Every finding on record at The Baptist Home At Brookmeade

Based on observation, record review, and interviews during an abbreviated survey the facility did not ensure an allegation of abuse was reported to the New York State Department of Health in accordance with State law within 24 hours of the incident for one (1) out of (3) three residents (Resident #1) reviewed for abuse. Specifically, Resident #1's Representative filed a grievance with the facility on 12/31/2025 that documented on 12/30/2025 staff were rough handling Resident #1 with toileting and bedtime care, yelling by staff, interference with Resident #1's telephone access, and denial of Resident #1's pain medication. There was no documented evidence of a report being submitted to the New York State Department of Health in IQIES.Findings include:The facility's policy titled, Identification and Reporting of possible victims of abuse, neglect, or mistreatment, last reviewed 04/09/2026 documented all cases of suspected or actual abuse, neglect, or mistreatment, including injuries of unknown source, exploitation, and misappropriation of resident property must be reported to the immediate supervisor/manager. All alleged violation are reported immediately, but not later than two hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in bodily injury, to the administrator of the facility and to other officials (including the State Survey Agency) in accordance with state law established procedures.Resident #1 was admitted to the facility on [DATE] with diagnoses that include Dementia, Major depressive disorder, and Type II Diabetes.Quarterly MDS dated [DATE] documented the resident had severe cognitive impairment with no behaviors present. Resident #1 required set up or clean up assistance with eating and supervision with toileting, independent with bed mobility and transfers. Resident #1 was always continent of urine and bowel.A review of the facility grievance for Resident #1 dated 12/31/2025 documented date of incident was 12/30/2025 and the family reported Resident #1 had rough handling with toileting and bed time care, yelling by staff, interference with the resident's telephone access, and denial of pain medication.There is no documented evidence of an allegation of abuse report being submitted to the New York State Department of Health.During an interview with Resident #1's Representative on 07/23/2026 at 10:33 AM they stated on 12/30/2025 they called Resident # 1, and the resident was upset, and they could not understand them. Resident # 1's Representative stated after the phone call with Resident #1 they called the nurse station, but she said no one answered, therefore, they went up to the facility and found Resident #1 in the wheelchair and crying and soiled, Resident #1 stated to them that some people should not be working in the facility. Resident #1 stated to Resident #1's Representative that they waited to use the bathroom, and the two aides were nasty with them and slammed them on to the toilet while talking about them. Administration was made aware and stated they investigated in-house and that staff would not be working with Resident #1. They get scared and wonder if there will be retaliation as result of them filing a report. They are not concerned about the charge nurses retaliating, but they are concerned about the aides.During an interview on 07/28/2026 at 11:12 AM the Director of Nursing stated they started the investigation once the family reported the allegation. The allegation was reported the day after the incident, and the family did not mention it to anyone because of fear of retaliation. On 12/30/2025 when the family was at the facility, they did not report this allegation to the staff that were present that day. Director of Nursing stated they investigated and at the conclusion of their investigation the allegation of abuse was not verified; therefore, they did not report this to New York State Department of Health. Director of Nursing stated they do not think it should have been reported because at the conclusion of their investigation they did not find abuse, and if they found something at the conclusion of their investigation then they would have reported it.During a telephone interview on 08/03/2026 at 12:38 AM the Administrator stated all allegations of abuse need to be reported to the Department of Health. The facility has two (2) hours to report an allegation if abuse cannot be ruled out. Administrator stated if the facility cannot come to a conclusion within the timeframe, then they need to submit it to the Department of Health. Resident #1 had a grievance filed and they investigated and concluded abuse did not occur. Therefore, they did not submit a report because their findings indicated that the abuse was unfounded. Administrator stated that if at the conclusion of the facility's investigation it resulted in verifying the abuse then it would be reported to the Department of Health.10NYCRR 415.4(b)(1)(ii)

Based on observation, record review and interview conducted during the recertification survey from 3/5/24- 3/11/24, the facility did not ensure that the call bell system was accessible for 1 of 27 residents reviewed for environment. Specifically, Resident #4 was observed on two occasions with the call bell system not within the resident's reach. The findings: The facility policy on call light or call bell system, entitled Call light: Accessibility and Timely Response dated February 2023, documented the purpose of the policy is to assure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. In addition, the call light will directly relay to a staff member or a centralized location to ensure appropriate response. Resident # 4 was admitted to the facility with diagnoses including dementia, rheumatoid arthritis, and diabetes. The Quarterly Minimum Data Set (MDS)assessment dated [DATE], documented the resident had severely impaired cognition and required 1 to 2 staff member for bed mobility and transfers, and required extensive assistance with activities of daily living. The fall care plan dated 1/10/24, documented Resident #4 was at high risk for falls related to a history of multiple falls within the past year, and decreased acuity. On 3/5/24 at 10:12 AM and on 3/6/24 at 9:11 AM, the resident was observed in bed awake; the call bell was hanging on the wall above the resident's bed and not within reach. During an interview on 3/6/24 at 9:15 AM, Staff #1 (Certified Nurse Aide) stated all residents should have their call bell within reach, and secured the call light to resident's bed linen while the resident was in bed. During an interview on 3/11/24 at 11:32 AM, Staff #2 (Licensed Practical Nurse Unit Manager) stated Resident #4 knew how to use their call bell, and when the resident was sitting in their chair the call bell should be secured to the resident. Staff # 2 stated when the resident was in their bed, the call bell should be secured to the resident's bed linen. 10NYCRR 415.3

