Every finding on record at The Enclave At Rye Rehab And Nursing Ctr

Based on observation, record review and interview during the recertification survey, the facility did not ensure the development and implementation of comprehensive person-centered care plans for each resident, consistent with resident rights that included measurable objectives and time frames to meet a resident's needs for one (1) of two (2) residents (Resident #7) reviewed for anticoagulant medication. Specifically, Resident #7 was on an anticoagulant medication (blood thinner) and there was no documented evidence that a care plan to address risks and care related to the anticoagulant medication was developed and/or implemented. The findings include:The 11/2025 policy titled Care Planning documented resident care plans are developed according to the timeframes and criteria established by S483.21. Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team.Resident #7 had diagnoses which included saddle embolism (blood clot) of pulmonary artery (artery carrying blood from right ventricle of the heart to the lungs for oxygenation) without acute cor pulmonale, atrial fibrillation (abnormal heart rhythm), and deep vein thrombosis (blood clot in a vein deep below the skin).The 8/05/2025 Quarterly Minimum Data Set (resident assessment) documented Resident #7 was receiving anticoagulant medication.The 2/15/2024 physician order documented Eliquis (anticoagulant, blood thinner) 5 mg twice a day for pulmonary embolism.There was no documented evidence in the comprehensive care plan to address Resident #7's use of anticoagulant medication.The 11/04/2025 Quarterly Minimum Data Set (assessment tool) documented, Resident #7 was receiving anticoagulant medication.On 01/22/2026 at 10:34 AM during an interview, Resident #7 stated they were on Eliquis. They stated they had vaginal bleeding a few weeks ago and the doctor stopped the Eliquis for a few days. They stated they had an ultrasound test and were fine now.On 01/27/2026 at 3:15 PM during an interview Registered Nurse Unit Manager #1 stated they were responsible for writing the care plans for the 2nd floor units. They stated an anticoagulant care plan should have been in place for Resident #7 who was on Eliquis. On 01/28/2026 at 12:08 PM during an interview, Licensed Practical Nurse Unit Manager #4 stated they were responsible for updating care plans with new information. They stated that when Resident #7 had a vaginal bleed and the Eliquis was placed on hold, they should have updated the anticoagulant care plan. They stated that if they had proceeded to update Resident #7's anticoagulant care plan, they would have noticed there was no active anticoagulant care plan in place, and they would have notified Registered Nurse Unit Manager #1 or the Director of Nursing.10 NYCRR 415.11 (c)(1)

Based on observation, record review and interview the facility did not ensure each resident who was unable to carry out activities of daily living received the necessary care and services for one (1) of four (4) residents (Resident #165) reviewed for Activities of Daily Living. Specifically, Resident #165, who required dependent assistance with activities of daily living, was observed during multiple observations with fingernails that were long and ungroomed.The findings include:The policy and procedure titled Activities of Daily Living last reviewed on 09/01/2024 documented appropriate care and services will be provided for residents who are unable to carry out activities of daily living independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, and grooming).Resident #165 was admitted to the facility with diagnoses including cancer, diabetes mellitus, legal blindness.The Minimum Data Set (resident assessment) dated 01/21/2026 documented Resident #165 was cognitively intact and needed substantial assistance from staff with personal hygiene and showers/bathing.The Comprehensive Care Plan titled Resident Required Assistance with Activities of Daily Living last updated on 01/29/2026, documented Resident #165 required substantial assistance of one person with personal hygiene, and shower/bathing.During observation and interview on 01/22/2026 at 12:53 PM and on 01/27/2026 at 9:14 AM, Resident #165's fingernails on both hands appeared long, with dark brown matter observed underneath the fingernails. Resident #165 stated that they would like their fingernails cleaned and trimmed but were unable to do so independently. Resident #165 stated that staff do not provide fingernail care. Resident #165 stated that their daughter trimmed and cleaned their fingernails during visits, but they could not recall the last time their fingernails were groomed.During interviews on 01/27/2026 at 9:44 AM and 11:41 AM, Certified Nurse Aide #11 stated that every time they provided assistance with personal hygiene, they paid attention to the resident's grooming needs, including fingernails that may be long or dirty. Certified Nurse Aide #11 stated that the last time they were assigned to Resident #165 was on 01/23/2026. They stated that at that time, they provided assistance with personal care but did not observe, clean or clip Resident #165's fingernails. Certified Nurse Aide #11 stated that they were responsible for clipping fingernails. During an interview on 01/27/2026 at 10:08 AM, Registered Nurse #13 stated that during their shift they saw Resident #165 multiple times a day, beginning with the initial rounds at 7:00 AM and during medication administration. Registered Nurse #13 stated they paid attention to Resident #165's physical appearance, including grooming and hygiene. Registered Nurse #13 stated they did not remember how Resident #165's fingernails looked today or during the previous week. Registered Nurse #13 stated that Certified Nurse Aides were responsible for resident's personal care, including cleaning and clipping fingernails.10 NYCRR 415.12 (a)(3)

Based on record review and interview during the recertification and abbreviated surveys (NY00315889), from 12/06/23 to 12/13/23, it was determined the facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents for 1 of 5 residents (Resident #42) reviewed for accidents. Specifically, Resident #42 fell from their bed when the plan of care for a 2 person assist with bed mobility was not followed. Subsequently, Resident #42 sustained fractures to both lower extremities. This resulted in actual harm that was not immediate jeopardy. Findings include: The Activities of Daily Living (ADL) Support policy, dated 05/19/23, documented appropriate care and services would be provided for residents who were unable to carry out Activities of Daily Living independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene, mobility, and toileting. Resident #42 was admitted to the facility with diagnoses including dementia, osteoporosis (brittle bones), and rheumatoid arthritis. The Annual Minimum Data Set (a resident assessment tool), dated 02/19/23, documented Resident #42 had severe cognitive impairment and required 2 or more persons to physically assist with bed mobility, transfers, and toilet use. Resident #42's comprehensive care plan, dated 02/17/23, documented the resident required assistance of two staff during bed mobility tasks. A facility accident/incident report dated 05/01/23, documented Resident #42 fell from their bed to the floor while receiving care from Certified Nurse Aide #1 and Registered Nurse #1. X-rays were ordered after the fall which showed fractures, and the resident was transferred to the hospital for further evaluation. The fall investigation summary, dated 05/01/2023, written by the Director of Nursing, documented on 05/01/23 at approximately 10:20 PM the resident was being provided incontinence care with Certified Nurse Aide #1 and Registered Nurse #1 and required a 2 person assist for bed mobility. Certified Nurse Aide #1 turned to reach for the brief to change the resident and the resident rolled out of bed. Registered Nurse #1 was walking to the other side of the bed when the resident rolled out of bed and Registered Nurse #1 was unable to prevent the resident from falling. Both staff attempted to prevent the fall but were unable to catch the resident to prevent the incident. The summary documented both staff rendering care were re-educated to be at the opposite sides of the bed prior to positioning the resident, and prior to rendering care. The summary documented the care plan was followed. The hospital history and physical examination, dated 05/02/23, documented Resident #42 sustained fractures of both lower extremities from a fall during care at their nursing home. During an interview on 12/08/23 at 1:20 PM, Registered Nurse #1 stated Certified Nurse Aide #1 called them to the room for help and they went to the sink to get water while Certified Nurse Aide #1 rolled the resident on their side. Registered Nurse #1 stated they were walking back from the sink when Certified Nurse Aide #1 turned away from the bed to get a disposable brief and the resident fell . Registered Nurse #1 stated she was not physically on the side of the bed when Resident #42 fell and was about an arm and a half's length away from the bed. Registered Nurse #1 stated Certified Nurse Aide #1 rolled the resident without their assistance and they usually did not roll the resident with one person. During an interview on 12/08/23 at 3:18 PM, Certified Nurse Aide #1 stated as they were turning Resident #42, Registered Nurse #1 was at the foot of the bed, not assisting them with the bed mobility of Resident #42. Certified Nurse Aide #1 stated they turned Resident #42 on their side as Registered Nurse #1 was going to the other side of the bed when the resident went over the edge of the bed and fell to the floor. During an interview on 12/08/23 at 11:08 AM, the facility's Director of Nursing stated a facility-wide in-service was initiated immediately following Resident #42's fall with major injury. During an interview on 12/12/23 at 12:25 PM, the facility's Medical Director confirmed Resident #42 sustained fractures of both lower extremities from the fall, and when Resident #42 returned to the facility, they required physical therapy, occupational therapy, and orthopedic care for their injuries. 10 NYCRR 415.12(h)(2)

