**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification survey from 1/29/2024 to 02/06/2024, the facility did not ensure the resident's representative was immediately notified of a need to alter the resident's treatment. This was evident for 1 (Resident #289) of 2 residents reviewed for Notification of Change out of 38 total sampled residents. Specifically, Resident #289 was ordered to start an antianxiety medication, Buspirone, and the designated representative was not immediately informed. The findings are: The facility policy titled Change in Resident's Condition or Status dated 11/2023 documented the facility will promptly notify the resident, their attending physician and representative of changes in their medical condition and/or status. Notification will be made within twenty-four hours of a change occurring. Resident #289 had diagnoses of dementia and recurrent falls. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #289 had severely impaired cognition. On 01/30/2024 at 11:40 AM, Resident #289's designated representative was interviewed and stated Resident #289 was started on Buspirone at the facility on 1/19/2024. They were not notified of the change in medication until 1/24/2024. The Medical Doctor Note dated 1/8/2024 documented Resident #289 was restless with verbal outbursts and Buspirone 5 mg will be ordered for anxiety. The Physician's Order dated 1/19/2024 documented Buspirone 5 milligrams 3 times daily for anxiety. The Orders Administration note dated 1/20/2024, 1/21/2024 and 1/22/2024 documented Resident #289 refused the Buspirone 5 mg. The Nursing Note dated 1/23/2024 at 09:38AM documented Resident #289's representative was informed the resident was ordered Buspirone 5 mg 3 times daily for anxiety. The designated representative requested the nurse have the Buspirone discontinued. There was no documented evidence Resident #289's designated representative was informed when Buspirone 5 mg was ordered for anxiety. On 02/05/2024 at 12:58PM, Licensed Practical Nurse #5 was interviewed and stated the nursing supervisor was responsible for contacting the designated representative of Resident #289 when the resident was prescribed Buspirone. On 02/05/2024 at 01:02PM, Registered Nurse # 5 was interviewed and stated they did not work on 1/19/2024 when Resident #289 was prescribed Buspirone. Physician's orders for psychotropic medication required designated representative approval. On 02/05/2024 at 02:43PM, the Medical Doctor #1 was interviewed and stated Resident #289 was agitated, and they provided a telephone order to the nurse for the resident to start receiving Buspirone 5 mg. The designated representative should be contacted prior to the start of new medication so they can be aware of the risks and benefits. The designated representative could agree or disagree with a new medication order. 10 NYCRR 415.3(f)(2)(ii)(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the Recertification Survey from 01/29/2024 to 2/06/2024, the facility did not ensure that a resident remained free of physical restraints. This was evidenced for 1 (Resident #36) resident reviewed for Physical Restraints out of 38 total sampled residents. Specifically, Resident #36 was seated in a wheelchair in the floor dining room in a boxed-in position preventing them from moving around. The findings are: The facility policy titled Restraint Usage dated 06/22 documented restraints shall only be used to treat the resident's medical symptoms and never for discipline or staff convenience. The dignity, rights and wellbeing of the resident will be maintained. Resident #36 had diagnoses of Autistic disorder, anxiety disorder, and Schizophrenia. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #36 was severely cognitively impaired and exhibited behavioral symptoms not directed towards others daily. On 01/29/2024 at 12:17 PM and 01/30/24 at 12:20 PM, Resident #36 was observed sitting in a wheelchair in the floor dining room with a wall to their left and behind them, a non-ambulatory resident in a recliner to their right and an overbed table directly in front of them. A non-ambulatory resident was seated directly in front of Resident #36's overbed table, preventing Resident #36 from moving from that seated location. A Physician's Orders dated 1/16/24 documented floor ambulation program by walking with partial handheld assistance of 1 person, for a minimum of 15 minutes twice daily, for a minimum of 150 feet up to a distance as tolerated. The Comprehensive Care Plan related to Alteration in Mood and Behavior was initiated 04/20/2015 documented Resident #36 stole food from other residents and ran away stuffing food in their mouth. Resident #36 hits themselves and screams when staff intervene. Interventions included Resident #36 eating meals in the hallway outside of the floor dining room with supervision. The Comprehensive Care Plan related to Resident #36's risk of victimizing others with socially inappropriate behavior, verbal disruption, and taking other resident's foods was created 6/19/2013 documented Resident #36 should be seated at arm's length from others as needed and separated from others during socially inappropriate episodes. Social services note dated 10/25/2023 documented Resident #36 had episodes of stealing food from other residents' trays and hitting and biting themselves during staff redirection. Staff monitoring ongoing. A Nursing Note dated 1/28/20 24 documented Resident #36 attempted to grab food from other resident's trays and was difficult to redirect. Resident #36 began hitting and biting themselves while seated on the floor when redirected by staff. Snacks were offered. On 02/01/2024 at 11:34 AM, Certified Nursing Assistant #10 was interviewed and stated Resident #36 had a behavior of grabbing other resident's food. Staff were able to monitor Resident #36 when they were seated in a wheelchair against the wall in the floor dining room. Resident #36 was prevented from being too close to other residents when placed in this position. There was no documented evidence Resident #36 was adequately assessed for and ordered to be restrained against a wall without being able to independently exit the area. On 01/30/2024 at 01:05 PM, Licensed Practical Nurse #2 was interviewed and stated Resident #36 was problematic, and redirection was difficult. Resident #36 had a diagnosis of mental retardation and sat quietly when placed in the seated position by the wall in the floor dining room. On 01/30/2024 at 01:13 PM, Registered Nurse Supervisor #3 was interviewed and stated placing Resident #36 in the floor dining room by the wall with a resident on each side could be considered a restraint because the resident could not get out of the area by themselves. On 02/02/2024 at 02:53 PM, the Assistant Director Social Work was interviewed and stated Resident #6's behavior of grabbing food from other resident's plates was new and performing repetitive actions with them seemed to calm the resident. On 02/06/2024 at 12:41 PM, the Chief Nursing Officer was interviewed and stated they were shocked Resident #36 was in an enclosed seating arrangement and the resident should not be hindered from moving around. 10 NYCRR 415.4(a)(2-7)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the Recertification survey from 01/29/2024 to 02/06/2024, the facility did not ensure adequate supervision and an environment free from accident hazards. This was evident for 1 (Resident #88) of 4 resident reviewed for accidents out of 38 total sampled residents. Specifically, Resident #88 was observed in possession of a sharp steak knife in their room. The findings are: Resident #88 had diagnoses of congestive heart failure and diabetes. The facility policy titled Accidents/incident/Occurrence dated 4/2023 documented the Comprehensive Care Plan will be reviewed and revised as needed to reflect occurrence and prevention measures. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #88 was cognitively intact. On 01/29/2024 at 10:53 AM, Resident #88 was observed in their room in bed and a sharp metal steak knife was observed standing up in a coffee mug on their bedside table. Resident #88 was interviewed and stated they had the knife since their admission to the facility in 2020 and always store it in the coffee mug on their bedside table. They used the knife to cut their food during mealtimes. The Comprehensive Care Plan related to Accidents dated 12/08/2020 documented Resident #88 was at risk for victimization and redirection provided as needed. There was no documented evidence Resident #88's possession of a knife was identified as a hazard and addressed. On 02/05/2024 at 12:04 PM, an interview was conducted with Certified Nursing Assistant #6 who stated that they conducted rounds in Resident #88's room on the morning of 1/29/2024 and observed the knife in the resident's coffee mug and this was not the first time they saw Resident #88 had a knife in their possession. Certified Nursing Assistant #6 reported the observation of the knife in Resident #88's room a few months ago to the nurse. Certified Nursing Assistant no longer thought the knife was a concern because Resident #88 told them it was not an issue with staff previously and did not seem like a threat. On 02/01/2024 at 11:00 AM, an interview was conducted with Licensed Practical Nurse #4 who stated they were not aware Resident #88 had a metal steak knife in their room. The knife was removed, and the supervisor was informed. On 02/02/2024 at 10:51 AM, an interview was conducted with Registered Nurse Supervisor #4 who stated they became aware Resident #88 had a knife in their room on 1/29/2024. Resident #88 was alert and oriented with no previous history of suicidal or homicidal behaviors. Visual rounds were being conducted on Resident #88's unit. On 02/05/2024 at 12:54 PM, an interview was conducted with the Assistant Director of Nursing who stated they were not aware Resident #88 had a knife in plain view in their room until 1/29/2024. On 02/06/2024 at 11:05 AM, an interview was conducted with the Chief Nursing Officer who stated the staff on Resident #88's unit fully acknowledged the responsibility to report finding a knife in a resident's room in a timely manner. 10 NYCRR 415.12(h)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during the Recertification survey from 1/29/2024 to 2/06/2024, the facility did not ensure the development and maintenance of policies and procedures for the monthly drug regimen review that include time frames for the different steps in the process. This was evident for 1 (Resident #78) of 5 residents reviewed for Unnecessary Medications out of 38 total sampled residents. Specifically, the facility policy for the drug monthly regimen review did not develop a timeline for the Medical Doctor to answer the pharmacist's recommendations for Resident #78. The findings are: The facility policy titled Drug Regimen Review dated 9/2021 documented the pharmacist will report any irregularities to the Medical Doctor, Director of Nursing and Medical Director. Medical Doctors will receive and respond appropriately to drug regimen reviews. Resident #78 had diagnoses of hypertension and left eye blindness. The Minimum Data Set 3.0 assessment dated [DATE] documented that Resident #78 had moderately impaired cognition. A Physician's Order dated 8/30/2023 documented Resident #78 received 1 drop of Latanoprost Ophthalmic Solution 0.005% in their right eye daily. The Drug Regimen Review dated 10/10/2023 documented the Pharmacist recommended Resident #78 receive Latanoprost eye drops at bedtime for better efficacy. The Drug Regimen Review documented Medical Doctor #1's signed in agreement on 12/27/2023. There was no documented evidence the facility developed a timeline for attending physician response of drug regimen reviews. On 02/06/2024 at 01:47PM, the Assistant Director of Nursing #2 was interviewed and stated the drug regimen review arrived via email and were forwarded to the Medical Doctor. The response could be delayed if the Medical Doctor takes time reviewing the recommendations. Medical Doctor #2 was assigned to Resident #78 in 10/2023 but no longer worked for the facility. There was a Medical Doctor assigned to cover the facility at all times and could be asked to address a drug regimen review. On 2/01/2024 at 04:30 PM, the Pharmacist Consultant was interviewed and stated they performed the drug regimen reviews. They check the resident's profile in the medical record to ensure their drug regimen reviews were sent to the correct assigned Medical Doctor. The Pharmacist was not aware of any recent Medical Doctor changes in the facility. The Director of Nursing, Assistant Director of Nursing, and nursing supervisors received a copy of all drug regime reviews. On 02/01/2024 at 5:25PM, Medical Doctor #2 was interviewed and stated they stopped working at the facility a few months ago and Medical Director #1 took over their caseload. The drug regimen review was reviewed weekly or as they were given by the Pharmacist. The nursing supervisor also provided the Medical Doctors with a copy of the drug regimen reviews. There was also a separate drug regimen review folder for pharmacy recommendations that could be reviewed. On 02/06/2024 at 11:29 AM, Medical Doctor #1 was interviewed and stated drug regimen reviews were completed timely. Medical Doctor reviewed the drug regimen reviews and signed when they agreed with a recommendation. 