Every finding on record at St Mary's Center Inc

Based on observation, record review, and interview during the Recertification Survey conducted from 02/05/2025 to 02/12/2025, the facility did not ensure that residents' right to a safe, clean, comfortable, and homelike environment was provided. This was evident in 3 of 4 units (Units 2, 3, and 5). Specifically, rooms were not cleaned, window screens were torn, windowsills were layered with dust, floor corners were embedded with in dirt, resident furniture in disrepair, resident equipment were not cleaned, and there was leak in the ceiling. The findings include but are not limited to: The facility was not able to provide a policy for environmental services. During multiple observations from 02/05/2025 through 02/12/25, the following were observed: 1. In the Lobby Area, seating furniture had torn cushion, the ceiling plaster was cracked and peeling with brown stains, the corner of the floors were embedded with dirt, and the elevator floor tiles had accumulated dirt. 2. In the Community Room, there were 3 black metal framed chair with missing bilateral arm cushion, window shades were stained, windowsills had layers of dust, the television was heavily layered with dirt and dust, multiple attached seatings had food particles, crumbs, and embedded dirt, ceiling fans were layered with dust, windows were dirty, folding tables were embedded with dirt and bent downward in the center, radiators were rusty and dirty, resident's bathroom had broken tile behind the toilet bowl, and walls had patches of white plaster paint. 3. In Unit 2, room [ROOM NUMBER]'s nightstand drawer was broken. The air conditioning unit in room [ROOM NUMBER] had a plywood affixed under the window and the linen bin was dusty and rusty. room [ROOM NUMBER] window shades were stained, the room was dusty, and there was a dirty plastic with duct tape around the air conditioning unit that was hanging. 4. In Unit 3, room [ROOM NUMBER] had ripped window screen. room [ROOM NUMBER] had dirty and broken window shades. room [ROOM NUMBER] had windows with plastic affixed with duct tape, and plywood in the air conditioning unit. room [ROOM NUMBER] bathroom had a bubbled ceiling plaster. room [ROOM NUMBER] and 308 had windows with duct tape covering the crack in the glass. room [ROOM NUMBER] had indented flooring, and mechanical lifts were layered with dirt and debris. 5. In Unit 5, the blood pressure stand had dirt and dust, the bins on the left side of the medication cart had yellowish dried stains, the wall-mounted phone had sticky brownish substance, there was a hole and leak on the staff lounge ceiling, the stairwell ceiling had yellowish stains, the plaster was peeling and had bubbles, the dirty linen bins were dirty and rusty. room [ROOM NUMBER] and 509's shared bathroom had a brown stain in the toilet bowl, shower had black grime on the tile grout. There was a duct tape and plastic with black grime that was covering the shower window. During an interview on 02/06/2025 at 11:25 AM, Resident #21 who reside in room [ROOM NUMBER] stated the glass is broken on their window and there is duct tape on the crack. They stated Maintenance covered the window with plastic to prevent the cold air from coming in. Resident #21 further stated the window had been that way for years and they would like the window fixed. During an interview on 02/06/2025 at 11:30 AM, Resident #14 who lives in room [ROOM NUMBER] stated their bathroom is not cleaned thoroughly and always looks dirty. During an interview on 02/12/2025 at 9:55 AM, Resident #25 who lives in room [ROOM NUMBER] stated they would like the crack in their window to be fixed because it looks crazy. During an interview on 02/12/2025 at 10:01 AM, Housekeeper #1 stated they are responsible for cleaning the lobby, community room, dining room, and basement. They stated they try to complete their job the best they can. They stated they do not dust every day, but they sweep and mop the floors daily and disinfect the chairs every day. During an interview on 02/12/2025 at 8:00 AM, the Lead Housekeeper stated it is their responsibility to oversee the Housekeeping Department and ensure that the staff are doing their job. They stated that rooms were dusted twice weekly. They stated they are responsible for cleaning the mechanical lifts and blood pressure stands. During an interview on 02/12/2025 at 10:01 AM, Maintenance Worker #1 stated they are the only staff in Maintenance and that their priority is to ensure that all electrical equipment are functional and safe, and that the plumbing and lighting fixtures are in working condition. They stated they currently have a leak on the 5th floor due to roofing problems and sometimes, toilets overflow that cause leakage. Maintenance Worker #1 stated they also have a leak in the ceiling when there is heavy snow or rain. During an interview on 02/12/2025 at 10:42 AM, the Assistant Administrator stated they oversee the Housekeeping and Maintenance Departments. They stated that the broken windows, leak in the ceilings, and broken furniture in the community room were discussed and brought to the Administrator's attention. The Assistant Administrator stated the Maintenance Staff is in the process of replacing ceiling tiles that were stained from the leaking roof and a contractor assessed the windows and gave an estimate to replace them last year. They stated that 2 windows have been replaced and the remaining windows that still need to be replaced are covered with plastic to prevent the cold air from coming in. The roof was also repaired but there is still a leak. The Assistant Administrator further stated they do not make rounds, but it is the Lead Housekeeper's responsibility to make rounds on the resident floors and report back to them. During an interview on 02/12/2025 at 11:14 AM, the Administrator was interviewed and stated they make rounds on the resident floors and community room at least 2-3 times per week to monitor that staff are in compliance with the regulations. The Administrator stated they did not notice the broken furniture or lack of cleanliness in the community room and was not aware the 5th floor ceiling had a leak. The Administrator stated they believe at one time an outside contractor worked on the roof. The Administrator also stated they have a couple of proposals for the windows and two windows have been fixed so far and there are some windows covered in plastic that need to be fixed or replaced. The Administrator further stated there are concerns with housekeeping and they are trying to get the company they contract with to send in new staff. 10 NYCRR 415.5 (h)(2) 44842

Based on observation, record review, and interview during the Recertification Survey conducted from 02/05/2025 to 02/12/2025, the facility did not ensure that the storage for controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 were safe and secure. This was evident in 1 of 4 units during the Medication Storage Task. Specifically, the Narcotic Box in Unit 2 was not properly secured. The findings are: The facility policy titled Medication Storage with a revised date of 02/2025 documented Scheduled II - V medications must be maintained in a separately locked, permanently affixed compartments or cabinets. During an observation on 02/05/2025 at 10:18 AM in Unit 2, the Medication Room located inside the nurse station was inspected. Narcotic Box # 1 was observed with a pad lock on top of the narcotic box, locking the outer metal door. The outer metal door when locked, contained a wide opening and remained not firmly closed and secured. There were multiple packs of Schedule II - V controlled narcotics observed inside the inner metal door when opened. Licensed Practical Nurse #1 was immediately interviewed after the observation on 02/05/2025. They stated the pad lock was used to lock the outer door because of an issue with the primary lock of the outer door. The Licensed Practical Nurse could not identify why this was an issue. During an interview on 02/05/2025 at 12:13 PM, the Assistant Director of Nursing stated there had been an issue with Narcotic Box #1's primary lock for some time now and that they installed a pad lock to resolve the issue. 10 NYCRR 415.18(e)(1-4)

Based on observation, interviews, and record review conducted during the recertification survey from 9/20/2023 to 9/27/2023, the facility did not ensure that a comprehensive, person-centered care plan (CCP) was developed for each resident. This was evident for 1 (Resident #29) of 15 total sampled residents. Specifically, a CCP related to infection was not developed for Resident #29 who had an active diagnosis of urinary tract infection (UTI). The findings are: Resident #29 had diagnoses of UTI and schizophrenia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #29 was cognitively intact. On 09/21/23 at 12:12 PM, Resident #29 was interviewed and stated they have burning upon urination and are receiving an antibiotic. The Medical Doctor (MD) note dated 09/19/2023 documented Resident #29 was ordered Macrobid for UTI. The MD note dated 9/20/2023 documented Resident #29 had an abnormal urine culture and was ordered Doxycycline 100 mg twice a day for 7 days. MD Orders dated 9/20/2023 documented Resident #29 receive Nitrofurantoin 100mg twice daily for 7 days and Doxycycline 100 mg twice daily for 7 days for UTI. There was no documented evidence a CCP related to UTI was developed and implemented for Residnt #28. On 09/26/23 at 09:07 AM, Certified Nursing Assistant (CNA) #4 was interviewed and stated some residents have a UTI and CNA #4 checks their urine and hydration. On 09/26/23 at 09:18 AM. Licensed Practical Nurse (LPN) #1 was interviewed and stated Resident #28 is receiving antibiotics. LPN #1 checks for rashes, shortness of breath, and pain or allergic reaction to antibiotic use. Resident #28 has a behavior of digging in their incontinence brief and this causes the resident to contract a UTI. On 09/27/23 at 11:45 AM, the Assistant Director of Nursing (ADON) was interviewed and stated any antibiotic use is covered under a CCP not specific to UTI. On 09/27/23 at 01:20 PM, the Director of Nursing (DON) was interviewed and stated they were unsure whether Resident #28 had a current CCP in place related to UTI. Staff use good hygiene and hydration. Residents don't often contract UTIs in the facility. 415.11(c)(1)

