Every finding on record at St Josephs Place

Based on observation and interview the facility failed to ensure a safe clean, comfortable, environment for three (3) of six (6) residents (Resident #20, Resident #25, Resident #33,) reviewed for Environment. Specifically, 1) wheelchairs for Resident #20 and Resident #25 were soiled, the walls in Resident #25's room had holes/dents/ unfinished paint and exposed caulk and Resident #33's wheelchair had torn fabric edges, soiled/worn padding on the armrests, and 2) the end cap on the radiator in the bathroom in room [ROOM NUMBER] was not affixed leaving an exposed sharp edge.The findings included:The policy for Wheelchair Cleaning and Disinfection last reviewed 11/03/2025, documented the facility committed to maintaining a clean and sanitary environment to reduce the risk of infection transmission. All wheelchairs will be cleaned and disinfected on a routine monthly basis using a standardized tracking and identification process.The policy for Corrective Maintenance Requests dated 05/01/2025 documented methods for requesting work requests are as follows: telephone reporting was appropriate for emergencies, client priority requests, and breakdowns; work request forms for non-routine jobs; site specific for client order entry systems, email, or other electronic messaging; web work request is the preferred method using internet/intranet capability. The policy applies to all facility personnel. 1) During an observation on 03/25/2026 at 8:57 A.M., Resident #25's wheelchair had dirt on the mesh sides and wheels. Resident #25 was not in the chair at that time.During an observation on 03/25/2026 at 9:11 A.M., Resident #33's wheelchair had grime on the wheels, the right arm rest pad was worn, and the left arm rest was worn and torn. Resident #33 was sitting in the wheelchair.During an observation on 03/25/2026 at 9:15 A.M., Resident #20's reclining wheelchair had stains, dust/dirt particles on the brown fabric on both sides and a visible dust film on the frame and cushion siding. During an interview on 03/25/2026 at 1:17 P.M., the Bio Med Area Service Manager stated wheelchair cleaning was their responsibility. They stated nursing was responsible for putting the wheelchairs in the dining area daily for cleaning and when cleaning was completed. They stated a colored band should be placed on the wheelchair indicating it was cleaned. They stated in March they used black bands and were not certain what band color was used in February. During an observation on 03/25/2026 at 1:29 P.M., no colored band was located on Resident #20's wheelchair. Resident #25 and Resident #33's wheelchairs had grey colored bands. During an observation on 03/27/2026 at 12:48 P.M., Resident #20's wheelchair had visible dust and dirt spots on the frame. 2) During an observation in room [ROOM NUMBER] on 03/24/2025 at 12:25 P.M., the end cap for the bathroom radiator was on the floor. The radiator had a sharp, pointy exposed edge. During an observation on 03/25/2026 at 10:04 A.M., the radiator end cap remained off and was on the floor. During an interview on 03/25/2026 at 10:20 A.M., Certified Nurse Aide #7 stated if a repair was needed, they would tell the unit clerk and they would enter an order for repair. They stated the broken radiator end cap in room [ROOM NUMBER] was an ongoing issue. They stated they thought maintenance worked on it before, but it did not appear to be repaired yet. During an interview and observations starting at 03/25/2026 at 11:02 A.M., the Director of Maintenance stated staff could place a work order request through the intranet. They stated the radiator end cap in room [ROOM NUMBER] should be secured and not on the floor. They stated they did not receive a work order to repair the radiator end cap. 10NYCRR 415.5 (h)(2)

Based on observations, interviews, and record reviews during the recertification and abbreviated surveys (2796313), the facility did not ensure that residents knew how to file a grievance or were informed of the response to the grievance for 12 of 12 residents (Resident #11, Resident #29, Resident #34, Resident #13, Resident #20, Resident #24, Resident #25, Resident #8, Resident #35, Resident #41, Resident #14, Resident #26) interviewed during resident council and one (1) of three (3) residents reviewed for care planning (Resident #17). Specifically, 1) Residents interviewed during resident council were not aware of the grievance process and there was no documented evidence listing the grievances and response to grievances; 2) Resident #17's representative had multiple concerns and grievances regarding Resident #17's plan of care that were inconsistently addressed and documented. The findings included:1)The facility Grievances policy dated 11/2016 documented the purpose as supporting each resident's right to voice grievances and assuring that after receiving a complaint/grievance, the facility actively seeks a resolution and keeps the resident/resident representative appropriately apprised of its progress toward resolution. During an interview on 03/24/2026 at 9:18 AM the Social Services/Admissions Coordinator stated they were the Grievance Officer and if they received a complaint, they would interview residents. They stated they would also email Administration with related information if it was something they could not resolve. They stated they could not provide a grievance log or grievance form for grievances.During an interview on 03/24/2026 at 9:37 AM, the supervising Administrator stated the Social Services/Admissions Coordinator was the Grievance Officer and should have a record of all grievances. During a Resident Council meeting on 03/24/2026 at 10:30 AM, Resident #8 stated residents air grievances in the meeting but outside the meeting the process is unclear. Other participating residents confirmed they did not know how to file grievances. During a follow up interview on 03/26/2026 at 11:47AM, the Social Services/Admissions Coordinator stated if they were made aware of a complaint or incident they would speak to the resident and try to resolve the issue. They would forward it to the Administrator or Director of Nursing if applicable. They stated administration would complete the additional investigation and follow through on those cases. They stated there were no forms or documentation to track grievance progress and resolution.During an interview on 03/26/2026 at 12:03 PM the Director of Nursing stated grievances should be monitored by Social Services and should have the nature of the complaint and what the resolution was. They stated their process was informal and depended on circumstances. They stated they discussed issues in morning meetings and residents expressed concerns during resident council. They stated the process was not completely clear and could be improved.2) Resident #17 had diagnoses that included cerebral infarction, occlusion and stenosis of the left carotid artery (blockage of the artery supplying blood to the brain on the left side), and myocardial infarction (heart attack).The admission Minimum Data Set, dated [DATE] documented moderately impaired cognition and that the resident and family were involved in assessment and goal setting. During an interview on 03/27/2026 at 9:10 AM Resident #17's representative stated there were multiple concerns expressed regarding Resident #17's care including miscommunication between nursing and rehabilitation, discharge planning, scheduling appointments, call bell response time, personal property, resident preferences, nutrition and proper diet. They stated they communicated everything to Administration and submitted everything via email and paper copies. They stated they had a family meeting on 03/11/2026 but felt dismissed. They stated they were not provided with updates unless they persisted. They stated communication was very poor. During an interview on 03/30/2026 at 10:59 AM, the Social Services/Admissions Coordinator stated they had a family meeting on 03/11/2026 to discuss concerns Resident #17's representative had since Resident #17 was admitted , but no documented evidence of how each grievance was addressed and/or resolved. During an interview on 03/30/2026 at 1:16 PM, the Director of Nursing stated Resident #17's representative expressed many concerns since Resident #17 was admitted . They stated most concerns were verbally discussed with the representative. They stated they did not document and investigate every complaint but did have a family meeting on 03/11/2026.10NYCRR 415.3(d)(1)(ii)