10 NYCRR 415.18(c)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews conducted during the Recertification survey, the facility did not ensure that individual resident financial records were made available to resident and resident representatives through quarterly statements. Specifically, quarterly statements were not provided in writing to residents and/or resident representatives within 30 days after the end of the quarter. This was evident for 2 of 3 residents reviewed for Personal Funds out of a sample of 38 residents. (Residents #105 & #103) The findings are: The facility policy titled Resident's Banking/Personal Needs Accounts dated 01/2005, last revised 06/2019 documented that quarterly statements are provided to residents regarding the status of their accounts. (1). Resident #105 was re-admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS) dated [DATE] documented that the resident had intact cognitive status. On 12/13/21 at 10:26 AM, during the initial pool interview, Resident #105 stated they had been in the facility for about 2 years, and their money was held by the facility but they had not received a financial statement. There was no documented evidence in the medical record that the resident or their representative had received a quarterly statement. (2). Resident #103 was admitted to the facility on [DATE]. The Quarterly MDS dated [DATE] documented that the resident had intact cognitive status. On 12/14/2021 at 09:44 AM, during the initial pool interview Resident #103 stated that they did not know anything about the money kept in the facility's account, whether there was still money there or how much was remaining as no-one had spoken to them about it or provided a quarterly statement since admission. There was no documented evidence in the medical record that the resident or their representative had received a quarterly statement. On 12/17/21 at 09:48 AM, an interview was conducted with the Financial Coordinator (FC #1). The FC #1 stated that the facility has contracted with a company that manages the residents' accounts. Statements are prepared by the company and sent to the facility. The FC #1 also stated that statements are mailed out to the resident's representatives that are not alert and oriented and are provided to the alert residents whenever they ask for it when they go for banking. The FC #1 further stated that they did not know how often statements are mailed out and they do not distribute statements to residents on the unit. On 12/17/21 at 10:28 AM, an interview was conducted with Social Worker #1. SW #1 stated that the financial office is responsible for providing statements to the residents. SW #1 also stated the Social Service department stopped providing statements to residents about 10 years ago, and they are not sure of how often the statements are being given to the residents. SW #1 further stated that they were not aware that the residents been receiving statements, and residents are assisted if they reported having any concern with their funds. On 12/17/21 at 10:37 AM, an interview was conducted with the Social Worker #2 (SW#2). SW #2 stated that the residents' statements are distributed through the financial office and they were unaware of how often statements were distributed. SW #2 also stated that they believe that the Financial office received the statements from an outside entity and distributed them to the residents. SW #2 further stated that Social Services have not been responsible for giving the statements to the resident since they started working in the facility for the past 5 years, but they know that the statement is supposed to be given quarterly. SW #2 stated that they were not aware that the residents had not been receiving statements regularly but will follow up to ensure that they get it. On 12/17/21 at 11:02 AM, an interview was conducted with the Administrator. The Administrator stated that the Business office is responsible for distributing the quarterly statements to the residents if the residents are alert and oriented. If the residents are not alert, the statements are expected to be mailed out to the family quarterly. The Administrator also stated that they were not aware that the residents were not receiving quarterly statements but a system would be put in place to correct this. 415.26(h)(5)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during Recertification and Facility Complaint investigations (NY00278901, NY00269594 ), the facility did not ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the State Survey Agency. Specifically, the facility did not report incidents of abuse to the New York State Department of Health (NYSDOH) within 2 hours. This was evident for 2 of 6 residents reviewed for Abuse out of a sample of 38 residents. (Resident #70 and Resident #646). The findings are: The facility policy and Procedure titled Abuse Prevention Protocol dated 01/2019 states that the acts of physical, verbal, psychological, and financial Abuse directed against residents are prohibited. Each resident has the right to be free from verbal, sexual, physical, and mental Abuse. The policy further states that residents will not be subjected to Abuse by anyone, including but not limited to staff, other residents' consultants, and staff from any agencies. Physical Abuse includes but is not limited to hitting, slapping, pinching, and kicking. The policy also states that the Administrator/DON/Designees shall notify the New York State Department of Health within 24 hours of knowing an alleged incident and within 2 hours if a severe bodily injury has occurred. 1.) Resident #70, the victim, was admitted with diagnoses that included Diastolic dysfunction, Bilateral lower extremity weakness, Peripheral Vascular Disease (PVD), Alcohol (ETOH) Abuse. The admission Minimum Data Set (MDS) dated [DATE] and Quarterly MDS dated [DATE] documented the resident had intact cognition. No wandering, rejection of care, or other behavioral symptoms were exhibited. A Registered Nurse (RN) Nurse's Note dated 07/02/21 documented at approximately 13:53 writer heard resident screaming Nurse, Nurse. Writer responded to call and upon arrival to resident's room, resident stated they came in my room and attacked me. Writer immediately called the Rapid Response Team (RRT) and tried to separate residents. At that time Resident #5 was seen biting Resident #70 to the right breast. Resident #5 then threw themselves to the floor screaming Just kill me. Writer then proceeded to calm down residents and complete full body assessment. VS: 136/82-76-97.4-18-98% on room air. Resident #70 noted with bleeding from right breast. Resident#70 is alert and oriented x3 and denied wanting to contact anyone on incident. Medical Doctor (MD) present during assessment and ordered resident #5 to be sent to [NAME] Hospital for Altered Mental Status (AMS), agitation, aggressive behavior, and fall. MD made aware and gave orders for resident #70 to be started on Augmentin 875mg twice a day (BID), Tetanus shot immediately (STAT) complete blood count/comprehensive metabolic panel (CBC/CMP) STAT, and to cleanse wound with Normal Saline (NS) apply bacitracin x 10 days and cover with dry protective dressing (DPD). Resident#70 is in stable condition at this time. A Physician's Progress note dated 07/02/21 documented that the nurse called that patient got bite on right breast. Patient (resident#70) was seen and examined at bed side -is not in any distress- Vitals are- P-72 BP-132/84 RR-18 Temp-98.6 On examination- AAOx3 Heart-rate normal Lungs-B/L clear Right breast bleeding from right breast A/P- 1) Bleeding from right breast due to bite -start Augmentin 875 mg bid + tetanus injection stat, CBC, CMP stat, daily dressing Resident #5, the Aggressor, was admitted with diagnoses that included Psychosis, Paranoid Schizophrenia, Anxiety Disorder, Compression Fracture, Fracture of first lumbar vertebra. admission MDS dated [DATE] documented resident is cognitively intact and physical and verbal behavioral symptoms occurred 1 to 3 days, which put the resident at significant risk for physical illness or injury and interferes with the resident's care. Documented rejection of care noted, occurring 1 to 3 days, and feeling down depressed or hopeless, occurring 12-14 days. A Psychiatry consult note dated 6/27/2021 that patient was admitted with Fractured L1 vertebra. Documented patient is overall behaviorally controlled but episodically agitated and dysphoric. A Registered Note (RN) Note dated 07/02/21 documented at approximately at 13:53 writer heard Resident #70 screaming Nurse, Nurse. Writer responded to call and upon arrival to resident's room, Resident #70 stated they came in my room and attacked me. Writer immediately called RRT and tried to separate residents. At that time Resident #5 was seen biting Resident #70 to the left breast. Resident #5 then threw themselves to the floor screaming Just kill me Writer then proceeded to calm down Resident#5 and complete full body assessment. VS: 189/110-111-20, Resident#5 refused temperature, (Oxygen saturation)O2 sat, and blood sugar(BS), then proceeded to get up from the floor and walk off and fall. Resident #5 fell on the back; did not hit head. No signs of visible injuries noted, skin is intact. Medical Doctor present during assessment and ordered Resident #5 to be sent to [NAME] Hospital for Altered Mental Status AMS, Agitation, Aggressive behavior, and fall. Attending Physician made aware. Resident #5 left unit in stable condition at 15:04. The facility's Quality Assurance Accident/Incident(A/I) investigation dated 07/02/21, documented time of A/I 1:53PM, with investigative summary stating that on Friday 07/02/21, at approximately 1:53 pm, Nursing Supervisor was on the unit when they heard Resident #70 state they came in my room and attacked me. (Registered Nurse Supervisor) RNS immediately called (Rapid Response Team) RRT and tried to separate residents. At that time, Resident #5 was seen biting Resident#70 to the right breast. Resident #5 then threw themselves to the floor screaming Just kill me. Resident #5 did not provide any explanation when asked what happened. RNS proceeded to calm down Resident #5. Revisions to the plan of care included room and unit change for Resident #5, Separation of Resident #5 and Resident #70 as appropriate, referred to social services for further counselling and psychological assurance, keep separated from other residents possibly disturbed by the behaviors exhibited whenever possible, and psychiatry consult (Psych on 7/3/21). The A/I documented the incident was reported on 7/3/21 to NYSDOH via the Health Commerce System (HCS). A Nursing Home to Hospital Transfer Form dated 7/02/21 documented resident #70 transfer to [NAME] Hospital with reason for transfer as Altered Mental Status (AMS), Agitation, Aggressive behavior, Fall The Health Electronic Response Data System (HERDS) Data Entry report documented that the incident occurred on 07/02/21 at 1:53PM and was reported on 07/03/21 at 6:15PM, via the Health Commerce System, more than 24 hours after the incident. Review of the NYS DOH Automated Complaint Tracking System (ACTS) Complaint/Incident Investigation Report documented date/time of occurrence: 07/02/2021 at 1:53pm. Submitted by facility: 07/03/2021 at 06:15:11 PM On 12/20/21 at 11:11 AM an interview was conducted with the Assistant Director of Nursing (ADNS), who stated that they worked with the Director of Nursing (DON) on this case, to report the matter. The ADNS stated that it must be reported within 24- 48 hours, and that it was reported timely when it occurred. The ADNS stated that the ADNS does the investigative summary, and the Care Coordinator does the incident report. On 12/20/21 at 12:17 PM an interview was conducted with the Director of Nursing (DON) who stated they could not recall why the incident was not reported the day it occurred. Stated that there was a lag in reporting that incident and was aware that it has to be within 2 hours for reporting cases like these. 2) Resident # 646 was admitted to the facility on [DATE] with diagnoses which include Dementia, Hypertension, and Diabetes Mellitus. The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #646 had severely impaired cognition with a Brief Interview of Mental Status (BIMS) score of 3/15. Resident #646 required extensive assistance of two persons for bed mobility and transfer. A Nurse's Progress Note dated 12/15/2020 at 10:50 PM documented that Resident # 646 informed the charge nurse during rounds that the roommate (Resident # 648) slapped me in my face. It is documented that the roommate just smiled when asked what happened. The Nursing Supervisor's Progress Note dated 12/15/2020 at 11:50 PM documented no visible injury, no redness, and no signs of pain. The doctor was informed and ordered to monitor both residents, A Nurse's Progress Note dated 12/16/2020 at 6:18 AM documented that Resident # 646 was moved to a different room. A Victimization Care Plan initiated on12/13/2019 documented that Resident # 646 is at risk for Victimization related to Dementia disease. The post-incident care plan was updated on 12/15/2020, and the intervention include room/unit change for resident/peer as appropriate. The Facility Quality Assurance: Accident/Incident Investigation dated 12/18/2020 documented that on 12/15/2020 at approximately 10:00 PM, Resident # 646 reported that the roommate slapped him/her in the face while sleeping. The roommate was sitting in the bed, and when asked if it was true, the roommate smiled at the nurse. There was no documented evidence this allegation of resident-to-resident abuse was reported to NYSDOH. During an interview on 12/20/2021 at 10:27 AM, the Assistant Director of Nursing (ADON) stated that they became aware of the alleged abuse incident on the same day. The supervisor's assessment revealed no redness or swelling, and Resident # 646 had no complaints of pain. The roommate was asked what happened but smiled and did not say anything. The roommate was ambulatory and was sitting on the bed at that time. Resident # 646 was moved to a different room. An investigation was initiated the same day and concluded that abuse did not occur. The ADON said that an abuse allegation is reported to New York State Department of Health (NYSDOH) if it is legitimate. They did not think that it was legitimate resident-to-resident abuse, so it was not reported. During an interview on 12/20/2021 at 10:45 AM, the Director of Nursing (DON) stated the supervisor initiated the investigation and concluded that abuse did not occur. The assessment revealed no swelling or discoloration. An abuse allegation was unfounded, and they did not identify that the roommate slapped Resident # 646. It was not reported to NYSDOH because abuse was ruled out. During an interview on 12/21/2021 at 12:30 PM, the Administrator stated that the Administrator reviews the investigations before signing. The Administrator said that injuries of unknown origin, resident to a resident altercation, and staff to resident abuse are reported to NYSDOH. The Administrator and the DON decide to report the alleged violation to DOH. Incidents are reported as soon as possible, depending on the nature of the incident. Some can take longer, and some can be two hours. 415.4(b)(1)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident #256 was admitted to the facility on [DATE] with diagnosis which include the following diabetes mellitus, Cerebrovascular accident, Hemiplegia, and depression. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented that the resident had intact cognition. The MDS further documented that Resident #256 had range of motion (ROM) for last 7 days and splint for last 6 days as restorative nursing programs. The physician's orders dated 8/27/21 documented ortho: hand grip splint to be worn on left hand when OOB (out of bed) as tolerated. Remove Q (every) 2 hours for skin checks. Reposition and reapply as tolerated every day and evening shift. There was no documented evidence in the medical record that a comprehensive care plan regarding care for the resident's contractures and hand splint was developed. On 12/13/21 at 12:00 PM, Resident #256 was interviewed. Resident #256 stated he/she was wearing a splint on the left hand due to contracture. On 12/16/21 at 11:31 AM, the Director of Rehab (DR) was interviewed. DR stated that the residents are assessed and screened every quarter for the potential to benefit from rehabilitative services such as physical and occupational therapy. The DR further stated that therapist will document any recommendations for assistive devices and restorative nursing services/exercises in the medical record. The recommendation should be picked up by nursing who initiates the care plan. The DR was asked to display the care plan related to contracture/assistive device for Resident #256 on the monitor screen. The DR stated the care plan for contracture/assistive device was not in place for Resident #256. On 12/17/21 at 09:29 AM, LPN #2 was interviewed. LPN #2 stated Nursing Supervisor is the responsible to initiate and update care plan and was not aware that the care plan related to contracture for Resident #256 was not initiated. On 12/17/21 at 11:42 AM, the Nursing Supervisor was interviewed. RN #2 stated that the Clinical Care Coordinator as well as RN #2 are responsible to initiate and update the care plan. RN #2 was not aware that care plan for contracture was not initiated for Resident #256. On 12/21/21 at 09:54 AM, the Director of Nursing Services (DNS) was interviewed. DNS stated that the admitting nurse will initiate resident's comprehensive care plan based on an assessment upon admission and all disciplines are responsible for the review and update of care plans.3) Resident #157 was admitted to the facility on [DATE] with diagnosis which include the following: fusion of spine/cervical region, neuralgia and neuritis, post laminectomy syndrome, bipolar disorder, and major depressive disorder. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented that the resident had intact cognition. The MDS documented activity did not occur for moving from seated to standing position, moving on and off toilet, and resident had no range of motion impairment of bilateral lower extremities. The MDS further documented that Resident #157 had no range of motion (ROM) for the last 7 days as restorative nursing programs. The physician's order dated 11/8/21 documented Active-Assistive ROM exercise program: Do active-assistive ROM exercises in all planes to resident's bilateral lower extremity (BLE) joints, twice daily, repetition as tolerated for a minimum of 15 minutes daily supine in bed. Every day and every evening shift. The PT Discharge summary dated [DATE] documented team communication/ collaboration: discontinue PT services after skilled PT treatment session secondary to maximum potential achieved. Communicated with interdisciplinary team. ROM program established/trained: active-assistive ROM exercises in all planes to resident's BLE joints, twice daily, repetition as tolerated for a minimum of 15 minutes daily supine in bed. There was no documented evidence in the medical record that a comprehensive care plan regarding ROM needs was developed. On 12/20/21 at 12:11 PM, the Physical Therapist (PT) was interviewed: PT stated when I evaluated resident back on October 12, 2021, resident's lower extremities were within functional limits. Also, resident has been non ambulatory since admission and requires a hoyer lift. The Resident had strength in both legs and no contractures when he/she last saw the resident. When the PT discharged the resident on 11/8/21, active assisted ROM for lower extremities was recommended. On 12/21/21 at 1:40 PM, the Clinical Care Coordinator (CCC) was interviewed: CCC stated the ROM would be done with therapy until the end of rehab. Then, they would give it to the CNAs to perform. Then, the ROM exercise would be entered into the CNAs task. Rehab would then initiate a ROM care plan. Nursing Supervisors and CCC are responsible to initiate and update care plans. Resident does not have a contracture or ROM care plan. 415.11(c)(1) Based on observations, record review and staff interviews during the Recertification survey, the facility did not ensure that a person-centered comprehensive care plan (CCP) was developed and implemented to address the resident's medical, physical, mental, and psychosocial needs. Specifically, 1). A care plan was not developed and implemented for a resident with contractures and splint device and 2). A care plan was not developed to address a resident's range of motion needs. This was evident for 2 of 2 residents reviewed for Limited ROM, and 1 of 2 residents reviewed for ADL Decline out of a sample of 38 residents. (Residents #10, #256 & #157) The findings are: The facility's Policy titled Care Planning-Interdisciplinary Team dated 04/2016 documented that the Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. The care plans shall be used in developing the resident's daily care and will be available to the staff personnel who have responsibility for providing care or services to the resident. 1) Resident #10 was initially admitted to the facility on [DATE], with diagnoses that included Peripheral Vascular Disease, Diabetes Mellitus, Alzheimer's Disease, Cerebrovascular Accident, and Hemiplegia. The Significant Change in Status Minimum Data Set (MDS) dated [DATE] documented that the resident had severe impairment in cognition with long and short-term memory problems. The MDS also documented the resident required extensive assistance of 2 staff for bed mobility, and was dependent on 2 staff for transfer, and was dependent on 1 staff for all other Activities of Daily living. The Multidisciplinary Rehab Screening Form (Therapist) dated 11/19/2021 documented: Right resting hand splint, remove Q2hrs for skin checks. The Physician's order dated 11/19/2021 documented: Orthosis: Right resting hand splint to be worn at all times, remove every 2hrs for skin checks. On 12/14/21 at 10:09 AM, Resident #10 was observed in room, with contracture of right hand, and there was no splint device applied. There was no documented evidence in the medical record that a comprehensive care plan was developed and implemented for resident's contractures and splint device. On 12/15/21 at 02:26 PM, an interview was conducted with Certified Nursing Assistant (CNA) #1. CNA #1 stated that the resident required total care, was taken out bed daily to the wheelchair equipped with a pad to rest and position the hands. CNA #1 stated that they are not aware of any splint device being used for the resident's hand support. On 12/16/21 at 11:42 AM, an interview was conducted with the Physical Therapist (PT). The PT stated that the splint device was recommended by the Occupational Therapist (OT), and ordered by the doctor prior to the resident's last hospitalization and was continued on re-admission on [DATE]. The PT also stated that nursing is expected to update the care plan and Certified Nursing Assistant Accountability Record (CNAAR) and to ensure that the splint device is applied as ordered. On 12/16/21 at 11:53 AM, an interview was conducted with Registered Nurse (RN) #1 who was the supervisor on the unit. RN #1 stated that the resident's order was checked, and it was documented in the CNAAR, but they did not understand why the Certified Nursing Assistant was saying that they are not aware of the device. RN #1 further stated that they were not aware that there was no CCP developed for the resident's contractures and splint device. RN #1 also stated that the RN Clinical Coordinator will be contacted to ensure that all the needed care plans are in place. On 12/16/21 at 12:21 PM, an interview was conducted with the RN Clinical Coordinator (RNCC). The RNCC stated that the supervisor covering the unit is supposed to initiate the care plan, and the CNAAR is also initiated by the supervisor. If noted that it is not done it is updated by the RNCC. The RNCC also stated that when the Rehab department issues the splint, the nursing department is supposed to be informed, but they were not sure why this was not done. The RNCC further stated that the supervisor covering the floor is supposed to review and report if it is not done. On 12/17/21 at 11:08 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the RN supervisors are responsible for initiating and updating the CCP and they are also supposed to initiate and update the CNAAR. The DON also stated that the Clinical Care Coordinator is expected to check that this is done and to see that the interventions are carried out as per the residents' plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident # 229 was admitted to the facility on [DATE] with diagnoses which include Diabetes Mellitus, Neuropathy, and Cellulitis. The Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 229 had intact cognition with a brief Interview for Mental Status (BIMS) score of 14 out of 15. A Care Plan Meeting Note dated 05/03/2021 at 2:58 PM had no documented evidence that Resident # 229 participated in the quarterly care meeting. A Care Plan Meeting Note dated 08/02/2021 at 3:33 PM had no documented evidence that Resident # 229 participated in the quarterly care plan meeting. A Care Plan Meeting Note dated 11/01/2021 at 3:45 PM had no documented evidence that Resident # 229 participated in the quarterly care plan meeting. The Care Plan Meeting Sign-in sheets dated 05/03/2021, 08/02/2021, and 11/01/2021 documented no signature for Resident #229, indicating the resident did not attend the meetings. There was no documented evidence in the medical record that Resident #229 was invited to the quarterly care plan meetings held on 05/03/2021, 08/02/2021, and 11/01/2021. During an interview on 12/13/2021 at 2:48 PM, Resident # 229 stated that he/she has never been invited to a care plan meeting. Resident stated that he/she would like to attend care plan meetings. During an interview on 12/20/21 at 10:41 AM, Social Worker #1 stated we were inviting residents for annuals, significant change, initials, and if the resident requested additional meetings. There have been four care plan meetings for Resident # 229. The Resident was invited to an annual care plan meeting on 2/8/21, and the Resident stated they would participate via phone. Resident # 229 was not invited to the quarterly care plan meetings held on 05/03/2021, 8/02/21, and 11/01/2021. On the attendance sheet we don't document that the resident declined. We document whether they attended or not. Anytime a resident attends a meeting, we sign them in as well. Also, we document in the progress notes that the resident attended. The facility policy is to invite residents to the initial, significant change, and annual care plan meetings, not quarterly meetings. During an interview on 12/20/21 at 10:49 AM, the Director of Social Service stated that the Resident and family are invited to the admission, annual, significant change, and if resident or family requests an additional care plan meeting. We follow the facility policy which is not to invite the resident/family to participate in the quarterly care plan meeting. 415.11(c)(2) (i-iii) Based on record review and interviews conducted during the Recertification survey, the facility did not ensure that each Resident or resident representative was offered the opportunity to participate in the revision and/or review of the comprehensive care plan. Specifically, cognitively intact residents were not invited to quarterly care plan meetings. This was evident for 2 of 38 sampled residents (Resident #94 and #229). The findings are: The facility's policy and procedure titled Care Planning-Interdisciplinary Team dated 04/2016 states that the Resident, the Resident family, and/or the Resident legal representative/guardian/surrogate are encouraged to participate in the development and revision of the Resident care plan. 1) Resident # 94 was admitted to the facility on [DATE] with diagnoses which include Post Traumatic Stress Disorder, Heart Failure, and Adult Failure to Thrive. The Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 94 cognition as intact with a brief Interview for Mental Status (BIMS) score of 15. A Care Plan Meeting Note dated 04/05/2021 at 3:16 PM has no documented evidence that Resident # 94 participated in the quarterly care meeting. The Care Plan Meeting Attendance Record dated 04/05/2021 had no documented evidence that Resident # 94 attended the meeting. A Care Plan Meeting Note dated 07/16/2021 at 10:39 AM has no documented evidence that Resident # 94 participated in the quarterly care plan meeting. The Care Plan Meeting Attendance Record dated 07/16/2021 had no documented evidence that Resident # 94 attended the meeting. There was no documented evidence in the medical record that Resident #94 was invited to the care plan meetings held on 4/5/2021 and 7/16/2021. During an interview on 12/13/2021 at 3:05 PM, Resident # 94 stated that he/she had not had a formal care plan meeting. He/she was invited to the initial care plan meeting last year and has not been invited to any further meetings. During an interview on 12/16/21 at 1:32 PM, the Social Worker #3 stated that the care plan meeting is done initially after admission, quarterly, annually, for a significant change, and if a resident or family requests. The nursing supervisor, rehab, recreation, and the Resident or the family are invited. There have been three care plan meetings for Resident # 94. The Resident was invited to the initial meeting on 12/12/2020, but the Resident declined to participate. Resident # 94 was not invited to the quarterly meeting held on 04/05/2021 and 07/16/2021. According to the facility practice, residents and/or representatives are not invited to participate in the quarterly meetings. During an interview on 12/17/21 at 10:35 AM, the Director of Social Service stated that the Resident and family are invited to the care plan meeting. The initial care plan meeting is held on admission, then quarterly, significant change, and annually. The resident/family are invited to the initial, annual, and significant modifications meeting but not the quarterly meeting. The facility policy is not to invite the resident/family to participate in the quarterly care plan meeting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and staff interviews during the Recertification survey, the facility did not ensure that needed services, care and equipment are provided to assure that resident with limited range of motion and mobility maintain or improve function based on the residents' clinical condition. Specifically, a resident was not provided with the splint device ordered to improve resident's contractures, this was evident for 1 out of 2 residents reviewed for Limited ROM out of a sample of 38 residents sampled. (Resident #10) The findings are: The facility's policy titled Rehab Services dated 12/31/2013 documented that indication of splint device is for prevention of permanent deformity caused by abnormal tone. Establish a wearing schedule: A patient adjusts to a new splint over time by following a wearing schedule that designates the amount of the time the splint is to be worn and the amount of time the splint should remain of each day Resident #10 was initially admitted to the facility on [DATE], with diagnoses that included Peripheral Vascular Disease, Diabetes Mellitus, Alzheimer's Disease, Cerebrovascular Accident, and Hemiplegia. The Significant Change in Status Minimum Data Set (MDS) dated [DATE] documented that the resident had severe impairment in cognition with long and short-term memory problems. The MDS also documented the resident required extensive assistance of 2 staff for bed mobility, and was dependent on 2 staff for transfer, and was dependent on 1 staff for all other Activities of Daily living. The MDS further documented that the resident had impairment on one side of upper and lower extremity. The Multidisciplinary Rehab Screening Form (Therapist) dated 11/19/2021 documented: Right resting hand splint, remove Q2hrs for skin checks. OOB (Out of bed) to reclining w/c with gel wedge cushion with B/L elevated leg rests with right arm trough and calf skirt pad. The Physician's order dated 11/19/2021 documented: Orthosis: Right resting hand splint to be worn at all times, remove every 2hrs for skin checks. OOB to reclining wheelchair with gel wedge cushion with B/L elevated leg rests with right arm trough with calf skirt pad for position and comfort secondary to generalized weakness causing impaired sitting balance. On 12/14/21 at 10:09 AM, Resident #10 was observed in room, with contracture of right hand, and there was no splint device applied. On 12/15/21 at 02:26 PM, an interview was