Based on observation, record review, and interviews conducted during the Recertification Survey from 9/20/23 through 9/27/23, the facility did not ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice. This was evident for 1 out of 2 residents reviewed for respiratory care out of 15 sampled residents (Resident # 87). Specifically, 1) Resident # 87 was observed using oxygen via the Nasal Cannula (NC) at 4 liters while the Medical Doctor's Order (MDO) documented 2 liters, and 2) There was no dated label on the oxygen tube. The findings are: The facility policy and procedure titled oxygen Administration, with the last revised date of 9/5/23, documented that oxygen is administered under a physician's orders except in the case of an emergency. Staff shall change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. Resident #87 was readmitted with diagnoses that include anxiety disorder and Chronic Obstructive Pulmonary Disease (COPD). The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #87's cognition intact with a Brief Interview of Mental Status (BIMS) score of 15. The Section O recorded that Resident #87 was on oxygen therapy. The Medical Doctor's Order (MDO) dated 9/15/23 documented oxygen via cannula 2 liters/minute as needed for shortness of breath. On 9/25/23 at 9:09 AM, Resident #87 was observed resting in bed. Portable oxygen concentrator at the bedside with oxygen 4 liters via Nasal Cannula (NC) in use. No dated label was observed on the tubing. On 9/26/23 at 9:06 AM, Resident #87 was observed resting in bed-a portable oxygen concentrator at the bedside with oxygen 3 liters via NC was in use. No dated label was noted on the tubing. The Comprehensive Care Plan (CCP) titled Respiratory Disorders-COPD initiated on 9/15/23 documented that Resident #87 is at risk for respiratory distress due to a diagnosis of COPD. The intervention includes oxygen therapy as per the physician's order. The Medication Administration Record (MAR) dated 9/15/23 to 9/25/23 documented oxygen 2 liters via NC as needed for shortness of breath. The Treatment Administration Record dated 9/15/23 to 9/25/23 has no documented evidence of the last time the oxygen tubing was changed. A medical progress note dated 9/22/23 at 2:09 PM documented that Resident #87 is on oxygen 2 liters via NC. The Nurse's Progress Note dated 9/24/23 at 11:47 PM documented that Resident #87 is on oxygen via NC for shortness of breath. The Nurse's Progress Note dated 9/25/23 at 11:38 PM documented no shortness of breath. Oxygen via NC continuously at 2 liters. During an interview on 9/25/23 at 11:54 AM, Licensed Practical Nurse #2 (LPN #2) stated that there was no label on the oxygen tube. Resident #87 has a doctor's order for 2 liters of oxygen for shortness of breath. LPN #2 does not know why the oxygen is set at 4 liters. During an interview on 9/25/23 at 11:59 AM, Registered Nurse #1 (RN #1) stated that Resident #87 has a portable oxygen concentrator with the oxygen set at 4 liters. They change the oxygen tube change every 24 hours. They usually put a date on the tubing when it is changed. During an interview on 9/26/23 at 8:58 AM, LPN #1 stated that Resident # 87 is on oxygen 2 liters as needed but uses it continuously except when the resident goes down to eat or smoke. The oxygen tube is changed every 24 hours by the night shift. They write the date on the tubing, which is not documented in the medical records. During an interview on 9/26/23 at 9:05 AM, RN #2 stated that Resident #87 oxygen concentrator is set at 3 liters. I saw the resident on oxygen 3 liters during rounds at the beginning of the shift. The doctor's order documented 2 liters as needed. I just came in and did not check the orders. During an interview on 9/26/23 at 11:02 AM, the Nurse Practitioner (NP) stated that Resident #87 is on oxygen 2 liters as needed for episodes of shortness of breath. The 2 liters are sufficient for the resident and help with their anxiety. During an interview on 9/26/23 at 12:25 PM, the Medical Director (MD) stated that Resident #87 is on oxygen 2 liters for chronic dyspnea and shortness of breath. There have not been any complaints that the resident needed an increase in the oxygen. During an interview on 9/27/23 at 1:26 PM, the Director of Nursing stated that staff are responsible for maintaining the oxygen concentrator. The oxygen tubing is supposed to be changed every week. The staff are supposed to put a date around the tubing when they change them. Resident # 87 is supposed to get oxygen 2 liters as needed. The nurses are supposed to ensure that the resident receives the oxygen per the doctor's order. The night shift is responsible for changing the tubing and labeling it. 415.12(k)(6)

Based on observation, record review, and interviews conducted during the Recertification Survey from 9/20/23 through 9/27/23, the facility did not ensure that the resident records were accurately documented in accordance with professional standards of practice. Specifically, Registered Nurse #3 (RN #3) signed for a 7:00 AM dose of Suboxone while the Suboxone was left in the medication cart. This was evident in 1 out of 8 residents reviewed for medication administration. (Resident #27). The findings are: The facility policy and procedure titled Medication Administration with last revised date 9/7/23 documented that it is the facility's policy to ensure that all residents are taking medications in a safe manner in accordance with physician's order. The nurse must observe right documentation after medication administration. Document/record after medication administration or medication refusal. Resident #27 was admitted with diagnoses that include Depression and Nicotine Dependence. The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #27's cognition intact with a Brief Interview for Mental Status (BIMS) score of 15. On 9/25/23 at 10:05 AM, Resident # 27 informed Registered Nurse #1 that they did not receive their 7:00 AM dose of Suboxone. On 9/25/23 at 10:15 AM, during medication administration, RN #1 took Suboxone 4mg-1 mg sublingual film from the narcotic box in the medication cart and administered it to Resident #27. The Medical Doctor's Order dated 6/28/23 documented Suboxone 4 mg-1 mg sublingual film, 1 film by sublingual route every 12 hours. Every Day at 7:00 AM and 7:00 PM. The Medication Administration Record (MAR) dated 9/25/23 documented that Suboxone 4mg was administered at 7:00 AM. The nurse's progress note dated 9/25/23 at 12:09 PM documented that a 7:00 AM dose of Suboxone 4mg-1mg sublingual film was given at 10:15 AM. During an interview on 9/25/23 at 11:49 AM, RN #1 stated that the night nurse (RN #3) signed the narcotic book and the MAR at 7:00 AM for the Suboxone. RN #1 cannot sign it, so they will document in the progress notes that the Suboxone was administered at 10:00 AM. They are required to administer the medication before they sign the MAR. They must sign out the controlled drug after they take it out. If the resident refuses, they must return it and sign that it was not administered. RN #3 signed the MAR for the Suboxone and left it in the medication cart. During an interview on 9/25/23 at 3:20 PM, RN #3 stated that they worked last on Units 3 and 4. They went to Resident #27's room [ROOM NUMBER] times, and the resident said that they were not ready to take the medication. They had already signed for the Suboxone in the MAR and were supposed to go back and document not given, but they forgot to go back. They are supposed to sign the MAR after the resident takes the medication. RN #3 said they made a mistake and forgot to click not administered. The Suboxone was locked in the medication cart. They came to the facility this afternoon and changed it, and documented that it was not given, the resident refused. During an interview on 9/27/23 at 12:46 PM, the Assistant Director of Nursing (ADNS) stated that Medication is given according to the physician's order. It is supposed to be given and documented in the MAR after the Medication is given. If a resident refuses, it must be documented that the resident refused and endorsed it to the next shift. During an interview on 9/27/23 at 1:48 PM, the Director of Nursing (DNS) stated the nurse's required to document after they administer the Medication. RN #3 said they forgot the resident did not take the Medication. They are required to give the Medication before they sign the MAR. 415.22(a) (1-4)