Based on observations, interviews, and record reviews during the recertification and abbreviated surveys (#2796313 and 2725477) the facility did not ensure that residents unable to carry out activities of daily living received the necessary assistance with toileting for one (2) of four (4) residents (Resident #27 and #17) reviewed for activities of daily living and other residents that expressed a delay in call bell times during the Resident Council meeting. Specifically, Resident #27 was not provided toileting assistance as needed to maintain or improve their ability to carry out activities of daily living. 2) Resident #17 was observed with their call bell on and not receiving care timely. 3) Other residents expressed concerns with not getting needs met due to delays in response to call bells, and delays were observed. Findings include:The facility policy Activities of Daily Living, last revised 04/2018, documented the facility shall ensure a resident is given the appropriate treatment and services to maintain or improve their ability to carry out the activities of daily living, including elimination and toileting. The facility No Pass policy last revised 06/2025 documented that patient safety is the responsibility of all employees and all staff will respond to patients or visitors in need. If they cannot help, they will find a staff member that can. Never pass the call light by, observe patient privacy, provide what they are asking for, access someone who can; safety first, smile and use the acronym-acknowledge, introduce, duration, explanation, and thank you.1) Resident #27 had diagnoses that included Parkinson's disease, dementia, and heart disease.The Annual Minimum Data Set (an assessment tool) dated 01/22/2025, documented the resident had severely impaired cognition, was dependent on staff for toileting hygiene and was always incontinent for bowel and bladder.Resident #27's care plan dated 01/19/2024 documented the resident had bladder incontinence related to impaired mobility, disease process, Parkinsons, and dementia. The intervention dated 01/19/2024 documented to check the resident for incontinence and change clothing as needed after incontinence episodes.Resident #27's care plan dated 03/06/2024 documented the resident was at risk for falls related to poor communication/comprehension/effects of Parkinson disease, poor balance, poor communication/comprehension, and unsteady gait. The intervention dated 04/24/2025 documented to anticipate toileting needs every two (2) hours and assist to the toilet.January, February and March 2026 Kardex documented the staff was to anticipate the resident's toileting needs every two (2) hours and to assist to the toilet. The resident required maximum assistance with one (1) staff member for toilet use and the resident required assistance of 2 staff for transfers.The January 2026 certified nurse aide documentation survey report had no documentation on 12 shifts for toileting the resident and on 59 occasions for performing two (2) hour checks on the resident.The February 2026 certified nurse aide documentation survey report had no documentation on 6 shifts for toileting the resident and on 27 occasions for performing two (2) hour checks on the resident.The March 2026 certified nurse aide documentation survey report had no documentation on 2 shifts for toileting the resident, and on 9 occasions for performing two (2) hour checks on the resident.A review of the 1/28/2026 Nursing Home Investigative Report documented that on 01/22/2026 at 3:00 PM, Resident #27's Family Member #1 discovered that the resident's e clothing and wheelchair cushion were saturated with urine. The Administrator was notified and confirmed the Residents #27 urine saturated clothing and wheelchair cushion. Certified Nurse Aide #13 was assigned to assist with the activities of daily living and certified nurse accountability tasks for Resident #27 from 07:00 AM to 03:00 PM on 01/22/2026. Certified Nurse Aide #13 stated they did not change the resident at all during the eight-hour shift and went home without doing any end of day cares for the resident or informing anybody at any point through the shift that they were unable to care for the resident.In an undated statement, Certified Nurse Aide #13 stated they did not check on Resident #27 until 11:00 AM on 01/22/2026.A staff assignment sheet dated 01/22/2026 documented Certified Nurse Aide #13 was not assigned to Resident #27. Certified Nurse Aide #13 was assigned 13 other residents.During an interview on 3/30/2026 at 12:04 PM, the Director of Nursing stated after Resident #27's family member reported that the resident was saturated in urine they checked on all the residents on Certified Nurse Aide #13's assignment. They stated the assignment sheet must have had a mistake as Certified Nurse Aide #13 admitted to not providing care.In an interview on 03/29/2026 at 6:05 PM, Resident #27's Family Member #2 stated they visited the facility every Sunday around 4:00 PM and had observed the resident with a strong urine smell three (3) times in the past few months. When notified of the urine, the facility staff cleaned the resident. It had been better the last six (6) weeks.In an interview on 03/30/2026 at 9:41 AM, Certified Nurse Aide #9 stated Resident #27 was checked every two (2) hours, after meals and before leaving at the end of day. They stated Resident #27 was able to stand to have their brief removed and could tell staff when they needed to be cleaned. 2) Resident #17 had diagnoses including cerebral infarction (stroke), and myocardial infarction (heart attack).The admission 5 Day Minimum Data Set, dated [DATE] documented the resident had moderately impaired cognition, no behaviors, and required maximal assistance with toileting, moderate assistance to shower, set up for upper body dressing, and moderate assist with lower body dressing.During an observation and interview on 03/23/2026 at 11:22 AM Resident #17's call bell was ringing and they stated they waited a long time for cares. They stated they had been waiting since 9:00 AM. At 11:31 AM staff responded to bell and assisted with morning cares.During an observation and interview on 03/25/2026 at 10:02 AM, upon surveyor entry to the unit, Resident #13 and Resident #17 were in bed and the call bell for their room was ringing. Resident #13 stated they had been waiting to get washed, dressed, and out of bed. They stated it was late, and they were usually up by that time. They stated they had been waiting for half an hour. At 10:20 A.M. Certified Nurse Aide #7 arrived to assist with care. During an interview on 03/27/2026 at 9:10 AM Resident #17's Representative stated call bell response time was very concerning. They stated they communicated their concerns to the staff, including specific episodes on 02/27, 02/28, and 03/07/2026, when the time exceeded one (1) hour. During an interview on 03/30/2026 at 1:16 PM the Director of Nursing stated call bells should be responded to when heard. They stated the time it took for staff to respond depended on the staff scheduled for the shift. They stated it was difficult to give a reasonable time frame, but thirty to sixty minutes was not acceptable. 3) The December 2025 Resident Council Minutes documented residents stated that call bell wait-times had improved some but continued to be answered on the longer side. They felt more nursing staff were needed. The January 2026 Resident Council Minutes documented that residents stated that call bell wait times continued to be on the longer side.The February 2026 Resident Council Minutes documented that call bell wait-times continued to be too long.Call bell audits completed by facility staff on 03/6/2026, 03/07/2026, 03/10/2026, and 03/12/2026 in response to call bell complaints documented a total of 23 observations. The longest recorded observation was 45 minutes followed by another 15 minutes for room [ROOM NUMBER] on 03/10/2026.During the Resident Council meeting on 03/24/2026 at 10:30 AM, Resident #26 stated response to call bells was too long and could be anywhere from 15 minutes to an hour regardless of the shift. Resident #8 stated on weekends they often only had 3 (three) certified nurse aides scheduled, contributing to the long call bell wait times. During an observation on 03/25/2026 at 9:36 AM, the call bell for room [ROOM NUMBER] bed was observed ringing. At 09:45 AM the bell continued to ring, and staff were observed passing the room. At 9:50 AM Certified Nurse Aide #9 entered the room and asked Resident #22 what they needed. Resident #22 stated they needed the bedpan. Certified Nurse Aide #9 asked why they had not let them know earlier when they were providing care. Resident #22 stated they did not have to use the bedpan earlier. Certified Nurse Aide #9 stated they would be back and returned at 10 AM to provide assistance.During an observation on 03/27/2026 at 11:00 AM the call bell was ringing for room [ROOM NUMBER]. A medication nurse was observed passing medications in the hallway outside of room [ROOM NUMBER]. The Social Work/Admissions Coordinator came out of their office across from the room but did not enter room [ROOM NUMBER]. At 11:11 AM Certified Nurse Aide #7 passed room [ROOM NUMBER] and Unit Clerk #8 passed room [ROOM NUMBER]. At 11:17 AM Unit Clerk #8 was asked to view the time on the call bell device and stated it was 27 minutes. At 11:19 AM, the call bell stopped ringing. During an interview on 03/27/2026 at 12:53 PM, Resident #22's Spouse stated they received at least 10 phone calls from Resident #22 during the overnight shift requesting that they call the nurses' station because they were waiting for someone to respond to their call bell. They stated when they called the nurses' station to get assistance for Resident #22, it took a long time for someone to answer the phone.During an interview on 03/30/2026 at 1:16 PM the Director of Nursing stated call bell response was a no pass policy. Call bells should be responded to when heard. They stated the time it took for staff to respond depended on the staff scheduled for the shift. They stated it was difficult to give a reasonable time frame, but thirty to sixty minutes was not acceptable. 10 NYCRR 415.12 (a) (3)