conducted with Certified Nursing Assistant (CNA) #1. CNA #1 stated that the resident required total care, was taken out bed daily to the wheelchair equipped with a pad to rest and position the hands. CNA #1 stated that they are not aware of any splint device being used for the resident's hand support. On 12/15/21 at 02:31 PM, an interview was conducted with the Licensed Practical Nurse (LPN) #1. LPN #1 stated that they had not be told of and were not aware that the resident had been ordered any special splint device. On 12/16/21 at 11:42 AM, an interview was conducted with the Physical Therapist (PT). The PT stated that the splint device was recommended by the Occupational Therapist (OT), and ordered by the doctor prior to the resident's last hospitalization and was continued on re-admission on [DATE]. The PT also stated that they did not understand why the staff are not applying it because it is not a new splint. PT further stated that they in-service was given to the nursing staff by the OT on the application of the splint device. PT further stated that the OT assigned to the resident was not available for interview and PT was not able to provide documented evidence of the in-service. On 12/16/21 at 11:53 AM, an interview was conducted with Registered Nurse (RN) #1 who was the supervisor on the unit. RN #1 stated that rounds are made on the unit to check every resident and monitor the staff to ensure that all interventions needed to be carried out are done, and if there is anything noted not done, the staff are educated to see that they are doing what is expected to be done. RN #1 also stated that resident's order was checked, and it was documented in the Certified Nursing Assistant Accountability Record (CNAAR), and they did not understand why the CNA and LPN are saying that they are not aware of the device. RN #1 stated they were not aware that resident's splint was not being applied as per order. On 12/16/21 at 12:21 PM, an interview was conducted with the RN Clinical Coordinator (RNCC). The RNCC stated that when the rehab issues the splint, the nursing department is supposed to be informed, but they were not sure why this was not done. The RNCC also stated that the supervisor covering the floor is supposed to oversee the staff to ensure that interventions are provided to the resident as per the plan of care. The RNCC further stated that they were not aware that the resident was not being provided with the splint device. On 12/17/21 at 11:08 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the unit LPN is responsible for supervising the CNAs, the RN supervises the LPNs, and the RNCC supervises the RN supervisors to ensure that interventions are carried out as per residents' plan of care. The DON further stated that they are going to re-educate the staff to ensure that the problem is corrected. 415.12 (e)(2)

Based on observation, record review, and staff interviews conducted during the Recertification survey, the facility did not ensure that medication and biologicals were discarded by expiration date. Specifically, 4 medications were found to be expired in the medication cart. This was evident for 1 of 8 units observed for Medication Storage (5th floor) The findings are: The facility policy and procedure titled Medication Storage and Handling, reviewed on 02/12, documented that storage of medication and other pharmaceuticals will be stored in the following methods: medications and other solutions past their noted expiration date will be removed from usage and returned to the pharmacy. On 12/15/21 09:49 AM, an observation was conducted of the medication cart on the 5th floor. The following medications were in the cart: One Incruse Ellipta Aerosol Powder Breath 62.5 mcg (micrograms) inhalation was observed in the medication cart. The directions documented to store in unopened foil tray, discard 6 weeks after foil tray opened or when counter reads 0, whichever one comes first. An open date of 10/5/21 was written on the box, and counter read 23. One Latanoprost eye drop solution labeled with an open date of 10/19/21 and a discontinuation date of 11/17/21. One Brimonidine Tartrate 0.2% solution labeled with an open date of 10/18/21 and a discontinuation date of 11/16/21. One Insulin Aspart had a discontinued date of 11/26/21 written on the medication. The Licensed Practical Nurse (LPN#3) who worked the morning shift was immediately interviewed. LPN #3 stated that this was not their regularly assigned floor, and the Nurses should have checked the medications and removed the expired medications from the cart. LPN #3 stated the expired medications will be removed, and the medications will be re-ordered from the pharmacy. On 12/17/21 at 02:33 PM, an interview was conducted with LPN #4 who stated that the 5th floor is their regular unit, and the night shift has been designated to clean the cart and ensure expired medications are removed. LPN #4 stated ultimately, it's everyone's responsibility to check. LPN #4 also stated that whoever opens the medication should put the date on it and when the medication is expired it should be thrown out and reordered. LPN #4 stated in this case, it was not done. On 12/17/21 at 02:50 PM an interview was conducted with RN #4 who stated that the Supervisors check the cart and the expiration dates, they assign the Supervisors to ensure that no medications are expired on the cart. Expired medications are removed and the Pharmacy is then called to reorder the medication. RN #4 stated this must be addressed to ensure that it doesn't happen again. On 12/21/21 at 09:30 AM an interview was conducted with the Clinical Care Coordinator (CCC #2) who is assigned to oversee the 5th floor. CCC #2 stated it is the responsibility of every shift to clean up the medication cart and throw out the expired medications. CCC #2 stated expired medications should be returned to the pharmacy and then ordered, and then they are filled. CCC #2 also stated that when the nurse comes on the unit, they are supposed to check the medication cart and should notify the Supervisor to let them know that the medication is expired. Stated that this time, there was a lapse in checks. 415.18 (d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. The facility's Policy and Procedure titled Catheter - Maintenance of Indwelling revised on 02/2012 documented that indwelling catheters will be cared for according to CDC recommendations which are incorporated into the following guidelines: - Drainage systems will be maintained to prevent leakage, contamination, or accidental disconnection, to always provide non-obstructed downhill flow of urine. Drainage systems must remain a closed sterile system. Resident #284 was admitted to the facility with diagnoses that included Renal Insufficiency, Renal Failure, ESRD, and Benign Prostatic Hyperplasia (BPH) with Lower Urinary Tract Symptoms. The Quarterly Minimum Data Set (MDS) dated [DATE] documented the resident had intact cognitive status and required extensive assistance of staff for Activities of Daily Living. The MDS also documented that resident had an indwelling catheter. On 12/13/21 at 10:34 AM, during the initial tour of the unit, Resident #284 was observed lying supine in bed sleeping. Urinary catheter bag was observed on the floor on the right side of the resident's bed. On 12/14/21 at 10:07 AM, Resident #284 was observed lying in bed sleeping, and the urinary catheter bag was touching the floor. On 12/15/21 at 10:51 AM, Resident #284 was observed in bed receiving care from Certified Nursing Assistant (CNA) #1, and the urinary catheter bag was observed on the floor under the bed full of urine. On 12/15/21, between 11:04 AM and 12:00 PM, resident was observed in bed after receiving care, and the urinary catheter bag was still on the floor. On 12/15/21 at 02:15 PM, an interview was conducted with Certified Nursing Assistant (CNA) #1. CNA #1 stated that resident is given AM (morning) care including bed bath, incontinent care, and grooming daily. The urine drainage bag is emptied every shift and changed every 2-3 days or when it is dirty, the bag is placed below the bladder and hung by the bed. CNA #1 also stated that the resident always take off urine bag when coming out of bed and sometimes places it on the floor. CNA #1 further stated that they have not been reporting or documenting that resident is placing the bag on the floor. CNA #1 stated that the bag was kept on the floor while giving incontinent care to the resident earlier in the day because they did not want to pick it up with soiled gloved hands during the care. On 12/15/21 at 02:36 PM, an interview was conducted with the Unit Charge Nurse, Licensed Practical Nurse (LPN) #1. LPN #1 stated that the CNAs are trained on how the catheter should be positioned, and they are supposed to know that the urine bag should not be touching the floor. LPN #1 also stated that the work on the unit is overwhelming and they have been so busy with other things and they could not be checking and monitoring every little thing that was not done right. LPN #1 further stated that nobody reported that the resident had been placing the urine bag on the floor and they had never noticed the bag on the floor. LPN stated that they are the only nurse on the floor but they will always call the supervisor to the floor if there is any problem. On 12/16/21 at 12:01 PM, an interview was conducted with the Registered Nurse (RN) #1 who was the supervisor on the unit. RN #1 stated that resident was offered the leg bag but refused to use it. RN #1 also stated that the CNA should know that the catheter bag should never been on the floor and they did not understand why the bag was left on the floor when the resident was in bed. RN #1 further stated that the staff will be re-educated to ensure that residents bags are not left on the floor. 415.19(a)(b) (1-3) Based on record review, and staff interviews during the Recertification survey, the facility did not ensure infection prevention control practices were followed to help prevent the spread, development, and transmission of communicable diseases and infections. Specifically, (1) the facility water management plan was not reviewed/revised within the last year, (2) the facility lacked a Legionella sampling plan based on the facility risk assessment, (3) oxygen tubing was observed with no label, and there was no documented evidence that the oxygen tubing was changed, and (4) a urinary catheter bag was observed touching the floor on multiple occasions. This was evident for the Water Management Plan reviewed for Infection Control and 1 of 2 residents sampled for Respiratory Care and 1 of 1 resident sampled for Urinary Catheter or UTI out of 38 residents sampled (Resident # 17 & 284). The findings are: (1) Record review of plan titled, Protection Against Legionella-Water Management Program, effective December 2016, revealed the plan was not reviewed/revised since the effective date. The facility water management plan was not reviewed/updated within the last year. (2) Water management plan lacked a sampling plan based on the facility risk assessment that identifies where Legionella and other opportunistic waterborne pathogens (e.g., Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system. Specifically, there was no documented evidence within the water management plan to indicate required components including but not limited to: specific monitoring sites; control limits at each control location; and policies and procedures for personnel, new staff or an outside consultant to identify specific sampling locations for the facility staff and consultants when performing sampling and maintenance activities. During an interview 12/17/2021 at approximately 12:00PM, the Director of Maintenance stated they have their water management plan and sampling was done by outside agency on annual basis. On 12/17/2021 at approximately 1:15PM, the Administrator was interviewed. They confirmed the findings and stated they would contact the vendor agency to get Facility Risk Assessment completed and update the water management plan. (3) The Facility's policy and procedure titled Oxygen Therapy Using Oxygen Concentrator states that oxygen therapy will be administered by a licensed professional nurse as prescribed by a physician. The procedure includes to change nasal cannula every 72 hours and as needed, and date when applied. Resident # 17 was admitted on [DATE] with the diagnoses which include Hypertension, Chronic kidney Disease, Diabetes Miletus, and Pulmonary Embolism. The Minimum Data Set (MDS) assessment dated [DATE] documented that Resident # 17 is severely impaired, never/rarely made decisions. Section O indicated that Resident #17 is on oxygen therapy. On 12/13/2021 at 10:45 AM, Resident #17 was observed using oxygen at 2 liters, and the oxygen tubing was not labeled. The same was observed on 12/14/2021 at 10:04 AM, 12/15/2021 at 10:24 AM, 12/16/2021 at 10:07 AM, and 12/17/2021 10:55 AM. A Physician Order dated 08/20/2021 included an order for Oxygen 2 liters/min via nasal cannula continuous every shift A Care Plan initiated on 09/09/2021 documented that Resident #17 is at risk as evidence by shortness of breath. The interventions include administer medication and treatment as ordered and administer oxygen as ordered. The Treatment Administration Record (TAR) dated 11/01/2021 to 12/20/2021 documented Oxygen 2 liters via nasal cannula. Physician Orders contained no documented evidence of an order for changing the oxygen tubing once every 72 hours. A review of the TAR dated 11/01/2021 to 12/17/2021 revealed no documented evidence of when the oxygen tubing was changed. During an interview on 12/17/2021 at 10:57 AM, Registered Nurse #3 (RN#3) stated that the oxygen tubing should be changed every 72 hours during the night. But since there is label, RN # 3 does not know when the tubing was changed. The tubing is supposed to be labeled with the date and time when it is changed. It is not documented in the Electronic Health Record so; they must go with the date on the label. They check the dated and if it is past then they will change it. During an interview on 12/17/2021 at 11:48 AM the Clinical Care Coordinator stated that Resident # 17 is on oxygen for shortness of breath. The oxygen tubing is supposed to be changed and labeled with date and time on Sundays and as needed by the night shift. It is not documented anywhere so they are supposed to label it. The supervisor is supposed to remind the nurse and make sure the tubes are changed. The supervisors on all the shifts are supposed to check and make sure that the tube is changed and labeled. During an interview on 12/20/2021 at 10:15 AM, the Director of Nursing (DON) stated that oxygen tubing is changed every 72 hours. Resident # 17 oxygen tubing was changed on Sunday and on Wednesday, but the staff forgot to date the tube. The staff is supposed to document changing the oxygen tubing in the Treatment Administration Record (TAR). with the date and time. The DON stated that they are unaware that the oxygen tube changing is not documented in the TAR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, during the Recertification Survey, the facility did not ensure that housekeeping and maintenance services were maintained. Specifically, wheelchairs were observed layered with an accumulation of dirt, dust and debris for 4 residents (Residents # 77; # 140; #109 and # 114). This was evident for 1 of 8 resident units observed for the Environment (Unit 2). The findings are: The facility policy titled Wheel Chair Cleaning dated March 2018 documented: It is the policy of [NAME] Care Center to ensure that residents' wheel chairs and walkers are cleaned on a regular basis. Depending on number of wheel chairs used on each unit, approximately two units are scheduled per week, each wheel chair is to be cleaned on a monthly basis. 