be levitating off the pillow. The wound care Physician stated residents often move, so the pillows may have to be repositioned to maintain offloading of the heels. A CCP dated 12/1/2021 titled Presence of Pressure Ulcer: Left Heel, was updated on 12/6/2021 to include a new intervention to use bilateral heel boots when in bed. The primary physician was interviewed on 12/6/2021 at 12:47 PM and stated that the wound care Physician is the expert regarding wound care. If the recommendation is for padding, offloading, heel boots, etc the nursing staff should just do it. CNA #1 was interviewed on 12/6/2021 at 2:14 PM and stated they (CNA #1) were not sure if the heel boots were on the CNA accountability record. CNA #1 stated that they (CNA #1) did not put the heel boots on Resident #158 today. The DNS was re-interviewed on 12/7/2021 at 2:14 PM and stated that when the wound consult was completed on 12/2/2021, the nurses were supposed to read it and ensure the nursing interventions, such as heel boots, were placed on the care plans, CNA accountability record, and on the resident. 415.12(c)(2)

Based on record review and staff interviews during the Recertification Survey and the Abbreviated Survey (Complaint # NY 243) completed on 12/9/2021, the facility did not ensure that each physician provided orders to meet the resident's care needs timely. This was identified for one (Resident #105) of one resident reviewed for Pain. Specifically, Resident #105 was admitted to the facility on [DATE] and had orders to receive [MEDICATION(S)] ([MEDICATION(S)] - Opioid [MEDICATION(S)]) for Abdominal Pain. The medication [MEDICATION(S)] was not available in the facility until 8/22/2019 (6 days after the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Additionally, Resident #105 was not administered [MEDICATION(S)] on 8/27/2019 and 8/28/2019 when the emergency supply of [MEDICATION(S)] delivered to the facility on [DATE] ran out and a standing narcotic prescription was needed from the Physician. The finding is: The facility's policy titled Controlled Substances - Ordering dated August 2017 documented that a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The prescription is faxed to the pharmacy and the medication is then delivered to the facility. While the medication is in route, the facility may utilize the emergency narcotic medication supply. The facility's policy titled Medication Administration and Documentation - General, last reviewed 8/1/2021, documented that medications are to be administered within a two-hour time frame (i.e. one hour before or after the medication order time). It is the responsibility of the Licensed Nurse to immediately notify the nursing supervisor if medication is unavailable for administration. Resident #105 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14 which indicated that the resident was cognitively intact. The MDS documented the resident had occasional pain in the last 5 days and rated the worst pain level as a 4 on a scale of 1-10. The Pain Management/Pain Risk Comprehensive Care Plan dated 8/16/2019 documented to administer pain medications as ordered by the Medical Doctor (MD). The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was discontinued on 8/17/2019 and a clarification order was requested. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was discontinued on 8/19/2019 and another clarification order was requested. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was discontinued on 9/2/2019 when the resident was discharged to the hospital. The August 2019 EMAR documented the following for [MEDICATION(S)] ([MEDICATION(S)]) 10 mg tablet - give 2 tablets (20 mg) by oral route once daily: 8/16/2019 9:00 AM - Awaiting delivery (from the Pharmacy). 8/18/2019 9:00 AM - Awaiting delivery (from the Pharmacy). 8/20/2019 9:00 AM - Awaiting Rx. MD notified. Will administer when available. 8/21/2019 9:00 AM - Awaiting delivery (from the Pharmacy). 8/27/2019 9:00 AM - Awaiting delivery (from the Pharmacy). MD made aware. 8/28/2019 9:00 AM - Awaiting delivery (from the Pharmacy). MD made aware. The Director of Quality from the facility's Pharmacy was interviewed on 12/7/2021 at 9:45 AM and provided the following information: On 8/15/2019 at 4:31 PM - A medication order, not a valid prescription, was received by the Pharmacy for [MEDICATION(S)] 10 mg tablet (2 tablets by mouth once daily) with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 8/17/2019 at 7:07 AM - A facility nurse called and asked the Pharmacy to contact the Prescriber (Physician) for a prescription. On 8/17/2019 at 7:52 AM - The Pharmacist is unable to reach the Physician and left a voicemail. On 8/19/2019 at 9:11 AM and on 8/21/2019 at 9:46 AM - A facility nurse calls and asks the Pharmacy to contact the Physician for a prescription. On 8/21/2019 at 11:11 AM - The Pharmacist reached the Physician and obtained a verbal emergency approval for 10 tablets (a 5-day supply). On 8/22/2019 at 12:27 AM - 10 tablets of [MEDICATION(S)] were delivered to the facility. On 8/28/2019 at 11:51 AM - A valid electronic prescription (eRx) was received from the Physician for 60 tablets of [MEDICATION(S)], however, the eRx did not include a diagnosis. On 8/28/2019 at 2:26 PM - The Pharmacist clarified the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On 8/29/2019 at 12:14 AM - 60 tablets of [MEDICATION(S)] were delivered to the facility. The Director of Quality from the facility's Pharmacy also stated that [MEDICATION(S)] is not a medication that is available from the facility's emergency narcotic medication supply. The Director of Nursing Services (DNS) was interviewed on 12/7/2021 at 1:45 PM and stated that once an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The DNS stated the resident did not receive the pain medication [MEDICATION(S)] because the Physician did not sign the required prescription. The facility's Medical Director was interviewed on 12/7/2021 at 3:00 PM and stated that the resident's Physician only worked at the facility for a short period of time. The Physician did not come to the facility often, only came at night, and many times you could not get in touch with the Physician. The Medical Director stated that if the facility was unable to reach the resident's Physician, the facility staff could have called them (Medical Director) or called the Pharmacy. The Medical Director then could have called the pharmacy to approve an emergency supply of the medication for a maximum of 5 days. The facility does not carry [MEDICATION(S)] in the facility's emergency medication box. The Medical Director stated that if they (Medical Director) were unable to leave a prescription at the facility, they (Medical Director) could fax the prescription to the pharmacy. The Administrator was interviewed on 12/8/2021 at 11:00 AM and stated that the resident should not have been without the medication for a week. 415.15(b)(1)(i)(ii)