Based on observation and interview, the facility did not ensure food was prepared and stored according to professional standards for food safety. Specifically, cold foods were not held at a safe holding temperature, prior to service, to prevent bacterial contamination. The findings are: During an observation on 12/13/2023 at 11:00AM, the Food Service Director (FSD) was obtaining pre-meal service temperatures of cold foods held on ice on the tray line. Multiple cold sandwiches were found to have temperatures greater than a safe holding temperature of 41 degrees Fahrenheit (F) or less, including: Egg salad sandwich 45.5 degrees Fahrenheit Turkey and cheese sandwich 53.2 degrees Fahrenheit Ham and cheese sandwich 55.3 degrees Fahrenheit In an interview at that time, the Food Service Director (FSD) stated that staff had made the sandwiches at about 9AM that morning and had stored them in the freezer. The FSD stated they will discard the sandwiches being held on the tray line. In an interview on 12/13/23 11:16 AM, the Dietary Aide (DA #1) responsible for preparing the sandwiches that morning stated that they made the sandwiches after 8AM and stored them in the freezer at around 9AM. Dietary Aide #1 stated that today the stock staff had turned off the freezer for deliveries, and that happens on Wednesdays and Thursdays. At that, the Dietary Aide #1 and surveyor checked the freezer, found that it was off, and checked the freezer thermometer which read +18 degrees Fahrenheit. In a follow up interview on 12/13/23 at 11:22 AM, the Food Service Director stated they would have turned the freezer off because it is too cold in there. In an interview on 12/13/23 at 11:25 AM, Dietary Aide/Cook #2, who was responsible for accepting and storing frozen foods deliveries that day, stated that when they pack away the frozen food, they turn off the freezer and leave the door ajar because the fan blows hard, it makes the air misty, and it is overwhelming and difficult to see things. Dietary Aide/Cook #2 stated that they turn the freezer back on between packing items. When asked if they had turned the freezer back on today, Dietary Aide/Cook #2 stated they thought that they did, but they were not 100% sure, as they had been called away to go to the storeroom. Dietary Aide/Cook # 2 stated that frozen foods are received on Wednesdays and Thursdays. 10 NYCRR 415.14(h)

F584 Based on interview, and record review during an Abbreviated Survey(NY 215), the facility failed to exercise reasonable care for the protection of resident property from loss or theft for 1 of 3 residents (Resident #1) reviewed. Specifically, Resident #1 had an unplanned discharge to the hospital from the [CONDITION(S)] center on 7/01/2021 without their belongings. There is no documented evidence that Resident #1 and/or Resident #1's POA were given or have received the belongings. The findings are: The Facility Policy titled discharged Patients/Residents-unexpected revised 8/01/2013 under :Clothing documented Concierge will reach out to resident families within 7 days of discharge to determine what to do with Resident belongings. The facility will store resident belongings for a period of 6 months. Resident/family will be notified by concierge that all belongings not picked up will be discarded. Resident #1 was admitted to the facility on [DATE] with diagnoses of Chronic Urinary Tract Infection ([CONDITION(S)]), Hypertension, Type 2 Diabetes and Dementia. The Minimum Data Set (MDS, an assessment tool) for Discharge, dated 6/18/2021, documented that the resident had a Brief Interview of Mental Status (BIMS) score of 14/15. Review of Resident #1's patient personal possessions form dated 2/24/2021 revealed 1 house coats and 4-night gowns. Review of Resident #1's patient personal possessions form dated 3/19/2021 revealed 3 bags with 1 hat, 1 scarf, 1 pair of pants, 2 pajama bottoms, 5-night gowns, 1 blouse and 2 undershirts. Review of the Nursing Progress noted 7/01/2021 revealed Resident #1 was transferred to the hospital from [CONDITION(S)]. Staff will follow up with hospital for further update. An Interview was conducted on 9/21/2022 at 1:58 PM with Maintenance/Housekeeping Director (MHD), the MHD stated when a resident is transferred to the hospital unexpectedly, the MHD is notified by Nursing via text. MHD stated a housekeeping staff is assigned to the room to clean and gather the residents belonging. Any belongings found in the room is boxed up and placed in storage. MHD stated any items of value are given to the nursing supervisor. according to the MHD, belonging are normally kept in storage for a maximum of 6 months and then they try to get in touch with residents family to inform them to pick up belongings/to find out what they would like to do with the items. MHD stated the following up process with residents and/ or resident's representatives is not documented. MHD state they could not recall having any items brlonging to Resident #1 or their family calling to request them. MHD checked the facility storage and confirmed there were no items for Resident #1 in storage. During an Interview on 9/21/22 at 2:08 PM with Assistant Director of Recreation (ADR), the ADR revealed recreation staff sometimes assist MHD with contacting families regarding belongings left at the facility. ADR stated MHD will supply a list of items that still need to be picked up and the ADR will reach out to those residents and /or resident's families. ADR stated they did not contact attempts to reach family or follow up attempts. During an Interview with Administrator on 9/21/2022 at 2:52 PM , the administrator revealed that when a resident goes to the hospital unexpectantly staff will pack up their belongings and box them up. Administrator normally stated the resident and/or their family will reach out to the facility but if they don't the assistant administrator will reach out to see what needs to be done with the belonging. Administrator stated the facility will hold a resident's belonging for up to 6 months. Administrator stated they do not document the communication regarding residents' belongings being picked up. Administrator stated they did not recall being contacted regarding Resident #1 belongings. The Administrator denied receiving any letter from the Power of Attorney (POA). During an Interview with Assistant Administrator on 9/21/2022 at 3:00 PM, the Assistant Administrator stated they contact families to follow up on if they would like to pick up resident's belongings. Assistant Administrator stated they do not document when contacting families. During an Interview with Resident #1's POA on 09/23/2022 at 11:30 AM, the POA stated they requested for the facility to mail Resident #1's belongings and the facility stated they could not. POA stated their lawyer sent out a certified letter to the facility requesting Resident #1's belonging be mailed. POA stated they could not recall the date of the letter but stated the facility stated they could not mail the items. POA stated they live far from the facility, and it was during COVID when the items were being requested. POA stated as of 01/2022 Resident #1's belonging has not been received from the facility. 415.5(h)(1)

