**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the Standard Survey completed on 11/20/23, the facility did not allow residents to choose activities, schedules, and health care consistent with his or her interests, assessments, and plan of care for two (Residents #8 and #26) of 2 residents reviewed. Specifically, residents were not provided a choice to take a tub bath because there was not a functioning tub bath in the facility. The findings are: The facility's policy and procedure (P&P) titled Resident Preference and Care Planning and Care Area Assessments - C.A.A. dated 10/3/17 documented all residents will have an interdisciplinary care plan developed that shall include measurable goals and timetables to meet each individual's medical, physical, mental, and psychosocial needs as well as review and implement resident wishes/choices and goals. The facility's P&P titled Comprehensive Care Plan dated 12/19/22 documented the resident has the right to participate in the development and implementation of his/her person-centered plan of care including but not limited to; the right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency and duration of care and any other factors related to the effectiveness of the plan of care. The planning process must incorporate the resident's personal and cultural preferences in developing goals of care. The facility's P&P titled Bathing - Tub Bath/Shower dated 4/17/13 documented all residents will receive a tub bath or shower at least weekly, more often if indicated or requested. Residents will be asked their preference upon admission, and this will be documented. The procedure documented to fill tub 2/3/full of lukewarm water, adjust body strap, assist resident to swing legs into tub turning chair at the same time or slide chair back into tub depending on which tub is being used. 1. Resident #8 had diagnoses that included major depressive disorder (MDD), bipolar disorder, and hypertension. The Minimum Data Set (MDS - a resident assessment tool) dated 10/12/23 documented Resident #8 was cognitively intact, was understood, and understands. The MDS dated [DATE] documented it was very important to resident to choose between a tub bath, shower, bed bath or sponge bath. Resident #8's Visual/Bedside [NAME] Report (guide used by staff to provide care) undated, identified as current by Regional Quality Assurance Registered Nurse, documented Bathing - Showers Tuesday Days and Friday Days. Resident #8's comprehensive care plan dated 5/8/20 documented, allow resident to make decisions concerning own care as much as possible. During an interview on 11/14/23 at 9:47 AM, Resident #8 stated they never had choice regarding a tub bath verses a shower. Resident #8 stated they had asked for a tub bath about a year ago, but the staff said the bathtub did not work. Resident #8 stated they would prefer a tub bath over a shower. 2. Resident #26 has diagnoses that include MDD, peripheral vascular disease (PVD, decreased circulation of the lower extremities), and generalized anxiety disorder. The MDS dated [DATE] documented Resident #26 was cognitively intact, was understood, and understand. The MDS documented that it was very important to resident to choose between a tub bath, shower, bed bath or sponge bath. Resident 26's Visual/Bedside [NAME] Report undated, identified as current by Regional Quality Assurance Registered Nurse, documented Bathing - Bathing/Showering: Provide sponge bath when a full bath or shower cannot be tolerated. Shower: Thursday Eve. Resident 26's comprehensive care plan dated 8/1/23 documented, allow resident to make decisions concerning own care as much as possible. During an interview on 11/13/23 at 1:11 PM, Resident #26 stated they have never been asked if they preferred a tub bath verses a shower because they believed the facility did not have a working tub. Resident #26 stated they would prefer a tub bath over a shower if the facility had a tub but understands from staff the tub has been broken for a long time. During an observation on 11/14/23 at 9:55 AM the 2nd floor tub room was blocked with the linen cart, upon moving the linen cart the tub was noted to have crusty white/ brown debris and rust around the drain and spout of the tub. The faucets would not turn and tub chair that maneuvers up and down to place a resident into the tub did not engage and move. During an interview on 11/16/23 at 2:00 PM, Certified Nursing Assistant (CNA) #5 stated they didn't know if the tub worked, believe residents were asked their bathing preferences upon admission. During an observation at this time CNA #5 had difficulty turning on the tub water faucet; stated the water wasn't getting warm and it appeared the tub was not working. The showering hose was clogged, and the chair lift did not function. CNA #5 stated there was not a tub on the 3rd floor and