Based on observation, interview, and record review during the recertification and abbreviated surveys (2796313), the facility failed to ensure that residents received treatment and/or care in accordance with professional standards of practice for one (1) of four (4) residents (Resident #17) reviewed for Activities of Daily Living. Specifically, Resident #17 was not scheduled to have a follow up appointment with the cardiologist within the time frame indicated on the patient hospital discharge instructions. Findings include:Resident #17 had diagnoses that included cerebral infarction, occlusion and stenosis of the left carotid artery (blockage of the artery supplying blood to the brain on the left side), and myocardial infarction (heart attack).The Patient Discharge Instructions dated 02/05/2026 documented schedule follow up with cardiology within one (1) month. The admission Minimum Data Set, dated [DATE] documented moderately impaired cognition and the resident and family were involved in assessment and goal setting. During an interview on 03/27/2026 at 9:10 A.M., Resident #17's representative stated Resident #17 was supposed to have a follow-up appointment with the cardiologist within one month of being admitted to the facility. They stated they had discussed the hospital discharge instructions and the appointment needed with the Director of Nursing but did not receive any assistance and scheduling was delayed. With persistence, they were finally able to get the appointment scheduled for 04/01/2026.During an interview on 03/30/2026 at 1:16 P.M. the Director of Nursing stated Resident #17's representative told them that a cardiology consultation needed to be scheduled for Resident #17 after they were admitted to the facility. They stated it should have been scheduled sooner but they did not see the follow up appointment on the discharge summary. They stated they were not aware there were additional discharge papers that documented the need to schedule a follow-up appointment with cardiology. 10NYCRR 415.12

Based on observation, record review, and interview, the facility failed to ensure each resident received necessary respiratory care, including oxygen therapy, in accordance with professional standards of practice and physician orders for one (1)) of three (3) residents (Resident #9) reviewed for Respiratory Care. Specifically, oxygen was not administered at the correct flow rate per physician order for Resident #9. Findings include:The policy and procedure titled Oxygen Administration, last revised 06/26/2025, documented the purpose was to ensure safe oxygen administration according to the physician's order.Resident #9 had diagnoses of chronic atrial fibrillation (long-term irregular heartbeat), congestive heart failure (fluid buildup in the lungs), and heart failure (the heart not pumping blood as effectively as expected).The Annual Minimum Data Set, dated [DATE] documented Resident #9 had severe cognitive impairment and received oxygen therapy.The physician order dated 12/23/2025 documented oxygen at two (2) liters per minute via nasal cannula as needed for shortness of breath.During observations on 03/23/2026 at 11:30 AM, 03/24/2026 at 9:00 AM, and 03/25/2026 at 10:30 AM, Resident #9 was in bed with three (3) liters of oxygen administered via nasal cannula.During an interview with Licensed Practical Nurse #1 on 03/30/2026 at 1:13 PM, they stated nursing staff on all shifts were responsible for properly calibrating oxygen. Licensed Practical Nurse #1 stated the oxygen should have been set at two (2) liters per minute and stated that the oxygen would be adjusted to the correct level as ordered.10 NYCRR 415. 12 (K) (6)

Based on observation and interview the facility failed to ensure proper disposal of garbage and refuse. Specifically, the recyclables front load dumpster was missing one lid, and one bag of food garbage was lying on the ground behind the kitchen loading dock.The findings are:The policy titled Waste Handling, Storage, Transportation and Disposal dated 10/01/2024, documented outside trash containers must be covered at all times and rodent resistant to mitigate the risk of vermin issues. Inspect areas and containers, including compactors to make sure all are properly cleaned and maintained.During an observation of the garbage area on 03/30/2026 at 01:32 P.M., the recyclables front load dumpster had one of its two lids missing which prevented the recyclable materials from being secured. One plastic bag of kitchen garbage was on the ground behind the kitchen facility loading dock. During an interview on 03/30/2026 at 01:35 P.M., the Food Service Director stated they were not aware of the missing lid on the recyclables front loading dumpster. The bag of garbage should have been placed into the trash compactor and not left on the ground. During an interview on 03/30/2026 at 01:43 P.M., the Administrator stated kitchen staff were responsible for the garbage and containers. Housekeeping was responsible for coordinating repairs of the containers with the refuse company. They stated they were aware that container lids must be present and able to function to prevent rodents or other animals.During an interview on 03/30/2026 at 01:56 P.M., the Director of Environmental Services stated the Food Service Director was responsible for contacting the refuse company with issues related to the condition of refuse bins.10 NYCRR 415.14(h)