Based on record review and staff interview during the recertification survey, the facility did not ensure that an Accident/Incident (A/I) Report was thoroughly investigated. This was evident for one (Resident # 8) of one resident reviewed for Abuse. Specifically, Resident #8 sustained a left (L) [MEDICAL CONDITION]. The Accident/Incident Summary did not include staff interviews from prior shifts after the injury was identified. The finding is: The facility's Accident/Incident Prevention Policy dated October 2017 documented that an Accident/Incident report will consist of any pertinent information including but not limited to: time, date, medical reports/diagnostic reports relevant to the occurrence, and staff statements as applicable. Resident #8 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident was usually understood and could usually understand. The resident had severely impaired cognitive skills for daily decision making with long and short term memory problems. The resident was an extensive assist of two persons for bed mobility, transfer, toilet use, and bathing. The Summary of the Accident/Incident dated 4/3/17 documented that the resident was observed at approximately 7:30 AM with (L) lower extremity abnormalities. The (L) outer hip had visible swelling, but no bruising or discoloration was noted. The (L) hip was abducted and externally rotated with the knee flexed outward. The resident was unable to rotate the (L) lower extremity and the affected limb was shortened. Non-verbal signs of pain and discomfort were noted on assessment, along with guarding and facial grimacing. The staff denied any incident or event to cause possible trauma. The resident unable to verbalize or recall details that caused the (L) leg injury secondary to cognitive impairment. There was only one statement obtained from the Certified Nursing Assistant (CNA) who was assigned to the resident that morning and who found the resident's (L) leg looking unusual when she went to provide AM care. The Director of Nursing Services (DNS) was interviewed on 12/5/17 at 11:15 AM and stated that there should have been staff interviews going back at least 48 hours to determine if something had occurred to the resident on another shift. The DNS stated that she could only find the summary of what happened to the resident on 4/3/17 and not the Incident/Accident Report which she could not locate. The Administrator was interviewed on 12/5/17 at 12:05 PM and stated that for an Accident/Incident Report all staff on the unit would have been interviewed for the past 48 hours; however, this report could not be located. The Administrator stated that she and the DNS are in charge of the Abuse Prohibition Protocol and the previous DNS kept all the Accident/Incident Reports in her office. The current DNS realized there was a problem on how the previous DNS was keeping the Accident/Incident Reports and the facility revised the policy. The facility now has a logging system and all Accident/Incident Reports are numbered and tracked from start to finish. 415.4(b)(1)(ii)

Based on observation, staff interviews, and record review during the recertification survey the facility did not ensure that a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1(Resident # 48) of 3 residents reviewed for pressure ulcers. Specifically, Resident #48's bilateral heels were noted on 11/29/17 by the 11 PM - 7 AM Licensed Practical Nurse (LPN) with discoloration and were soft and tender; however, a full assessment by a Registered Nurse (RN) of the resident's heels was not relayed to the physician in a timely manner resulting in a delay in treatment. The finding is: Resident #48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 11/5/2017 Quarterly Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 4, indicating the resident had severe cognitive impairment. The MDS documented that the resident required extensive assistance for bed mobility, was at risk for pressure ulcer development, and did not have a pressure ulcer. A Comprehensive Care Plan (CCP) effective 2/2/2017 titled Pressure Ulcers/At Risk for Skin Breakdown documented that the resident was at risk for skin breakdown due to limited mobility, [MEDICAL CONDITION], and impaired cognition. A nursing progress note dated 11/29/2017 at 8:14 AM, written by the 11 PM-7 AM LPN Charge Nurse, documented that during rounds the resident was noted with discoloration to bilateral heels, area soft and tender to touch, heel booties applied and legs elevated on pillow to offset heels. The resident was to be evaluated this AM by wound team. Oncoming nurse endorsed. On 11/30/2017 at 12:00 PM the LPN Charge Nurse was interviewed. She stated that she was not aware of any concerns with the resident's heels and that there were no current treatment orders for the heels. The nurse was referred to the progress note of 11/29/2017 at 8:14 AM, and said that she would speak to her supervisor. A nursing progress note was entered on 11/30/2017 at 5:35 PM, written by the Assistant Director of Nursing (ADNS), who is a member of the wound team. The note documented that the resident had bilateral feet [MEDICAL CONDITION] of 3+ (3+ is the measure of the depth of the [MEDICAL CONDITION] and the amount of time for the indentation to rebound). The note further documented that the left heel had a serosanguinous (containing serum and/or blood cells) blister that was intact, and measured 5.7 centimeters (cm) x 5.7 cm. The right lateral heel had movable skin, no fluid was felt, and measured 5.6 cm x 8 cm. The MD was made aware and orders were received to cleanse both heels with normal saline and apply skin prep daily and leave open to air. A referral was made to rehabilitation for offloading of the heels and a consult was ordered for podiatry. Treatment orders were entered as follows: --Left heel blister, cleanse with normal saline, pat dry then apply skin prep daily and as needed, leave open to air, dated 11/30/2017 at 5:55 PM. --Right heel blister, cleanse with normal saline, pat dry then apply skin prep daily and as needed, leave open to air, dated 11/30/2017 at 5:58 PM. A late nurses progress note dated 12/1/2017 at 8:20 AM written by the overnight RN Supervisor who worked the 11 PM-7 AM shift on 11/28/2017 night-11/29/2017 morning documented that on 11/29/2017 she was called by the charge nurse to assess the resident who was noted with a change of skin integrity to both heels. The RN observed the bilateral feet with resolving [MEDICAL CONDITION], darkened area of discoloration to both heels, no open area, area soft and tender to touch, heels were elevated on a pillow, will continue to monitor. There was no documentation regarding