1.) On 05/10/19 at 10:05 AM, the wheelchair of Resident # 77 was observed with an accumulation of dirt, dust and debris while in the dining room area. 2.) On 05/10/19 at 10:05 AM, the wheelchair for Resident #140 was observed with an accumulation of dirt, dust and debris, while in the dining room area. 3.) On 05/10/19 at 10:08 AM, the wheelchair for Resident #109 was observed with an accumulation of dirt, dust and debris while in the dining room area. 4.) On 05/10/19 at 10:10 AM, the seat cushion and wheelchair of Resident #114 was observed with an accumulation of of crumbs, dust, dirt and debris, while sitting in the dining room area. A review of the Wheel Chair, schedule for May, 2019 found discrepancies between the actual wheel chair schedule and the actual Wheel chair Cleaning Form. On 05/10/19 at 10:14 AM the 2nd floor unit Housekeeper was interviewed. The Housekeeper stated that wheelchairs are washed at night from 10: 00 PM - 6:00 AM by an assigned housekeeping staff member. The Housekeeper further stated they should also be noticing if wheelchairs are in need of immediate cleaning. The Director of Environmental Services was interviewed at 10:20 AM on 05/10/19. She stated that she is responsible for ensuring the visitors , staff, and residents have a safe, clean, and comfortable environment. She further stated that each morning, environmental rounds done to observe staffs' work which includes environmental cleanliness, elimination of odors, and wheelchair maintenance. The Housekeeping staff and each unit are provided with a monthly wheelchair cleaning schedule. The DES stated she has a housekeeping staff member from 10:00 PM - 6:00 AM whose duties include the power washing washing of wheelchairs. If a wheelchair needs immediate attention for cleaning, the nurse on the unit can notify her. The Housekeeping staff should be reporting wheelchairs that require immediate washing. She could not verify the number of wheelchairs on each unit. 415.5(h)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, during the Recertification survey, the facility did not ensure that the assessment accurately reflected the resident's status. Specifically, 1.) Residents with Hemodialysis, oxygen use, and inplanted defibrillator were not captured on the Minimum Data Sets (MDS) assessments. 2.) A resident who was not in use of a Ventilator was coded as receiving Ventilator ttreatment while in the facility. This was evident for 2 of 38 residents reviewed for MDS Assessment (Resident #167 and 275). The findings are: 1) Resident #167 was re-admitted [DATE] with diagnoses which include Heart Failure, Diabetes Mellitus Hypernatremia, and End Stage Renal Disease. On 05/07/19 at 11:39 AM resident #167 was observed in room sitting on the bed. An arteriovenus (AV) fistula was noted on the left hand of the resident. The resident stated he has been on dialysis for about 7 years, and goes for dialysis 3 times a week on Tuesday, Thursday and Saturday. The Quarterly Minimum Data Set 3.0 (MDS) assessment, Reference Date (ARD) 3/8/2019, documented that the resident was re-admitted [DATE], with diagnoses which include Heart Failure, Hypertension, Pneumonia, diabetes Mellitus, Hypernatremia, Hyperlipidemia, Anxiety, Asthma. The MDS documented the resident requires supervision with 1 person assist for bed mobility, transfer, Locomotion, toilet use and personal hygiene. The MDS did not include hemodialysis among the specialized treatments received by the resident. The Comprehensive Care Plan (CCP) for Dialysis, created on 3/16/17, documented that the resident is at risk for complications related to Hemodialysis access site. The CCP was revised on 6/4/18, with the goal that the resident will remain free of redness, swelling, excessive bleeding, drainage, tenderness to access site. On 7/26/2018, the CCP was updated. Interventions included: Resident will have to go snacks to go on dialysis days; Visually observe shunt site after dialysis for redness, swelling, excessive bleeding, drainage, tenderness to access site; Check bruit and thrill s/p dialysis. The Physician's order, revision date 3/17/2019, documented: Consult: Queens Dialysis center every T/TH/SAT; Check left arm AV fistula for bleeding, bruit and thrill every shift and alert MD for complication; No BP or Blood work to the left arm. On 05/10/19 at 10:30 AM, the MDS Coordinator (MDSC) was interviewed. The MDSC stated that in order to complete the MDS assessment, she reviews Physician's orders, speaks with the staff on different shifts, and observes the residents to corroborate the information. She also stated that every month she checks to see if every area is captured, but she did not understand why the error noticed on the current MDS was not captured. She stated that she is aware that the resident is on dialysis, but it could have been the error of the assessor. The MDS coordinator further stated that immediate action will be taken to correct the situation 2) Resident #275 was admitted to the facility on [DATE] with diagnoses which include Hypertension, Diabetes Mellitus, Heart Failure, and Automatic Implanted Defibrillator. On 05/08/19 at 11:17 AM, the resident was observed in the room, sitting on a wheel chair, alert and awake. The resident was interviewed about care received. An oxygen tank and a cardiac monitoring machine were observed bedside. On 05/10/19, a review of the MDS assessment dated [DATE] documented the resident had intact cognition. The MDS further documented the resident had diagnoses of Hypertension, Diabetes Mellitus, Heart Failure, and End Stage Renal Disease. The MDS documented the resident received specialized treatments of Hemodialysis and ventilator while a resident. Furthermore, there was no indication on the MDS that the resident receiving oxygen treatment and no indication that the resident had an implanted defibrillator. A review of the resident admission record dated 02/18/15 documented that the resident has a diagnosis of Automatic Implantable Cardiac Defibrillator. A review of current May 2019 Physician's order documented the following: Oxygen 2 Liter per minutes via nasal Canula as needed. The order was initiated 4/10/19. There was no documented evidence in the medical record that the resident was ever on a ventilator. The MDS assessment also did not include oxygen therapy under treatments received by the resident. On 05/10/19 at 12:10 PM, an interview was conducted with the MDS Director. She stated that she had been doing the MDS since 2102, and she is responsible for accuracy of the MDS assessment. She stated that the resident was never on ventilator at this facility. She acknowledged coding resident # 275 as a ventilator resident was an error. The MDS director also stated that, a resident with the use of intermittent or continuous use of oxygen must be coded on the MDS. 415.11(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews conducted during the recertification survey, the facility did not ensure the development and implementation of comprehensive person-centered care plans for each resident, consistent with the resident rights that includes measurable objectives and time frames to meet residents medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Specifically, a comprehensive care plan was not developed for a resident who was admitted with a cardiac monitoring machine. This was evident for 1 of 38 sampled residents (Resident # 275). The finding is: A facility Policy and Procedure related to Resident Care Planning dated April 2016 documents that the facility will develop individualized comprehensive care plan which include measurable goals, and timely meet the resident's medical, nursing, mental and psychosocial needs of each resident. The Care plan further documented that Comprehensive care plans is developed with 7 days of the completion of the resident comprehensive assessment. Resident #275 was admitted to the facility on [DATE]. As per the admission record dated 02/18/15 documented that the resident was admitted with the following diagnoses which include Hypertension, Diabetes Mellitus, Heart Failure, Automatic Implanted Defibrillator, and End Stage Renal Disease. On 05/08/19 at 11:17 AM, the resident was observed in the room, sitting on a wheel chair, alert and awake. During the resident interview, the resident stated that he goes to dialysis three times a week, and has been on hemodialysis treatment for few years. Resident was also observed with oxygen tank near bedside, and a cardiac monitoring device (Boston Scientific cardiac monitoring machine) was also observed at the bedside table. The resident stated that the machine was given to him a few years ago, and it transmits his heart rates to his cardiologist. If there is a problem, they will contact me or the nursing home. On 5/10/19, a review of the resident admission record dated 02/18/15 documented that the resident has a diagnoses of Automatic Implantable Cardiac Defibrillator. A review of Physician order dated 5/01/19 documented the following: Boston Scientific cardiac monitoring machine to be plugged at all time. The comprehensive care plan did not reflect the cardiac monitoring machine or include interventions regarding care or monitoring required for the machine. On 05/10/19 at 11AM, an interview conducted with the Register Nurse Manager (RN #3). The RN stated that the staff are aware that the resident has a implanted defibrillator and cardiac monitoring machine that has to be plugged in at all times. RN #3 further stated that she started working here in February 2019, and she is responsible for care plaining. She further stated that the resident had a cardiac care plan, but the use of the cardiac monitoring machine was not included. She stated that I think we missed it. 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations interview and record review during a Recertification Survey, the facility did not ensure that a resident with a pressure ulcer, receive the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Specifically, a pressure relieving device for a resident with foot/leg ulcer was missing and observed not in place. This was evident for 1 of 3 Residents reviewed for Pressure Ulcer Care (Resident # 293). The finding is: Resident # 293 was admitted on [DATE] with diagnoses which include Venous/ Arterial Ulcers and Cellulitis (bacterial skin infection) to lower extremity. The initial Minimum Data Set 3.0 (MDS) assessment dated [DATE], documented the resident had intact cognition and required extensive staff assistance for activities of daily living (ADL) needs. The MDS further documented the resident was admitted with Stage 2 and Stage 3 pressure ulcers. On 05/07/19 at 10:20 AM, Resident #293 was observed while in bed with her right leg resting on one pillow. A wound dressing was observed on her right lower leg, exposing her toes which appeared red and swollen. The resident was awake and alert. The resident stated that for five days, she has been missing her heel booties. She stated that a few days ago, a staff member told her the booties were sent to the laundry. She continued to say that she has to place a pillow herself to provide pressure relief for her right foot, and since she already has a heel pressure ulcer, she is concerned about developing more or making it worse. She stated that the heel booties provide her with comfort and relieve her from worry. They make a difference. On 05/08/19 at 8:05 AM, the resident was observed in bed, asleep. The resident was not wearing heel booties at this time. Her right leg was resting on a pillow. A right lower leg dressing was observed, and a stocking was observed on her right foot, exposing her toes. On 05/09/19 07:43 AM, the resident was observed while in bed. Heel booties were observed in place to both feet. The resident stated that she was relieved to have them on, and the staff just provided them to her. She stated that she feels better with the booties on while in bed, and not as concerned about the heel pressure ulcer with the booties in place. The Comprehensive Care Plan initiated on 02/20/19 (CCP) for Pressure Ulcer documented, impaired skin integrity as evidenced by stage 3 ulcer present. At risk for deterioration. Interventions included use of lower extremity pressure reducing device to bed. Review of the CNA Accountability record (Profile History Report) dated 02/26/19 documented, apply heel bootie while in bed. Wound Care Note dated 05/10/19 documented foot wound right heel, off load pressure on area. On 05/09/19 at 12:00 PM, the Certified Nurse Aide (CNA) assigned was interviewed. She stated that the resident requires extensive assist of one person. The resident has a pressure ulcer on her foot and should be wearing protectors while in bed, to relieve pressure on the heel. She stated that the heel booties were sent to the laundry on Thursday, May 2nd, and should have returned the following day, May 3rd. The CNA stated that she worked the weekend on May 4th and 5th. She stated that she checked the laundry room for the booties and found none. She stated that she did not report this to her nurse. On 05/09/19 at 12:14 PM, the Registered Nurse Unit Manager (RNM) was interviewed. She stated that she was the person who provided the Resident with a new pair of booties. The RNM stated that she requested a pair from the housekeeping department. She stated that she was not made aware that the resident needed booties before now. The Aides should be reporting these issues, and the CNA accountability record documents that the booties should be in place. Off-loading pressure on pressure ulcers is a treatment provided by nursing. This intervention is on the CNA accountability record because it should be a part of the resident's care. On 05/13/19 at 07:35 AM, the State Agency (AS) attempted to observe the wound care treatment as scheduled, however, the treatment had already been completed by the night shift nurse. 