**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the most recent recertification survey, the facility did not ensure that appropriate behavioral care was provided to address the ongoing problem of depression for 1 of 5 residents (Resident #33) reviewed for the use of psychoactive medications. Specifically, 1) the resident's initial comprehensive assessment did not address the resident's behavioral care history which necessitated the need for the treatment of depression with the use of an antipsychotic medication and two antidepressant medications prior to and upon admission to the facility; and 2) the ongoing assessments of depression by the psychiatrist were addressed by increasing the dose of an antidepressant with no consideration for the provision of supportive counseling for a period of seven months (from January 2018 to July 2018). The findings are: Resident #33, a [AGE] year-old male with the diagnoses of Major Depression (a mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life) was admitted to the facility on [DATE]. The resident's admission physician's orders included an antipsychotic medication, Abilify, and two antidepressant medications, Paxil and Zoloft, for the treatment of major depression. The admission Minimum Data Set (MDS, an assessment instrument) revealed that the resident had no cognitive impairment and was receiving psychoactive medications (antidepressant and antipsychotic) during the assessment period. The Care Area Assessment (CAA, an extension of the MDS designed to provide in depth information about the root cause for the triggered care area) was reviewed. This CAA did not refer to any other source that could provide in depth information about the use of the above mentioned medications or the resident's behavioral/psychiatric history. The CAA noted that the Medication Administration Record (MAR) should be reviewed for further information. The MAR was reviewed and provided no historical information regarding the resident's behavioral/psychiatric history requiring the use of the medications. Additionally there was no history regarding the use of these medications prior to admission to the facility. This infomation was necessary to develop an approriate plan of care to address the resdient's behavioral care needs. The resident's plan of care addressing depression was initiated on 10/21/17. The goal was for the resident to exhibit indicators of depression, anxiety and sad mood less than daily. The interventions included to achieve this goal were to 1) administer the medications as ordered and monitor for effectiveness and side effects, 2) psy (psychiatric) consult as indicated and 3) monitor for signs and symptoms of depression. On 12/19/17 an initial psychiatric evaluation was completed for the resident. This evaluation noted that the facility's nursing staff reported that the resident's mood demonstrated lack of reaction to pleasant events and that he showed indifference. The psychiatrist's assessment was that the resident's mood was a bit better. The diagnoses of depression NOS (not otherwise specified) was made and a recommendation was made to increase Zoloft from 50 mg to 75 mg daily. This evaluation made no reference to the root cause(s) for the resident's depression prior to admission and since admission to the facility. It also included no recommendations to address the need for supportive counseling or other non-pharmacological interventions to help the resident cope and minimize dependence on psychoative medications . On 12/31/17 a physician's order was obtained to increase Zoloft to 75 mg. On 1/29/18 the resident was again evaluated by the psychiatrist. This evaluation showed that a recommendation was made for Zoloft to be increased due to ongoing problems with depression. There was no reference made regarding supportive counseling. On 2/6/18 the physician's orders included the increase of Zoloft from 75 mg to 100 mg, which remained in effect at the time of this review. A review of the resident's medical record (social workers notes and the evaluation of the resident's plan of care) did not include evidence that the need for supportive counseling was addressed by the care planning team memebers between 12/31/17 and 8/8/18 prior to increasing Zoloft. On 8/9/18 the resident was evaluated by a psychologist. The psychological evaluation noted feelings of depression, trouble sleeping, poor appetite, feeling bad about self and thoughts that would be better off dead. This evaluation also noted that the resident was depressed about not being able to walk and the recent loss of a friend. Ongoing psychological counseling was initiated after this evaluation. Subsequent to the initiation of counseling, the annual MDS dated [DATE] and the most recent quarterly MDS dated [DATE] showed that the resident had no cognitive impairment and no mood problems. The annual MDS also showed that the resident expressed preferences to be engaged in multiple activities. On 6/5/19 the resident was interviewed. He stated that he gets sad at times about not being at home. The social worker assigned to the care of the resident from the time of admission to the time of the psychological evaluation (8/9/18) was no longer employed by the facility. The current social worker was interviewed on 6/7/19 in the afternoon. She was asked to comment on the lack of supportive counseling for the resident and reliance solely on the use of medication to address his problem of depression. After reviewing the resident's record she offered no rationale or explanation why the need for supportive counseling was not addressed prior to 8/9/18. 415.12(f)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review conducted during the recertification survey and an abbreviated survey (#NY00230838), the facility did not provide pharmaceutical services to assure accurate acquiring, receiving and administering of all medications to meet the needs of each resident. This was evident for 1 resident (Resident # 13) reviewed for administration of medications. Specifically, 1) the nursing staff did not ensure that a cholesterol lowering medication, Lipitor, documented on the Medication Administration Record as being administered was specifically ordered for the resident, and 2) that this medication was refilled when indicated. The findings are: The facility Policy and Procedure (P&P) for Ordering and Receiving Medications from the dispensing Pharmacy documented the following; a.)Reorder medication (three to four) days in advance of need to assure an adequate supply is on hand. b.) The refill order is electronically transmitted to the pharmacy. Resident #13 is an [AGE] year-old female admitted to the facility on [DATE] with the diagnoses of Dementia, Hyperlipidemia, Congestive Heart Failure, Alzheimer's disease, and Type 2 Diabetes Mellitus. A physician's order dated 10/3/2018 included a new order for Lipitor (a cholesterol lowering medication) 10 mg to be given by mouth at bedtime. A blister pack (a type of packaging that protects