Based on observations, interviews and record review conducted during a recertification survey 3/5/24-3/11/24, the facility did not ensure that the comprehensive person-centered care plan was developed for 1 of 1 residents (#92) reviewed for eye infections. Specifically, there was no care plan in place to address Resident #92's medical needs for an eye infection. Findings include: The facility policy for Care Plan Development dated 2/8/24 documents The facility is committed to providing comprehensive and person-centered care to residents. The policy outlines the procedures for timely development and review of comprehensive care plans. Resident #92 was admitted with diagnoses and conditions including Diabetes Mellitus, Dementia and anxiety. The Minimum Data Set, an assessment tool dated 10/27/23 documented the resident had severe cognitive impairment and needed assistance from staff with all personal hygiene and eating. A nurses note dated 3/1/24 documented the resident's right eye was red and draining. The physician was called and a new order for an antibiotic eye drops was received. The March 2024 Treatment Administration record documented the resident had treatments in place of occusoft eye lid scrub daily. Medications and treatments were documented as given. There was no care plan in place with goals and interventions that addressed monitoring and effectiveness of interventions. During an interview with the Assistant Director of Nursing on 3/8/24 at 10:16 AM, they stated that Registered Nurses were responsible for initiating and updating care plans. The Assistant Director of Nursing reviewed the residents record and was unable to find a care plan which addressed the needs of the resident for their eye infection. The Assistant Director of Nursing stated the resident had recurring eye infections and there was a plan, but it was resolved in December and no longer active. They stated the plan should have been activated at the time the eye drops were ordered because it would contain the assessment and effectiveness of interventions and monitoring. 10NYCRR 415.11(c)(1)

Based on observation, record review and interview conducted during a recertification survey from 3/5/24 to 3/11/24, the facility did not ensure that the necessary assistance and care were provided to carry out activities of daily living (ADLs) for 1 of 2 residents reviewed for dignity. Specifically (Resident #261) was not toileted or provided with continent care from 3/4/23 at 6:00 PM until 3/5/24 at 11:40 AM the following day after asking for assistance and using call bell. Findings include: Resident #261 was admitted to the facility on [DATE] and had diagnoses including fracture of lower end of the right femur, presence of right artificial knee joint, and pain in right leg. The Comprehensive Care Plan for urinary continence and bowel continence, dated 3/5/24, documented to provide urinal, bedpan, commode, elevated toilet seat as needed and as directed by Certified Nurse Aide assignment/nursing instructions. Provide privacy and respect during toileting or incontinence care to promote dignity and toilet before and after meals and at night if awake. The Certified Nurse Aide Accountability record dated 3/4/24 (11PM-7 AM shift), was not signed for until 3/7/24 at 3:20 PM by (certified nurse aide, staff #6) and documented incontinent care was provided with substantial/maximal assistance. Certified Nurse Aide Accountability record dated 3/5/24 (7 AM-3PM shift), not signed for until 3/7/24 at 3:20 PM by (certified nurse aide, staff #6) documented incontinent care was provided with substantial/maximal assistance. On 3/05/24 at 11:00 AM, Resident #261 was on the verge of tears and stated they had to go to the bathroom badly. The resident's call bell had been activated the resident stated it had been at least 20 minutes. Resident #261 stated they were admitted last night at 6:00 PM and they were told last night they could use the commode, but nobody ever came. The resident stated they were told later they could not use the commode until evaluated by rehab. On 3/05/24 at 11:20 AM, Staff #6 room entered the room and stated they told Resident #261 they would come after finishing care for another resident. When observed on 3/5/24 at 3:45 PM, there was a commode in the room. Resident #261 stated that rehab did the evaluation sometime after lunch and the commode was brought to the room around 3PM. The resident stated they were told by staff it took so long because they could not find a commode. On 3/06/24 at 11:04 AM, Staff #6 entered room turn call bell off and told the resident they would be right back to assist the resident. On 3/07/24 at 1:00 PM, when interviewed, the resident stated the first time the Certified Nurse Aide provided care on the previous day was when the surveyor was there and the Certified Nurse Aide turned off the call bell. The Certified Nurse Aide Accountability documentation for March 2024 was received on 03/07/2024 at 3:30 PM, and the Assistant Director of Nursing was interviewed and stated they realized the staff had not document for a few days and informed the surveyor that all of the staff would be written up. On 3/11/24 at 10:23 AM, Staff #6 (certified nurse aide) stated they started their shift 3 AM on 3/5/24 and the resident did not ring the bell that night or that morning. Staff #6 stated they went to room that morning around 11:30 AM, and was unable to toilet resident without commode, but changed the incontinence brief. Staff #6 stated the commode was brought around 3 PM that day. Staff #6 stated they were not sure how long the call bell was on 3/5/24. Staff #6 stated they did not document continence care for their shift 3/4/24 and 3/5/24 because they were very busy. Staff #6 stated before they left for the day they were supposed to stop at office and make sure documentation was done. Staff #6 stated if they did not complete their documentation, they were to complete it as soon as possible. Staff #6 stated the supervisor monitored their documentation and informed them on 3/7/24 to complete the documentation that was missing for 3/4/24 and 3/5/24. On 3/11/24 at 12:40 PM, Staff #10 (Registered Nurse Supervisor) stated they were working 11 PM-7 AM shift on 3/4/24-3/5/24. Staff #10 stated they were responsible for monitoring the certified nurse aide documentation to make sure it was complete. Staff #10 stated they were not aware Staff #6 did not document for 3/4/24 and 3/5/24. 10 NYCRR 415.12(a)(3)