Based on observation, interview, and record review the facility failed to ensure that soiled linens were handled, stored, processed, and transported to prevent the spread of infection. Specifically soiled linen carts were observed stored both overflowing and closed on the unit hallway adjacent to the clean linen cart. There were bagged soiled linens observed on the floor and open bags with exposed soiled linens in the soiled utility room.The findings included: The policy titled Soiled Linen Handling dated 10/01/2024 documented linen hampers should not be overfilled with soiled linens. Soiled linen carts are taken to the holding area after placing soiled linens in the cart. During an observation on 03/27/2026 at 11:06 AM an open overflowing soiled linen cart was stored in the hallway adjacent to the clean linen cart along the wall next to room [ROOM NUMBER]. During an observation on 03/27/2026 at 11:22 AM of the soiled utility room, bagged soiled linens were on the floor and soiled linens were exposed and coming out of bags and bins in the room.During an interview on 03/27/2026 at 11:24 AM, Certified Nurse Aide #2 stated overflowing carts of soiled linens should not be in the hallway and should have been moved to the soiled utility room. They stated soiled utility room should not have dirty linen bags on the floor and exposed dirty linens in the room. They stated soiled linens should be contained in appropriate bins.During an observation on 03/29/2026 at 04:10 PM, a closed soiled linen cart with soiled linens was stored in the hallway adjacent to the clean linen cart along the wall next to room [ROOM NUMBER].During an interview on 03/30/2026 at 01:16 PM the Director of Nursing stated soiled linen carts should be transferred into the soiled utility room after use. Full and open carts should not be stored in the hallway and should be transferred into the soiled utility room. They stated soiled linens should be contained in the appropriate bags and receptacles in the soiled utility room and should not be on the floor. 10NYCRR 415.19 (c)

Based on interview and record review conducted during the most recent recertification survey, the facility did not ensure that appropriate behavioral care was provided to address the ongoing problem of depression for 1 of 5 residents (Resident #33) reviewed for the use of psychoactive medications. Specifically, 1) the resident's initial comprehensive assessment did not address the resident's behavioral care history which necessitated the need for the treatment of [REDACTED]. The findings are: Resident #33, a [AGE] year-old male with the [DIAGNOSES REDACTED]. The resident's admission physician's orders [REDACTED]. The admission Minimum Data Set (MDS, an assessment instrument) revealed that the resident had no cognitive impairment and was receiving psychoactive medications (antidepressant and antipsychotic) during the assessment period. The Care Area Assessment (CAA, an extension of the MDS designed to provide in depth information about the root cause for the triggered care area) was reviewed. This CAA did not refer to any other source that could provide in depth information about the use of the above mentioned medications or the resident's behavioral/psychiatric history. The CAA noted that the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Additionally there was no history regarding the use of these medications prior to admission to the facility. This infomation was necessary to develop an approriate plan of care to address the resdient's behavioral care needs. The resident's plan of care addressing depression was initiated on 10/21/17. The goal was for the resident to exhibit indicators of depression, anxiety and sad mood less than daily. The interventions included to achieve this goal were to 1) administer the medications as ordered and monitor for effectiveness and side effects, 2) psy (psychiatric) consult as indicated and 3) monitor for signs and symptoms of depression. On 12/19/17 an initial psychiatric evaluation was completed for the resident. This evaluation noted that the facility's nursing staff reported that the resident's mood demonstrated lack of reaction to pleasant events and that he showed indifference. The psychiatrist's assessment was that the resident's mood was a bit better. The [DIAGNOSES REDACTED]. This evaluation made no reference to the root cause(s) for the resident's depression prior to admission and since admission to the facility. It also included no recommendations to address the need for supportive counseling or other non-pharmacological interventions to help the resident cope and minimize dependence on psychoative medications . On 12/31/17 a physician's orders [REDACTED]. On 1/29/18 the resident was again evaluated by the psychiatrist. This evaluation showed that a recommendation was made for [MEDICATION NAME] to be increased due to ongoing problems with depression. There was no reference made regarding supportive counseling. On 2/6/18 the physician's orders [REDACTED]. A review of the resident's medical record (social workers notes and the evaluation of the resident's plan of care) did not include evidence that the need for supportive counseling was addressed by the care planning team memebers between 12/31/17 and 8/8/18 prior to increasing [MEDICATION NAME]. On 8/9/18 the resident was evaluated by a psychologist. The psychological evaluation noted feelings of depression, trouble sleeping, poor appetite, feeling bad about self and thoughts that would be better off dead. This evaluation also noted that the resident was depressed about not being able to walk and the recent loss of a friend. Ongoing psychological counseling was initiated after this evaluation. Subsequent to the initiation of counseling, the annual MDS dated [DATE] and the most recent quarterly MDS dated [DATE] showed that the resident had no cognitive impairment and no mood problems. The annual MDS also showed that the resident expressed preferences to be engaged in multiple activities. On 6/5/19 the resident was interviewed. He stated that he gets sad at times about not being at home. The social worker assigned to the care of the resident from the time of admission to the time of the psychological evaluation (8/9/18) was no longer employed by the facility. The current social worker was interviewed on 6/7/19 in the afternoon. She was asked to comment on the lack of supportive counseling for the resident and reliance solely on the use of medication to address his problem of depression. After reviewing the resident's record she offered no rationale or explanation why the need for supportive counseling was not addressed prior to 8/9/18. 415.12(f)(1)