415.12(3)(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during a recertification survey, the facility did not ensure that pain management was provided to a resident who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, the Licensed Practical Nurse (LPN) did not administer prescribed pain medication to a resident prior to a wound dressing change. This was evident for 1 of 3 residents reviewed for pressure ulcer care. (Resident # 284). The finding is: Resident # 284 was admitted to the facility on [DATE] with diagnoses which include: Hypertension, Failure to Thrive, and Pressure Ulcers on Back, Buttock, and Hip. On 5/13/19 at 7:10AM, the resident was observed in the room sitting in the Geri-Chair. The resident was alert and awake but unable to make conversation. On 5/13/19 at approximately at 7: 00AM , upon arrival of the State Agency Representative to the unit, the night Licensed Practical Nurse (LPN # 1) stated that she had performed the wound care for resident #284 at 6:00AM. When asked LPN # 1 if she was aware that the wound was scheduled to be observed today at 7:00 AM, she stated that she was never aware. The LPN further stated that she has been working here for the past 5 years as an LPN, she works 11 PM to 7AM, 5 days a week. She stated that the wound is not scheduled on her shift. She stated the wound changed today because the night CNA was doing the AM care. She stated the wound is scheduled for the day nurse, but she was told by the night supervisor to change the wound at 6:30 AM. The Physician's order dated 04/09/19 documented the following wound care order: Left Gluteus: Cleanse area with NSS. Pat dry. Apply Mupirocin Ointment, cover with Calcium Alginate & Foam Dressing one time a day for wound healing related to Pressure Ulcer. The orders further documented the resident should receive Tylenol Tablet 325 MG (Acetaminophen)- 2 tablest via G-Tube every day and evening shift and 30 minutes prior dressing change for Pain. On 05/13/19 at 7: 22 AM, a review of Medication Administration Record documented that the resident did not receive the order of Tylenol Tablet 325 MG (Acetaminophen)- 2 tablets via G-Tube prior to the dressing change on 5/13/19 at 6:00 AM. On 05/13/19 at 7: 22 AM, LPN # 1 was interviewed. She stated that she never administered the pain medication to the resident prior to wound dressing change. She stated that the resident does not receive early medication like Synthroid. She also stated that resident # 284 only receives medication during the 7 to 3 shift. The MAR was reviewed with the LPN # 1 who acknowledged that Tylenol Tablet 325 MG 2 tablet via G-Tube 30 minutes prior dressing change was never administered. On 05/13/19 at 07:38 AM, an interview conducted with LPN #2 who she stated that she has been working here for 4 years, she works 7 to 3pm, 5 days per week. LPN # 2 stated that the wound is usually changed between 7 and 10 AM, and that she was aware that the State Agency Representative was coming to observe the wound at 7am and she was ready to perform wound care. LPN # 2 stated she was surprised to hear that the wound had been changed. On 05/13/19 at 11:32 AM, an interview conducted with the DNS who stated that she spoke with all supervisors in the evening to inform them that the State Agency Representatives are coming to observe the wound at 7:00 AM ON 5/13/19. The DNS could not explain why the wound dressing was changed at 6 AM 415.12

Based on observation and interview, during the Recertification Survey, the facility did not ensure that food was served in accordance with professional standards for food service safety. Specifically, during a lunch meal observation, the Certified Nurse Aide (CNA) was observed using her bare hands to remove a bread roll from the cellophane bag and placed the bread on the resident's plate. This was evident for 1 of 8 resident floors observed for the Dining Observation task (4th floor). The finding is: On 05/07/19 at 12:05 PM, during a lunch meal observation on the 4th floor, the CNA was observed assisting Resident #160 with setting up their lunch. The CNA used her bare hands to remove a bread roll from the cellophane bag and placed the bread on the resident's plate. On 05/09/19 at 7:54 AM, the CNA was interviewed. The CNA stated that food should not to be touched with bare hands because it is an infection control issue. She stated that she has been in-serviced on how to handle food, and she should have used a barrier when handling the bread. She further stated that she was not thinking. The Unit Registered Nurse Manager (RNM) was interviewed on 05/09/19 at 12:05 PM. She stated that staff have in-services on how to handle food, and handling food with bare hands is not the facility practice. The RNM stated that she observes meal times to ensure staff are handling food properly. 415.14(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) Resident #198 was admitted from an acute hospital on [DATE] with diagnosis which includes Falls, Rhabdomyolysis, and Hepatitis C. The Quarterly Minimum Data Set (MDS), Assessment Reference Date (ARD) 4/15/2019 documented that resident has severe impairment in cognition with current diagnosis of Hypertension, Diabetes Mellitus, Hyperlipidemia, Non-Alzheimer's Dementia, Depression, Psychotic disorder. The MDS also documented the resident is on Antipsychotic and Antidepressant medications, and that Antipsychotics were received on a routine basis only; No gradual dose reduction (GDR) had been attempted. There was no documentation that the Physician documented a GDR was clinically contraindicated. The Comprehensive care Plan on Psych meds updated 4/6/2019 documented: The resident uses psychotropic medications (Trazodone & Risperdal) r/t behavior management, disease process. Also documented that 3/23/19 - Remeron d/c due to weight gain and Trazodone started The Physician's order with revision date 4/12/2019 documented: Trazodone HCI tablet 50mg at bedtime for depressive disorder. Risperidone 0.5mg PO 2 times daily for Unspecified Psychosis. Comprehensive Care Plan on behavior dated 1/1/16 documented Alteration in Mood/Behavior secondary to mood disorder with the goal Resident will demonstrate use of effective coping strategies, and with interventions Determine cause of behavior; Administer medications as ordered by MD; Observe for side effect of medications; Redirect negative behavior; Maintain a calm environment; Psych consult as ordered by MD. The Comprehensive Care Plan on Alteration in Mood/Behavior noted on chart was initiated 01/01/2016. There was no documented evidence that the CCP was reviewed or updated since it was created. On 05/09/19 at 11:47 AM, an interview was conducted with the Unit Manager/Registered Nurse (RN#1).The RN stated that she has been working in the facility for about 2 months. RN #1 stated that as per record, resident was admitted with diagnosis of Major depressive disorder, unspecified dementia without behavior disturbance, unspecified psychosis not due to substance, unknown physiological condition, Opioid dependence and relentlessness and agitation. RN #1 stated that the resident has not been noted with any significant change in diet or behavior since her employment in the facility. The RN stated that the care plans are updated if there is any significant change in resident's condition/behavior, and if there is a note or report from any discipline, the care plan is updated to reflect the change. Care plans are also updated quarterly during quarterly assessment if there is no episodic issue during the period. RN #1 stated that there is no specific care plan for resident behavior other than the the one for Alteration in mood. The last update was 1/1/16. She could not say why the CCP was not updated because she has been employed in the facility since March 2019. 415.11(c)(2)(i-iii) Based on observations, record review, and staff interviews conducted during the recertification survey, the facility did not ensure that the Comprehensive Care Plan (CCP) was reviewed after each assessment or revised with changes in the resident's needs. Specifically, (1) a resident at risk for victimizing other residents, did not have their CCP revised to reflect the current interventions to address this risk (Resident #46); (2) a resident's CCP was not reviewed and revised to reflect the resident's behavior improvement (Resident #97); (3) a resident's CCP for Mood/Behavior was not reviewed/revised after the quarterly assessment (Resident #198). This was evident for 3 of 5 residents reviewed for Unnecessary Medications out of a total sample of 38 residents (Resident #s 46, 97, and 198). The findings are: 1) A facility Policy and Procedure related to Resident Care Planning dated April 2016 documents that the comprehensive care plan/Assessments of Residents are revised as information about the resident and the Resident's condition change. The Care Plan/interdisciplinary team is responsible for the review and updating of care plans. Resident #46 was admitted to the facility 10/06/17 with diagnoses which include: Major Depressive Disorder, Recurrent, Vascular Dementia with Behavioral Disturbance, Other Symptoms & Signs Involving Emotional State, and Other Specific Personality Disorders. The resident's most recent Quarterly MDS dated [DATE] documented the resident had received an antipsychotic medication 7 out of 7 days prior to the assessment being completed. Resident #15 also received antipsychotic medication on a routine basis and no Gradual Dose Reduction (GDR) was attempted. Diagnoses of Psychotic Disorder (other than Schizophrenia) and Major Depressive Disorder were not documented on the MDS. In addition, the resident was documented as having no hallucinations or delusions, did not exhibit any behavioral symptoms towards others 4-6 days within the past 2 weeks and wandered daily. The Comprehensive Care Plan (CCP) focusing on Alteration in Mood/Behavior was initiated 1/19/18. The resident was documented as having an actual behavior problem as evidenced by being physically abusive (specify: slap roommate on face) secondary to behavior problems and impaired cognitive function. The CCP documented staff members observed the resident moving his bed around to different sides of his room, with the door closed and locking it with his bed. The staff were unable to go into the room and give care, despite encouragement. The resident refused to open door on 4/30/19. The CCP further documented that the interventions to address the Resident's mood/behavior include: redirect negative behavior, ongoing assessment of behaviors, administer medications as ordered, observe for side effects of medications, offer rest periods/quiet times, maintain a calm environment A CCP focusing on resident at risk to victimize others was initiated 12/28/17. The CCP documented that Resident #46 attempted physical aggression (grab at or towards another resident) and attempted to follow staff (becoming belligerent, shouting/pointing finger at staff when redirected). The resident was transferred from the 6th floor to the 2nd floor on 4/26/2019. The CCP further documented that the interventions in place to address the resident's mood/behavior include: Referred to social service for further counseling, Psychiatry consult secondary to physical aggressive/restlessness. Review of the Nursing Notes dated 12/1/2018 to 5/01/2019 documented that Resident #46 continues to be disruptive to other residents and staff member. The resident is redirected by staff but becomes physically aggressive towards them when redirected. A review of the Medical Doctor (MD) and Nurse Practitioner (NP) notes from 2/1/19 to 3/28/19 did not reveal any documentation that the resident was having any hallucinations or had any behavior related to a diagnosis of Schizophrenia. The CCP related to Resident #46 being at risk for abuse/victimization was not reviewed and revised with evaluations and new interventions to address the fact that the current interventions to prevent the resident from grabbing other residents were ineffective. The CCP was not reviewed and revised with new interventions when the current interventions for discouraging Resident #46 from moving his bed around and locking the door with his bed therefore were not effective. On 05/10/19 12:27 PM, an interview was conducted with the Registered Nurse Unit Manager (RN#3). The unit Manager stated that resident was transferred to her floor from the 6th floor on 4/26/19 after a resident-to-resident altercation. The resident has not had any altercations since he was transferred to the floor, but he does have behaviors. She further stated the resident has major depressive disorder, other specific personality disorders,and vascular disorder with major disturbance. The resident was seen by psychiatry for a review of medication s/p (status post) altercation on 4/15/19. The resident had multiple altercations on the previous floor. The psychiatrist recommended continuing the current dose of meds and supportive treatment for cognitive impairment and psychiatry follow-up as needed. She stated the resident displayed behaviors three times where staff reported that he would move the bed behind the door to prevent anybody, most likely other residents, from coming into his room. The RN further stated they got him a Spanish language board so that they can communicate with him to answer his requests, and they call the family to request visits. The RN stated the Recreation Department came to speak with resident in Spanish with language dialogue and board provided to counsel him for reassurance. She stated staff asked him why he was doing what he was doing, and the behavior stopped with the last incident on 5/1/19. The social worker, recreation department and nursing intervened, and, since then, there have been no behaviors. She stated they continue monitoring. The resident participates in unit floor activities since the transfers, and he is doing much better. He also watches television in his room as well. Unit Manager stated that she is responsible for creating, revising, and updating all care plans on the unit. She stated that the responsibility is shared between the night supervisors and unit managers. The Unit Manager stated that she was told that the CCP had to be updated every 90 days. 2) The facility policy and procedure on Care Plan was revised on April 2016 stated that the care planning/interdisciplinary team is responsible for the review and updating of care plans: when there has been a significant change in the resident's condition. When the desire outcome is not met. When the resident has been readmitted to the facility from a hospital stay and at least quarterly. Resident #97 is a resident admitted to the facility on [DATE] with diagnoses which include Psychotic Disorder, Anxiety, Restlessness and Agitation, Epilepsy and Recurrent Seizure, Alzheimer's Disease, Insomnia, Dementia. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had severely impaired cognition. The Comprehensive Care Plan (CCP) for impaired cognitive function/dementia or impaired thought process r/t Dementia, psychotropic drug care plan was created on 11/16/18 was never revised. The goal for the resident is to maintain current level of cognitive function and to be able to communicate basic needs on a daily basis. The Physician's orders dated 4/8/19 documented that more recently resident's behavior is more manageable with less psychosis and mood symptoms. He has history of mood lability, agitation, combativeness, oppositional behavior, elevated anxiety with restlessness and wandering in and out of other rooms in an intrusive manner towards others. There was no documented evidence that the CCP was reviewed and revised to address the resident's behavior improvement. On 5/13/19 at 12:41 PM, an interview was conducted with the Registered Nurse (RN #4) who stated when there is a new problem, care plans are initiated right away so everybody could be on the same page. I was on vacation when the resident developed the rash. The nurse supervisor who was on duty did not create the care plan. On 05/13/19 at 02:09 PM, an interview was conducted with the Director of Nursing Who stated that CCP are updated quarterly and as needed. If there is no change, they will put no change, continue same plan of care in the progress note and update individual care plan that need to be updated. I understand what you are saying that even though there is no change, we will make sure we update the care plan and date it so everyone can see that the care plan was revised.