Based on observations, record reviews and staff interviews on the recertification and abbreviated surveys (NY00328105) from 3/5/24 to 3/11/24, the facility did not ensure that necessary medications were administered according to the physician order for 1 of 5 residents (Resident #92) reviewed for medications. Specifically, Resident #92 was prescribed antibiotic eye drops for 3 days but was given 8 extra doses beyond the three days. The findings are: An undated facility policy for Medication Reconciliation documents the facility reconciles medication frequently throughout a residents stay to ensure that the resident is free from any significant medication errors. Resident #92 was admitted with diagnoses and conditions including Diabetes Mellitus, Dementia and anxiety. The Minimum Data Set, an assessment tool dated 10/27/23 documented the resident had severe cognitive impairment and needed assistance from staff with all personal hygiene and eating. The physician order dated 03/01/24 document Tobramycin 0.3% eye drops for unspecified blepharitis; instill 1 drop in each eye 3 times a day for 3 days. The Medication Administration Record was reviewed and documented the eye drops were scheduled to be administered at 8:00AM, 1:00PM, 7:00PM with the first dose starting on 3/2/24 at 8:00 AM. On 3/7/24 at 1:00PM the drops were still being administered for a total of 17 doses. The prescribed amount was for 9 doses. During an interview on 3/8/24 at 10:38 AM, Staff#5 (Licensed Practical Nurse) stated they gave medications to the resident including the eye drops. The Staff #5 stated they did anticipated the drops were coming to an end but was not paying attention to the dates and the resident got extra doses. During an interview with the Assistant Director of Nursing on 3/8/24 at 10:16 AM, they stated when the order was received from the physician it was put in the resident's record by the nurse. The nurse administering the medications was supposed to look over the orders for accuracy and sign it was reviewed but in this case it was not done. They stated all nurses needed to read the order for accuracy before administering any medications including the start and stop times, and if that was done the error may not have happened. NYCRR 415.25

Based on observation, record review and interview conducted during the recertification survey, the facility did not ensure that food contact and non-food contact equipment and kitchenware were maintained in sanitary condition in accordance with standards for food service safety. Chapter 1 Sub-Part 14-1 of the State Sanitary Code states that food contact surfaces are to be washed, rinsed and sanitized after each use and when contaminated; non-food contact surfaces are to be cleaned as often as necessary to keep the equipment free of accumulation of dust, dirt, food particles and other debris. The findings are: A tour of the kitchen conducted on 3/31/19 between 10:30 AM and 11:30 AM revealed the following: 1. - Reach in refrigerators #1 (juice refrigerator) and #2 (dessert refrigerator) were both observed to have soiled exterior surfaces and interior surfaces of doors, interior door jams, and interior walls and bottoms. The soiling consisted of both dry and sticky-to-touch spills that were brown-ish, pink-ish, and white-ish in color. 2. - The microwave table top was soiled with whitish-colored areas of dried spills. Cleaned trays for food preparation and service were stored on the table top. - The lower shelf of the microwave table was soiled with whitish-colored dried spills. - One-half of the lower shelf was covered with an open weave drying mat upon which greater than ten cleaned food containers were stored. An accumulation of dried debris was observed beneath the drying mat. -The bottom of the microwave table utensil drawer was soiled with dusty, brownish-colored, greasy-to-touch residue. Greater than 15 cleaned serving utensils were stored in the drawer. 3. - In the cook's area, the tracks of a soiled cooling rack were noted with dusty, greasy-to-touch residue and the lowest track was soiled with an accumulation of dried food debris. At that time, the rack was in use for cooling three pans of cake. The cook assigned to the kitchen on 3/30/19 (who was responsible for monitoring the cleaning of the kitchen by the Dietary Aides and maintenance of a sanitary kitchen environment) was interviewed on 4/4/19 at 11:25 AM. He revealed that he would not have checked the reach-in refrigerators, microwave table, or cooling rack unless those areas were specified on the schedule for cleaning that day. At that time, the Dietary Aide cleaning schedule for 3/30/19 was reviewed with the cook, who then reported that those cleaning tasks were not on the schedule, so he would not have checked those areas for cleaning. 415.14(h)