Based on interview and record review conducted during the Recertification and Complaint survey (NY 535, NY 370), the facility did not ensure all alleged violations involving abuse were reported to the State Survey Agency no later than 2 hours after the allegations were made for 2 allegations of resident-to-resident physical abuse involving 4 of 4 residents reviewed for Abuse (Resident #s 20, 86, 34, and 135). Specifically, (1) an incident of resident-to-resident abuse, involving Resident #20 and Resident #86, occurred on 1/5/20 at 11:25AM was reported to NYSDOH on 1/7/20 at 11:17AM; (2) An incident of resident-to resident abuse, involving Resident #34 and Resident #135, occurred on 1/22/2020 at 5:55 PM and was reported to NYSDOH on 1/23/2020 at 4:15 PM. The findings are: The facility policy titled Abuse, Neglect and Exploitation last revised 4/3/22 documented allegations of abuse will be reported to the Administrator, state agency, adult protective services and to all other required agencies no later than 2 hours after the allegation is made. 1) Resident #20, the victim, had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) dated [DATE] documented the resident was cognitively intact and displayed no adverse behaviors during the assessment period. Resident #86, the aggressor, had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented the resident was cognitively intact and displayed no adverse behaviors during the assessment period. The Accident/Incident (A/I) Report dated 1/05/20 documented Resident #86 grabbed Resident #20 and slammed Resident #20 onto the floor on 1/05/20 at 11:25AM. The NYSDOH Automated Complaint Tracking System (ACTS) documented the facility reported this allegation of resident-to-resident abuse involving Resident #20 and Resident #86 on 1/07/20 at 11:17AM. 2) Resident #34 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #34 was cognitively intact and displayed no behavioral symptoms toward others during the assessment period. Resident #135 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident # 135 was cognitively intact and displayed no behavioral symptoms toward others during the assessment period. The Accident/Investigation (A/I) Report dated 1/22/2020 documented on 1/22/2020 at 5:55 PM, Resident #34 pushed Resident #135's rollator, and Resident #135 retaliated by hitting Resident #34 on the left wrist. Resident #34 reported left wrist discomfort. The NYSDOH ACTS documented the facility reported the allegation of resident-to-resident abuse involving Resident #34 and Resident #135 on 1/23/2020 at 4:15 PM. On 04/07/22 at 02:52 PM, the Director of Nursing (DON) was interviewed and stated after the nursing supervisor informs him/her of allegations of abuse, he/she is responsible for reporting the allegations to NYSDOH within 24 hours. The facility investigation into resident-to-resident abuse involving Residents #34 and #135 was completed and reported to the NYSDOH on 1/23/2020, within 24 hours of the occurrence. The DON was unaware allegations of abuse should be reported to NYSDOH within 2 hours. On 04/07/22 at 03:25 PM, the Administrator was interviewed and stated abuse allegations, including resident to resident altercations, must be reported to the NYSDOH within 2 hours of occurrence while the facility initiates an investigation. 415.4(b)2

Based on record review and interview conducted during the Recertification survey, the facility did not ensure the Comprehensive Care Plan (CCP) was reviewed and revised by the interdisciplinary team, which includes the resident and the resident's representative, after quarterly review assessments for 1 of 15 residents reviewed (Resident #9). Specifically, there was no documented evidence Resident #9 was invited to their quarterly CCP meeting held 7/23/21. This is evidenced by: The facility policy titled Care Plan Meeting, last reviewed 11/21, documented the Social Worker (SW) will invite the resident and/or family by phone, letter, e-mail, or in-person 24 hours prior to the CCP meeting. Resident #9 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Date Set 3.0 (MDS) dated [DATE] documented Resident #9 was cognitively intact, able to make themselves understood, and participated in their assessment. Resident #9 was interviewed on 04/05/22 at 02:20 PM and stated they had not been invited to their CCP meetings with the interdisciplinary team (IDT). The CCP Meeting attendance sheet documented a quarterly CCP meeting for Resident #9 was held on 7/23/21. There was no documented evidence Resident #9 was invited to the quarterly CCP meeting held on 7/23/21. On 04/07/22 at 04:13 PM, the Resident Service Manager (RSM) was interviewed and stated RSMs were responsible for verbally inviting residents to CCP meetings one week and then 24 hours prior to the meeting date. RSM stated Resident #9 attended their CCP meetings; however, they were unable to produce documented evidence Resident # 9 was invited to the 7/23/21 CCP meeting. On 04/07/22 at 04:38 PM, the Director of Nursing (DON) was interviewed and stated the SW/RSM was responsible for verbally inviting residents to attend their CCP meetings one week and then 24 hours in advance of when the meeting was scheduled. Resident #9 was cognitively intact and able to attend their CCP meetings; however, the DON was unable to provide documented evidence Resident #9 received an invitation to the CCP meeting on 7/23/21. 415.11(c)(2)(i-iii)