Based on interview and record review conducted during the recertification survey, the facility did not develop and implement a comprehensive person-centered care plan with measurable goals, time frames and interventions to meet the needs of 1 of 4 residents (#54) reviewed for pressure ulcers and 1 of 3 resident (#133) reviewed for respiratory care. Specifically, Resident # 54 did not have a care plan in place to address a stage 3 sacrum pressure ulcer and Resident # 133 did not have a care plan to address oxygen therapy. The findings are: Resident #54 was admitted with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS-a resident assessment tool) dated 11/13/2019 and the Quarterly MDS dated [DATE] revealed that the resident had a stage 3 pressure ulcer. Review of the January 2020 physician's orders [REDACTED]. Review of the physician's note dated 01/22/2020 revealed that the resident had a stage 3 pressure ulcer to the sacrum for the past 230 days duration. An interview conducted with the Unit Manager #1 on 01/28/2020 at 11:13 AM revealed that it is the Unit Manager's responsibility to initiate and update care plans. She further stated that Resident #54 developed a pressure ulcer in May 2019 but it was not care planned. An interview conducted with the Director of Nursing (DON) on 01/29/2020 at 01:33 PM revealed that there was no care plan developed for the stage 3 pressure ulcer. Resident #133 was admitted with [DIAGNOSES REDACTED]. Review of Resident #133's January 2020 physician's orders [REDACTED]. [MEDICATION NAME]-[MEDICATION NAME] Solution ([MEDICATION NAME][MEDICATION NAME]), three milliliters via mask every six hours for SOB. Oxygen at two liters per minute via nasal cannula as needed for SOB. Review of the comprehensive care plan revealed no care plan in place related to oxygen therapy. In an interview on 01/28/20 at 12:53 PM with the MDS Coordinator she stated the Unit Manager together with the interdisciplinary team was responsible for initiating a care plan for Resident #133. The MDS Coordinator stated there was no care plan in place related to oxygen therapy for Resident #133. 415.11(c)(1)

Based on observation, interview and record review conducted during the recertification survey, the facility did not implement an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development of communicable diseases and infections. Specifically, 1. a Licensed Practical Nurse (LPN) did not perform hand hygiene prior to administration of medications and 2. the facility did not protect oxygen equipment from surface and air contaminants. The findings are: 1. Observation on [DATE]20 at 10:16 AM revealed that Resident #133 was in bed while the oxygen concentrator was on and set at 2 L/min. However, the oxygen tubing including the nasal canula was on the floor. Resident #133's nebulizer mask was on the bedside table, unbagged. Further observation on 01/24/2020 10:39 AM showed that Resident #133's nebulizer mask was again on the bedside table, unbagged. Additional observation on 01/28/2020 11:00 AM showed that Resident #133's nebulizer mask was again on the bedside table, unbagged. 2. Observation on [DATE]20 at 10:25 AM and again on [DATE]20 at 4:00 PM revealed that Resident #11's [MEDICAL CONDITION] mask was on top of the [MEDICAL CONDITION] machine unbagged. 3. Observation 01/28/2020 at 10:45 AM with the Assistant Director of Nurses (ADON), Unit Manager #1 and the Maintenance Director revealed that Resident #11's [MEDICAL CONDITION] mask was on top of the [MEDICAL CONDITION] equipment, unbagged. The resident was wearing the nasal canula for oxygen support. The oxygen concentrator had two areas for filters, one on each side. The Maintenance Director confirmed the right side of the concentrator was missing a filter and the filter on the left side was saturated with white particles. 4. Observation during an initial tour of the facility on [DATE]20 revealed that Resident #67's nebulizer mask was draped over items at the bedside and was unbagged. Further observation on 01/28/2020 at 10:48 AM with Unit Manager #1 revealed that the nebulizer mask was unbagged and sitting on top of the beside stand. 5. Observation on 01/28/2020 at 10:02 AM with Registered Nurse #3 revealed that Resident #104's nebulizer tubing was on the floor. 6. During an initial tour of the facility on [DATE] Resident #348's [MEDICAL CONDITION] mask was draped over the equipment and unbagged. During follow up observation and interview on 1/28/2020 at 9:48 AM with Licensed Practical Nurse (LPN) #2 the filter on the back of Resident #348's oxygen concentrator was saturated with a white substance. LPN #2 said, It's filthy. LPN #2 also said the filters on the oxygen concentrators were supposed to be inspected and maintained weekly by the Maintenance Department. During an interview on 1/28/2020 the Maintenance Director said that the maintenance staff are to check the oxygen concentrator filters weekly. He said they may have missed this one (Resident #348's). The Maintenance Director said that the maintenance staff do not document the weekly oxygen concentrator checks. 415.19 (a) (1-3)

Based on observation, interview and record review conducted during an abbreviated survey (NY 795), the facility did not provide person-centered care and services necessary to maintain the highest practicable physical, mental and psychosocial well-being for one of three residents reviewed for quality of care/unnecessary hospitalization (Resident #1). Specifically, the facility did not investigate incidents of possible substance abuse or develop a plan to address the resident's individual needs and minimize risk of potential recurrence after the resident tested positive for opioid drugs. The findings are: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS; a resident assessment and screening tool) of 01/26/18 documented that the resident had independent cognitive skills for daily decision making and no mood or behavior problems. This MDS further documented that the resident was taking antipsychotic, antianxiety and antidepressant medications during the last seven days of the assessment period. The 2/6/18 Social Service Comprehensive Intake Assessment noted that the resident had a history of [REDACTED]. An Interdisciplinary Progress Notes (IPN) entry by a Licensed Practical Nurse (LPN) on 4/20/18 at 2:35 PM documented that the resident was observed in bed, lethargic, arousable to touch but goes back to sleep, and loud snoring. Vital signs were obtained and oxygen was administered. The physician examined the resident and ordered to transfer the resident to the hospital. Emergency Medical Service (EMS) was called and, upon arrival, intravenous access was established and administered [MEDICATION NAME] (used in an emergency to reverse or block the effects of opioids, especially in overdose). The resident became alert after [MEDICATION NAME] was given by EMS and was transferred to the emergency room . The resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no documented evidence of investigation to rule out opioid drug use or to determine a possible source of opioid drugs as a potential cause of the resident's lethargy and positive response to [MEDICATION NAME]. There was no documented evidence that a person-centered care plan was developed to address a potential episode of drug use or to minimize risk of further potential for substance abuse to the extent possible. An IPN entry by the LPN on 6/17/18 at 11:16 AM documented that the resident was found in bed very lethargic, not responsive as usual and was transferred to the hospital. The resident was readmitted to the facility on [DATE]. The accompanying hospital medical record that was sent with the resident upon discharge included a urine toxicology report for a test obtained during the resident's previous 4/20/18 hospital admission that was positive for [MEDICATION NAME] (an opioid drug used to treat severe pain and narcotic drug addiction). The facility physician's orders [REDACTED]. There was no documented evidence of investigation to determine how the resident may have obtained and consumed [MEDICATION NAME]. There was no evidence a care plan was developed to address physical, mental and psychosocial needs related to substance abuse. An IPN of 7/31/18 documented that at 7:30 AM, the resident was found unresponsive, very lethargic and diaphoretic (sweating). The resident was sent to the hospital following physician's orders [REDACTED]. The Director of Nursing (DON) was interviewed on 8/2/18 at 8:41 AM. The DON stated that she received a call from the hospital on [DATE] stating that the resident tested positive for substance abuse and that she was asked if the resident was taking any narcotics or other substances. The DON stated that she started an investigation on 8/1/18. 415.12