Based on observation, record review and interviews conducted during the recertification survey, the facility did not ensure that staff followed facility protocol and standards of practice to ensure safe delivery of medication. Specifically, (1) a randomly observed resident was not provided direct supervision of the medication administration by the medication nurse (2) the resident was not assessed by the interdisciplinary team to determine if the resident can safely self-administer medication. (Resident #31). The findings are: Resident # 31 had [DIAGNOSES REDACTED]. According to the 1/25/19 quarterly minimum data set ( MDS- a resident assessment tool) the resident had a score of 13 out of 15 on the BIMS (Brief Interview for Mental Status) indicating she was cognitively intact. This assessment further documented the resident was independent with activities of daily living (ADLs) except dressing and toileting which required supervision. During initial screening of the resident on 3/31/19 at 11:43 AM, a cup containing 6 medications was observed on the resident's bedside table. The resident was interviewed at that time and stated that the nurse left her morning medications for her to take. The resident stated that the nurses routinely leave the medications at her bedside and she takes them when she is ready. The resident did not take the medications while the surveyor was present. There was no nurse present to provide direct supervision. A follow up observation and interview was conducted on 3/31/19 at 2:05 PM. The now empty medication cup was on the bedside table and the resident stated that she took them. Review of the clinical records, including assessments, Medication Administration Record [REDACTED]. Additionally, the resident's current physician's orders [REDACTED]. The Licensed Practical Nurse (LPN # 1) was interviewed on 3/31/19 at 2:10 PM and stated that she left the medications for the resident to take. She further stated that she did not observe the resident take the medications and that she should have waited for her to take her them. On 4/01/19 at 11:34 AM LPN-Charge Nurse (LPN # 2) approached the surveyor and stated that she had counseled LPN # 1 for leaving the medications at the resident's bedside for her to take, as indicated above. LPN # 2 further stated that the resident was not assessed for self-administration of medications and that LPN # 1 should not have left the medication on the resident's bedside table. 415.3 (e) (1) (vi)

Based on observation, record review and interview conducted during the recertification survey, the facility did not ensure that staff followed proper gloving, handwashing technique, and protection of unused items that would be returned to the treatment cart, to prevent cross contamination and the spread of infection. This was evident for 1 of 2 residents (Resident # 99) reviewed for pressure ulcers on the B Unit. The findings are: Resident # 99 has [DIAGNOSES REDACTED]. The 3/20/19 minimum data set (MDS- a resident assessment tool) documented the resident had severely impaired cognition and had an unstageable pressure ulcer. The At risk for Skin Breakdown Care Plan was initiated on 11/3/2018 and updated 3/18/19 to address the resident's left buttock unstageable pressure ulcer The physician's orders [REDACTED]. A wound observation was conducted on 4/4/2019 at 12:14 PM and the following was observed: The Licensed Practical Nurse (LPN # 1) took a pair of gloves from her potentially contaminated uniform pocket to perform the resident's wound care and was stopped by the surveyor. Following this, LPN # 1 donned a new pair of gloves, picked up a gauze packet, touching the outside of the packet in the process, to remove the gauze pad. With her gloved hand, LPN # 1 then picked up a small normal saline pod and squirted a small amount on the resident's left buttock wound, which had slough material covering the wound bed. This was followed by a quick pat dry with the gauze pad, then the application of the Santyl Ointment. The wound was not adequately cleansed from the inner aspect of the wound to the outer aspect using a circular motion. One piece of gauze pad was used during the dressing change. Additionally, the LPN's handwashing technique was brisk, and less than the required 20 second duration. Following completion of the wound care procedure, LPN # 1 placed the Santyl ointment that was in a plastic bag directly on top of the resident's sink without a protective barrier. LPN # 1 then tied the plastic bag containing the soiled material, while holding the plastic bag containing the Santyl Ointment. While transporting both items together, the Santyl ointment fell out of the plastic bag onto the floor. LPN # 1 picked it up and returned it to the plastic bag, then placed it on top of the treatment cart. After discarding the plastic bag, LPN # 1 then returned the potentially contaminated bag and Santyl ointment to the resident's treatment storage bin. LPN # 1 was interviewed on 4/4/19 immediately following the wound care procedure and stated that she was aware of the above errors. 415.19 (a)(1-3)