measurements or if anyone was notified. A Podiatrist progress note, dated 12/1/2017 at 8:47 AM, documented that the resident had bilateral heel bullae (raised, fluid filled bubble). The Podiatrist recommended leaving the bullae in place, do not drain, and off loading shoes to relieve pressure on the heels. An order, dated 12/1/2017 at 8:56 AM, was entered for heel suspension boots to be worn at all times, remove every shift to monitor skin integrity. Comprehensive Care Plans for right and left heel blisters were made effective on 12/1/2017. The interventions included but were not limited to: apply local treatments as ordered by the physician, heel suspension boots to both feet when in bed. The Resident Nursing Instructions form, which is utilized by the Certified Nursing Assistants (CNA) and provides direction for care needs, was reviewed. The Resident Nursing Instructions form documented interventions under the bed mobility section, dated 12/1/17, to use heel suspension boots to both feet when in bed. On 12/1/2017 at 11:28 AM the 11 PM-7 AM LPN that wrote the progress note on 11/29/2017 at 8:14 AM was interviewed. She stated that her shift gets Resident #48 dressed and out of bed and that she informed the 11 PM-7 AM (overnight) RN Supervisor about the heel findings. The LPN stated that she did not endorse the findings to the next shift nurse and that the overnight RN Supervisor stated she would speak to the wound team when they came in. On 12/1/2017 at 1:02 PM Resident #48's heels were observed with the LPN Charge Nurse. Discolored skin was observed on both heels and bilateral blisters were present. On 12/1/2017 at 1:25 PM the ADNS, who had written the progress note on 11/30/2017 at 5:35 PM, was interviewed. She stated that she did not receive a report about the heels initially on 11/29/2017 when the observation was made by the overnight LPN. She stated that if she was made aware of the heel problems on 11/29/2017, she would have immediately done her assessment that day and not on 11/30/2017. A physician progress notes [REDACTED]. On 12/4/2017 at 9:40 AM the Director of Nursing Services (DNS) was interviewed. She stated that wound care rounds are done on Wednesdays, and on Wednesday, 11/29/2017, the wound care team only saw the residents with active orders. S he stated the ADNS, who is a member of the wound team, was not aware of the heel problem on 11/29/2017 and therefore did not see the resident. The DNS stated the ADNS saw the resident as soon as she was informed on 11/30/2017. The DNS further stated that the overnight RN Supervisor who did the initial assessment did not write a note and assumed the resident would be seen by the wound team. On 12/4/2017 at 1:19 PM the Certified Nursing Assistant (CNA) who was assigned to Resident #48 on the 11 PM-7 AM shift on 11/28/2017 night-11/29/2017 morning was interviewed. She stated that the resident turns by himself when he is in bed. The CNA stated she noticed discoloration to the resident's heels and that she notified the nurse, who put heel booties on the resident. The CNA further stated that his ankles were already elevated on pillows to keep his heels off the bed because they were swollen. On 12/5/2017 at 8:36 AM the overnight RN Supervisor who worked the 11 PM-7 AM shift on 11/28/2017 night-11/29/2017 morning was interviewed. She stated that she assessed the resident's heels and wrote her findings on a piece of paper, but forgot to write a progress note. The RN Supervisor stated that she passed her findings on to the LPN wound nurse. On 12/5/2017 at 9:29 AM the LPN wound nurse was interviewed. She stated that she was told by the overnight RN Supervisor on the morning of 11/29/2017 about Resident #48's heel condition. She stated that she told the overnight RN Supervisor that a note had to be put in the resident's medical record. The LPN stated that she also told the ADNS, but that the ADNS wanted to wait for the progress note to be written. 415.12(c)(1)

Based on record review and staff interviews during the recertification survey the facility did not ensure that medication irregularities reported by the consultant pharmacist were reviewed and acted upon by the physician for 1 (Resident # 6) of 5 residents reviewed for unnecessary medications. Specifically, the consultant pharmacist made a recommendation to taper the medication Quetiapine (also known as [MEDICATION NAME], an antipsychotic medication) that was prescribed for Resident #6. However, there was no documented evidence that the physician reviewed the recommendation or acted upon it. The finding is: The facility's policy titled Drug Regimen Monthly Review dated November 2016 states that the prescriber/licensed designee shall act upon the drug regimen review findings/recommendations in a timely manner of 7-14 days or less, and shall document on the drug regimen review form whether he/she agrees or disagrees with the recommendation, and provide a brief clinical rationale if no change is to be made. Resident #6 is [AGE] years old and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 9/6/2017 Quarterly Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 6, indicating the resident had severe cognitive impairment. The MDS documented that the resident received antipsychotic, antidepressant, and diuretic medications the prior 7 days. The hospital discharge instructions dated 6/9/2017 documented the resident was to continue receiving Quetiapine 25 milligram (mg) oral tablet three times per day. The facility's physician's orders [REDACTED]. Resident #6's medication regimen was reviewed by the consultant pharmacist on 6/30/2017. The consultant pharmacist report, dated 6/30/2017, documented: Currently receiving [MEDICATION NAME] 25 mg three times per day for behaviors associated with dementia without attempt to taper. Please evaluate current dosing, consider trial taper to 25 mg twice daily, or document inability to do so. The report has agree or disagree boxes that are to be checked by the physician that were not checked. In addition, the physician did not sign the report. There was handwriting on the report stating Family disagrees with recommendations. Review of the medical record revealed that there was no documented evidence that the physician addressed the pharmacy report or had spoken with the family. The Director of Nursing Services (DNS) was interviewed on 12/4/17 at 9:45 AM and stated the doctor that the pharmacy consultant report was addressed to in June 2017 is no longer associated with the facility. She stated that she was unable to identify whose handwriting was on the report (Family disagrees with recommendations.) The DNS stated the pharmacy reports are supposed to be followed up and addressed by the physician and that the physician is supposed to document either that they agree with the recommendation or provide a reason if they disagree with the recommendation. The DNS further stated the physician is responsible to sign the report and that if the family disagrees, the physician should speak with the family, provide education, and document this in a note. 415.18(c)(2)