Based on interview, observation and record review conducted during the recertification survey and an abbreviated survey (#NY 838), the facility did not provide pharmaceutical services to assure accurate acquiring, receiving and administering of all medications to meet the needs of each resident. This was evident for 1 resident (Resident # 13) reviewed for administration of medications. Specifically, 1) the nursing staff did not ensure that a cholesterol lowering medication, [MEDICATION NAME], documented on the Medication Administration Record as being administered was specifically ordered for the resident, and 2) that this medication was refilled when indicated. The findings are: The facility Policy and Procedure (P&P) for Ordering and Receiving Medications from the dispensing Pharmacy documented the following; a.)Reorder medication (three to four) days in advance of need to assure an adequate supply is on hand. b.) The refill order is electronically transmitted to the pharmacy. Resident #13 is an [AGE] year-old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A blister pack (a type of packaging that protects individual doses of medication) designed for 30 [MEDICATION NAME] tablets and labeled with the resident's name was reviewed on 6/4/19. This review showed that the blister pack was dispensed by the pharmacy to the facility on [DATE] to be refilled after 10/28/2018. (This date signified the date the facility was to alert the pharmacy of the next refill.). Review of the Medication Administration Record (MAR) for the month of (MONTH) (YEAR) showed that the administration of [MEDICATION NAME] started on 10/4/2018 and that the medication was administered for the entire month except on 10/5/2018. According to a nurse's note on 10/5/18 the medication was not administered due to medication pending delivery. Additionally, another nursing noted 10/23/18 showed that the resident refused to take the medication on that date. In (MONTH) (YEAR) the MAR showed that the medication was administered for the entire month except on 11/2/2018, 11/3/2018 and 11/20/2018. The MAR showed that on these dates the resident refused the medication. In (MONTH) (YEAR) the MAR showed that the medication was administered from 12/1/2018 to 12/7/2018 and the medication was discontinued on 12/8/2018. According to the MAR for the period of 10/4/18 to 12/7/18 [MEDICATION NAME] was administered to the resident 60 times and refused 4 times. Since the blister pack received by the facility on 10/4/18 contained only 30 tablets, the Director of Nursing (DON) was asked on 6/6/19 to show evidence that additional [MEDICATION NAME] was obtained from the pharmacy to account for a total of 64 tablets. The DON failed to produce any such evidence. Multiple nursing staff who administered [MEDICATION NAME] to the resident during the period of 10/4/18 to 12/7/18 (as evidenced by their initials on the MAR) and the vendor pharmacist were interviewed to account for the accurate acquiring, receiving, and administration of the resident's medication. The responses are as follows: - On 6/4/2019 3:40 PM LPN #1 stated that she administered [MEDICATION NAME] whenever she was assigned to the resident. She said LPN #2 informed her that the [MEDICATION NAME] blister pack had too many tablets left on it. She said the resident refused her medications a few times. But she had no documentation to reflect it. - On 6/4/2019 at 4:15 PM LPN #2 stated that on 10/5/2018 she documented that [MEDICATION NAME] delivery was pending and did not realized that it was actually delivered on 10/4/2018 and placed in a different cart. She also stated that she was the person to administer the first tablet from the blister pack on 10/9/2018 (despite documentation on the MAR showing that the resident was administered the medication 4 times from 10/4/18 to 10/8/18). She further stated that sometime after 10/9/2018 she realized that the blister pack was not used and brought it to the attention of the charge nurse and DON who assured her that she would take care of it. However, nothing was done about it. (This DON was no longer employed by the facility.) - On 6/6/2019 at 12:55 PM LPN #3 stated via telephone that when she was assigned to the resident the blister pack was supposed to have been completed but it was not, so she reported it to the DON who requested blood work to check the resident's cholesterol level. - On 6/6/2019 at 1:40 PM the vendor pharmacist stated via telephone that [MEDICATION NAME] 30 day blister pack was filled and delivered to the facility on [DATE] and another 30 day blister pack was filled and sent to the facility on [DATE] following a call from the facility by a staff member requesting a refill. She further stated that the order was discontinued 12/8/2018. - On 6/6/2019 at 2:40 PM LPN #4 (who administered the medication on 10/4/18 and is no longer working at the facility) stated via telephone that he did not remember much from the incident as it occurred a long time ago. But he remembered administering the medication the days he was assigned to give them to the resident. He further stated if there was no medication in house the nurses would borrow from another resident receiving the same medication. When asked if he had borrowed medications, LPN #4 did not acknowledge that he administered borrowed medication to the resident. - On 6/7/2019 at 9:30 AM LPN #5 stated via telephone that she was on orientation during the time of the incident and she resigned her position after the two weeks of suspension of all 3-11 shift LPNs. She further stated that she administered the medication as per physician orders [REDACTED]. (The surveyor verified LPN #5's documentation.) - All the above nurses, excluding LPN #4, denied that they borrowed medications. On 6/7/19 in the afternoon the DON was asked to review the facility's records to determine if anyone had signed that they received the second blister pack reported by the vendor pharmacist to have been delivered on 11/22/18. After conducting a search, the DON reported that no documented evidence was found to show that the second blister pack was requested and/or received by the facility. Documentation provided for the receipts of medications for 10/4/18 showed no evidence that the blister pack dispensed on 10/4/18 for the resident was received by the facility on that date. In summary, the MAR showed that 60 [MEDICATION NAME] tablets were administered and 4 refused, totaling 64 tablets for which the facility should account. The evidence provided above did not demonstrate that the facility ensured that the each tablet of [MEDICATION NAME] recorded on the MAR as being administered were specifically dispensed by the pharmacy for this resident. Also, the facility did not ensure that the system in place to account for the receipt of medications was implemented. 415.18(e)(2)

Based on observation and interview during the recertification survey, the facility was not in compliance with Section 915 of the (YEAR) edition of the International Fire Code as adopted by New York State, which requires the installation of carbon monoxide detectors in buildings with fuel-fired appliances. Carbon monoxide detectors were not installed in mechanical rooms containing fuel fired equipment (laundry room, boiler room, generator room, etc) or in previously approved locations. The findings are: The life safety tour of the facility was conducted during the recertification survey on 6/7/19 between 9:00 AM - 1:00 PM. At that time it was observed that carbon monoxide monitors were not installed in areas in which fuel fired (natural gas and diesel) equipment was located. These areas included the generator room located off of the stairwell adjacent to resident room [ROOM NUMBER], the hospital kitchen, the boiler room, and laundry room. In an interview at 9:15 AM on 6/7/19, the Director of Facilities Management stated that there is no fuel fired equipment located on the nursing home unit. He also stated that the hospital is working with local code enforcement officials (Fire Marshal, Code Compliance Officer, Building Inspector) to install carbon monoxide detectors as part of a hospital renovation project that was underway. 483.70 (b)

Based on record review and interview conducted during the most recent re-certification survey, the facility did not ensure that the residents' representatives were notified in writing of the residents' transfer to the hospital. This was evident for 2 of 2 residents (#19, and #34) reviewed for hospitalization . The findings are: 1. Resident # 19 was admitted to the facility 1/9/17 with [DIAGNOSES REDACTED]. The Nursing Progress Notes dated 5/12/19 revealed the resident had episodes of emesis (vomiting) of undigested food and on 5/13/19 the resident was transferred to the hospital with temperature of 102 degrees Fahrenheit. The Admission note dated 5/18/19 revealed the resident had a 5/13/19 discharge to the hospital due to a temperature of 102 with emesis, with a new [DIAGNOSES REDACTED]. The Nurse Manager (RN #1) was interviewed on 6/7/19 at 11:46 AM and stated the nursing staff notified the residents' representatives via telephone when a resident was transferred to the hospital. The Social Worker (SW) was interviewed on 6/7/19 at 11:48 PM and stated she was not aware that the facility was required to send written notification of hospital discharge to the residents' representatives. 2. Resident # 34 was admitted to facility on 5/1/19 with [DIAGNOSES REDACTED]. The Nursing Progress Notes dated 5/13/19 revealed the resident received [MEDICATION NAME] (an antibiotic) for a [DIAGNOSES REDACTED]. The Progress Note of 5/15/19 indicated the resident was transferred to the hospital due to a temperature of 102.8 and had a [DIAGNOSES REDACTED]. The Nurse Manager (RN #1) was interviewed on 6/7/19 at 11:46 AM and stated the nursing staff notified the residents' representatives via telephone when a resident was transferred to the hospital. The Social Worker (SW) was interviewed on 6/7/19 at 11:48 PM and stated she was not aware that the facility was required to send written notification of hospital discharge to the residents' representatives. 415.3(h)(1)(iii)(a-c)