Based on interview and record review conducted during a recertification survey, the facility did not ensure that the designated representative of one of one resident (#10) reviewed for notification of change was promptly informed of the need to alter the resident's dietary care plan. Specifically, the resident's designated representative was not informed promptly of the need for swallowing therapy and change in the consistency of the resident's diet. The findings are: Resident #10 is a [AGE] year old female with [DIAGNOSES REDACTED]. A note by the Speech and Language Pathologist (SLP) dated 5/3/17 revealed that the resident was seen for swallowing evaluation and that skilled swallowing treatment was recommended for 5 weeks to improve safety and tolerance of a least restrictive diet. The discharge note by the SLP dated 5/24/17 stated that a regular diet with cut-up meats into bite size pieces was recommended for the resident. A review of the resident's record revealed no evidence that the resident's designated representative was notified of the need for the change in the resident's care plan at the time the change was initiated to include the swallowing evaluation and therapy. The designated representative was interviewed on 6/8/17 at 12:02 PM and stated that she was not always notified of the need to change the resident's treatment. She further stated that she was not aware of the need for the therapy by the SLP until after the fact. The unit Registered Nurse manager (RN#1) was interviewed on 6/9/17 at 11:35 AM if she had informed the family about the changes in the resident's treatment plan mentioned above. RN #1 stated that the expectation was that the SLP would be the one to notify the family of the changes. The SLP was interviewed on 6/9/17 at 12:10 PM and stated that when the resident was about to be discharged from therapy, she called the family to inform them that the plans were being made to discharge the resident from therapy. She stated she thought that nursing had informed the family of the need for therapy. The SLP stated that it was important for the family to be informed promptly due to the risk associated with the change in the consistency of the resident's diet and lack of family knowledge. 415.3(e)(2)(ii)(c)

Based on interview and record review conducted during a recertification survey, the facility did not ensure that comprehensive care plans with measurable objectives, time frames and appropriate interventions were initiated to address urinary incontinence and active medical [DIAGNOSES REDACTED].#25). The findings are: Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. a. Urinary Incontinence According to the Admission Minimum Data Set (MDS; a resident assessment tool) of 2/24/17, the resident had no cognitive impairment, required extensive assistance of two people for transfers and toileting, extensive assistance of one person for locomotion, was wheelchair bound, and was continent of bladder function. The resident was subsequently assessed on the Quarterly MDS dated [DATE] and showed that the resident was occasionally incontinent of bladder function (less than seven episodes of incontinence in a 7-day period). A review of the resident's comprehensive care plan showed no measurable goals, time frames and interventions to address the decline in the residents bladder status, nor was there was any documentation to explain the change in the resident's condition. A review of the Certified Nurse Aide documentation for the month of June 2017 showed that the resident continued to have episodes of incontinence. The unit Registered Nurse manager was interviewed on 6/12/17 at 3:42 PM regarding the care plan that addresses the decline in urinary continence. She stated she reviewed the resident's comprehensive care plan and could not find one. b. Medical Conditions The resident's May-June 2017 medication regimen included the following medications: [REDACTED] - [MEDICATION NAME] 5 mg daily for Hypertension - Atorvastatin 40 mg daily for [MEDICAL CONDITION] - [MEDICATION NAME] 40 mg daily for Heart Failure - [MEDICATION NAME] 20 mg daily [MEDICAL CONDITION] - Senna plus 2 tabs daily for constipation - Tylenol 650 mg daily for pain unspecified. The resident's plan of care did not address the use of these medications and medical conditions. The unit RN manager was interviewed on 6/12/17 at 3:42 PM and stated that she could not find any care plans to address the above conditions and medications after reviewing the resident's comprehensive care plan. 415.11(c)(1)

Based on interview and record review conducted during the most recent recertificaiton survey, the facility did not ensure that care and treatment were provided to 1 of 3 residents (#25) reviewed for urinary incontinence to address the decline in urinary continence, and to potentially restore the resident's previous level of urinary continence status to the extent possible. The findings are: Resident #25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Admission Minimum Data Set (MDS; a resident assessment tool) of 2/24/17, the resident had no cognitive impairment, required extensive assistance of two people for transfers and toileting, extensive assistance of one person for locomotion, was wheelchair bound, and was continent of bladder function. The resident was subsequently assessed on the Quarterly MDS dated [DATE] and showed that the resident was occasionally incontinent of bladder function (less than seven episodes of incontinence in a 7-day period). The resident's comprehensive care plan showed no measurable objectives, time frames and appropriate interventions to address the decline in the residents bladder status, nor was there was any documentation to explain the change in the resident's condition. The Certified Nurse Aide documentation for the month of June 2017 showed that the resident continued to have episodes of incontinence. The unit Registered Nurse manager was interviewed on 6/12/17 at 3:42 PM regarding the care plan that addresses the decline in urinary continence. She stated she reviewed the resident's comprehensive care plan and could not find one. The resident was interviewed on 6/12/17 at 4:12 PM and stated that there were different reasons why he was incontinent at times. He stated that at times he has to wait after he rings the bell for assistance. At the time of this interview, a urinal was present in the resident's room. He stated that he uses the urinal when he is in bed during the night time. 415.12(d)(2)