Based on record review and interviews conducted during an abbreviated survey (NY 795), the facility did not develop a person-centered care plan with measurable objectives and interventions for one of four residents (Resident #1) reviewed for quality of care/unplanned hospitalization . Specifically, upon admission, the resident revealed a history of drug abuse that was not an active concern. Following a hospitalization , the facility was notified that the resident tested positive for opiates. A care plan was not developed to address the resident's physical, mental and psychosocial needs and to minimize risk of recurrent drug use. The findings are: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS; a resident assessment and screening tool) of 2/2/18 documented that the resident had intact cognitive skills for daily decision making and did not exhibit any mood or behavior problems. The 2/6/18 Social Service Comprehensive Intake Assessment noted that the resident had a history of [REDACTED]. An Interdisciplinary Progress Notes (IPN) entry by a Licensed Practical Nurse (LPN) on 4/20/18 at 2:35 PM documented that the resident was observed in bed, lethargic, arousable to touch but goes back to sleep, and loud snoring. Vital signs were obtained and oxygen was administered. The physician examined the resident and ordered to transfer the resident to the hospital. Emergency Medical Service (EMS) was called and, upon arrival, intravenous access was established and administered [MEDICATION NAME] (used in an emergency to reverse or block the effects of opioids, especially in overdose). The resident became alert after [MEDICATION NAME] was given by EMS and was transferred to the emergency room . There was no documented evidence that a person-centered care plan with measurable objectives, time frames and interventions was developed to address a potential episode of drug use or to prevent further potential occurrence of substance abuse to the extent possible. An IPN entry by the LPN on 6/17/18 at 11:16 AM documented that the resident was found in bed very lethargic, not responsive as usual and was transferred to the hospital. The resident was readmitted to the facility on [DATE]. The accompanying hospital medical record that was sent with the resident upon discharge included a urine toxicology report for a test obtained during the resident's previous 4/20/18 hospital admission that was positive for [MEDICATION NAME] (an opioid drug used to treat severe pain and narcotic drug addiction). The facility physician's orders [REDACTED]. Following readmission, a Social Worker (SW #1) initiated a care plan on 6/25/18 to address the resident's impaired cognitive function and thought processes related to [MEDICAL CONDITION]. This care plan noted that the resident had a history of [REDACTED]. No measurable objectives or interventions to address the resident's physical, mental or psychosocial needs or to prevent recurrence of drug use were identified in the care plan. An IPN of 7/31/18 documented that at 7:30 AM, the resident was found unresponsive, very lethargic and diaphoretic (sweating). The resident was sent to the hospital following physician's orders [REDACTED]. The Director of Nursing (DON) was interviewed on 8/2/18 at 8:41 AM and stated that she was informed by the hospital on [DATE] of the resident's positive tests results for substance abuse and that she immediately initiated an investigation. The resident was readmitted on the evening of 8/2/18. SW #1 was interviewed on 8/8/18 at 8:30 AM about care planning for the issue of substance abuse. SW #1 stated that the resident had a history of [REDACTED]. She stated that the facility received documentation from the hospital on [DATE] that the resident was positive for substance abuse. SW #1 stated she documented the fact that the resident had a history of [REDACTED]. 415.11(c)(1)

Based on record review and interview conducted during an abbreviated survey (NY 795), the facility did not thoroughly investigate an allegation of abuse for one of three residents (Resident #1) reviewed for abuse. Specifically, the facility terminated investigation prior to completion following the resident's retraction of the allegation. The finding is: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS; a resident assessment and screening tool) of 02/02/18 documented that the resident had independent cognitive skills for daily decision making and no mood or behavior problems. A written statement by an Occupational Therapist (OT) dated 7/24/18 revealed that the resident told the OT that she was sexually assaulted on 7/23/18. The OT wrote in her statement dated 7/24/18 that she was seated in the ADL suite of the rehab gym when the resident approached the OT and stated that she did not know who he was, but he raped her in the vagina and the rectum in the middle of the night in her room when she was sleeping and that she couldn't see him. The OT informed the nursing supervisor. The Psychologist wrote in a statement dated 7/24/18 that she was asked by the nursing supervisor to evaluate the resident after she claimed that someone came last night at 2 AM and raped her. The resident was oriented to month and year, confused about today's day. Discussed with supervising nurse and social worker. The Director of Nursing (DON) wrote in a statement on 7/24/18 that she saw the resident and asked the resident about her allegation of sexual assault. The resident told her that a man put something in her vagina and rectum, claimed it was a penis. The DON told the resident that she needed to go to the hospital and the resident refused. The DON offered to examine her and the resident refused and stated nothing happened to her, that no one touched her and that she was not raped. She told the DON to leave her alone. Medical Interim Progress Notes dated 7/25/18 noted the resident had past medical history that included Urethral Abscess, status [REDACTED]. Patient claims that someone inserted object in her private area/rectum - not able to specify when and where, states, I have amnesia. After explaining that she had GU procedure, states that it might be the reason for her pain and she wants to withdraw her previous complaint. Patient offered to be sent ASAP to ER for evaluation - refused. Understands situation as of present time. An unsigned statement obtained from the resident by the DON and the Social Worker on 7/25/18 documented that the resident alleged that, about two nights ago, a man came into my room and put his hand over my mouth and nose very tightly. The curtain was drawn but it was dark and I couldn't see him. He sexually assaulted me while my roommates were sleeping. I feel he has done this before. I cannot describe him, it was dark in the room. He was very professional. I feel he targeted me because I am younger than everyone else. I didn't report this because I was in shock and couldn't believe it occurred. I refused to go to the ER to get examined. I don't want to be in the ER for hours. I have been there done that and nothing is going to come out of it. I waited too long. I showered and the semen is gone. Now the only thing left is the burning sensation I feel when I urinate. It is extremely painful. There is nothing left for me to say. The Social Worker wrote in a statement dated 7/26/18 that resident had no recollection of any events. The resident stated that she had no issues or concerns and felt safe in the facility. There was no documented evidence that the facility completed a thorough investigation of the resident's allegation of sexual abuse. There was no documented evidence that interviews and statements were promptly obtained from staff members on duty with access to the resident or knowledge of events on the unit at the time of the alleged abuse. An Interdisciplinary Progress Note revealed that the resident was sent to the hospital on [DATE] after the resident was found unresponsive in the facility. The resident was treated and during interview by the hospital staff, the resident claimed that she was raped in the nursing home. The hospital then reported the incident to the State Survey agency. The DON was interviewed on 8/2/18 at 8:41 AM and on 8/3/18 at 11:30 AM. The DON reported that an investigation of the resident's allegation of sexual abuse was initiated on 7/24/18 and suspended on 7/25/18 when the resident denied being raped and retracted her statements. Social Worker #1 was interviewed on 8/2/18 at 10:20 AM and stated that, on 7/25/18 at noon, she went to interview the resident and the resident stated an incident had occurred. She asked the resident if she could recall the time and she stated it was dark. She asked if she could identify any markings or anything and the resident stated she couldn't. SW #1 interviewed the resident again on the 7/26/18 and the resident stated she had amnesia and she didn't remember talking to her the day before. The psychologist was interviewed on 8/2/18 at 1:55 PM and stated that the supervisor called her on 7/24/18 at around 6:30 PM because of the patient's experience. The resident told her that she believed somebody raped her around 2 AM. The resident stated she didn't know who it and she didn't want to accuse anybody. She couldn't give any descriptions. The resident told the psychologist that she would use a knife to kill anybody that would come to her and hurt her. The psychologist stated that, I believe it was brought on by her own confusion with a background of drug abuse and pain from the genital [MEDICAL CONDITION]. The Administrator was interviewed on 8/3/18 at 1:10 PM and stated he was made aware of the rape allegation he thinks the next morning. He remembered that he heard the resident retracted her allegation through the DON. He instructed the DON to do proper documentation. They continued to interview her. The MD and SW talked with the resident and they discussed it in morning report. The Administrator stated that, honestly, he felt it did not happen. The resident ended it and ruled it out. 415.4