Based on record review and interview conducted during a recertification survey, the facility did not develop a comprehensive care plan with measurable objectives and time frames for one of five residents reviewed for unnecessary medications (Resident #5). Specifically, there was no care plan to address the use of an antispychotic medication ([MEDICATION NAME]). The findings are: Resident #5 has [DIAGNOSES REDACTED]. The current physician's orders [REDACTED]. The Quarterly Minimum Data Set (MDS; a resident assessment tool) of 2/3/16 revealed that the resident scored 3 out of 15 on the BIMS test (used to measure memory and orientation) which suggested that the resident has severely impaired cognitive skills in daily decision making; and was receiving anti-psychotic, anti-depressant and anti-anxiety medications seven days a week during the assessment period. The subsequent Quarterly MDS of 5/4/16 revealed the resident has severely impaired cognitive skills and was taking an anti-psychotic, anti-depressant and anti-anxiety medications seven days a week during the assessment period. Both MDS assessments indicated that the resident did not exhibit any delusions, hallucinations, [MEDICAL CONDITION] and other behavioral symptoms. The resident's care plans were reviewed and revealed there was no documented evidence that a care plan was developed for antipsychotic drug use. Review of the nurse's note indicated that the resident had a verbal altercation with another resident on 6/15/15. There were no behavioral symptoms documented to justify the need to start the resident on [MEDICATION NAME]. Upon further review of the resident's clinical records, including the monthly medication regimen reviews and the psychiatrist's progress notes, revealed that the resident has been stable for a long time and has not shown any behavioral or management issues. There was no documented evidence that a gradual dose reduction was attempted since 6/16/15. The Registered Nurse unit Manager was interviewed on 6/29/16 at 3:00 PM and stated that a care plan was not developed for the antipsychotic medication [MEDICATION NAME]. The unit manager further stated that the resident is still on [MEDICATION NAME] and that there has not been a dose reduction since 6/16/15. The assigned Certified Nursing Aide (CNA) was interviewed on 6/30/16 at 11:49 AM and stated that the resident's behavior has been the same for a long time and that there are times when the resident gets upset and lash out at them. The CNA stated when resident does that, they will leave her alone and come back later. The CNA further stated that sometimes the resident gets upset at the other residents and when that happens they will move her away from them. The Director of Nursing (DON) was interviewed on 6/30/16 at 1:30 PM and stated she reviewed the resident's care plan and that a care plan for antipsychotic use does not exist for this resident. The DON also stated that there is no evidence of a gradual dose reduction for the medication [MEDICATION NAME] despite the resident's stable mental status and occasional outbursts during cares and lashing out at others. The psychiatrist was interviewed on 6/30/16 at 3:30 PM and stated that the resident has been stable on her medications and he did not feel that the medications need to be reduced because she was stable. The psychiatrist stated he will consider doing so now. 415.11 (c) (1)

Based on record review and interview conducted during a recertification survey, the facility did not ensure that a resident was adequately monitored for use and continued use of an antipsychotic medication ([MEDICATION NAME]) for one of five residents reviewed for unnecessary medications (Resident #5). Additionally, a gradual dose reduction (GDR) was not attempted since the medication was started on 6/16/2015 The findings are: Resident # 5 has [DIAGNOSES REDACTED]. The current physician's orders [REDACTED]. The Quarterly Minimum Data Set (MDS; a resident assessment tool) of 2/3/16 revealed that the resident scored 3 out of 15 on the BIMS test (used to measure memory and orientation) which suggested that the resident has severely impaired cognitive skills in daily decision making; and was receiving an anti-psychotic, anti-depressant and anti-anxiety medications seven days a week during the assessment period. The subsequent Quarterly MDS of 5/4/16 revealed the resident has severely impaired cognitive skills and was taking an anti-psychotic, anti-depressant and anti-anxiety medications seven days a week during the assessment period. Both MDS assessments indicated that the resident did not exhibit any delusions, hallucinations, [MEDICAL CONDITION] and other behavioral symptoms. The resident's care plans were reviewed and revealed there was no documented evidence that a care plan was developed for antipsychotic drug use. Review of the nurses note indicated that the resident had a verbal altercation with another resident on 6/15/15. There were no behavioral symptoms documented to justify the need to start the resident on [MEDICATION NAME]. Upon further review of the resident's clinical records, including the monthly medication regimen reviews and the psychiatrist's progress notes, revealed that the resident has been stable for a long time and has not shown any behavioral or management issues. There was no documented evidence that a gradual dose reduction was attempted since 6/16/15. The Registered Nurse unit Manager was interviewed on 6/29/16 at 3:00 PM and stated that a care plan was not developed for the antipsychotic medication [MEDICATION NAME]. The unit manager further stated that the resident is still on [MEDICATION NAME] and that there has not been a dose reduction since 6/16/15. The assigned Certified Nursing Aide (CNA) was interviewed on 6/30/16 at 11:49 AM and stated that the resident's behavior has been the same for a long time and that there are times when the resident gets upset and lash out at them. The CNA stated when resident does that, they will leave her alone and come back later. The CNA further stated that sometimes the resident gets upset at the other residents and when that happens they will move her away from them. The Director of Nursing (DON) was interviewed on 6/30/16 at 1:30 PM and stated she reviewed the resident's care plan and that a care plan for antipsychotic use does not exist for this resident. The DON also stated that there is no evidence of a gradual dose reduction for the medication [MEDICATION NAME] despite the resident's stable mental status and occasional outbursts during cares and lashing out at others. The psychiatrist was interviewed on 6/30/16 at 3:30 PM and stated that the resident has been stable on her medications and he did not feel that the medications need to be reduced because she was stable. The psychiatrist stated he will consider doing so now. 415.12(l)(1)