Based on record review and interview conducted during an abbreviated survey (NY 127) on 3/10/2021, the facility did not ensure that a resident has the right to be free from abuse and neglect. This was evident in 1 out of 3 residents sampled for Abuse (Resident # 1). Specifically, on 12/26/2020, Resident#1 was dragged out of the elevator by a Certified Nursing Assistant (CNA#1). The findings are: Review of the Facility's Policy and Procedure Reporting Abuse to Facility Management undated, documented that our facility will not condone resident abuse by anyone, including staff members, physicians, consultants, volunteers, staff of other agencies serving the resident, family members, legal guardians, sponsors, other residents, friends or other individuals. Review of the Facility's Policy and Procedure In-Service Training Undated, documented that all employees are required to attend our facilities resident rights an abuse prevention program in service training sessions prior to having any resident contact and annually. Annual in-service training programs include educational sections on understanding the resident's abusive action, resolving conflicts, and recognizing signs and symptoms of abuse. Resident#1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS, a resident assessment tool) dated 11/05/2020, documented that resident #1 was severely cognitively impaired. The MDS documented that resident #1 required supervision with setup and one-person assistance with activities of daily living. The resident was discharged on [DATE]. Review of the Falls Comprehensive Care Plan (CCP) dated 12/09/2020, documented: Resident #1 will be safe, free from abuse/mistreatment. Interventions for resident #1 was one to one observation. Review of The physician's orders [REDACTED].#1 was on one to one observation every day for 24 hours. Review of The Treatment Administration Record for December 2020 documented one to one observation from 12/9/2020 to 12/30/2020. Review of The CNA Inservice Record Continuing Education documented that CNA#1 attended The Elder Abuse Prevention, The Elder Abuse and Exploitation and The Elder Abuse and Neglect training on 02/19/2020. The Continuing Education for Nursing Home Administrators documented that Understanding Abuse and Neglect (w/video) was completed on 06/05/2019. Review of The Resident Accident/Incident report dated 12/26/20 documented that between 5:20 PM - 6:00 PM, Resident#1 was observed in supine position on the elevator. CNA#1 was standing over resident #1. CNA#1 grabbed resident's leg left foot and left arm and dragged resident #1 off the elevator and then grabbed the resident under both armpits and dragged resident #1 from elevator to the room. RN#1 told the CNA#1 to stop. The incident was reported to the Director of Nursing (DON) and the CNA#1 was sent home. RN#1 documented that a head to toe body check was done, there were no visible signs of injury and the physician was notified. Review of the Family Nurse Practitioner (FNP-BC) documentation dated 12/28/20, resident #1 was dragged to the room by CNA # 1. Resident #1 was unable to communicate the incident because of disorientation to time, place and person, there were no physical injury observed. Resident #1 did not exhibit any sign of pain or discomfort. Review of a handwritten statement from RN#1 documented that on 12/26/20 between 5:20 PM and 6:00 PM the elevator door opened on the 3rd floor and resident #1 was lying in the supine position inside the elevator. CNA#1 grabbed Resident#1 on the left arm and left leg and dragged resident #1 out of elevator. CNA#1 was told to stop but did not. CNA #1 then grabbed Resident#1 under both armpits and dragged resident #1 to the room. Resident#1 was screaming help me, help me while CNA#1 was dragging her. CNA#1 then walked out of the resident's room leaving resident #1 on the floor. Resident #1 placed in the bed and head to toe body check was done, no visible injury was noted. The DON was informed and spoke to CNA#1 on the phone. CNA#1 was sent home immediately. Review of an emailed response from CNA#1 dated 01/06/2021 documented, On 12/26/2020. Resident#1 was taken to warm up lunch on the 5th floor, after getting on the elevator, resident #1 threw herself on the floor. When the elevator got to the third-floor resident #1 was pulled from the elevator into the room. Review of the Investigation Summary dated 12/28/2020, The Assistant Director of Nursing (ADON) documented, that RN#1 reported on 12/26/2020 between 5:20 PM and 6:00 PM, resident #1 was dragged out of the elevator by CNA#1. The incident was witnessed staff RN#1, CNA#2 and Resident#2 and statements were obtained. The conclusion documented based on the staff and resident #2 interview and review of the video surveillance that physical abuse had occurred. All staff were in-serviced on resident abuse and neglect. Review of the video provided by the facility on 03/10/2021 at 12:00PM: Image # 0645: Identified CNA#1 standing and Resident#1 holding onto the handrail. Image # 0645 stamped 12/26/20 on 5th floor at 06:53:26 - 6:54:21 showed CNA#1 with meal tray in the right hand and Resident#1 with left hand holding the handrail standing at the elevator facing each other. CNA#1 at 6:53:43, points to the elevator then grabs Resident#1 right hand and walks into the elevator pulling Resident#1. Resident#1 resists and continue to hold the handrail. CNA#1 exists the elevator and uses the right hand to release Resident#1 hand from the handrail, pulls resident #1 with the left hand, Resident#1 bends to sit, stubbled to the floor then sat upright on the floor. CNA#1 released right hand of Resident#1 and presses the elevator button. Resident#1 remained sitting on the floor, CNA#1 bent over resident then stood up straight. Image # 0646 stamped 12/26/20 on the 5th floor showed Resident#1 was sitting upright on the floor. CNA#1 placed hands under the armpits of Resident#1 and pulls her into the elevator. Image # 0643 stamped 12/26/20 showed CNA#1 holding Resident#1 left hand and foot, pulls resident #1 out of the elevator. CNA#1 released Resident#1 hand and foot then places her hands over Resident#1 shoulders grabbing underneath Resident#1 arms and begins to pull in the direction of RN#1 standing at the medication cart. RN#1 moved out of the way while her left hand is on CNA#1 back then shoulder as CNA#1 pulled Resident#1 past RN#1. CNA#2 appeared after CNA#1 pulled the resident past the medication cart, both RN#1 and CNA#2 then followed CNA#1. Review of the facility letter dated 12/29/2020 documented that on Tuesday December 29th, 2020 at 10:00 AM, a fact-finding meeting was held with CNA#1 (on the phone) and other facility members. CNA#1 admitted to dragging resident #1 from the elevator to the room. CNA#1 stated it was protecting the coworkers from the resident. CNA#1 was asked if she was trained on how to handle difficult residents and admitted being trained at St Mary's, but decided to use a procedure learned at another facility. Review of a facility letter dated 01/11/ 2021,that was sent to CNA#1 documented the termination from the position as a certified nursing assistant effective on 01/11/ 2021 for resident abuse. During an interview on 03/10/2021 at 1:38 PM, RN#1 stated that while standing next to medication cart on the 3rd floor, the elevator door opened, and CNA#1 was standing over Resident#1 who was laying on floor of the elevator. CNA#1 then grabbed resident #1 left arm and foot and dragged resident #1out of the elevator. CNA#1 stood behind resident #1, placed arms under Resident#1 arm pits and dragged resident#1, who was screaming for help to the room. RN #1 reported to the physician and the DON and checked Resident #1 vital signs and ensured that resident #1 was comfortable. The DON instructed CNA#1 to leave the building and security was informed. During an interview on 03/10/2021 at 2:49pm, Resident#2 stated she heard Resident#1 screaming for help and saw resident #1 being dragged to the room by CNA#1. During a telephone interview on 03/10/2021, CNA#1 stated that Resident#1 got agitated and fell on the floor in the elevator. On the 3rd floor Resident#1 was held under arm and taken to the room. RN#1 tried to intervene, but CNA # 1 wanted to get Resident #1 to the room. CNA#1 stated training on abuse was provided at the facility. CNA#1 stated Resident #1 was not hit but a phone call came from director to leave the premises. During a telephone interview on 03/10/2021 at 3:21PM, CNA#2 stated that the facility provided in-service training on residents' behaviors and how to care for residents. On the 3rd floor, CNA#1 was seen pulling Resident#1 pass the nursing station. Resident#1 hands were in the air while being pulled to the room. During an interview on 03/10/2021 at 4:40 pm the DON stated that on 12/26/2020, it was reported at between 5:20 PM and 6:00 PM, CNA#1 was observed dragging Resident#1 from the elevator to the room. The RN#1 told CNA #1 to stop but CNA#1 continued to drag the resident to the room. The DON spoke to CNA#1 who acknowledged dragging Resident#1 to the room and was told to leave the facility. CNA#1 responded no problem. DON informed RN#1 to have security escort CNA#1 out of the facility. 415.4(b)(1)(i).

Based on record review and interviews conducted during the recertification survey, the facility did not provide written information to all adult residents informing them of their right to formulate an advance directive. The facility's policy on Advance directives did not include providing residents with written information prior to or upon admission. The facility also did not have follow-up procedures in place to provide the information to the individual at other appropriate times after admission. Specifically, Two residents had a designated Health Care Proxy (HCP). However, they did not have the New York State HCP form signed and located in their medical record. In addition based on the review of records and staff interviews it was found that the facility did not provide information in a written format informing residents of their right to formulate Advance Directives. The findings include, but are not limited to two Residents. Residents # 8 and 18. The findings are: The Advance Directives Policy and Procedure revised as of 4/2013 documented that prior to or upon admission of a resident, the Social Services Director or designee will inquire about the existence of any written advance directives. The Advance Directives Policy also documented that information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. 1) Resident #8 was admitted on [DATE] with a [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented that the resident was independent in decision-making. The MDS also documented that the resident is the only person who participated in her assessment. An interview was conducted with Resident #8 on 09/12/19 at 02:19 PM. The resident stated that she had been in the facility for approximately 2 years. The resident stated that she understands that a Health Care Proxy (HCP) is when someone is appointed to make medical decisions for her is she were sick and unable to do so. Resident #8 stated that her sister is currently her only HCP agent, but she could not recall signing a HCP form prior to admission or while residing in the facility. A Medical Orders for Life-Sustaining Treatment (MOLST) form dated 5/25/17 documented that the resident had a Health Care Proxy and Living Will (LW) completed. The Resident Face Sheet documented that the resident is Full Code and has a HCP and LW. The Face Sheet also documented that the resident contacts are a sister and a daughter. The Role of the sister was not filled in. The documented Role of the resident's daughter was Emergency Contact. The Comprehensive Care Plan (CCP) for Advance Directives: HCP dated 3/19/2019 documented the that resident has a HCP in place. The CCP documented Medical, Nursing, and Social Services staff are responsible for assessing the resident's cognitive capability and discussing materials with the resident to clarify Advance Directive understanding. An update to the CCP dated 4/16/19 documented that the resident's sister is her HCP. The physician's orders [REDACTED]. There was no documented evidence in the medical record that Resident #8 filled out and signed the New York State HCP form. Interviews were conducted with the Director of Resident Services (DORS) on 09/09/19 at 11:57 AM and 09/12/19 at 02:11 PM. The DORS stated that she is the person responsible for educating resident's regarding Advance Directives and ensuring that the record accurately reflects the resident's Advance Directive wishes. The DORS stated that she previously assisted residents with filling out and signing the New York State HCP form, but once the facility started using electronic medical records (EMR) in 2014, she no longer completed the HCP forms with residents. The DORS stated that the facility no longer utilizes the HCP forms. Residents are currently verbally educated and provide a verbal determination as to whether they would like to initiate an Advance Directive. A resident who wishes to have a HCP will verbally tell the DORS who they would like to elect as their HCP agent and the DORS updates the Resident Face Sheet with this information. The DORS will also complete a MOLST form electronically and will check off on the MOLST form that the resident has a HCP in place. The DORS stated that when a resident is transferred to a hospital, clinic, alternate care facility, or discharged to the community, the DORS or Nursing staff provide the resident with the Resident Face Sheet to indicate which Advance Directives the resident currently has in place. There have been times that the DORS has been contacted by admitting hospitals asking her to send the resident's HCP forms even after being sent the Resident Face Sheet. Upon admission to the facility, a resident's Advance Directive status is determined and any existing HCP forms are uploaded to the resident's EMR. The facility honors any prior Advance Directive that a cognitively impaired resident is admitted to the facility with. Residents that initiated a HCP after being admitted to the facility would not be asked to fill out or sign the New York State HCP form. The DORS would only verbally confirm the HCP contact information with the resident and update the Resident Face Sheet with this information. Moving forward, the DORS stated that she will be filling out HCP forms with the residents and keeping them on file. 2) Resident #18 was admitted to the facility on [DATE] The Most recent MDS assessment dated [DATE] documented the resident as being cognitively intact. The Comprehensive Care Plan (CCP) for Advance Directives: Health Care Proxy dated 7/12/2019 documented that resident has a Health Care Proxy in place. It documented the following: Resident/Representative/Legal Guardian will be provided education regarding Advance Directives upon admission and during stay in the facility X6 (in 6) months. Interventions specifically address to assess the resident's cognitive ability, discuss and review materials with resident, family, legal representation to clarify and understanding of Advance Directives. The SW note in this section only documents that the Resident's health care proxy is his sister. The note section of this care plan did not document that the SW provided written information to the resident on how to formulate advance directives, formalize the Health Care Proxy by completing the NYS Health Care Proxy form. The Medical Orders for Life-Sustaining Treatment (MOLST) form, last reviewed 6/13/2019, documented the resident is full code. The Advance Directive section of the MOLST documented the resident has a Living Will and Health Care Proxy. There was no copy of the completed Health Care Proxy form in the medical record. The physician's orders [REDACTED]. The orders further documented the resident is a full code (meaning they want to be resucitated). The Resident Face Sheet from the EMR documented the resident's sister is named as the Health Care Proxy/Emergency contact. The SW noted dated 9/11/2019 documented that the SW met with the resident. The resident reported that his sister is the primary health care proxy. There was no documented evidence in the medical record that a New York State Health Care Proxy form was completed by the resident, or that the resident was provided written information informing him of how to formulate advance directives. On 09/10/19 at 02:17 PM, the Director of Resident Services (DRS) was interviewed. The DRS stated that Advance Directives are offered to all residents upon admission. The HCP forms should be scanned into the Electronic Medical Record (EMR). They would be located in the documents section. The hard copy of the HCP and Advance Directives is no longer kept since the facility transitioned to the EMR in 2014. 415.3(e)(1)(ii)