Based on interview and record review conducted during a recertification survey, the facility did not ensure that all the medications prescribed and administered to 1 of 5 residents (Resident #84) reviewed for unnecessary medications were necessary. Specifically, there was lack of parameters to determine the need for the administration of [MEDICATION NAME] as medication of choice when it was given on multiple occasions. The findings are: Resident #84 is a [AGE] year old female and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's June 2017 medication regimen included the following medications for pain: [MEDICATION NAME] every 3 days, [MEDICATION NAME] 650 mg every 6 hours as needed for pain on a scale of 1-5 and, [MEDICATION NAME] concentrate 100 mg/5 ml (give 5 mg) every 4 hours as needed. A review of the Medication Administration Records the months of May 2017 and June 2017 revealed that [MEDICATION NAME] was administered on the following dates: 5/25, 5/27, 5/28, 5/29 and on 6/10. There was no documentation in the resident's clinical record as to the level of the resident's pain and why [MEDICATION NAME] was the medication of choice on those dates when administered. The unit Registered Nurse manager was interviewed on 6/12/17 at 2:30 PM regarding the lack of parameters for the use of the [MEDICATION NAME] and she stated that she would contact the physician. 415.12(l)(1)

Based on interview and record review conducted during a recertification survey, the facility did not ensure that the plan of care for one of four residents reviewed for urinary incontinence (Resident #135) was revised to address a change in the resident's level of continence. This had the potential for more than minimal harm that was not immediate jeopardy. The findings are: Resident #135 has [DIAGNOSES REDACTED]. The resident was admitted to the facility in April 2014. The initial Minimum Data Set (MDS, an assessment instrument) dated 4/14/14 revealed that that the resident was continent of urine, required oversight with toileting, and was able to ambulate independently with a walker. The initial comprehensive plan of care was developed in 4/2014 and did not address urinary continence. The quarterly MDS assessment dated [DATE] noted a decline in the resident's urinary continence status in that the resident was occasionally incontinent of urine (defined in the MDS as less than 7 episodes of incontinence during the assessment period). This MDS also indicated that the resident continued to require oversight with toileting and ambulated with a walker. The resident's plan of care was not revised to reflect and address the change in the resident's level of urinary continence. According to a nursing note dated 10/20/14, the resident was found sitting on the floor and complained of pain to the left hip at that time. The resident was transferred to the hospital and was admitted with the [DIAGNOSES REDACTED]. After the resident's readmission to the nursing facility, an MDS assessment for a significant change in status was completed with a reference date of 10/24/14. This MDS showed that the resident was then frequently incontinent of urine (defined in the MDS as 7 or more episodes of urinary incontinence, but at least one episode of continent voiding during the assessment period), required extensive assistance with toileting and locomotion utilizing a wheelchair and did not ambulate. A quarterly MDS assessment dated [DATE] continued to reflect this level of functioning. This MDS also showed that the resident had a Brief Interview for Mental Status (BIMS) score of 13 indicative of minimal cognitive impairment and independent decision making. There was no documented evidence that the resident's comprehensive plan of care was revised to address the decline in the resident's level of urinary continence or to use interventions to attempt to restore as much urinary continence as possible. The Certified Nurse Aide (CNA #1) assigned to the resident's care on the day shift was interviewed on the morning of 2/18/15. CNA #1 stated that, currently, the resident was able to use a walker, sometimes requested to use the bathroom and that the resident was sometimes incontinent. CNA #1 also stated that there was no set toileting schedule for the resident. The Registered Nurse responsible for MDS assessments (RN #1) was interviewed on 2/18/15 at 3:05 PM. RN #1 stated that the reason for the incontinence was due to the recent [MEDICAL CONDITION] and a urinary tract infection in the hospital. RN #1 also stated that there was no care plan to address incontinence and that bowel incontinence was being addressed instead of urinary incontinence. The evening shift CNA (CNA #2) was interviewed on 2/19/15 in the afternoon and stated that the resident was usually incontinent when she was asleep. 415.11(c)(2)(iii)