Based on observation, record review, and staff interviews during recertification survey the facility did not ensure that residents who use [MEDICAL CONDITION] drugs receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue these drugs for 1 (Resident # 6) of 5 residents reviewed for Unnecessary Medications. Specifically, Resident #6 was prescribed Quetiapine (also known as [MEDICATION NAME], an antipsychotic medication) 25 milligram oral tablet three times per day. The Psychiatrist and pharmacy consultant both recommended a tapering of the medication, however, there was no documented evidence that the Physician took any action. The finding is: Resident #6 is [AGE] years old and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 9/6/2017 Quarterly Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status (BIMS) score of 6, indicating that the resident had severe cognitive impairment. The MDS documented that there were no [MEDICAL CONDITION] indicators or behavioral problems. The hospital discharge instructions dated 6/9/2017 documented the resident was to continue receiving Quetiapine 25 milligram (mg) oral tablet three times per day. The facility's physician's orders [REDACTED]. A Comprehensive Care Plan (CCP) titled [MEDICAL CONDITION] Drug Use, effective 6/9/2017, had a goal for the resident's medication to be reduced to the lowest possible therapeutic dose or discontinued. A CCP titled Behavioral Symptoms was first initiated on 6/12/2017 because the resident was verbally aggressive towards staff and was yelling at them to get out of her room. The resident was redirected with positive effect. The next CCP update was not until 7/25/2017. On 7/25/2017 the resident was noted packing clothes to leave, had increased confusion and agitation. The MD was made aware and ordered one dose of [MEDICATION NAME]. A urine-analysis/culture and sensitivity (UA/C&S) was pending. On 6/15/2017 the resident was evaluated for Psychotherapy services. The Psychotherapy progress note, dated 6/15/2017, documented the resident was cooperative and calm, not oriented to time or place, had no idea of her age, and that decision making was severely limited. The Psychotherapist documented that there was no evidence of any delusions or other psychotic features and the resident was not in need of or a candidate for psychotherapy services. Resident #6's medication regimen was reviewed by the consultant pharmacist on 6/30/2017. The consultant pharmacist report, dated 6/30/2017, documented: Currently receiving [MEDICATION NAME] 25 mg three times per day for behaviors associated with dementia without attempt to taper. Please evaluate current dosing, consider trial taper to 25 mg twice daily, or document inability to do so. The report has agree or disagree boxes that are to be checked by the physician that were not checked. In addition, the physician did not sign the report. There was handwriting on the report indicating that the family disagreed with the recommendations. Review of the medical record revealed that there was no documented evidence that the physician addressed the pharmacy report or had spoken with the family. A weekly Psych-Behavior Nursing Note, dated 7/1/2017, documented the resident had [DIAGNOSES REDACTED]. On 7/8/2017 Resident #6 was seen by the Psychiatrist. The Psychiatrist progress note, dated 7/8/2017, documented that the resident was prescribed Quetiapine 25 mg three times per day. The resident is reported by nursing to be compliant with medications and cooperative with treatment but has baseline confusion with impaired cognition. The resident's behavior was reported to be generally manageable and non-problematic despite being confused. The resident has not displayed any aggressive or significant disruptive behavior since admission. There was an episode of agitation and verbal disruption on 6/10/2017, but progress notes did not indicate any repeat of such behavior. The psychiatrist recommended, upon chart review and discussion with staff, to decrease Quetiapine to 25 mg two times per day since the behavior was reported to be manageable and non-problematic. A nursing progress note dated 7/10/2017, written by a Licensed Practical Nurse (LPN), documented that the writer had spoken to the resident's family about the Psychiatrist's recommendations to taper the Quetiapine, however, the family did not want any changes. The note documented that the primary Physician was informed of family wishes and the resident was to remain on [MEDICATION NAME] 25 mg three times per day. A nursing progress note dated 7/11/2017, written by a Registered Nurse (RN), documented the family was again contacted about the Psychiatrist's recommendations to taper Quetiapine. The RN documented that the family stated that any slight change in the medication regimen will make the resident very upset and agitated and that the family requested that there were no changes. There was no documentation in this note that the RN had spoken to the Physician. Review of the medical record revealed that there was no documented evidence that the Attending Physician had spoken to the family about the recommendations or provided education to the family. The Director of Nursing Services (DNS) was interviewed on 12/4/2017 at 9:45 AM and stated that the Attending Physician for Resident #6 for the June-July 2017 period is no longer associated with the facility. She stated that if the family disagreed with the Psychiatrist recommendations, then the Primary Physician should have spoken to the family and provided a rationale for the recommendations and documented these discussions. On 12/4/2017 at 10:12 AM Resident 36's current Attending Physician was interviewed. He stated that if a family refuses he would want to make sure that it is the health care proxy that is refusing. He added that the Psychiatrist could also speak to the family regarding the [MEDICAL CONDITION] medications. He stated that if an RN calls the family and the family refuses the medication recommendations, then there is not much that could be done. He further stated there would be further follow-up going forward. On 12/4/2017 at 11:00 AM the facility's Medical Director was interviewed. She stated that she would try to hold one of the doses; for instance, if the medication was three times per day, she would try two times per day and see what happens. In addition, she stated that the family could be educated about the black-box warning related to the anti-psychotic drugs. 415.12(l)(2)(ii)