Based on interviews and record review conducted during the recertification survey, the facility did not develop and implement a comprehensive person-centered care plan (CCP) to meet the medical needs identified in the comprehensive assessment. Specifically, a CCP related to vision was not developed for a resident with impaired vision (Resident #32). The finding is: The Policy and Procedure for Comprehensive assessment dated ,[DATE] documented: The comprehensive care plan must be person-centered and include the following: The facility is required to develop care plans that describes the resident's medical, nursing, physical, mental and psychosocial needs and preferences and how the facility will assist in meeting these needs. Resident #32 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A Significant Change Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented that the resident is cognitively intact. The MDS also documented that the resident's ability to see in adequate light (with glasses or other visual appliances) is adequate and that he wears corrective lenses. On 09/09/19 at 10:30 AM, Resident #32 stated that he wears eyeglasses but feels that he may need a new prescription since they are not effective. The resident stated that he had not seen an eye doctor in a very long time. An Ophthalmology Consult dated 7/25/18 documented that the resident was referred to the Eye Clinic after complaining of poor vision and requesting new eyeglasses. The Ophthalmologist documented that the resident had reduced vision right eye even with correction, unknown etiology. [MEDICAL CONDITION] suspect. Will schedule visual field and follow up of reduced vision. Given prescription (Rx) for glasses. A Medical Doctor (MD) note dated 7/25/18 documented the same information that was documented on the Ophthalmology Consult. A Glasses Prescription dated 7/25/18 documented that the resident's right and left eye sphere was -.50 and to add +2.50 and that the glasses were picked up on 8/14/18. There was no documented evidence that a CCP related to Vision was developed and present in the resident's medical record. On 09/11/19 at 02:17 PM, an interview was conducted with the Assistant Director of Nursing (ADON), the staff member responsible for developing and updating residents' CCPs. The ADON stated that if the resident has a condition that effects their vision, then a CCP related to vision will be implemented. After reviewing the Ophthalmology Consult, the ADON stated that the condition described is indeed something that would effect the resident's vision and a CCP related to vision should have been implemented. The ADON stated that this must have been an oversight. 415.11(c)(1)

Based on interviews and record reviews conducted during the recertification survey, the facility did not ensure that a resident received proper treatment to maintain vision. Specifically, a resident with visual impairments did not have a follow up Ophthalmologist appointment scheduled when indicated in his medical record. (Resident #32) The findings are: The facility Policy and Procedure regarding Specialty Services and dated 6/2018 documents that the Physician will review the recommendation of the consulting provider and will follow recommendations as necessary. If return visit is necessary, physician will give date to medical clerk to make appointments. The facility's policy did not document how the facility would address following up with consulting providers that fail to make the recommended follow-up consultation appointments for residents. Resident #32 was admitted with [DIAGNOSES REDACTED]. A Significant Change Minimum Data Set ((MDS) dated [DATE] documented that the resident was cognitively intact. The MDS also documented that the resident's ability to see in adequate light (with glasses or other visual appliances) is adequate and the resident wears corrective lenses. On 09/09/19 at 10:30 AM, Resident #32 stated that he wears eyeglasses but feels that he may need a new prescription since they are not effective. The resident stated that he had not seen an eye doctor in a very long time. An Ophthalmology Consult dated 7/25/18 documented that the resident was referred to the Eye Clinic after complaining of poor vision and requesting new eyeglasses. The Ophthalmologist documented that the resident had reduced vision right eye even with correction, unknown etiology. [MEDICAL CONDITION] suspect. Will schedule visual field and follow up of reduced vision. Given prescription (Rx) for glasses. A Medical Doctor (MD) note dated 7/25/18 documented the same information that was documented on the Ophthalmology Consult. A Glasses Prescription dated 7/25/18 documented that the resident's right and left eye sphere was -.50 and to add +2.50 and that the glasses were picked up on 8/14/18. There was no documented evidence that a follow up appointment was scheduled with the Ophthalmologist or Eye Clinic as recommended. On 09/12/19 at 11:24 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON acknowledged that the resident did not have a follow-up appointment with the Ophthalmologist or Eye Clinic since his initial appointment on 7/25/18. The ADON stated that since the consult documented that the eye clinic would schedule the visual field and follow-up of reduced vision, the facility did not follow-up with the office to make the appointment. The facility was not contacted by the Ophthalmologist to schedule a follow up appointment, and, as a result, no further action was taken. The ADON stated that the facility's policy is that the MD will review all consults and follow the recommendations. Any follow-up consults will then be given to the person who schedules the appointments. In this case, the consult was reviewed but a follow-up date was not indicated therefore the facility did not take action to schedule an appointment. The ADON was not certain what the facility Policy and Procedure for Specialty Services dictates regarding how long the facility should wait to follow-up when a consultant's office does not reach out to schedule a follow-up appointment. 415.12(3)(b)