Based on record review and interview conducted during an abbreviated survey (NY 795), the facility did not promptly report an allegation of sexual abuse to the State Survey Agency for one of three residents (Resident #1) reviewed for allegation of abuse. The finding is: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS; a resident assessment and screening tool) of 02/02/18 documented that the resident had independent cognitive skills for daily decision making and no mood or behavior problems. A written statement by an Occupational Therapist (OT) dated 7/24/18 revealed that the resident told the OT that she was sexually assaulted on 7/23/18. The OT documented that the resident stated that she did not know who he was, but he raped her in the vagina and the rectum in the middle of the night in her room when she was sleeping and that she couldn't see him. The OT informed the nursing supervisor. The Psychologist wrote in a statement dated 7/24/18 that she was asked by the nursing supervisor to evaluate the resident after she claimed that someone came last night at 2 AM and raped her. The resident was oriented to month and year, confused about today's day. Discussed with supervising nurse and social worker. The Director of Nursing (DON) wrote in a statement on 7/24/18 that she saw the resident and asked the resident about her allegation of sexual assault. The resident told her that a man put something in her vagina and rectum, claimed it was a penis. The DON told the resident that she needed to go to the hospital and the resident refused. The DON offered to examine her and the resident refused and stated nothing happened to her, that no one touched her and that she was not raped. She told the DON to leave her alone. Medical Interim Progress Notes dated 7/25/18 noted the resident had past medical history that included Urethral Abscess, status [REDACTED]. Patient claims that someone inserted object in her private area/rectum - not able to specify when and where, states, I have amnesia. After explaining that she had GU procedure, states that it might be the reason for her pain and she wants to withdraw her previous complaint. Patient offered to be sent ASAP to ER for evaluation - refused. Understands situation as of present time. An unsigned statement obtained from the resident by the DON and the Social Worker on 7/25/18 documented that the resident alleged that, about two nights ago, a man came into my room and put his hand over my mouth and nose very tightly. The curtain was drawn but it was dark and I couldn't see him. He sexually assaulted me while my roommates were sleeping. I feel he has done this before. I cannot describe him, it was dark in the room. He was very professional. I feel he targeted me because I am younger than everyone else. I didn't report this because I was in shock and couldn't believe it occurred. I refused to go to the ER to get examined. I don't want to be in the ER for hours. I have been there done that and nothing is going to come out of it. I waited too long. I showered and the semen is gone. Now the only thing left is the burning sensation I feel when I urinate. It is extremely painful. There is nothing left for me to say. The Social Worker wrote in a statement dated 7/26/18 that resident had no recollection of any events. The resident stated that she had no issues or concerns and felt safe in the facility. There facility did not report the resident's allegation of sexual abuse to the State Survey Agency according to State and Federal requirements. An Interdisciplinary Progress Note revealed that the resident was sent to the hospital on [DATE] after the resident was found unresponsive in the facility. The resident was treated and during interview by the hospital staff, the resident claimed that she was raped in the nursing home. The hospital then reported the incident to the State Survey agency. The DON was interviewed on 8/2/18 at 8:41 AM and stated that the allegation of sexual assault was not reported because the resident retracted her statement that the incident happened and that the resident refused to go to the hospital for further evaluation. The Administrator was interviewed on 8/3/18 at 1:10 PM and stated he was made aware of the rape allegation he thinks the next morning. He remembered that he heard the resident retracted her allegation through the DON. The Administrator stated their conclusion was that they didn't feel it was necessary to call it in to the State Survey Agency. The Administrator stated that, honestly, he felt it did not happen. The resident ended it and ruled it out. 415.4(b)(4)