Based on observation and staff interviews during the recertification survey the facility did not ensure that the infection prevention and control program was followed to help prevent the transmission of communicable diseases and infections on two of three nursing units. Specifically, on the third and fourth floor nursing units the charge nurses stated that after using blood glucose monitors (glucometers) they clean them using alcohol prep pads rather than a germicidal wipe. The finding is: The facility's undated policy titled Infection Control and Blood Glucose Monitoring states to clean and disinfect glucometers after each use between residents. The policy does not specify what type of product should be used to disinfect the glucometer. On 11/29/2017 at 12:47 PM the 4th floor medication cart was observed with the Licensed Practical Nurse (LPN) Charge Nurse. There was one glucometer in the cart that is used for all residents on the unit that require blood glucose testing. Alcohol prep pads were observed in the top drawer of the cart, but no germicidal wipes. The LPN stated that she cleans the glucometer after each use with alcohol wipes. She stated that there may be another type of wipe that can be used and proceeded to check a unit storeroom. After checking the storeroom, she said the other type of wipe she was looking for was not in the storeroom. On 11/29/2017 at 12:54 PM the 3rd floor medication cart was observed with the LPN Charge Nurse. There was one glucometer in the cart that is used for all residents on the unit that require blood glucose testing. Alcohol prep pads were observed in the top drawer of the cart. The LPN stated that he cleans the glucometer 99.9% of the time with alcohol pads. He stated that he could use the purple-top wipes (germicidal) with gloves, but most of the time alcohol pads are used. The germicidal wipes were observed in the bottom drawer of the medication cart. On 11/29/2017 at 1:06 PM the 2nd floor medication cart was observed with the LPN Charge Nurse. There was one glucometer in the cart that is used for all residents on the unit that require blood glucose testing. The LPN stated that the glucometer is cleaned with the purple-top germicidal wipes. There was a container of the germicidal wipes on top of the cart. On 11/29/2017 at 1:30 PM the Director of Nursing Services (DNS) was interviewed. She stated that the nurses must use the germicidal purple-top container wipes to clean and disinfect glucometers after each use. The DNS stated the nurses would be inserviced. A list of diabetic residents was provided by the DNS on 11/29/17. At the time of the survey there were two diabetic residents on the 4th floor and there were five diabetic residents on the 3rd floor. 415.19(a)(1-3)

Based on observation, and staff interview during the recertification survey the facility did not ensure that for one of three nursing units, (fourth floor) housekeeping and maintenance services were provided to maintain a sanitary, orderly, and comfortable interior. Specifically, several of the fourth floor resident rooms and the dayroom/dining room were observed to have multiple areas of exposed plaster; ripped and torn wallpaper; walls in need of painting; cable line plastic covers were separated from the wall and/or broken; cove molding missing in areas, and/or separated from the wall and generally heavily soiled. Also observed were chipped/missing floor tiles, and rusted radiators in resident rooms/bathrooms. The findings included but are not limited to: During resident room observation on the fourth floor on 10/11/2016 between 11:00 AM and 1:10 PM the following was observed: In Room #402 (Resident #70) The cove molding was separated from the wall to the right of the resident's bed. There were small holes observed in the wall opposite the resident's bed. The sheet rock was broken under the window, and also on the left and right side of the window. There were multiple areas of chipped paint behind the beds. Room #406 (Resident #29) The floor to the left of B bed had a cracked tile with the corner of the tile missing. The wall paper behind the resident's bed was ripped and peeling. The wall across from the resident's bed was observed to have peeling and cracked areas of plaster. The plastic cable cover across from the resident's bed at the base of the wall was cracked and had cable wiring exposed. The cable cover was detached from the base of the wall. The outlet cover plate for the cable wires was separated from the wall. The wall behind the resident's bed had a red electrical outlet with plugs in it and the plate was lifting from the wall, the sheet rock surrounding the unit was cracked and had open gaps. The wall to the side of the bathroom was observed to have multiple plaster cracks. The cove molding was observed to be separated from the wall at the area behind the bed and between the window and the closet. The room was in need of painting. Room #414 A (Resident #43) The lower wall across from both beds was observed to have areas of missing paint with sheet rock exposed. The plastic cable cover along the entire length of the wall was broken and protruding from the wall with cable wire hanging out in the center. The cover plate for the cable wire was separated from the wall and hanging loose from the wall. The wall to the left corner of the bathroom and the wall alongside the resident's bed has a large gap at the lower base of the corner with cracked/broken sheet rock. The floor between the resident's bed and the bathroom wall was heavily soiled and the cove molding was soiled and in disrepair. The floor between B bed and the window was heavily soiled. There were cracks in the wall under the windows on the right lower corner and center. The wallpaper behind B bed was ripped and peeling. There was a hole in the bathroom door and missing wood by the doorknob. The left bottom drawer of the closet is broken with the face of the drawer lying in the drawer. An observation of the fourth floor day/dining room was completed on 10/11/2016 between 12:15 PM and 12:45 PM and the following was observed: The wall paper was ripped and peeling throughout the room. There was wall paper missing to the left of the window. The floor cove molding was missing to the right of the entrance. The floor area in the right back corner of the room was heavily soiled. The cove molding was pulling away from the wall by the radiator. Further environmental observations were made on the fourth floor on 10/12/16 between 11:30 AM and 1:00 PM. Examples include but were not limited to: Room #403: The walls were plastered to the right and left of the entrance door. A gouge was observed at the corner of the wall. There was torn wall paper behind the resident's bed. The wall to the left of the bed by the sink was observed to have torn sheet rock. The walls need painting. The