Based on observations, record reviews and staff interviews during a recertification survey, the facility did not ensure that the resident's drug regimen was free of unnecessary medications. Specifically, two residents were prescribed [MEDICAL CONDITION] medications with no evidence of behaviors to support the ongoing use of [MEDICAL CONDITION] medications, and there were no gradual dose reductions (GDR) attempted within the last two years. This was evident for 2 of 5 residents reviewed for the use of unnecessary medication (Resident # 11 and Resident # 21). The findings are: The facility policy titled, [MEDICAL CONDITION] Medication updated 06/2019 documented, After medications are ordered for a resident, the staff and practitioner shall seek an appropriate dose and duration for each medication that also minimizes the risk of adverse consequences. All medications shall be considered for possible tapering. Tapering that is applicable to antipsychotic medications shall be referred to as gradual dose reduction. The staff and Physician will consider tapering of medications as one approach to finding an optimal dose or determining whether continued use of a medication is benefiting the resident. The Staff and Practitioner will consider tapering under certain circumstances, including when the resident's clinical condition has improved or stabilized, the underlying causes of the original target symptoms have resolved, Non-pharmalogical interventions, including behavioral interventions have been effective in reducing symptoms or a resident's condition has not responded to treatment or has decline despite treatment. The Facility policy also documented that the physician will review periodically whether current medications are still necessary in their current doses. The Physician will order appropriate tapering of medications as indicated. The time frames and duration of tapering attempts should be based on relevant factors including other medications that the resident is taking, underlying causes of symptoms, individual risk factors, and pharmalogical characteristics of the medications. Residents who use antipsychotic drugs shall receive gradual dose reductions (GDR), unless clinically contraindicated. Within the first year after a resident is admitted on an antipsychotic medication or after the resident has been started on an antipsychotic medication, the staff and practitioner shall attempt a GDR in two separate quarters. After the first year, the facility shall attempt a GDR at least annually, unless clinically contraindicated. 1) Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] indicated that the resident had intact cognition, was totally dependent on staff for all Activities of Daily Living (ADLs) and received antidepressant and antipsychotic medication daily. There was no evidence of acute mental changes. The resident had no disorganized thinking, altered level of consciousness, or difficulty focusing attention. The resident displayed no mood symptoms or symptoms of [MEDICAL CONDITION]. There were no behaviors that indicated [MEDICAL CONDITION] on the MDS. There were no verbal, physical and other behavioral symptoms directed toward others. There were no delusions and no hallucinations documented in the MDS. There were no rejection of care behaviors documented in the MDS. In addition, a Gradual Dose Reduction (GDR) had not been attempted. On 09/10/19 at 03:26 PM, 09/11/19 at 09:34 AM, 09/11/19 at 02:22 PM, and 09/12/19 at 11:31 AM, the resident was observed in bed sitting calmly with no signs of aggression noted. There were no signs of delusions or hallucinations noted. On 09/11/19 at 02:24 PM, the resident stated that she was on [MEDICATION NAME] and [MEDICATION NAME] prior to being admitted to the facility. The resident sstated that she is currently on [MEDICATION NAME] and Effexar for [MEDICAL CONDITION]. The resident also stated that the [MEDICAL CONDITION] medication dosages have not being reduced the past two years. The resident's current orders and Medication Administration Record [REDACTED]. The resident was initially prescribed [MEDICATION NAME] 200 mg twice daily as of 7/14/17. Review of nursing progress notes from (MONTH) (YEAR) to (MONTH) 2019 contained no documentation of behaviors or other justification for the continued use of antipsychotic medication. The nursing notes do not document that the Resident exhibited any inappropriate behaviors that would indicate [MEDICAL CONDITION]. Review of antipsychotic medication monitoring records from (MONTH) (YEAR) to (MONTH) 2019 documented no verbal disruptive behaviors, no physically aggressive behaviors and no socially inappropriate behaviors. The antipsychotic monitoring records do not document that the resident has exhibited any inappropriate behavior that would indicate [MEDICAL CONDITION]. Review of psychiatry notes dated 9/14/18, 12/14/18 and 09/06/19 contained no documented evidence about the resident's behavior. There was no documented evidence that the resident exhibited inappropriate behaviors, delusions or hallucinations. The Psychiatrist notes do not document that the resident exhibited any inappropriate behavior that would indicate [MEDICAL CONDITION]. The Psychiatry note dated 3/15/19 documented that a GDR is clinically contraindicated. However, the psychiatry note does not document any rationale for why a GDR is clinically contraindicated. There was no documented evidence that a GDR was attempted for the resident's [MEDICATION NAME] in the last two years. There was no documentation for why a GDR was contraindicated. On 09/11/19 at 02:33 PM, the Certified Nursing Assistant (CNA #1) was interviewed. CNA #1 stated that the resident is totally dependent on staff for all activities of daily living. CNA #1 stated that the resident's mood changes from day to day. The resident had some behavior issues in the past. On 09/11/19 at 02:39 PM, the Licensed Practical Nurse (LPN # 1) was interviewed. LPN #1 stated that the resident sometimes resists care. The resident is usually calm. Sometimes, when the resident does not want to get out of bed, she will scratch and spit at staff. The resident has not exhibited any hallucinations, delusions and agitations within the past year. On 09/11/19 at 02:45 PM, the Registered Nurse (RN # 1) was interviewed. RN #1 stated that the resident has not exhibited any inappropriate behaviors during the past year. There were no hallucinations and no delusions noted in the past year. The resident has been calm. There were no signs of aigitation noted in the resident's medical record. On 09/11/19 at 02:56 PM, the Psychiatrist was interviewed. The psychiatrist stated that the resident is on [MEDICATION NAME] due to major [MEDICAL CONDITION] with psychotic features. The resident hear voices and the resident is paranoid. The resident has agitated behaviors from times to time. The Psychiatrist further stated that he has not attempted a Gradual dose reduction the past two years due to the resident's hallucinations, delusions, and disruptive behaviors. 2) Resident #21 was initially admitted on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set 3.0 ((MDS) dated [DATE] indicated that the resident had intact cognition, requires supervision for most activities of daily living and received antidepressant medication daily. It documented that the resident had no evidence of acute mental changes. The resident has no disorganized thinking, altered level of cosciousness, or difficulty focusing attention. There were no mood symptoms exhibited. There were no verbal, physical and other behavioral symptoms directed toward others. There were no rejection of care behaviors exhibited. In addition, the MDS documented that a Gradual dose reduction has not been attempted. On 09/10/19 at 03:12 PM,On 09/11/19 at 09:46 AM and On 09/11/19 at 12:03 PM, the resident was observed in a good mood with no signs of distress noted. The resident's current orders and Medication Administration Record [REDACTED]. Review of nursing progress notes from (MONTH) (YEAR) to (MONTH) 2019 contained no documentation of behaviors or other justification for the continued use of [MEDICAL CONDITION] medications. The nursing notes do not document that the resident has verbalized that he was experiencing an increase in depressive symptoms. Review of (MONTH) (YEAR) to (MONTH) 2019 antipsychotic medication monitoring records documented no depressed mood, verbal disruptive behaviors, no physically aggressive behaviors and no socially inappropriate behaviors. Pharmacy Reviews dated 7/15/19 and 8/15/19 recommended that [MEDICATION NAME] and Trazadone dosages should be tapered. The physician's documented response agreed with recommendations. The tapering of the [MEDICAL CONDITION] medications recommended by the pharmacist was never attempted. Review of psychiatry notes dated 7/20/18,10/12/18, 3/22/19 and 04/19/19 contained no documented evidence about resident's behavior and low mood. The Psychiatrist notes do not document that the resident has reported that he was experiencing an increase in depressive symptoms. There is no documentation supporting how the IDT team and the Psychiatrist determined that the resident needed to continue to take the same dosages of antidepressants for the last two years. In addition, there are no documentation explaining whether or not the antidepressants were effective. Psychiatry note dated 01/11/19 does not document any rationale for why a GDR is clinically contraindicated. On 09/11/19 at 02:56 PM, LPN # 1 stated that the resident is usually in a good mood. The resident would usually mingle with the other residents. The resident gets depressed sometimes. The resident participates in group activities on a daily basis. The resident is doing well overall. On 09/11/19 at 03:09 PM, The Psychiatrist stated that the resident has chronic depression. The Psychiatrist stated that he has not attempted to do a gradual dose reduction for [MEDICATION NAME] and Trazadone because the two antidepressant medications are working. The Psychiatrist stated the resident is on low dose of [MEDICATION NAME] and low dose of Trazadone. 415.18(c)(1)