Based on interviews and record review conducted during a recertification survey, the facility did not provide timely rehabilitation services for 1 of 1 resident (#86) reviewed for rehabilitation services. Specifically, resident #86 did not receive Physical Therapy/Occupational Therapy evaluation and treatment as recommended and ordered by the physician. The findings include: Resident #86 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The 3/25/18 Quarterly Minimum Data Set (MDS; a resident assessment and screening tool) indicated that the resident's BIMS score (Brief Interview for Mental Status) was 15 out of 15 which suggested that resident was cognitively intact; required supervision of one person for bed mobility, transfers, and eating; extensive assistance of one staff for toilet use; and received scheduled and as needed pain medications with frequent complaints of moderate pain. A consult with rheumatology dated 4/10/18 included a recommendation to start therapy for frozen shoulder; a 4/11/18 physician prescription included Physical Therapy for 12 weeks with a [DIAGNOSES REDACTED]. a 5/8/18 nursing note documented the resident was seen by the physician and ordered PT/OT evaluation and treatment; a 5/23/18 physician order [REDACTED]. The resident was interviewed on 5/23/18 at 9:38 AM and she stated that the physician in the community had discussed with her the need for therapy but it had not been started in the facility since admission. She said she did not know why she had not been provided therapy. The resident stated she had asked the Therapy Director once or twice before about receiving therapy and had been told that she was not aware of any physician recommendation. She stated she asked her facility physician about receiving therapy and he told her that he had put an order in the computer since (MONTH) (YEAR). The resident stated she has pain constantly on the right shoulder and finds it very difficult to move her arm. The Therapy Director was interviewed on 5/25/18 at 10:48 AM and she stated that the resident had always asked for therapy because she said she had a lot of chronic pain. She said she was not informed by the physician to start therapy. She said the resident had been functionally stable and she could not justify putting her on therapy. The Therapy Director stated she first needed documentation showing a functional decline in order for a resident to be considered for therapy. Recently she was told by the resident that she was having increased difficulty with ambulating, and toilet use. She stated she spoke with the nursing staff and they decided to put her on therapy but not until 5/23/18 (see above physician's orders [REDACTED]. The Therapy Director further stated that when a resident goes out to an appointment and comes back with a recommendation for therapy, she follows up with the physician to make sure the referral was correct and then the resident is seen. She was unable to provide documented evidence addressing follow up with the consulting physicians recommendations and orders. The physician was interviewed on 5/25/18 at 1:19 AM and stated that after the recommendations from an outside physician were received, the Therapy Director and her staff should evaluate and make a determination if therapy would benefit the resident. The physician stated further that he had put in an order for [REDACTED]. The Unit 2 charge nurse was interviewed on 5/25/18 at 3:10 PM and stated that she obtained and placed an order for [REDACTED]. She said she does not think the resident's pain is chronic and that the painful shoulders might be the reason the resident was having trouble wiping herself after bowel movements. 415.16(a)

Based on observation and interview conducted during a recertification survey, the facility did not ensure that food storage practices met professional standards of practice. Specifically, 1 out of 2 nourishment refrigerators (Second Floor) contained foods that were either expired, undated or post dated. The finding is: Nourishment refrigerators were observed on [DATE] at 03:29 PM and the following items were found in the Second Floor refrigerator: - spaghetti and sauce for room [ROOM NUMBER] was undated; - ravioli and sauce for room [ROOM NUMBER] was undated; - sweet potato had the resident's name and was dated [DATE] (food can be kept no longer than 3 days); - salmon, chicken marsala and chicken parmesan were post dated to [DATE]. (Foods must be dated on the date it was placed in the refrigerator). The unit Licensed Practical Nurse present at the time of the observation was interviewed on [DATE] at 3:31 PM and stated he was a new employee and was not familiar with the facility policy regarding storage of food in the unit refrigerators. The Food Service Director (FSD) at was interviewed on [DATE] at 3:35 PM and stated that foods should be thrown out after 24 hours. He further stated he had notices posted on the refrigerators and that he was not aware that the notices were removed. When asked about the post dated food items, the FSD did not provide an explanation. 415.14(h)

Based on observations, record reviews and interviews conducted during a recertification survey, the facility did not follow proper hand hygiene to prevent cross contamination for 2 of 6 residents (#103 and #45) observed during medication pass. Specifically, the medication nurses did not follow proper hand hygiene during preparation of medications and between residents during medication pass. The findings are: The current Facility Medication Administration Competency Form indicated that staff has to perform hand hygiene appropriately prior to administering medications, and perform hand hygiene before and after resident contact, contact with medical equipment and whenever exiting a resident's room and before returning to the medication cart. 1. During a medication pass on Unit 3 on 5/31/18 at 9:11 AM, a Licensed Practical Nurse (LPN #1) was observed to open and close an inhaler for resident #99. She then placed the inhaler back into the medication cart. She then proceeded to resident #103, prepared his medications and administered them. She did not follow proper hand hygiene protocol to disinfect her hands at anytime during the preparation and administration of the medications between the residents. LPN #1 was interviewed immediately after the observation and she stated that she usually cleans her hands between residents during medication administration. She stated she did not have a hand sanitizer on her medication cart during medication pass. LPN #1 stated she had a small hand sanitizer on her person but did not use it during the medication administration. 2. During a medication pass on Unit 3 on 5/31/18 at 10:00 AM, LPN #2 prepared and then administered medications to resident #45. She then proceeded to obtain the medications of resident #27, placed them on top of the medication cart, and administered the medications to resident #27. LPN #2 was not observed to perform proper hand hygiene at anytime during and in between the preparation and administration of the medications between the residents. LPN #2 was interviewed following the medication pass. She stated that she had forgotten to clean her hands between residents during medication administration and that she usually does not forget. 415.19(b)(1)

Based on record review and interview the facility did not ensure that catheter care was provided in accordance with professional standards of care. This was evident for 1 of 2 residents (#14) reviewed for catheter care. Specifically, the order to change the Foley catheter was not clearly written that resulted to changing the catheter contrary to the medical provider's order. The finding is: Resident #114 has [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS; a resident assessment and screening tool) dated 4/10/18 indicated the resident had an indwelling catheter at the time of the assessment. The person-centered care plan for Indwelling Foley Catheter last updated on 5/6/18 indicated the resident has a catheter for [MEDICAL CONDITION] due to [MEDICAL CONDITION] with dysuria (difficulty in urination) and Bladder Neck Obstruction. Interventions included but not limited to change the Foley catheter every 6 weeks using size 18 FR with 15cc balloon. The care plan was also updated on 5/6/18 and indicated that the Foley catheter was removed in the hospital on [DATE] and a new one was inserted using 16FR with 10cc balloon due to bladder neck obstruction. The (MONTH) (YEAR) Treatment Administration Record (TAR) that included the instructions when to change the Foley catheter documented to change the Foley catheter every 4 weeks otherwise instructed, every night shift every Tuesday for [MEDICAL CONDITION]. size 16FR 10cc balloon size. Review of the physician's orders [REDACTED]. During the month of May, as indicated by initials on the TAR, the resident's catheter was changed on 5/15/18 and on 5/22/18, as well as on 5/4/18 when the catheter was changed in the hospital, prior to admission, as noted on the above care plan. The nursing and medical progress notes of 5/11/18 to 5/29/18 revealed no documented evidence to indicate the reason(s) for changing the catheter. The unit Registered Nurse (RN) manager was interviewed on 5/29/18 at 3:00 PM and she stated she didn't know the reason why the catheter was changed on 5/15/18 and 5/22/18. The RN reviewed the physician's orders [REDACTED]. She stated further that the night nurses probably read the order as it is and changed the Foley catheter every Tuesday instead of every 4 weeks. Following surveyor intervention, the unit RN manager rewrote the order to read, Change Foley catheter every 4 weeks as needed. In an interview on 5/31/18 at 9:00AM, the RN manager stated she would include the word and so the order would read Change Foley catheter every 4 weeks, and as needed. 483.25(e)(1)-(3)