shower room across from room #402 was observed to have 3 missing and 2 chipped tiles on the saddle at the entrance to the room. Room #404: The corner of the wall to the left of the entrance was cracked at the base of the corner. An area of cove molding was missing on the wall to the left of the entrance. The wallpaper behind both A and B beds was observed torn with peeling wall paper and large areas of missing wall paper. Two floor safety mats leaning against the wall by the windows were observed to have torn corners and rips on the side. The plastic cable covers across from B bed were dislodged from the wall. The cove molding to the left of the radiator was separated from the wall. The room needed painting. Room #405 The wall to the left of the entrance was observed to have large areas of plaster. The cove molding was separating from the wall to the left of the entrance. There was sheet rock separating from the wall beneath the windows. There were tears in the wall paper to the left of the bed. Room #410 The wall at the left of the entrance had multiple tears in the sheet rock. There was a hole in the sheet rock under the window. There was a chipped floor tile next to B bed. The sheet rock was exposed behind both A and B bed on the lower half of the wall. On 10/12/16 at 2:00 PM the Administrator was interviewed and stated that the facility has a plan in place to renovate the fourth floor including resident rooms and the unit day room. The Administrator stated that the estimated start of the renovation is March 2017. The administrator stated that the renovation was postponed in order to accommodate the replacement of the windows in the facility. The administrator further stated that the maintenance and housekeeping departments will be making repairs in the resident rooms while awaiting the renovation. On 10/13/16 at 9:35 AM the Licensed Practical Nurse (LPN) charge nurse was interviewed. The LPN stated that she was aware that the other nursing floors were renovated prior to her working here, but that she was not aware of any plan for renovation of the resident rooms or the unit day room on the fourth floor. The Director of Maintenance was interviewed on 10/13/2016 at 2:10 PM. The Director stated that he went through the 4th floor unit yesterday and has replaced and attached new cable covers to the walls. The Director stated that he and his staff have started to strip the floors and clean the cove molding in the resident rooms on the 4th floor. He stated that he would be making repairs on the fourth floor one room at a time and as needed while waiting for the renovations to start. The Director further stated that he believes the renovations for the unit are scheduled to start in March. The Director stated that an outside company does the room renovations. 415.5(h)(2)

Based on observations, record reviews, and staff interviews during the recertification survey, the facility did not ensure that each resident's rights to participate in planning care and treatment or changes in care and treatment were followed. This was evident in 1 of 1 resident reviewed for care plan participation and 1 of 1 resident reviewed for vision services from a total of 24 Stage 2 sampled residents. Specifically, 1) the family member of Resident #80 was interviewed and stated that the family was not always invited to the care plan meetings; 2) Resident #115 had a Vision Care Plan that included interventions to wear and maintain the eye glasses, however, the resident did not have eye glasses. The findings are: 1) Resident #80 has [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE]. An interview with the family member was conducted on 10/16/15 at 11:06 AM. The Family member stated that he was the person who would be responsible involving the resident's care. The family member also stated that the staff had never called him to be invited in the resident's care plan meetings. The family member stated that he was very interested and desired to attend and participate the resident's care plan meeting if invited. An interview with the Social Worker (SW) was conducted on 10/21/15 at 1:30 PM. The SW stated that the resident's family member, who is responsible for the resident's care, will only be invited on the initial care plan meeting and then only annually. The SW added, that the family member is not invited with other care plan meeting unless there is a significant change. 2) Resident #115 was originally admitted on [DATE] for short-term rehabilitation with [DIAGNOSES REDACTED]. The 7/31/2015 Admission Minimum Data Set (MDS) assessment documented that the resident had a Brief Interview for Mental Status (BIMS) score of 7, indicating the resident is cognitively impaired. The MDS documented that the resident had impaired vision but no corrective lenses. A Comprehensive Care Plan (CCP) for Vision, effective 7/24/2015, documented that the resident had impaired vision secondary to [MEDICAL CONDITION] and the aging process and used glasses but did not have them on admission. However, interventions included to have eye glasses on when awake and to maintain the eyeglasses (i.e., cleaning, labeling). On 10/15/2015 at 2 PM Resident #115 was observed in her room with her son. She was not wearing eye glasses. On 10/19/2015 at 9:20 AM Resident #115's Certified Nursing assistant (CNA) was interviewed. She stated that she had not seen the resident with eye glasses. The CNA asked the resident in her native Creole about eye glasses. The resident stated that she had eye glasses in Haiti, but they broke and were not replaced. On 10/19/2015 at 9:30 AM the Licensed Practical Nurse (LPN) Charge Nurse was interviewed. She stated that Resident #115 was not admitted with eye glasses and that the vision care plan should be updated to remove the interventions related to wearing and maintaining eye glasses. 415.11(c)(2)(i-iii)