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident #198 was admitted from an acute hospital on [DATE] with diagnoses which include Dementia, Falls, Rhabdomyolysis, Hypertension (HTN), Hepatitis C, and Diabetes Mellitus (DM). The Quarterly Minimum Data Set (MDS), Assessment Reference Date (ARD) 4/15/2019, documented that resident had severely impaired cognition with current diagnoses of Hypertension, Diabetes Mellitus, Hyperlipidemia, Non-Alzheimer's Dementia, Depression, and Psychotic disorder. The MDS also documented that resident is on Antipsychotic and Antidepressant medications, and that Antipsychotics were received on a routine basis only. No gradual dose reduction (GDR) had been attempted, and there was no documentation that the Physician determined GDR was clinically contraindicated. On 05/09/19 at 09:43 AM, the resident was observed sitting in a wheelchair (w/c) in the day room, taken to his room for an interview and stated that he cannot remember when he was admitted to the facility, unable to recall the date and time, but able to engage in simple discussion. Resident stated he does not know the name and type of the medication being given to him because he does not ask, stated that they give me injection, but I don't know what. Resident also stated, I was on methadone long time ago to control my mood, but they stopped giving it to me. Resident stated that he does not know why it was stopped. The Psychiatry Consult dated 9/11/2015 documented the consult was requested for an evaluation of mental status and management. The consult documented that resident was admitted with a history of Methadone withdrawal, Hx (history) of falls, Dehydration, Rhabdomyolysis, DM, HTN, Hep C, and OA (Osteoarthritis). The resident was on a Methadone program. The consult also documented that the resident does not have a history of previous psychiatric treatment or hospitalization. There were no acute incidents reported, and the resident did not display episodes of aggressive behavior. The re-admission Orders from the Acute Hospital dated 11/06/2015 documented that resident was on Risperidone (Risperdal) 0.25 mg (milligrams) PO (by mouth) Q8H (every 8 hours) PRN (as needed) for signs and symptoms of delirium/agitation. Risperdal is an antipsychotic medication used to treat Schizophrenia, Bipolar Disorder, or irritability associated with autistic disorder. The FDA black box warning indicates that elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk for death. Risperdal is not approved for use in patients with dementia-related psychosis. The facility submitted a record of psychotropic medications received by the resident. The record documented the resident received Risperdal 0.25 mg BID, upon readmission, from 11/10/15 to 11/17/15. The Psychiatry Consult Reevaluation note dated 11/17/2015 documented that the resident was admitted with a history of chronic systolic heart failure, DM, HTN, HLD (Hyperlipidemia), Chronic Hep C, NPH (Normal Pressure Hydrocephalus), and Methadone dependence. The resident was recently hospitalized due to NPH and was s/p (status post) right ventriculoperitoneal shunt. The chart was reviewed, and updated information was obtained from the nursing staff. The staff reported the resident displayed episodes of aggressive behavior and irritability. The consult documented Recommendations: continue with Methadone; as discussed with RN staff to increase Risperdal to 0.5mg PO BID for his agitation and outburst. The facility record of psychotropic medications received by the resident documented the resident received Risperdal 0.5 mg BID from 11/17/15 to present. The Comprehensive Care Plan (CCP) on Psych meds updated 4/6/2019 documented: The resident uses psychotropic medications (Trazodone & Risperdal) r/t (related to) behavior management, disease process. The CCP documented that 3/23/19 - Remeron d/c (discontinued) due to weight gain and Trazodone started. The Comprehensive Care Plan on behavior dated 1/1/16 documented Alteration in Mood/Behavior secondary to mood disorder with the goal Resident will demonstrate use of effective coping strategies, and with the interventions: Determine cause of behavior; Administer medications as ordered by MD; Observe for side effect of medications; Redirect negative behavior; Maintain a calm environment; Psych consult as ordered by MD. There was no documented evidence in the medical record that the facility assessed the resident's behaviors and attempted to come up with person-centered non-pharmacological interventions besides redirection. There was no comprehensive care plan to address mood. The Psychiatric Consult Follow up notes dated 4/26/2016 documented that the psychiatrist reviewed the chart and obtained and update from the nursing staff. The resident's behavior was unchanged and manageable. There were no outbursts since the resident was transferred to a new unit. The resident was confused and cognitively impaired. There were no overt vegetative signs and symptoms of depression, and the resident was not suicidal or homicidal. There was no overt AVH (Audial/ Visual Hallucinations) or acute psychosis. The resident had diagnoses of Anxiety Disorder NOS and Dementia. The psychiatrist recommended continuing Remeron 30 mg. The facility record of psychotropic medications received by the resident documented the resident received Remeron 30 mg daily from 4/26/16 to 3/23/19. The psychiatry note dated 4/26/16 recommends to continue the Remeron insinuating the resident was on Remeron prior to 4/26/16. The Psychiatric Consult Follow up notes from 7/16/2016 to 3/23/2019 were reviewed. The notes documented that Chart reviewed and obtained update from nursing staff. No incident reported/ No acute changes reported. All notes recommended continuing the Risperidone 0.5 mg BID to avoid relapse of his psychosis. The consult dated 3/23/2019 recommended: Continue on Risperidone 0.5mg BID protocol to avoid relapse of his psychosis. Switch Remeron to Trazodone 100 mg Q HS (at bedtime) due to his increased weight recently. The facility record of psychotropic medications received by the resident documented the resident received Trazodone 50 mg HS from 3/23/19 to present. The Remeron was discontinued on 3/23/19. There was no documented evidence that the attending physician or psychiatrist evaluated the risks versus benefits for the resident to receive Risperdal despite the FDA black box warning. There was no documented evidence that a Gradual Dosage Reduction (GDR) was attempted for the Risperdal despite the fact that the staff reported to the psychiatrist that the resident had no changes in behavior. The resident was on Remeron for almost 3 years with no attempts at GDR despite no changes in symptoms or description of mood symptoms. The Psychotropic Weekly Nurses Notes from 4/27/2016 to 12/21/2016 were reviewed. The notes documented repeatedly that resident Maintained on Risperidone 0.5mg for unspecified psychosis. Ramelteon 8mg for insomnia, and Methadone 35mg for opioid dependence. Resident verbally abusive at times .Uses foul language in Spanish. Attempts to redirect met with some success. Continue to monitor. Psychotropic Weekly Nurses Note dated 12/28/2016 documented Maintained on Risperidone 0.5mg for unspecified psychosis. Ramelteon 8mg for insomnia, and Methadone 35mg for opioid dependence. As of 11/28 resident placed on Remeron 15mg for appetite/depression. Increase food intake noted. Resident verbally abusive at times, however for the past week resident has been more subdued. Uses foul language in Spanish. Attempts to redirect met with some success. Continue to monitor. Psychotropic Weekly Nurses Note reviewed between 1/23/2017 and 5/10/2017 documented repeatedly that resident Maintained on Risperidone 0.5mg for unspecified psychosis. Ramelteon 8mg for insomnia, and Methadone 35mg for opioid dependence. Remeron 15mg for appetite/depression. Increase food intake noted. Resident verbally abusive at times, however for the past week resident has been more subdued. Uses foul language in Spanish. Attempts to redirect met with some success. Continue to monitor There was no documentation in the medical record that described the details of the resident's behavior. There was no documented evidence that the staff attempted to look at the patterns or details regarding what triggered the yelling or cursing. There was no documented evidence in the behavior notes that the resident displayed symptoms of psychosis such as hallucinations or delusions. There was no documented evidence that the resident was evaluated for a Gradual Dosage Reduction (GDR) of Risperdal when there were no changes in the resident's behaviors from 4/27/16 to 5/10/17. The Dementia-related behaviors continued despite the Risperdal. The Psychotropic Weekly Nurses Notes from 5/24/2017 to 8/2/2017 documented repeatedly that resident Maintained on Risperidone 0.5mg for unspecified psychosis, Ramelteon 8mg for insomnia, and Methadone 35mg for opioid dependence. Remeron 15mg for appetite/depression. Resident remains stable. No behavioral issues noted. The Psychotropic Weekly Nurses Notes from 9/13/2017 to 3/20/2019 repeatedly documented resident's psychotropic medications (Trazodone 50mg PO for depression, Risperidone 0.5mg PO for psychosis), and documentation that No behavioral issues noted every week. There was no documented evidence that the resident was evaluated for a Gradual Dosage Reduction (GDR) of Risperdal when the resident displayed no behavioral symptoms from 5/24/17 to 3/20/19. The Medication Regimen Review (MRR) dated 11/20/2018 documented the following Consultant Pharmacist recommendations: Currently receiving Clonidine for treatment of hypertension. Also noted to be receiving antidepressant therapy. Please note that Clonidine has potential to induce/exacerbate depression. Please evaluate risk versus benefit of Clonidine and consider taper to discontinue Clonidine and monitor blood pressure, if appropriate. Physician response documented: Disagree, Cont. as ordered. There was no documented evidence in the medical record that the physician explained the clinical rationale for continuing the Clonidine depsite the Pharmacist's recommendations. The MRR dated 12/18/2018, Consultant Pharmacist recommendations documented: Currently receiving Ramelteon (Rozerem) at bedtime for Insomnia. Please evaluate current need, consider trial taper to PRN for 1 week then discontinue, if appropriate. Physician Response documented Disagree; Still c/o Insomnia. Continue meds. F/U Psych. The MRR dated 3/20/2019, Consultant Pharmacist recommendations documented Currently receiving Risperidone 0.5mg twice daily for psychosis. No recent behavior problems noted. Please evaluate current dosing, consider trial taper to 0.5mg daily dosing, or document inability to do so. Physician Response documented Disagree, Psych consult. There was no documented evidence in the medical record that the attending physician documented their clinical rationale for continuing the Risperdal despite the pharmacist's recommendations. The current Physician's order with revision date 4/12/2019 documented: Trazodone HCI tablet 50mg at bedtime for depressive disorder (started 4/1/19). Risperidone 0.5mg PO 2 times daily for Unspecified Psychosis. The Psychiatric Consult Follow up notes dated 4/19/2019 documented: Request by staff to follow up adjustment of medication. Chart reviewed and obtained update information from nursing staff. Discussed case with nursing supervisor of patient's dosages of Trazodone and he is currently on 50mg. No acute changes reported as he is at his current baseline. He will need to continue his current psychotropic medication protocol to avoid relapse. On 05/09/19 at 11:20 AM, an interview was conducted with the Certified Nursing Assistant (CNA #1). The CNA stated that she has been working in the facility for the past 17 years and has been having the resident's assignment since the 1st of May this year. Resident is taken out of bed by the night staff and given the breakfast by the day tour. The resident is taken back to bed after lunch if noted to be sleeping or not feeling comfortable. The CNA stated also that resident has not displayed any behavior problem since she has been taking care of the resident. On 05/09/19 at 11:47 AM, an interview was conducted with the Unit Manager/Registered Nurse (RN#1). RN stated that she has been working in the facility for about 2 months. The RN stated that as per record, resident was admitted with diagnoses of Major depressive disorder, unspecified dementia without behavior disturbance, unspecified psychosis not due to substance, unknown physiological condition, Opioid dependence, relentlessness and agitation. The resident is monitored and assessed daily to check if there is any behavior outburst or problem. If there are concerns, she checks the medication that may cause the problem, calls the doctor for what needs to be done, gives medication as per physician's order, and re-assesses for the effectiveness. The RN stated that relevant information regarding medication monitoring is usually discussed during the morning report where all departmental heads are in attendance. The physicians are notified of concerns via the communication book, or they may be called on phone if there is an emergency. Concerns are also documented in the daily shift report and in the progress notes. The RN stated that the resident has not been noted with any significant change in diet or behavior since her employment in the facility. The RN further stated that the resident is being followed up by the psychiatrist, but there has not been any gradual dose reduction. On 05/10/19 at 09:12 AM, the Psychiatrist (MD #1) was interviewed and stated that the resident was seen last on 4/19/19 for a follow-up evaluation. MD #1 further stated: when resident first came in, he was reported to be agitated, with periods of outbursts. The resident was monitored almost weekly for over a period of time. The behavior became such that psychotropic meds were needed because the resident was on opioids and taking Methadone for a long period of time. The MD stated that after observing the resident for some time and receiving continuous reports from the nursing staff that the resident continued to be agitated during care, it was decided to start him on low dose of Risperidone. When asked about evaluating for GDR, MD #1 stated that it is an ongoing process and is not up to him. He relies on nursing and the CNAs to obtain information. He stated he is just a consultant the comes weekly or as needed. He sees the resident, listens to staff, and reviews their recommendations. The Psych MD stated that he is not included in the interdisciplinary team (IDT) meetings. He does not receive any written report of irregularities identified by the pharmacist. MD #1 also stated: It is a judgement call not to change anything at this time, but if nursing tells him to make the change he will do so. MD stated that it is not a high dose, and since the nursing said, don't change anything, I'm afraid to change because I think if I change it there may be problem. On 05/10/19 at 12:21 PM, the Attending Physician (MD #2) was interviewed. MD #2 stated that he believes the resident was admitted with the behavior of psychosis diagnosed from the hospital. The resident was seen by the Psychiatrist who reported that resident has some depression and was started on the medication. MD #2 stated that other approaches attempted prior the use of psychotropic medication are redirection by the staff and whatever recreation is giving the residents with behavior. The attending MD stated that he thinks due to the behavior reported, the psychiatrist has to recommend medications so that the resident does not decompensate. MD #2 stated that as far as he can remember, the Psychiatrist said that if the medication is reduced, it might relapse the behavior. MD #2 further stated that he is included 24/7 in the IDT meetings for the resident. He received the report of irregularities identified during the MRR from pharmacy. The MD stated he responds to the recommendation noted by documenting he agrees or disagrees. On 05/13/19 at 02:06 PM, the Pharmacist was interviewed. The Pharmacist stated that MRR is done once a month. The Pharmacist stated that the documentation is checked for the need and effectiveness of the PRN medications and psychotropic medications. The labs and diagnosis in the physician's order is also reviewed. The Pharmacist stated any potential chance to adjust or discontinue the medication is recommended where necessary. The Pharmacist also stated that report of any irregularities is immediately made available to the facility's Director of Nursing and the Physician in writing via Physician Referrals /Findings. The Registered Nurse on duty is also notified when the irregularity requires immediate action. 