Based on interview and record review conducted during a recertification survey, the facility did not ensure that the necessary care to restore as much normal bladder function as possible was provided for one of four residents reviewed for urinary incontinence (Resident #135). Specifically after a resident was assessed to have a decline in level of urinary continence, no planned interventions were put in place to address the decline. This had the potential for more than minimal harm that was not immediate jeopardy. The findings are: Resident #135 has [DIAGNOSES REDACTED]. The resident was admitted to the facility in April 2014. The initial Minimum Data Set (MDS, an assessment instrument) dated 4/14/14 revealed that that the resident was continent of urine, required oversight with toileting, and was able to ambulate independently with a walker. The initial comprehensive plan of care was developed in 4/2014 and did not address urinary continence. The quarterly MDS assessment dated [DATE] noted a decline in the resident's urinary continence status in that the resident was occasionally incontinent of urine (defined in the MDS as less than 7 episodes of incontinence during the assessment period). This MDS also indicated that the resident continued to require oversight with toileting and ambulated with a walker. The resident's plan of care was not revised to reflect and address the change in the resident's level of urinary continence. According to a nursing note dated 10/20/14, the resident was found sitting on the floor and complained of pain to the left hip at that time. The resident was transferred to the hospital and was admitted with the [DIAGNOSES REDACTED]. After the resident's readmission to the nursing facility, an MDS assessment for a significant change in status was completed with a reference date of 10/24/14. This MDS showed that the resident was then frequently incontinent of urine (defined in the MDS as 7 or more episodes of urinary incontinence, but at least one episode of continent voiding during the assessment period), required extensive assistance with toileting and locomotion utilizing a wheelchair and did not ambulate. A quarterly MDS assessment dated [DATE] continued to reflect this level of functioning. This MDS also showed that the resident had a Brief Interview for Mental Status (BIMS) score of 13 indicative of minimal cognitive impairment and independent decision making. There was no documented evidence that the resident's comprehensive plan of care was revised to address the decline in the resident's level of urinary continence or to use interventions to attempt to restore as much urinary continence as possible. The Certified Nurse Aide (CNA #1) assigned to the resident's care on the day shift was interviewed on the morning of 2/18/15. CNA #1 stated that, currently, the resident was able to use a walker, sometimes requested to use the bathroom and that the resident was sometimes incontinent. CNA #1 also stated that there was no set toileting schedule for the resident. The Registered Nurse responsible for MDS assessments (RN #1) was interviewed on 2/18/15 at 3:05 PM. RN #1 stated that the reason for the incontinence was due to the recent [MEDICAL CONDITION] and a urinary tract infection in the hospital. RN #1 also stated that there was no care plan to address incontinence and that bowel incontinence was being addressed instead of urinary incontinence. The evening shift CNA (CNA #2) was interviewed on 2/19/15 in the afternoon and stated that the resident was usually incontinent when she was asleep. 415.12(d)(1)

Based on observations, record reviews and interviews, the facility did not promote care for residents in a manner and in an environment that maintained and enhanced each resident's dignity and respect in full recognition of his/her individuality. Specifically, a Licensed Practical Nurse (LPN) was observed to expose a resident's body in a common area during a medication pass (Resident #123). This was evident for one resident during random observations and resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. Finding are: During observation of medication administration on Unit B 12/18/12 at 8:15AM, the LPN was observed to lower Resident #121's blouse, without asking her permission, and to remove and replace a medication patch from her mid to upper back in a crowded dining room. In an interview with the LPN immediately following this medication administration observation the nurse stated that she should have brought the resident to her room and removed the old patch in private and applied the new one in a manner which afforded the resident more dignity and privacy. In a subsequent interview with the Unit Manager Registered Nurse, at 1145 AM, she also stated that the resident should have been taken to her own room and had the medication patch applied in private out of respect for the resident and to ensure her dignity. 415.5(a)

Based on interview and record review, the facility did not ensure that a plan of care was developed to address active psychosocial and medical problems for which medications were prescribed. This was evident for 1 of 23 sampled residents (Resident #68). This had the potential for more than minimal harm that is not immediate jeopardy. The findings are: Resident #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Progress Notes by the psychologist revealed that the resident had difficulty with adjustment to a decline in her mobility, increased dependence on staff and the possibility of long term care placement. On 10/12/12 the physician wrote an order for [REDACTED]. A review of the resident's plan of care did not reveal any measurable goal(s) and interventions to address anxiety and the use of [MEDICATION NAME]. Specifically, non-pharmacological non-pharmacological interventions to be utilized by staff to reduce anxiety, what symptoms of anxiety to monitor and the frequency of monitoring of these symptoms were not indicated. 2. Additionally, the resident was prescribed [MEDICATION NAME], a stool softener, to address constipation. There were no measurable goals or non- pharmacological interventions identified to address constipation. The Unit Manager/RN responsible for the development of care plans was interviewed on 12/20/12 at 11:11 AM. She acknowledged that there were no care plans as indicated above. 415.11(c)(1)