individual doses of medication) designed for 30 Lipitor tablets and labeled with the resident's name was reviewed on 6/4/19. This review showed that the blister pack was dispensed by the pharmacy to the facility on [DATE] to be refilled after 10/28/2018. (This date signified the date the facility was to alert the pharmacy of the next refill.). Review of the Medication Administration Record (MAR) for the month of October 2018 showed that the administration of Lipitor started on 10/4/2018 and that the medication was administered for the entire month except on 10/5/2018. According to a nurse's note on 10/5/18 the medication was not administered due to medication pending delivery. Additionally, another nursing noted 10/23/18 showed that the resident refused to take the medication on that date. In November 2018 the MAR showed that the medication was administered for the entire month except on 11/2/2018, 11/3/2018 and 11/20/2018. The MAR showed that on these dates the resident refused the medication. In December 2018 the MAR showed that the medication was administered from 12/1/2018 to 12/7/2018 and the medication was discontinued on 12/8/2018. According to the MAR for the period of 10/4/18 to 12/7/18 Lipitor was administered to the resident 60 times and refused 4 times. Since the blister pack received by the facility on 10/4/18 contained only 30 tablets, the Director of Nursing (DON) was asked on 6/6/19 to show evidence that additional Lipitor was obtained from the pharmacy to account for a total of 64 tablets. The DON failed to produce any such evidence. Multiple nursing staff who administered Lipitor to the resident during the period of 10/4/18 to 12/7/18 (as evidenced by their initials on the MAR) and the vendor pharmacist were interviewed to account for the accurate acquiring, receiving, and administration of the resident's medication. The responses are as follows: - On 6/4/2019 3:40 PM LPN #1 stated that she administered Lipitor whenever she was assigned to the resident. She said LPN #2 informed her that the Lipitor blister pack had too many tablets left on it. She said the resident refused her medications a few times. But she had no documentation to reflect it. - On 6/4/2019 at 4:15 PM LPN #2 stated that on 10/5/2018 she documented that Lipitor delivery was pending and did not realized that it was actually delivered on 10/4/2018 and placed in a different cart. She also stated that she was the person to administer the first tablet from the blister pack on 10/9/2018 (despite documentation on the MAR showing that the resident was administered the medication 4 times from 10/4/18 to 10/8/18). She further stated that sometime after 10/9/2018 she realized that the blister pack was not used and brought it to the attention of the charge nurse and DON who assured her that she would take care of it. However, nothing was done about it. (This DON was no longer employed by the facility.) - On 6/6/2019 at 12:55 PM LPN #3 stated via telephone that when she was assigned to the resident the blister pack was supposed to have been completed but it was not, so she reported it to the DON who requested blood work to check the resident's cholesterol level. - On 6/6/2019 at 1:40 PM the vendor pharmacist stated via telephone that Lipitor 30 day blister pack was filled and delivered to the facility on [DATE] and another 30 day blister pack was filled and sent to the facility on [DATE] following a call from the facility by a staff member requesting a refill. She further stated that the order was discontinued 12/8/2018. - On 6/6/2019 at 2:40 PM LPN #4 (who administered the medication on 10/4/18 and is no longer working at the facility) stated via telephone that he did not remember much from the incident as it occurred a long time ago. But he remembered administering the medication the days he was assigned to give them to the resident. He further stated if there was no medication in house the nurses would borrow from another resident receiving the same medication. When asked if he had borrowed medications, LPN #4 did not acknowledge that he administered borrowed medication to the resident. - On 6/7/2019 at 9:30 AM LPN #5 stated via telephone that she was on orientation during the time of the incident and she resigned her position after the two weeks of suspension of all 3-11 shift LPNs. She further stated that she administered the medication as per physician orders and documented when the resident refused to take the medicine. (The surveyor verified LPN #5's documentation.) - All the above nurses, excluding LPN #4, denied that they borrowed medications. On 6/7/19 in the afternoon the DON was asked to review the facility's records to determine if anyone had signed that they received the second blister pack reported by the vendor pharmacist to have been delivered on 11/22/18. After conducting a search, the DON reported that no documented evidence was found to show that the second blister pack was requested and/or received by the facility. Documentation provided for the receipts of medications for 10/4/18 showed no evidence that the blister pack dispensed on 10/4/18 for the resident was received by the facility on that date. In summary, the MAR showed that 60 Lipitor tablets were administered and 4 refused, totaling 64 tablets for which the facility should account. The evidence provided above did not demonstrate that the facility ensured that the each tablet of Lipitor recorded on the MAR as being administered were specifically dispensed by the pharmacy for this resident. Also, the facility did not ensure that the system in place to account for the receipt of medications was implemented. 415.18(e)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during the recertification survey, the facility was not in compliance with Section 915 of the 2015 edition of the International Fire Code as adopted by New York State, which requires the installation of carbon monoxide detectors in buildings with fuel-fired appliances. Carbon monoxide detectors were not installed in mechanical rooms containing fuel fired equipment (laundry room, boiler room, generator room, etc) or in previously approved locations. The findings are: The life safety tour of the facility was conducted during the recertification survey on 6/7/19 between 9:00 AM - 1:00 PM. At that time it was observed that carbon monoxide monitors were not installed in areas in which fuel fired (natural gas and diesel) equipment was located. These areas included the generator room located off of the stairwell adjacent to resident room [ROOM NUMBER], the hospital kitchen, the boiler room, and laundry room. In an interview at 9:15 AM on 6/7/19, the Director of Facilities Management stated that there is no fuel fired equipment located on the nursing home unit. He also stated that the hospital is working with local code enforcement officials (Fire Marshal, Code Compliance Officer, Building Inspector) to install carbon monoxide detectors as part of a hospital renovation project that was underway. 483.70 (b)