Based on observation, record review, and interview, the facility did not ensure that each resident's drug regimen was free of unnecessary medications. Specifically, one resident received an anti-psychotic medication without a clear continued indication for use, and without an attempt at gradual dose reduction within the last year. This was evident for 1 of 5 residents reviewed for Unnecessary Medication (Resident #23). The finding is: Resident #23 is a [AGE] year-old, admitted to the facility on [DATE], with the following [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented the resident had intact cognition, hearing intact and the resident is understood. The resident has no mood or potential indicators of [MEDICAL CONDITION], no hallucinations and no delusions, no physical or verbal or behaviors noted, and no rejection of care and high functional status. The Comprehensive Significant Change (MDS) 3.0 assessment dated [DATE] documents the following: Hearing intact, speech clear, cognitively intact, The resident has no mood or potential indicators of [MEDICAL CONDITION], no hallucinations, no delusions, no physical or verbal or behaviors noted, and no rejection of care and high functional status. On 3/3/17 at 12:54PM the resident was observed in the community day room playing BINGO. On 03/06/17 at 9:21AM the resident was observed playing BINGO in the community room. The resident stated, The first Friday of the month the facility gives out prizes to the winner of the BINGO game. On 3/7/17 at 9:14AM The resident was observed to be alert, and very engaging. The resident stated, I am in pain due to previous fracture and the weather makes it worse. Resident denied feeling depressed and/or anxious. The resident stated that she had her pain medication in the morning and will go back downstairs to the community room where she socializes. The Comprehensive Care Plan (CCP) for [MEDICAL CONDITION] Drug Use dated 8/9/16: Potential for Adverse Drug Reaction/side effects documents Note: significant side effects are of [MEDICAL CONDITION] medication may include tardive dyskinesia, akathisia, cognitive and behavioral changes. The interventions included: Evaluated action of medication and side effects, observe for signs of decline in functional or cognitive status, monitor for changes in behavior or mood, and encourage verbalization of feelings. The Medication Administration Record [REDACTED]. The resident was also receiving [MEDICATION NAME] 30 mg at bedtime HS, and [MEDICATION NAME] 5mg 3 times a day TID The FDA approved product labeling documents only two approved clinical indications for the use of [MEDICATION NAME]. [MEDICATION NAME] is indicated for use in the treatment of [REDACTED]. The resident does not have a [DIAGNOSES REDACTED]. The Interdisciplinary Notes from October 2016 to March 2017 were reviewed. There were no documented incidents of behavior problems. The Physician's (MD) Orders dated February 2016 to March 2017 were reviewed. They documented the resident was prescribed [MEDICATION NAME] ([MEDICATION NAME]) 5 mg Q HS for [MEDICAL CONDITION] NOS and changed to Major [MEDICAL CONDITION], recurrent on 8/3/16. The order documented that the [MEDICATION NAME] was originally ordered on [DATE] in the system. The Psychiatry Consultation dated 3/11/16 documented the resident feels less depressed and ready for discharge. Denied Hallucinations or delusions. Mood tense and sad. Recommendation to f/up with Psych in the Adult Day Care: [MEDICATION NAME] 5mg HS, [MEDICATION NAME] 30mg HS and [MEDICATION NAME] 150MG The Psychiatry Consultations dated 6/17/16, 11/4/16, 11/14/ and 2/3/17 all documented the resident continued to be treated with antipsychotic medications. The consultation documented that the Patient needs to continue on [MEDICATION NAME] 30MG HS, [MEDICATION NAME] 5mg HS and [MEDICATION NAME] 5 MG TID to help maintain low level of psychotic depression with anxiety. On all consults mental status is documented as alert, speech soft affect [MEDICATION NAME] and mood is tense and sad. Hallucinations and delusions are denied and no suicidal or homicidal ideas. The Pharmacist Monthly Drug Regimen Review dated 9/21/2016 documented that resident is receiving [MEDICATION NAME]. Please follow-up. The Attending Medical Doctor (MD) answered the form on 10/25/16 that the Psychiatrist refused. There was no explanation for the refusal in the medical record. The Pharmacist Monthly Drug Regimen Review dated 11/22/16, documented: it is recommended that the [MEDICATION NAME] 5 mg be tapered to 2.5 mg as there are no recent behaviors. The Psychiatrist answered the form that the Pharmacist needs to refer to his note dated 11/14/16. The Pharmacist Monthly Drug Regimen Review dated 1/18/17 documented: it is recommended to taper the [MEDICATION NAME] ([MEDICATION NAME]) as it can increase the risk for falls. The Attending (MD) answered that the [MEDICATION NAME] is needed as per the Psychiatrist. There was no further explanation given as to why the [MEDICATION NAME] was needed at the current dose. No documented evidence of increase behaviors, paranoia, delusions, depression, hallucinations, symptoms of panic or anxiety. There was no documented evidence in the Medical Record that a Gradual Dose Reduction (GDR) was attempted for [MEDICATION NAME] 5MG in the last year. On 3/6/17 at 9:38AM, the Certified Nursing Assistant (CNA) was interviewed and stated, I know the resident well and in the last few months she had numerous changes due to a wrist fracture. Normally she is mild and easy to get along with. Attends group activities and has friends here. She only gets anxious if you are late to help her get dressed in the morning, but other than that she is fine. On 3/7//2017 9:25AM The attending physician (MD) was interviewed and stated, I am the Medical Director and also the resident's attending doctor since she was admitted in 2011. When she came into the facility she had anxiety issues and panic attacks, The resident did not have agoraphobia in the facility. That was when she was in the community. This only happened when we tried to discharge her, and she did not want to go home and she felt anxious. For the most part the resident stabilized. Recently the resident has been much more stable and improved in my opinion. The [MEDICATION NAME] is for [MEDICAL CONDITION] and the [MEDICATION NAME] 5mg at bedtime is for depression. The FDA approves labeling for these drugs. I believe [MEDICATION NAME] is for [MEDICAL CONDITION] for the [DIAGNOSES REDACTED]. The MD proceeded to read the black box warnings but stated the resident does not have these diagnosis. I can tell you that the Psychiatrist uses these medications due to his experience. According to the federal regulations the medication should have been titrated. I always defer to the Psychiatrist but I sign the orders. I have been reordering the drug for the past 12 months. it was discussed, Unfortunately, I have not tapered the [MEDICATION NAME] as I cannot taper the medication without the Psychiatrist. Going forward I will have to work with the Psychiatrist and the Administrator to be more proactive in treating the residents receiving [MEDICAL CONDITION] medications. On 03/07/2017 at 10:24 AM the Licensed Practical Nurse (LPN) was interviewed and stated, Last year the resident was agitated and was verbally abusive. So in addition to the resident's current medications the resident was taking Klonopin. That medication was discharged in December. The resident has more sleep disturbances than anxiety and depression and those medications are given at night. I believed the resident is getting the medication for the sleep disturbances not any depression. I know the resident is taking [MEDICATION NAME] and that can be given for depression. I learned about the [MEDICAL CONDITION] medications in school, but at work I look up the side effects in the nursing reference book. I have not seen her exhibit any behaviors and I work Monday-Friday 8-4 day shift and sometimes on the 12-8 AM night shift. There is no nursing monthly notes that documents any behaviors or mood disturbances such as hallucinations or dellusions. On 3/6/17 at 11:05 AM, the Psychiatrist was interviewed and he stated, I come to the facility twice a week and have been involved with the residents care since she came to the facility. The resident has [MEDICAL CONDITION]. That is what the [MEDICATION NAME] is for, the depression and it helps with sleep disturbances. The resident was taking trazadone before but the resident is not taking that medication for over a year now. The [MEDICATION NAME] 5mg at bedtime is for hallucinations and delusions which is the psychotic portion of the depression. When the psychiatrist consult notes were read back to clarify if the resident had any psychotic symptoms in the past year, He further stated that the resident was sucidal three years ago but nothing recent, that is why he was fearful to reduce the medication so the resident would not have a psychotic episode, even though the resident was stable for the past three years. He further stated I use the [MEDICATION NAME] to treat depression and to be like an enhancer. The FDA approves [MEDICATION NAME] for [MEDICAL CONDITION] and [MEDICAL CONDITION] Disorder. The resident does not have a [DIAGNOSES REDACTED]. The resident is sad and tense but not enough reason to be on [MEDICATION NAME]. He further stated that I do not recall any conversation about tapering this resident. There are no documented evidence in the resident's medical record of any hallucinations, dellucisons to warrant the continued use of [MEDICATION NAME] in the last year. The facility policy and procedure titled, Psychoactive Medications dated 3/03 documents: All medications shall be considered for possible tapering. Tapering that is applicable to antipsychotic medications shall be referred to as a gradual dose reduction. Residents who use antipsychotic drugs shall receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. There is no documented evidence a Gradual Dose Reduction was attempted as required by Federal regulations. [MEDICATION NAME] was being prescribed for a non FDA approved clinical indication. 415.12(1)(1)

Based on interview and record review the facility did not ensure that residents funds were readily available, including on weekends. This was evident for one resident reviewed for Personal Funds. (Resident # 18). The findings are: Resident # 18 is a [AGE] year old admitted to the facility on [DATE] from an acute care hospital with [DIAGNOSES REDACTED]. The Annual Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had intact cognition. During the resident interview conducted on 12/21/15 at 11:50 am the resident stated that there was no access to personal funds on the weekend because the people who give out the money are not here. Throughout the survey period a notice entitled Resident Banking Hours was observed posted in a locked glass cabinet on the wall in the main lobby area which documented banking transactions are done between the hours of 3:00pm and 4:00pm daily and finance office hours are 9 am-5pm Mon-Fri. There was no documented evidence that resident funds were made available to residents in the evening and on weekends. On 12/23/15 at 10:25 am, an interview was conducted with the Manager of Finance Operations who stated that the distributions of funds occurs on the 1st, 3rd and 15th of each month and is available during the hours of 3pm-4pm on each business day. She further stated that funds cannot be obtained outside of the specified hours because the business office is closed. On 12/23/15 at 11:10 am an interview was conducted with the Director of Nursing who stated that petty cash is made available to residents after hours. She further stated that while this information was not posted on the banking hours' notice, resident services usually takes care of dispersing the funds on the weekend. On 12/23/15 at 11:50 am an interview was conducted with the Director of Resident Services who stated that there was currently no process in place for resident's to access to funds outside of banking hours. She further stated that a community meeting would be held with all residents today and they will be informed of the changes and how they can access their funds. 415.26 (h)(5)