Based on record reviews and interviews conducted during a recertification survey, the facility did not ensure that 1 out 1 resident was given the opportunity to participate in the development, review, and revision of her care plan. Specifically, resident #84 was not invited/included in her annual care plan meeting. The finding is: Resident #84 has [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS, a resident assessment and screening tool) dated 10/4/17 indicated the resident scored 15 out of 15 on the BIMS (Brief Interview Mental Status; used to measure memory recall and orientation) and suggested the resident to be cognitively intact. An invitation was sent and was addressed to the resident's spouse on 9/28/17 to attend the annual evaluation at the Comprehensive Care Plan Meeting which had been scheduled to take place on 10/10/17. The Comprehensive Care Plan sign in sheet with an Annual MDS Assessment Care Plan date of 10/10/17 did not note the resident or her spouse being in attendance. There was no reason documented as to why the resident and or her husband were not able to attend. Resident #84 was interviewed on 5/22/18 at 11:18 AM and she stated she did not remember ever being invited to a care plan meeting in the past two years since she had been in the facility. The Unit 3 Social Worker (SW) #1 was interviewed on 5/30/18 at 1:00 PM and she said that the residents were invited to care plan meetings for Annual and Significant Change MDS but not a quarterly basis. She stated that the residents were aware of the meetings but could choose not to attend. When requested, SW #1 was unable to provide a signature attendance sheet signed by this resident. SW #1 stated they tried to document when a resident does not attend the care plan meetings but she could not guarantee that a note was done. She further stated that upon checking for documentation of the resident/family not wishing to attend the care plan meeting, she was unable to locate such note. The resident's representative was interviewed on 5/31/18 at 10:56 AM and stated that he said he does not remember ever being invited to a meeting with the staff to discuss the care of the resident. He further stated that he probably attended one before but only attended the facility meeting either weekly or monthly that involved discussions or concerns at the facility. 415.11(c)(2)(i-iii)

Based on interview and record review conducted during a recertification survey, the facility did not develop a person-centered care plan with measurable objectives, timeframes and interventions for 1 of 1 resident (#131) reviewed for pain. Specifically, there was no person-centered care plan, including but not limited to pain medications, to address pain for Resident #131 who was being treated for [REDACTED]. The finding is: Resident #131 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission MDS (Minimum Data Set; a resident assessment and screening tool) dated 4/2/18 coded the resident's BIMS score (Brief Interview of Mental Status; used to test the resident's memory recall and orientation) to be 15 out of 15 which suggested that the resident is cognitively intact); required extensive assist of one staff member for bed mobility, transfers, and toilet use and required supervision of one staff member with meals; had occasional complaint of pain of a 1 out of 10 on the pain scale. The Care Area Assessment section of this MDS (areas triggered that will require further assessment and evaluation) did not trigger pain. The resident sustained [REDACTED]. The physician was notified and ordered pain medications as follows: - 4/20/18, [MEDICATION NAME]-[MEDICATION NAME] Tablet 5-325 mg give 1 tablet every 6 hours as needed for severe pain; discontinued (D/C) on 5/3/18; - 4/23/18, Tylenol 325 mg every 12 hours as needed for pain; D/C on 5/24/18; - 4/24/18, Pain Relieving Ultra Patch 5% apply to left hip once daily x 14 days - 5/04/18, [MEDICATION NAME] 5-325 mg 1 every 6 hours as needed and 30 minutes before therapy; - 5/10/18, [MEDICATION NAME] HCL 5 mg give 1 tab every 8 hours; D/C on 5/21/18; - 5/10/18, [MEDICATION NAME] 5-325 mg give 1 tab every 24 hours as needed, give 1 tab 30 minutes before therapy; D/C on 5/22/18 - 5/22/18, [MEDICATION NAME] HCL 5 mg every 8 hours for severe pain; - 5/23/18, [MEDICATION NAME] 5-325 mg give 1 tablet one time daily prior to Physical Therapy. The Nurse Practitioner and physician progress notes [REDACTED]. The resident received pain medications and was evaluated for their effects and outcomes. There was no documented evidence that a person-centered care plan was initiated to address pain. The Unit 2 Registered Nurse (RN #1) was interviewed on 5/29/18 at 1:46 PM. She stated that the care plans are done by the RN charge nurse. She stated that an assessment is done when pain medications are administered. Upon request to find the care plan, RN #1 stated she's unable to find the pain care plan on the electronic medical record where the documentation should have been in place. The Director of Nursing (DON) was interviewed on 5/29/18 at 1:54 PM. The DON stated that everyone should help out to complete the care plans while the unit manager was out on a leave. The MDS Coordinator was interviewed on 5/29/18 at 2:30 PM and she was unable to find a care plan for pain. The Unit 2 RN #2 was interviewed on 5/29/18 at 2:34 PM and stated that she was on a leave and was not able to complete all the required care plans. She said she was responsible for the unit care plans and when she was out, others should follow up and check the care plans. Following surveyor intervention, the facility initiated a person-centered care plan to address the care of this resident related to pain on 5/29/18. 415.11(c)(1)

Based on interviews and record review conducted during a recertification survey, the facility did not ensure that the medication regimen for 1 of 5 residents reviewed for unnecessary medications was free from unnecessary medications (Resident #57). Specifically, the resident's behaviors for which [MEDICATION NAME] (an antipsychotic medication) and [MEDICATION NAME] (a medication approved for the treatment of [REDACTED]. The findings are: Resident #57 is a [AGE] year old female with the [DIAGNOSES REDACTED]. The Quarterly Minimum Data Sets (a resident assessment tool) 9/4/16 and 12/4/16 revealed the resident scored 6 on the BIMS test (Brief Interview for Mental Status; used to measure memory and orientation) which suggested the resident had severe cognitive skills in daily decision making; had no problems with delusions, hallucinations and behavior; reported difficulty with sleeping and concentrating; had little energy; and was receiving an antipsychotic ([MEDICATION NAME] 50 mg in the morning and 25 mg at hour of sleep) and an antidepressant medication ([MEDICATION NAME] 100 mg daily). The resident's plan of care in effect in September 2016 and recently evaluated on 12/11/16 addressed the use of an antipsychotic and antidepressant medications. This care plan did not identify any behavioral symptoms for which the antipsychotic medication was prescribed. There was a corresponding behavioral care plan which stated the resident had [MEDICAL CONDITION] (loss of ability to understand or express speech) and pseudobulbar affect. The care plan further indicated the resident may become agitated demonstrated by yelling and/or tearful outbursts. The goal of the care plan was for the resident to have fewer episodes of frustration as evidenced by fewer crying episodes (less than one weekly). The interventions to achieve this goal included the use of [MEDICAL CONDITION] medications as ordered by the physician, monitor behavior episodes, and attempt to determine underlying causes (consider location, time of day, persons involved and situations). This care plan further stated the behavior and potential causes would be documented. The nurses' note of 9/15/16 to 12/21/16 (the most recent note) revealed no documented evidence that the resident's behavioral symptoms were monitored and analyzed. The physician evaluated the resident on 12/6/16 and noted the resident was started on [MEDICATION NAME] 10 mg daily for pseudobulbar affect. The evaluation of the behavioral care plan on 12/11/16 by the social worker (SW) showed the resident continued to have frustration and tearful/verbal outbursts. As noted, none of these incidents were reflected in the nursing notes. Additionally, no additional notes were documented describing the possible underlying cause or causes of the resident's behaviors. The psychiatric nurse practitioner (NP) recommended on 12/16/16 that [MEDICATION NAME] be decreased to 25 mg daily. There was no documented evidence that this recommendation was implemented. The resident's physician was interviewed in the afternoon of 1/9/17 regarding the reason for not implementing the recommendation. The physician stated the resident exhibited crying behavior, paranoia and delusional thinking and that [MEDICATION NAME] was prescribed to address the crying behavior instead of implementing the recommendations made by the NP. The physician was then informed, after review of the resident's clinical record, that none of the behaviors she mentioned were reflected in the nurses' notes as occurring since 9/15/16. Immediately following this interview, the Registered Nurse (RN) unit manager was interviewed about the monitoring of the resident's behavior and stated the monitoring of the resident's behavior should be reflected in the nursing progress notes. The nurse manger then reviewed the resident's record and did not find any documented evidence of behavior monitoring. 415.12(l)(1)