Based on observations, interviews and record reviews, the facility did not ensure the appropriate disposal of a controlled drug in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions. Specifically, a Licensed Practical Nurse (LPN) disposed of a medication patch containing a controlled substance without having a second nurse to witness its' destruction in order to prevent the opportunity for diversion or misuse. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The findings are: During medication administration on Unit B on 12/18/12 at 8:15AM, the LPN was observed to remove a Duragesic patch (a narcotic transdermal medication) from Resident #121's back and dispose of it into the container for sharp instruments without having a second facility nurse witness this destruction. (A witness to the destruction of a Duragesic patch is necessary because some of the narcotic remains in the patch and could potentially be diverted or misused). In an interview with the LPN immediately following this observation, she stated that she did have a witness to the removal of the Duragesic patch but did not realize that the nurse was required to witness the destruction as well. After consideration, the LPN said "that makes sense since the patch is a narcotic". In an interview with the Unit Manager Registered Nurse at approximately 11:35AM on this same day, she stated that the facility policy mandates that two nurses witness the disposal of Duragesic patches. 415.18(d)

Based on observations, record reviews and interviews, the facility did not promote care for residents in a manner and in an environment to ensure that aseptic techniques and handwashing practices were utilized to prevent the potential spread of infection. Specifically, the LPN was observed to place a soiled medication patch on the table where residents were dining and another LPN was observed to place medications into his bare hands prior to transferring them to a medication cup when administering medication to a resident (Residents #121 and #95 respectively). This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The findings are: 1. During a medication administration on Unit B on 12/18/12 at 8:15AM, the Licensed Practical Nurse (LPN) was observed to remove a medication patch from Resident #123's mid to upper back in a crowded dining room and place the soiled patch on the clean table where other residents were being served breakfast. The LPN then gathered up the soiled patch and exited the dining room without cleaning the table for the other residents. In an interview immediately after this observation, the LPN stated that she should have removed the patch in private and thus avoided the risk of potential spread of infection to other residents. and that, not having done this, she should have ensured that the dining table was free of potential contamination after she placed the soiled patch on it. 2. During a medication pass observation on Unit D on 12/18/12 at 8:33AM, the LPN was observed to assist Resident #95 to his room and help to transfer the resident form his wheelchair to a recliner chair. The LPN then returned to the medication cart, and without washing or sanitizing his hands, proceeded to pour medications for the resident, thus potentially contaminating the medication cart. The LPN was also observed to pop two of the resident's medications from two blister packs directly in the palm of his hand prior to dropping each medication into a medication cup, thus contaminating the medications prior to administering them to the resident. In an interview with the LPN immediately after this observation, he stated that he should have washed his hands prior to pouring the medications and should have popped the medications directly into the medication cups without touching the pills with his bare hands, both for the purposes of controlling potential infections. 415.19(a)(1-3)

Based on observation and interview, the facility did not ensure that essential kitchen equipment was being maintained in safe operating condition. This had the potential for more than minimal harm that is not immediate jeopardy. The findings are: An inspection of the kitchen on 12/17/12 and 12/21/12 in the morning revealed the following: 1. A dusty fan was observed near the rack with clean pans on 12/12/12 and on 12/21/12. The ventilation system over the stoves, exhibited an accumulation of dust, noted on 12/21/12. At that time the Food Service Director (FSD) acknowledged that the vent was in need of cleaning. 2. On 12/21/12 an accumulation of condensate was observed dripping from the ceiling above the clean end of the dishwasher. At that time the, FSD stated that this condition was a a result of the steam from the dishwasher. The Maintenance Director , who was also present, stated that the exhaust system was not adequate to handle the amount of steam generated by the dishwasher 415.29(b)(j)(1)

Based on record review and staff interview, the facility did not ensure that residents/legal representatives were informed of their right to have demand bills reviewed by a Medicare Provider. Specifically, the facility did not inform a resident/legal representative of his/her right to appeal the decision of the Quality Improvement Organization (QIO) an independent reviewer. This was evident for 3 of 4 residents reviewed for Demand Bills (Residents # 115,141,149). This resulted in no actual harm with the potential for more than minimal harm. Findings include but are not limited to: A review of Resident #149's Liability and Beneficiary Appeal Notice dated 11/28/11 revealed that the resident/legal representative was informed by the facility that the resident's Medicare coverage for skilled care in the facility would end on 11/30/11. Although, the resident or legal representative was informed of her/his right to have this decision by the facility reviewed by the QIO, an independent reviewer; the facility did not inform the resident or legal representative of their right to appeal the decision with the Medicare Provider. A review of the QIO's decision dated 11/30/11, indicated that it was determined that the resident no longer required skilled care and would not be eligible to receive Medicare coverage. However, there was no documentation that the facilty informed the resident/legal representative of her/his right to appeal the decision of the QIO by having a Medicare Care Provider review the demand bill. In an interview with the facility's person responsible for Demand Bills on 1/27/12 at 1:45PM, she stated that the facility was unaware that the Resident #149 or her legal representative had the right to appeal the decision of the QIO and that the facility was required to inform in writing to the resident/legal representative of their right to allow a Medicare Provider to review the demand bill. 415.3(g)(2)(i)