Based on observation, staff interview, and record review during the recertification survey the facility did not ensure that care was provided to meet professional standards of quality. Specifically, during observation of the medication pass on 10/15/2015 for Resident #4, the Licensed Practical Nurse (LPN) Charge Nurse did not administer the 9 AM dose of Eliquis, 2.5 milligrams (mg), but then signed-off on the Medication Administration Record [REDACTED]. The finding is: Resident #4 has [DIAGNOSES REDACTED]. The 9/26/2015 Quarterly Minimum Data Set (MDS) assessment documented that the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. A physician's orders [REDACTED]. Eliquis is a medication that helps prevent platelets from sticking together and forming a clot. On 10/15/2015 at 9:55 AM the LPN Charge Nurse was observed administering medications to Resident #4. Medications administered included Carvedilol 3.125 mg (2 tabs), [MEDICATION NAME] 20 mg (1 tab), Multivitamin tablet, and [MEDICATION NAME] supplement 8 ounces. On 10/15/2015 at 10:50 AM the LPN Charge Nurse was interviewed about the Eliquis. She checked the computer and realized that it was also due with the other 9 AM medications. She looked through the medication cart and could not find additional Eliquis tablets. In addition, she stated that she would change the MAR indicated [REDACTED]. On 10/15/2015 at 11:15 AM the LPN Charge Nurse provided a form that she said the Physician had to sign that was required by the pharmacy in order for additional Eliquis to be provided. She stated that she would discuss this form with the Physician. The LPN stated that the pharmacy had previously sent a shipment of Eliquis for Resident #4 and the resident last received the Eliquis on 10/14/15 at 5 PM. A nursing note, dated 10/15/2015 at 4:32 PM written by the LPN Charge Nurse states that the Medical Doctor was notified that the medication Eliquis 2.5 mg was not administered on tour and as per the Medical Doctor the medication was discontinued. On 10/19/2015 at 11:45 AM a pharmacy representative from the pharmacy that provides medications to the facility was interviewed. She stated that a shipment of 6 tablets of Eliquis was sent to the facility for Resident #4 and received at 2:53 AM on 10/12/2015. The representative said this was the first shipment of Eliquis for Resident #4. The packing slip provided by the pharmacy shows that 6 tablets of Eliquis, 2.5 mg, for Resident #4 were received and signed for on 10/12/2015 by a staff LPN. The MAR indicated [REDACTED]. Subsequent doses were documented as being given on 10/12/2015 (9 AM and 5 PM), 10/13/2015 (9 AM and 5 PM), and 10/14/2015 (9 AM and 5 PM) for a total of 7 doses. On 10/21/2015 at 11:25 AM the LPN that signed off for the 10/11/2015, 5 PM Eliquis dose was called and a message left. This was the same LPN that signed the packing slip receiving the medication on 10/12/2015. On 10/21/2015 at 1:50 PM the DNS stated he spoke to the LPN that documented the administration of Eliquis on 10/11/2015 at 5 PM. The LPN told the DNS that it was an error. 415.11(c)(3)(i)

Based on observation, record review and staff interviews during the Recertification Survey, the facility did not ensure that for one resident with a known Psychiatric Disorder, that effective interventions to address ongoing behavioral disturbance were in place. This was evident for one of one resident reviewed for behavior from a total of 24 Stage 2 sampled residents. Specifically, Resident #107 with a [DIAGNOSES REDACTED]. The findings are: Resident # 107 had [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set assessment dated [DATE] documented that the resident's cognition was intact with a Brief Interview for Mental Status score of 14. The Behavioral Care plan dated 5/21/15 documented and included the following goal: Resident will not display behavior that may cause harm to herself and or others for three months. The Behavioral Care Plan interventions include: Assess for the causes of behaviors Explain all procedures Monitor for the effectiveness of medications Protect resident from self-injury Provide emotional support Social Work visits as needed (PRN) Redirect resident PRN Refer the resident to Psychiatry PRN When upset, use calm gentile approach. Social Work (SW) Progress Notes were reviewed and revealed that there were multiple documented episodes of this resident's behavior not being in control with episodes that included yelling and cursing at staff. The most recent SW progress note dated 10/20/15 at 11:26 AM documented verbal aggression toward care givers and verbal disruption. The 10/20/15 progress note documented that the resident was out in the hallway, yelling. Calming approach tried with little effect. The Physician was made aware and was coming to the facility. An interview was conducted with the SW on 10/20/15 at 12:00 PM. She explained that she has been in the facility a year and has worked with difficult psychiatric residents in the past. In addition, she explained that there is a Behavioral Care Plan developed for the residents' resistive behaviors. An interview was conducted on 10/20/15 at 12:10 PM with the Licensed Practical Nurse (LPN) Charge Nurse. The LPN stated that the behavioral interventions for the resident are not really effective. She explained that you try to calm her but for the most part she is agitated often. The LPN further explained that sometimes the resident yells from her room at the other residents. The LPN further explained that the resident had a standing order for an antianxiety medication. On 10/20/15 at 12:30 PM, the resident could be overheard yelling inappropriate verbiage and threatening the nursing and dietary staff. An interview with the Certified Nurse Aide (CNA) was conducted on 10/20/15 at 12:45 PM. The CNA explained that sometimes efforts to keep the resident calm work. She further explained that even the boyfriend could not calm the resident down today. An interview conducted with Physician on 10/20/15 at 1:45 PM revealed the following: The resident yells at the Physician and her behavior is an ongoing problem. The Physician further explained that the resident does not want to return to her old apartment. She is not a danger to herself. The Physician stated that the facility will attempt to find a long term placement in a psychiatric unit. An interview conducted with the RN Supervisor on 10/20/2015 at 2:25 PM revealed that she is aware of the resident's inappropriate behaviors and that since she is too vocal she probably does not belong here. 415.12(f)(1)

Based on observation, record review, and staff interview during the recertification survey, the facility did not ensure that the resident environment remains as free of accident hazards as is possible to prevent accidents. This was evident on 1 of the 3 nursing units toured on the first day of the survey. Specifically, on the 2nd Floor Unit, the Soiled Linen Closet was not locked. There was a container full of sharps found inside the closet. A screw of the closet door lock was observed to be sticking out and preventing the door from properly locking. The finding is: During the initial tour of the 2nd Floor Unit conducted on 10/15/15 at 9:30 AM, the following was observed: -the Soiled Linen Closet was not locked -a container full of sharps was found inside the closet -a screw of the closet door lock was observed sticking out preventing the door to properly lock. There were several ambulatory residents on the unit. The Soiled Linen closet is near the dining room and breakfast was in process. The Licensed Practical Nurse (LPN) Unit Charge Nurse was immediately interviewed on 10/15/15 at 9:35 AM. The LPN stated that the Soiled Linen Closet should be locked at all times. An interview with the Unit Housekeeping Staff was conducted on 10/15/15 at 9:40 AM. The Housekeeping Staff stated that the closet should be locked and that he will have the Maintenance Staff to repair the screw on the door lock that prevented the door to properly lock the closet door. There was no work log request for the Soiled Linen Closet door prior to 10/15/15. 415.12 (h)(1)