415.15(b) (2) (iii) Based on observation, record reviews, and staff interviews during the Recertification Survey the facility did not ensure residents were from unnecessary antipsychotic medications. Specifically, residents with diagnoses of Dementia and no history of psychiatric diagnoses, were prescribed psychotropic drugs without an appropriate indication and adequate monitoring to treat dementia-related behaviors. In addition, there were no person-centered nonpharmacological interventions put into place to address the behaviors, and there was no attempt at gradual dosage reduction in the absence of behaviors. This was evident for 2 of 5 residents reviewed for Unnecessary Medications (Resident #77 and #198). The findings are: The facility Policy and Procedure related to Psychotropic Medications dated April 2016 documents that a Physician shall order psychoactive medications only to treat specific conditions. The policy further documents that the prescriber shall attempt gradual dose reductions, unless clinically contraindicated. The policy also documented that the clinical staff will observed, document and report to the attending physician information regarding the effectiveness of any interventions, including antipsychotic. FDA ALERT [6/16/2008]: FDA is notifying healthcare professionals that both conventional and atypical antipsychotics are associated with an increased risk of mortality in elderly patients treated for dementia related psychosis. In April 2005, FDA notified healthcare professionals that patients with dementia-related psychosis treated with atypical antipsychotic drugs are at an increased risk of death. Since issuing that notification, FDA has reviewed additional information that indicates the risk is also associated with conventional antipsychotics. Antipsychotics are not indicated for the treatment of dementia-related psychosis. 1) Resident #77 is a resident admitted on [DATE] with diagnosis that included Vascular Dementia with Behavior Disturbance (as per admission Record onset date 01/28/19) and Unspecified Psychosis (onset date 01/30/19) not due to a substance or known physiological condition. The admission Minimum Data Set (MDS) Assessment Reference Date (ARD) of 02/02/19, documented the resident had no serious mental illness or intellectual disability, clear speech, was rarely understood, and rarely understands cognitive status severely impaired. No displayed behaviors of physical / verbal aggression nor rejection of care. The resident displayed no behaviors of physical / verbal aggression or rejection of care, and no psychosis. The MDS documented no behavioral symptoms that would impact the resident or others. The resident required extensive assistance for activities of daily living needs (ADL's) and a wheel chair for mobility. The resident was frequently incontinent of bladder and bowel. The resident's diagnoses included Non -Alzheimer Dementia and Sequelae of Cerebral Infarction. The MDS further documented that the resident received psychotropic's (AP) medications on a routine basis with no gradual dose reduction (GDR) due to being clinically contraindicated by physician. On 05/09/19 at 9:35 - 10:00 AM the resident was observed sitting in his wheelchair, in the dining room area. The resident was calm, chin to chest, eyes closed, easily aroused. The resident was encouraged by staff to use crayon for coloring but was not interested. The resident was stood up from her wheelchair and was re-directed to sit. The resident remained standing for 2 minutes before sitting back down. The resident was not participating in the ongoing activities. The resident stood up from her wheelchair again for several seconds before sitting back down. On 05/09/19 from 11:27 AM to 11: 35 AM the resident was observed in dining room with their head down chin to chest and eyes closed. The resident was easily aroused when her name was called by the State Agent (SA) who sat beside her. The resident was not interviewable with slurred, slow speech. The resident remained seated, calm, and quiet during this time. No attempts were made to stand up from her wheel chair. Review of the Comprehensive Care Plan (CCP) for Antipsychotics Medication, dated 03/05/19 documented the use of seroquel,depokote, trazodone related to behavior management, disease process (psychosis). Further documentation on 03/05/19 for a gradual dose reduction (GDR) of zypreza which was discontinued, and seroquel was started. Interventions included medical doctor to consider dosage reduction when clinically appropriate; monitor side effects and adverse reaction. The Hospital and Community and Community Patient Review Instrument (PRI) dated 01/23/19 documented the resident has no known history of verbal / physical aggression. The resident had no known history of disruptive, infantile or socially inappropriate behaviors and no hallucinations. The Hospital Discharge Medication Information, dated 01/28/19 documented that Resident #77 received Zyprexa 6.25 milligrams (mg) at night by mouth, in addition to receiving Zyprexa 3.75 mg daily in the afternoon, and Zyprexa 2.5 mg in the morning for Vascular Dementia without behavioral disturbance. The resident received Divalproex Sodium (Depakote) for Vascular Dementia without behavior disturbance. Lacosamide (Vimpat)100 mg twice daily for Vascular Dementia with behavior with disturbance, unspecified dementia. Zyprexa is an antipsychotic medication used to treat schizophrenia and acute manic episodes associated with bipolar disorder. The Food and Drug Administration (FDA) black box warning documents antipsychotics can cause an increased risk of death in elderly people who are confused, have memory loss, and have lost touch with reality (dementia-related psychosis). There is an increased risk of stroke or mini-strokes called Transient Ischemic Attacks (TIAs) in elderly people with dementia-related psychosis. Antipsychotics are not approved for use in these patients. Depakote is a drug used to treat manic episodes associated with bipolar, epilepsy and migraines. Vimpat is a controlled substance used for seizures. Review of current list of medications for May, 2019 documented: On 01/29/19 the resident was started on Lacosamide 100 mg twice a day for Vascular Dementia without behavior disturbance. On 03/06/19 the resident was started on Trazadone 50 mg twice a day for Depressive Disorder. On 02/20/19 was started on Valproic Sodium Solution 250 mg /5 milliter (ml) daily for unspecified convulsions. On 03/06/19, Zypreza was stopped, and the resident was started on Seroquel 100 mg three times a day (morning, evening, night) for unspecified psychosis not due to a substance or known physiological condition. Seroquel is an antipsychotic medication used to treat Schizophrenia and Bipolar Disorder. Seroquel is not approved for use in residents with dementia-related psychosis. Review of the Behavior Notes: 02/07/19; 02/12/19; 02/27/19; 03/04/19; 03/20/19; 03/21/19 and 04/25/19 documented the following: 02/07/19: Resident continues to get out of bed despite education. Not easily redirected. combative towards staff. Close observation. 02/12/19: Resident with confusion at baseline. Out of bed (oob) in day room for status post (s/p) fall continues to display agitation /restless behavior, not easily redirected, behavior not altered by medication. Resident constantly tries to get up from chair to ambulate independently despite being ambulated, toileted and offered snacks and hydration. Emotional support/constant re-direction offered to no avail resident often requires 1:1 supervision for safety reasons. 02/27/19: Res. continues to try to get up from wheelchair (w/c), not easily re-directed. 03/04/19: Resident continues to get out of w/c and attempted to ambulate with an unsteady gait, not easily re-directed. 03/20/19: Resident continues to display behaviors, continues to get up from w/c, not easily re-directed, safety maintained. 03/21/19: Continues to get out of w/c, difficult to re-direct. 04/25/19: Resident combative /abusive towards others. Review of the Individual Resident Participation Profile, dated 01/2019 for the months of January thru May 2019 found that the resident was identified exhibiting a behavior on just one (1) day in the month of April. Specifically on April, 8, 2019 this document was marked with a letter B indicating Behavior. Review of psychiatric notes dated: 02/02/19; 03/05/19; 03/23/19; 03/29/19 and 05/04/19 documented the following: 02/02/19: 76 y/o female here for psychiatric evaluation of her mental status and management. Has a history of Vascular Dementia with behavior issues and agitation. On Zyprexa 5 miligram (mg) by mouth twice a day and 5 mg at bedtime for psychosis. Patient not able to provide history. There are no acute incidents reported recently but has not displayed any episodes of aggressive behavior nor irritability. Mood: labile with agitation, Affect: constricted.no paranoia, no suicidal ideation, no sign symptom of depression. Impression: psychosis NOS Recommendation: Treat underlying medical etiology adjust her Zyprexa to 5 mg po bid and 5 mg hs. monitor for side effects (s/e). 03/05/19: psychiatric visit documented that on 02/23/19 the medication was adjusted due to increasing agitation. Obtained updated information from nursing staff. Recently staff had expressed concern about her agitation and not sleeping. Patient has a history of behavioral issues and agitation and was prescribed Zyprexa for her psychosis. Recommend: discontinue Zyprexa and switch to Seroquel 100 mg by mouth twice a day and at bedtime for agitation and psychosis. Recommend: discontinue Zyprexa and switch to Seroquel 100 mg po bid and 100 mg po hs, for agitation and psychosis. Continue Depakene liquid 250 mg daily for mood swing. Continue Trazodone 50 mg twice a day. 03/09/19 Psychiatric follow up visit for agitation and erratic behavior. Chart reviewed and obtained update information from nursing staff. patient continues with Seroquel due to insomnia and out of control behavior. No adverse effects reported, more calmer and sleeping has improved. However, patient had been reported of escalation and increasing psychosis. No SI; no s/s depression. Recommend: Seroquel 100 mg po bid and 100 mg hs for agitation and psychosis. continue Depakene 250 mg daily for mood swings. Continue Trazodone 50 mg po twice a day. 03/23/19: Psychiatric follow up visit for agitation and erratic behavior. No paranoia, No depression. Continue medications and monitor. 03/29/19: Psychiatric follow up visit for agitation and erratic behavior. Continue with Seroquel due to insomnia and out of control behavior. Patient recently suffered a swollen hand. No acute findings. Patient will continue her medications to avoid relapse. 05/04/19 Psychiatric follow up visit documented increasing agitation and erratic behavior. Psychotropic Weekly Nurses Note from 05/01/19, documented that the resident often tries to get up from w/c, re-directed with some success. Continue medications to avoid relapse. Review of the Primary Physician monthly notes dated 03/31/19 - 05/06/19 repeated documented the following: Dementia / psychosis; Continue with Seroquel; Continue with Trazodone. There is no documented evidence that her medications are being monitored for effectiveness. There is no documented evidence regarding what behaviors are being treated by the Seroquel, Depakene, and Lacosamide. There is no documentation by the physician regarding monitoring the resident's depression symptoms and evaluating whether the Trazodone is effective. On 05/09/19 at 10:32 AM the assigned Certified Nurse Assistant (CNA) who stated that the resident is assigned to her for the whole month of May, 2019. The CNA stated that the resident is a nice person, does not give her any problems. She stated that the only thing about the resident is that she gets up from her chair a lot and is on fall precautions, and has to be careful with her. The CNA further stated that the resident is confused, is not a fighter and is not showing signs of aggression. On 05/09/19 at 10:20 AM The unit Licensed Practical Nurse (LPN) was interviewed and she stated that she has not notices any behaviors except to say that the resident does get up a lot from her wheel chair and we just re-direct her back down. It is not always easy to re-direct her,as she remains standing and wants to try to walk. Someone is always around to keep her safe. On 05/09/19 at 10:36 AM the Registered Nurse Manager (RNM) was interviewed and she stated the resident use to be combative at times during toileting, sundowning during the evening. The RNM stated that the resident's behavior has changed since February of this year and is now much calmer. On 05/09/19 at 04:28 PM the primary physcian was interviewed. He stated that he is not a psychiatrist and leaves that part of the resident's care to them, as he is not a specialist in this area. He further stared that the resident does get up from her chair, but she does not have psychosis as far as he knows. He further stated that he reviews the hospital records and is aware that she entered the facility on psychotropic medications, which is why he referred the resident to the psychiatrist. He stated that the resident is not a danger to herself or others. He stated that she does get agitated and gets up often from her chair and it could be a danger to other residents and herself, although not yet. On 05/10/19 at 08:51 AM, the psychiatrist was interviewed and he stated that he speaks to staff to get updates on his residents. He stated that the staff had reported to him that the resident is difficult to re-direct, and they asked him to help them because she was out of control and becomes aggressive and combative towards staff. The Psychiatrist stated he has not seen the resident agitated during his visits. He stated that he sees that she is calmer now, and they have a few months to determine if a reduction is warranted.