Based on interview and record review conducted during a recertification survey, the facility did not ensure that each resident's plan of care was implemented as written for 1 of 5 residents reviewed for unnecessary medications. Specifically, the resident's plan of care addressing the monitoring of behavioral symptoms for which two medications were prescribed, [MEDICATION NAME] (antipsychotic medication) and Neudexta (a medication approved for the treatment of [REDACTED]. The findings are: Resident #57 is a [AGE] year old female with the [DIAGNOSES REDACTED]. The Quarterly Minimum Data Sets (a resident assessment tool) 9/4/16 and 12/4/16 revealed the resident scored 6 on the BIMS test (Brief Interview for Mental Status; used to measure memory and orientation) which suggested the resident had severe cognitive skills in daily decision making; had no problems with delusions, hallucinations and behavior; reported difficulty with sleeping and concentrating; had little energy; and was receiving an antipsychotic ([MEDICATION NAME] 50 mg in the morning and 25 mg at hour of sleep) and an antidepressant medication ([MEDICATION NAME] 100 mg daily). The resident's plan of care in effect in September 2016 and recently evaluated on 12/11/16 addressed the use of an antipsychotic and antidepressant medications. This care plan did not identify any behavioral symptoms for which the antipsychotic medication was prescribed. There was a corresponding behavioral care plan which stated the resident had [MEDICAL CONDITION] (loss of ability to understand or express speech) and pseudobulbar affect. The care plan further indicated the resident may become agitated demonstrated by yelling and/or tearful outbursts. The goal of the care plan was for the resident to have fewer episodes of frustration as evidenced by fewer crying episodes (less than one weekly). The interventions to achieve this goal included the use of [MEDICAL CONDITION] medications as ordered by the physician, monitor behavior episodes, and attempt to determine underlying causes (consider location, time of day, persons involved and situations). This care plan further stated the behavior and potential causes would be documented. The nurses' note of 9/15/16 to 12/21/16 (the most recent note) revealed no documented evidence that the resident's behavioral symptoms were monitored and analyzed. The physician evaluated the resident on 12/6/16 and noted the resident was started on [MEDICATION NAME] 10 mg daily for pseudobulbar affect. The evaluation of the behavioral care plan on 12/11/16 by the social worker (SW) showed the resident continued to have frustration and tearful/verbal outbursts. As noted, none of these incidents were reflected in the nursing notes. Additionally, no additional notes were documented describing the possible underlying cause or causes of the resident's behaviors. The psychiatric nurse practitioner (NP) recommended on 12/16/16 that [MEDICATION NAME] be decreased to 25 mg daily. There was no documented evidence that this recommendation was implemented. The resident's physician was interviewed in the afternoon of 1/9/17 regarding the reason for not implementing the recommendation. The physician stated the resident exhibited crying behavior, paranoia and delusional thinking and that [MEDICATION NAME] was prescribed to address the crying behavior instead of implementing the recommendations made by the NP. The physician was then informed, after review of the resident's clinical record, that none of the behaviors she mentioned were reflected in the nurses' notes as occurring since 9/15/16. Immediately following this interview, the Registered Nurse (RN) unit manager was interviewed about the monitoring of the resident's behavior and stated the monitoring of the resident's behavior should be reflected in the nursing progress notes. The nurse manger then reviewed the resident's record and did not find any documented evidence of behavior monitoring. 415.11 (c)(3)(ii)

Based on observation, record review and interview conducted during a recertification survey, the facility did not ensure that food was prepared and stored under sanitary conditions. Specifically, chicken that was being cooked and cooled for the next day, was not cooled properly. Additionally, temperature logs were not being kept to ensure proper cooling. This was evident during review of the facility's kitchen and food service. The findings are: Observation of the facility kitchen was conducted on 11/6/15 at 10:45 AM. Fresh chicken was observed in the kitchen after being delivered with other frozen chicken and was being sent back to the purveyor for improper packaging. The frozen chicken was not wrapped in sealed packing and was placed directly on ice that was packed in the box. The cook was interviewed at that time and stated that he was sending the frozen chicken back due to poor packaging but he was not sending the fresh chicken back. The fresh chicken was packaged in an airtight plastic bag. The cook stated that he was going to cook it, cool it and use it the next day for chicken salad and puree chicken. The cook stated that he needs to get the temperature down to 41 degrees Fahrenheit (F). The cook was not able to state the proper time frames for proper cooling. Chicken is considered a potentially hazardous food and needs to be cooked and cooled properly to prevent bacterial contamination. The Food Service Director was not available for interview. The temperature of the cooling chicken was taken on 11/6/15 at 1:20 PM and revealed that it was 120 degrees F. The chicken was observed in a four-inch deep pan tightly covered with a plastic wrap and aluminum foil. When this observation was pointed out to the cook, he vented the wrappings by poking holes in it and lifted a corner of the wrapping to allow heat to escape. At 2:45 PM on the same date, the chicken temperature was 80 degrees F. At 3:20 PM, two hours after the first temperature was taken, the chicken was still over 80 degrees F (84 degrees). The surveyor then requested the cook to take the temperature of a piece of chicken that was deeper down in the pan. At this point, the cook stated he would take the chicken out of the four-inch pan and put it in shallow pans to cool. Improper cooling and reheating are major causes of food-borne illness. Potentially hazardous foods requiring refrigeration must be cooled by an adequate method so that every part of the product is reduced from 120 degrees F to 70 degrees F within two hours, and from 70 degrees F to 45 degrees F or below within four additional hours. Bacteria that cause food poisoning grow at temperatures between 45 degrees F and 120 degrees F. The cooling requirement limits the length of time that potentially hazardous food is in the temperature range at which harmful bacteria can grow. (http://www.health.ny.gov/environmental/indoors/food_safety/coolheat.html) The administrator, who was the acting Food Service Director at the time of the survey, was interviewed on 11/9/15 at 10:45 AM regarding cooling logs and the cooling practices for cooked and cooled foods. The administrator stated they just started documenting cooling temperatures on Friday, 11/6/15, following surveyor intervention. The administrator further stated that they cook and cool chicken on Monday, Wednesday and Fridays. There was no documented evidence that cooling logs were being kept prior to 11/6/15. 415.14(h)