Based on record review, staff interview, and observation during the recertification survey, the facility did not ensure that a resident having pressure sores received necessary treatment and services to promote healing. This was evident for one of three residents reviewed for pressure ulcers in a total of 24 stage 2 sampled residents. Specifically, Resident #33 was identified by the facility on initial admission 4/10/2012 to have a Suspected Deep Tissue Injury (DTI)/ Intact Blister to the resident ' s Left Heel. There was no documented evidence in the medical record that the resident ' s skin impairment was treated until 4/20/2012, ten days later when the blister to the resident ' s left heel opened. This resulted in actual harm that is not immediate jeopardy. The finding is: Resident #33 was admitted to the facility 4/10/12 with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented in (section M0150) that the resident was at risk for developing pressure ulcers. There was no documentation in section M0300 (G) that the resident had a suspected DTI. The resident had short and long term memory problem and was moderately impaired in daily decision making. The Quarterly MDS assessment dated [DATE] document the resident also had short and long term memory problem and was moderately impaired in daily decision making. A pressure ulcer dressing change observation was conducted with the License Practical Nurse (LPN) on 11/27/12 at 11:10 AM. The wound to the resident's Left heel and the area above the heel was irregular in shape like the figure "8". The area to the lower heel revealed yellow slough (per MDS guidelines, Stage 4) to the inner wound edge and wound base pink. The area above the heel revealed yellow slough to the wound base. The Nursing Admission/Readmission assessment dated [DATE] documented " Discoloration probably a DTI Intact Blister " to the Left Heel. The physician progress notes [REDACTED]. There was no further description of the Left Heel skin condition in the Nurse's note or the Physician notes until 4/20/2012. A Nursing Progress note dated 4/20/2012 documented the resident was noted with an open blister to his left Heel and the Physician was aware. Treatment ordered to cleanse the left Heel open area with Normal Saline then apply [MEDICATION NAME] Ointment topped with Dry Protective Dressing (DPD) until healed. Therapy made aware for open back Darco shoes. A Weekly Pressure Sore Progress assessment dated [DATE] documented Left heel Suspected DTI measuring 3 cm x 3.5 cm draining moderate amount of serosanguinous drainage, wound color red pink, and surrounding pink and [MEDICAL CONDITION]. On 4/24/12 the wound was not staged and measured 6 cm x 8 cm draining moderate amount of serosanguinous drainage. On 11/21/12 the wound was a Stage 4 and measured 8 cm x 3 cm x 0.1 cm draining small amount of serosanguinous drainage, wound color pink with yellow slough and surrounding skin pink. In the comment section it is documented improvement is slow. A Nurse's Note dated 4/25/12 documented the resident was seen by D/U rounds team for evaluation of left heel DTI measuring 6 cm x 8 cm, no undermining with moderate serosanguinous exudate. A Resident Treatment Administration Record (TAR) dated 4/2012 lacked documented evidence that a treatment was in place for the resident ' s left Heel from 4/10/2012 to 4/20/12. The TAR revealed that the treatment was started to the resident's left heel when the blister opened on 4/20/2012. The TAR also revealed that the resident was on universal Fragile Skin Precaution since 4/20/2012. A review of the physician's orders [REDACTED]. A Comprehensive Care Plan developed for Pressure Ulcer dated 4/10/2012 documented the resident has pressure ulcer secondary to decrease functional status and impaired mobility. Intervention includes A) Nursing will do treatment as per the Physician order, B) Nursing will monitor progress of pressure ulcer and report negative findings to the Physician C) Nursing will measure pressure ulcers weekly and as necessary (PRN) recording same on wound flow sheet. The At risk pressure sore Care Plan dated 4/10/12 documented relieving device, heel pads. In an interview conducted with the DNS on 11/27/12 at 11:50 AM, she stated that the resident's "DTI intact blister" was monitored on a weekly basis. In a subsequent interview with the DNS on 11/27/12 at 1:30 PM, she stated that when a resident has a suspected DTI or an intact blister a heel pad is used. The DNS stated that all newly admitted residents are placed on universal fragile skin precaution and receive heel booties. The DNS further stated that it was on weekly wound rounds that they found the open blister to the resident's left heel. In an interview conducted on 11/27/12 at 1:45 PM with the 7:00 AM to 3:00 PM Certified Nursing Assistant (CNA), he stated that on 4/11/12, the following day after the resident was admitted he was assigned to the resident. The CNA stated that he observed a discoloration that was soft and fluid filled to the resident's left heel. The CNA stated that he reported the discoloration to the unit nurse. The CNA stated that the resident was ambulatory and that he assisted him to the bathroom. The CNA stated that the resident wore sneakers when he was first admitted and that after the blister was observed the sneaker was not worn on the left foot. The CNA stated the resident did wear heel booties. A telephone interview was conducted on 11/27/12 at 1:55 PM with the attending Physician. The Physician stated that he documented in the Medical History and Plan of Care that the resident had bruises and an Unstageable pressure ulcer to the left heel. The Physician stated that the resident had an open Unstageable wound to the left heel on 4/12/12 and that a DPD with heel pad is the usual treatment. The Physician further stated that the resident should be followed by the wound care team weekly and appropriate ointment ordered as needed. The RN who completed the Nursing Admission Assessment on 4/10/2012 was unavailable for interview. The Facility Pressure Ulcer Prevention Policy and Procedure revised 10/2009 documented the Director of Nursing will conduct ongoing monitoring of the facility's skin integrity program to ensure that appropriate preventative interventions are in place for "at risk" residents and residents with actual pressure ulcers have a plan of care implemented to promote healing of the ulcer. 415.12(c)(1)(2)