Based on observation , record review and interviews the facility did not ensure that infection control practices were maintained. Specifically, during a wound care observation the RN (Registered Nurse) did not remove her gloves, wash her hands and don clean gloves after cleansing the residents pressure ulcer. This was evident for one resident reviewed for Pressure Ulcer. (Resident #21) The findings are: The resident is a [AGE] year old admitted with [DIAGNOSES REDACTED]. The Quarterly MDS (Minimum Data Set) 3.0 assessment dated [DATE] documented: intact cognition, total dependence of 2 person for personal hygiene, dressing, transfers, toileting. The MDS further documented incontinence of bowel and bladder. Physician orders [REDACTED]. A wound are observation was conducted on 12/231/5 at 10:30 AM and the following was observed: The Registered Nurse (Charge Nurse) assisted by Certified Nursing Assistant (CNA), removed the soiled dressing from the sacral wound and discarded the soiled dressing into a plastic bag. The RN then proceeded with cleansing the wound with a normal saline soaked gauze. The RN did not remove her gloves, wash her hands and don clean gloves after cleansing the wound and proceeding with the remainder of the wound care. An interview was immediately conducted and the RN was unable to explain why she did not remove her gloves after cleansing the wound. IThe RN Supervisor (RNS) was interviewed on 12/23/15 at 11:30 am. The RNS stated that the nurse should have washed her hands and donned clean gloves after cleansing the wound. 415.19 (a)(1-3)

Based on observations and interviews the facility did not ensure that food was stored, prepared, and distributed under sanitary conditions. Specifically, (1) food stored in the refrigerator was not dated ; (2) potentially hazardous cold foods were not held at the proper temperature; and (3) the dishwasher did not reach the temperature necessary to sanitize the dishware and utensils. This was evident for the Kitchen. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. The findings are: (1) On 11/20/13 at 9:20am, individually wrapped cold cuts, were observed stored unlabeled and undated in the refrigerator. On 11/20/13 at 9:21am, the Food Service Director (FSD) was interviewed and stated the cold cuts should have been dated before being stored in the refrigerator. (2) On 11/22/13 at 11:35am, food temperatures were taken during a tray line observation. The cold food temperatures were as follows: cole slaw - 50 degrees Fahrenheit (F) tartar sauce - 47.6 degrees F milk (in insulated cannister) - 59 degrees F. Cold foods should be held and served at or below 41 degrees F. On 11/22/13 at 11:50am, the Food Service Director (FSD) was interviewed and stated that he was aware the cold food temperatures need to be below 41 degrees F. He also stated that cold foods are chilled in the kitchen before being placed in dining room and tray line. He further stated that appropriate cold food temperatures on the tray line are maintained with ice bags, but he did not know why the ice bags were not on the tray line today. (3) On 11/21/13 at 1:10pm, during a dishwashing observation, the Dishwasher rinse cycle temperature was 118 degrees Fahrenheit (F). The Dishwasher rinse temperature did not increase above 118 degrees F for 3 consecutive wash/rinse cycles. On 11/21/13 at 3:00pm, a second observation was conducted and the Dishwasher rinse cycle fluctuated between temperatures of 130 degrees F and 143 degrees F. The dishwasher final rinse cycle temperature should be 180 degrees F in order to sanitize the dishware and utensils. On 11/21/13 at 1:15pm and 3:15pm, the Food Service Director (FSD) was interviewed and stated that he was aware that the rinse cycle should be 180F. He further stated that the dishwasher was working properly in the morning. He also stated that the booster heater may be the cause for the rinse cycle not reaching the appropriate temperature. The FSD stated that he would call the company to have the machine looked at today, and the kitchen would begin using paper plates. 415.14(h)

Based on observation and interview, the facility did not ensure that essential equipment was maintained in safe operating condition. Specifically, the Dishwasher was not in working condition. This was evident for 1 of 1 Dishwashers observed in the Kitchen. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. The findings are: On 11/21/13 at 1:10pm, during a dishwashing observation, the Dishwasher rinse cycle temperature was 118 degrees Fahrenheit (F). The Dishwasher rinse temperature did not increase above 118 degrees F for 3 consecutive wash/rinse cycles. On 11/21/13 at 3:00pm, a second observation was conducted and the Dishwasher rinse cycle fluctuated between temperatures of 130 degrees F and 143 degrees F. The dishwasher final rinse cycle temperature should be 180 degrees F in order to sanitize the dishware and utensils. On 11/21/13 at 1:15pm and 3:15pm, the Food Service Director (FSD) was interviewed and stated that he was aware that the rinse cycle should be 180F. He further stated that the dishwasher was working properly in the morning. He also stated that the booster heater may be the cause for the rinse cycle not reaching the appropriate temperature. The FSD stated that he would call the company to have the machine looked at today, and the kitchen would begin using paper plates. On 11/22/13 at 9:23am, the FSD was interviewed and stated that the dishwasher was checked by an Ecolab service technician on 11/21/13, and it was determined that a replacement part was needed in order for the booster heater to maintain a rinse cycle temperature of 180 degrees F. He further stated the repair of the dishwasher was scheduled for 11/25/13, and disposable utensils would be utilized until the dishwasher is operational. 415.5(e)(1)(2)

Based on record review and interview, the facility did not ensure that the Notice of Medicare Provider Non-Coverage was provided when a resident's Medicare services were terminated. This was evident for 1 of 1 residents reviewed for Liability Notices & Beneficiary Appeal Rights (Resident #32). This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. The finding is: Resident #32 is a [AGE] year-old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 assessment ((MDS) dated [DATE] documented the resident had intact cognition (Brief Interview of Mental Status score 15 out of 15). The resident was provided a "SNF Determination on Admission" letter dated 9/16/13. The letter informed the resident that he would no longer be covered under Medicare as of 9/24/13. The letter did not include information about the resident's right to an expedited review of the service termination by the Quality Improvement Organization. On 11/22/13 at 11:43am, the Manager of Finance Operation was interviewed and stated that the Notice of Medicare Provider Non-coverage letters are filed in the finance office, but nursing generates the letters and gives them to the residents. She further stated that the letters should contain information about the resident's right to an expedited appeal and how to begin the process. On 11/22/13 at 12:45pm, the Assistant Director of Nursing (ADON) was interviewed and stated that she provided the letter to the resident to inform him of the end of Medicare coverage. She further stated that the facility has been using the same form for years. The ADON also stated that the letter should be updated to include the required information about the expedited appeal. 415.3(g)2)(i)

Based on observation and interview, the facility did not ensure that a clean and comfortable environment was provided. Specifically, dirt build up on tiles, stained walls, and a dirty metal food service cart were observed. This was evident for the 1 of 1 Dining Rooms observed (the Main Dining Room). This resulted in no actual harm with potential for more than minimal harm. The finding is: On 11/20/13 at 12:10PM, the Main Dining Room (MDR) was observed during lunch. The perimeter of the entrance to the MDR was observed with dust and dirt build-up. The wall on the right side of the entrance had broken plaster and spatters of a dark yellow substance by the steps. Both sides of the walls by the steps had gray areas approximately 5 inches starting at the level of the steps and going up. There was a tall metal food service cart in the MDR with dried old spills inside and outside of the door. The bottom edges of the cart were dusty and had old dried spills that were dark gray in color. On 11/20/13 at 12:30PM and 11/21/13 at 2:06PM, the Food Service Director was interviewed and stated that the cart was used to hold plastic serving trays brought to the dining room from the kitchen. He further stated that it was the responsibility of the food service staff to clean the cart, and he is responsible for ensuring the cleaning is done. On 11/21/13 at 1:20PM, the Housekeeper was interviewed and stated that housekeeper responsible for the cleaning of the floors and walls was not available, but he would address it immediately. 415.5(h)(1)

Based on observation and interview, facility did not ensure that housekeeping and maintenance services to maintain a sanitary environment were provided. Specifically, a resident's w/c had dirt on the metal frame. This was evident for 1 of 30 residents reviewed in the Census Sample (Resident #42). This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. The finding is: Resident #42 is a [AGE] year-old with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had severely impaired cognition (Brief Interview of Mental Status score 6 out of 15). The MDS further documented the resident used a wheelchair for mobility. On 11/20/13 at 11:29 AM, the resident's wheelchair (w/c) was observed with dirt on the metal rails and dust on the breaks. The right arm rest had cracked vinyl covering, exposing the white padding material underneath. On 11/21/13 at 1:00 PM, the Housekeeping Supervisor was interviewed and stated that the housekeepers on each unit are supposed to clean the wheelchairs twice per week. He further stated that there is no tracking form kept on the w/c cleaning, and no one is assigned to follow-up with the staff regarding the status of w/c cleaning. The regular Housekeeper on the unit was not available for interview. 41.5(h)(2)