Based on observation, record review and interview conducted during a recertification survey, the facility did not provide the necessary treatment and services in accordance with the resident's written plan of care for one of three residents reviewed for unnecessary medications (Resident #57). Specifically, referral to a psychiatrist was not conducted in order to evaluate the resident's behavioral status and determine the appropriateness of the resident's [MEDICAL CONDITION] medications. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The findings are: Resident #57 has [DIAGNOSES REDACTED]. The Admission MDS (Minimum Data Set; a resident assessment tool) of 11/21/14 indicated that the resident scored nine out of fifteen on the BIMS (Brief Interview for Mental Status: a test used to measure memory and orientation) which suggested that the resident had moderately impaired cognition and that the resident exhibited verbal behavior symptoms directed toward others that occurred one to three times weekly. Review of the Interim (Telephone) physician's orders [REDACTED]. The consultant pharmacist conducted a medication regimen review (MRR) on 3/19/15 and suggested to the physician at that time, to consider a psychiatric consultation. The Attending Physician agreed with this recommendation and documented the same on the MRR. Review of the comprehensive care plan dated 5/31/15 included an intervention to provide psychiatric evaluation per physician's orders [REDACTED]. A review of the resident's clinical record including the consultation reports and other interdisciplinary records revealed there was no documented evidence that a psychiatric evaluation was conducted. The Attending Physician was interviewed on 6/1/15 at 12:00 PM and stated that the psychiatric evaluation should have been done and that is was overlooked. The unit Registered Nurse Manager (RNM) was interviewed on 6/1/15 at 12:30 PM and stated that the psychiatric evaluation should have been done and that it was overlooked. The RNM stated that the procedure for picking up physician's orders [REDACTED]. 415.11(c)(3)(ii)

Based on observation, record review and interview conducted during a recertification survey the facility did not provide appropriate psychiatric evaluation for one of three residents reviewed for unnecessary medications (Resident #57). Specifically, referral to a psychiatrist was not conducted in order to evaluate the resident's behavioral status and determine the appropriateness of the resident's [MEDICAL CONDITION] medications. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The findings are: Resident #57 has [DIAGNOSES REDACTED]. The Admission MDS (Minimum Data Set; a resident assessment tool) of 11/21/14 indicated that the resident scored nine out of fifteen on the BIMS (Brief Interview for Mental Status: a test used to measure memory and orientation) which suggested that the resident had moderately impaired cognition and that the resident exhibited verbal behavior symptoms directed toward others that occurred one to three times weekly. Review of the Interim (Telephone) physician's orders [REDACTED]. The consultant pharmacist conducted a medication regimen review (MRR) on 3/19/15 and suggested to the physician at that time, to consider a psychiatric consultation. The Attending Physician agreed with this recommendation and documented the same on the MRR. Review of the comprehensive care plan dated 5/31/15 included an intervention to provide psychiatric evaluation per physician's orders [REDACTED]. A review of the resident's clinical record including the consultation reports and other interdisciplinary records revealed there was no documented evidence that a psychiatric evaluation was conducted. The Attending Physician was interviewed on 6/1/15 at 12:00 PM and stated that the psychiatric evaluation should have been done and that is was overlooked. The unit Registered Nurse Manager (RNM) was interviewed on 6/1/15 at 12:30 PM and stated that the psychiatric evaluation should have been done and that it was overlooked. The RNM stated that the procedure for picking up physician's orders [REDACTED]. 415.12(f)(1)

Based on record review and staff interview, the facility did not inform a resident/legal representative of the right to appeal the decision to terminate Medicare coverage that was made by the QIO (Quality Improvement Organization, an independent reviewer), and to have a Demand Bill reviewed by a Fiscal Intermediary (FI) or Medicare Administrative Contact (MAC). This was evident for one of four residents reviewed for Liability Notices and Beneficiary Appeal Rights (Residents #74). This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The findings are: A review of Resident #74's Liability and Beneficiary Appeal Notice, dated 1/2/13, revealed that the resident/legal representative was informed that the resident's Medicare coverage for skilled care in the facility would end on 1/4/13 and that the resident/legal representative had the right to have this decision by the facility reviewed by the QIO. A review of the QIO's decision, dated 1/6/13, indicated that the QIO determined that the resident no longer required skilled care and would not be eligible to receive further Medicare coverage. There was no documented evidence in the clinical record that the facility informed the resident/legal representative of the right to appeal the decision of the QIO and have a FI or MAC review the Demand Bill to determine if further coverage would be provided. The staff member responsible for processing Demand Bills was interviewed on 4/6/13 at 2:15PM. This staff member stated that she was unaware that the resident or her legal representative had the right to appeal the decision of the QIO. The staff member stated that she was not aware that the facility was required to inform the resident/legal representative, in writing, of their right to allow a FI or MAC review the Demand Bill. 415.3(g)(2)(i)

Based on observation, interview and record review, the facility did not ensure that a newly admitted resident was consuming sufficient fluid to meet her assessed daily minimum requirement. Specifically, the facility did not identify that the resident was consuming significantly less fluids than her daily assessed requirement and did not develop and implement measures to prevent potential dehydration and other health related problems such as urinary tract infections and fecal impaction/constipation. This was evident for one of four residents reviewed for hydration (Resident #98). This had the potential for more than minimal harm that was not immediate jeopardy. The findings are: Resident #98 was admitted to the facility on [DATE] after a brief hospitalized from [DATE] - 3/8/13. During this hospital stay the resident was treated for [REDACTED]. According to the Minimum Data Set Assessment, dated 3/15/13, the resident had a BIMS (Brief Interview for Mental Status) score of 10 out of 15 on a test used to measure attention, orientation and ability to recall new information. An assessment for dehydration was done upon admission to the facility on [DATE]. The assessment noted that the resident was considered to be at risk for dehydration secondary to the recent history of a urinary tract infection. The nutritional assessment, dated 3/11/13, noted that the the resident's daily fluid requirement was 1600 cc - 1800 cc daily and that her actual fluid intake at that time was 1500 cc - 1700 cc daily. The initial comprehensive care plan revealed that the resident would be provided at least a total of 1500 cc fluids with meals. A review of the nurse aide care guide revealed that the resident consumed an average of 717 cc of fluids daily from 3//9/13 - 4/3/13, which represented approximately 45% of her assessed daily requirement of 1600 cc. There was no documented evidence in the dietary notes, nurses notes, comprehensive care plan, or elsewhere in the clinical record, that the nursing or dietary staff identified that the resident was not meeting her daily fluid requirement or that interventions were put in place to increase the resident's daily fluid consumption. The resident was observed at lurch time on 4/5/13 and was served about 3 ounces (90 cc) of water and 4 ounces (120 cc) of juice. She refused the water and consumed less than 75 % (less than 90 cc) of the juice. The resident was interviewed at that time and stated that she did not drink tea or coffee. The dietitian, who was present, then offered ginger ale to the resident which the resident refused, stating that she did not drink it. The Dietitian was then interviewed to determine how much fluid the resident was consuming daily. The Dietitian stated that she did not know how how much fluid the resident consumed daily and that nursing would have that information. After the meal observation the Certified Nurse Aide assigned to the resident and the RN Charge Nurse were interviewed about the adequacy of the resident's fluid intake. The RN Charge Nurse stated that the amount of fluids recorded by the Certified Nurse Aides reflected what was consumed at meal times and the additional fluids the resident consumed between meals. The Certified Nurse Aide reported that the resident usually drank about 240 cc of fluids at meal times and that a pitcher of water was left in her room. The Certified Nurse Aide stated that, at times, the resident requested water in the afternoon but that she usually did not take fluids when they were offered. The RN Charge Nurse reported that she was not aware of who reviewed the data recorded by the Certified Nurse Aides regarding the adequacy of the resident's fluid consumption. The RN Charge Nurse stated that fluid intake was monitored for three days for new admissions and that the Dietitian should be asked about the monitoring of fluid intake otherwise. 415.12(j)

Based on interviews and record review, the facility did not ensure that the drug regimen for a resident was free from unnecessary drugs. Specifically, the care planning team did not consider or address, in a timely manner, gradual dose reduction of multiple psychoactive medications in a resident's medication regimen. This was evident for one of ten residents (Resident #20) reviewed for unnecessary drugs. This had the potential for more than minimal harm that is not immediate jeopardy . The findings are: Resident #20 has [DIAGNOSES REDACTED]. According to the The Minimum Data Set (MDS) Assessment, dated 2/27/13, the resident had a BIMS (Brief Interview for Mental Status) score of two out of a possible fifteen on a test used to measure attention, orientation and ability to recall new information. The resident's medication regimen included the long term use of the anti-psychotic medications [MEDICATION NAME] 75mg daily at bedtime and [MEDICATION NAME] 5mg daily, as well as, the anti-anxiety drug [MEDICATION NAME] 0.25mg twice a day and the anti-depressant medication [MEDICATION NAME] 10mg daily since 5/12 through the most current 3/5/13 orders. physician's orders [REDACTED]. The resident's most recent Psychiatric Evaluation was completed eleven months ago on 5/15/12 and indicated that the resident's behavior was stable at that time. There were no recommendations to consider gradual dose reduction (GDR) or attempt to taper psychoactive medications. The resident's care plan that addressed the risk for adverse effects related to psychoactive medications, dated 3/6/13, included interventions to monitor the resident for the effectiveness of medications and for the team to provide ongoing assessment for gradual dose reduction (GDR). There was no documented evidence in the clinical record of on going assessments for GDR of the resident's psychoactive medications. There was no evidence in the clinical record of attempts to taper the resident's medications or of rationale documented by the team to justify the benefits of ongoing use of the medications that outweighed the potential complications of long term psychoactive drug use. A review of physician progress notes [REDACTED]. There was no documented evidence that the physician considered or ruled out the possibility of gradual dose reduction or discontinuation of any of the psychoactive drugs. The Pharmacist Consultant Monthly reviews, dated 11/15/12 and 3/5/13, included recommendations for tapering the resident's psychoactive medications. There was no evidence of, and the facility did not provide, a response by the physician in support of the recommendation or to justify the benefits for continuing the resident's psychoactive medications and dosages without GDR. There was an attempt to contact the physician by telephone on 4/5/13. The physician was unavailable for interview. The resident was observed to be calm on 4/5/13 at 3:10PM, sitting the dayroom. The Director of Nursing (DON) was interviewed on 4/5/13 at 3:15PM and she stated that the resident's condition has been stable with some improvement regarding the resident's activities of daily living. The DON was not aware of why the recommendations from the Pharmacist Monthly Review were not addressed. 415.12(l)(1)

Based on interview and record review during the recertification survey, the facility did not ensure that pharmacist's reports were acted upon in a timely manner for one of ten residents reviewed for unnecessary medications. Specifically, a physician did not respond to a pharmacist's recommendation to taper psychoactive medications for Resident #20 in order to carry out the recommendation or justify the benefit of not tapering the medications. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. The findings are: Resident #20 has [DIAGNOSES REDACTED]. According to the The Minimum Data Set (MDS) Assessment, dated 2/27/13, the resident had a BIMS (Brief Interview for Mental Status) score of two out of a possible fifteen on a test used to measure attention, orientation and ability to recall new information. The resident's medication regimen included the long term use of the anti-psychotic medications Seroquel 75mg daily at bedtime and Abilify 5mg daily, as well as, the anti-anxiety drug Xanax 0.25mg twice a day and the anti-depressant medication Celexa 10mg daily since 5/12 through the most current 3/13 orders. The Pharmacist Consultant Monthly Reviews, dated 11/15/12 and 3/5/13, included recommendations for tapering the resident's psychoactive medications. The resident's care plan that addressed the risk for adverse effects related to psychoactive medications, dated 3/6/13, included an intervention to provide ongoing assessment for gradual dose reduction (GDR). There was no documented evidence in the 3/13 physician progress notes [REDACTED]. There was no documented evidence of rationale to justify the benefits of ongoing use of the medications that outweighed the potential complications of long term psychoactive drug use. There was no evidence of, and the facility did not provide, a response by the physician in support of the recommendation or to justify the benefits for continuing the resident's psychoactive medications and dosages without gradual dose reduction or discontinuation. There was an attempt to contact the physician by telephone on 4/5/13. The physician was unavailable for interview. The resident was observed to be calm on 4/5/13 at 3:10PM, sitting the dayroom. The Director of Nursing (DON) was interviewed on 4/5/13 at 3:15PM and she stated that the resident's condition has been stable with some improvement regarding the resident's activities of daily living. The DON was not aware of why the recommendations from the Pharmacist Monthly Reviews were not addressed. 415.18(c)(1)

Based on interview and record review, the facility did not ensure that reasonable resident preferences were accommodated. Specifically, the frequency of showering for residents was determined by a schedule established by the facility without input from the residents or consideration of resident preferences. This was evident for two of two residents (Residents #98 and #101 reviewed for choices and had the potential for no more than minimal harm. The findings are: 1. Resident #101 was admitted to the facility on [DATE]. According to the Minimum Data Set, an assessment instrument, dated 3/19/13, the resident indicated that it was somewhat important to her to choose between a shower or bath. During a routine interview on 4/3/14 at 1:50PM, the resident stated that staff members decided whether she would have a shower or a bath. The resident further stated that staff members also decided when she would have a shower or bath. The Certified Nurse Aide and the RN Charge Nurse were interviewed on the afternoon of 4/3/12 and reported that the residents on the unit were showered twice weekly based on their room assignment. The RN Charge Nurse stated that was just the way it has been done. 2. Resident #98 was admitted to the facility on [DATE]. The Minimum Data Set, dated dated [DATE], indicated that the resident was interviewed during the assessment process and reported that it was very important to her to choose between a shower or bath. During a routine interview on 4/3/13 at 9:48AM, the resident stated that staff members never asked her whether she preferred to have shower or bath. The RN Charge Nurse was interviewed on 4/3/13 at 2:38PM and stated that residents were showered according to their room assignment, for a total of twice weekly, and not according to the residents' preferences. 415.5(e)(1))