that this was the only tub in the facility. CNA #5 stated the facility was not able to provide a tub bath to residents upon their preference because the facility did not have a working tub. During an interview on 11/16/23 at 2:09 PM, Licensed Practical Nurse (LPN) #6 stated they do not know; if the facility tub was in working order, who was responsible to ask the resident's their bathing preference, and when the last time the tub was in working order. LPN # 6 stated they believed it was important for residents to choose their bathing preference, believed it was a resident's right to preferences and the facility should have a working tub. During an interview on 11/16/23 at 2:14 PM, LPN #4 Unit Manager (UM) stated residents were offered a bathing preference of showering or bed bath but not a tub bath because the facility doesn't have a working tub. During an interview on 11/17/23 at 9:50 AM, Activities Department Director #1 stated they completed the MDS section of Preferences for Routine and Activities on the annual MDS as it prompts the question: How important is it to you to choose between a tub bath, shower, bed bath, or sponge bath?. The Activities Department Director #1 stated they did not ask residents their bathing preferences, does not have any evidence the residents were asked their specific bathing preferences. They would not offer a tub bath because the facility doesn't have a working tub. The Activities Department Director stated the facility doesn't have a process to determine the resident's bathing preference. During an interview on 11/17/23 at 9:55 AM, Maintenance Department Director #1 stated the 3rd floor tub was removed from the facility approximately 2 years ago because it was broken and was unable to be repaired. The 2nd floor tub had been broken for at least 2 years and was unable to be repaired because there were no available parts as the tub was outdated. Maintenance Department Director #1 stated Administration was aware there was not a working tub in the facility. During an interview on 11/17/23 at 10:01 AM, the Corporate Quality Assurance Registered Nurse (RN)/ Acting Director of Nursing stated were not aware the facility didn't have a working tub and did not know if staff had asked residents their preference for bathing. (Tub versus shower). During an interview on 11/17/23 at 10:18 AM, Regional [NAME] President of Operations stated they were the Administrator for the facility last year and knew the facility did not have a working tub but had not replaced it because they didn't have any residents that requested a tub bath. The Regional [NAME] President stated they did not know if staff asked residents their bathing preferences of tub bath/shower/bed bath and stated did not have evidence residents were provided a choice. The Regional [NAME] President of Operations stated it was important for residents to have a choice and the facility should have determined if a resident wanted a tub bath. Additionally, they stated at this time the facility did not have the means to provide a tub bath upon a resident's request. 10 NYCRR 415.5(b)(3)

Based on interviews and record reviews conducted during a Recertification Survey completed 11/20/23, the facility did not ensure they consulted with the resident's physician when medications were not administered as ordered for one (Resident #4) of two residents reviewed for notification. Specifically, the physician was not notified when the resident's insulin was being administered late multiple days on the evening shift. The findings are: The policy and procedure Medication Administration - General dated 10/29/12 documented all medications must be given at the right time and signed for after administration on the Medication Administration Record (MAR). 1.Resident #4 had diagnoses including diabetes mellitus type II, transient cerebral ischemic attack (TIA, temporary impairment of blood flow to the brain), and dementia. The Minimum Data Set (MDS- a resident assessment tool) dated 8/14/23, documented Resident #4 was cognitively intact and received insulin injections. Resident #4's physician orders dated 9/26/23 documented Levemir (insulin) FlexPen inject 28 units subcutaneous (SQ) in the morning and inject 20 units SQ at bedtime. Review of Resident #4's Medication Administration Records (MARs) for September 2023 - November 2023 documented Levemir was to be administered at 9 AM and 9 PM. Review of the Medication Admin Audit Report revealed that Levemir 20 units SQ was given after 10 PM on 19 occasions in September 2023, 16 occasions in October 2023 and 9 occasions in November 2023. Seventeen of those forty-four were administered after 11 PM. Review of progress notes from September 2023 to November 2023 revealed the physician, had not been notified of medications administered out of the 1-hour allotted timeframe. During an interview on 11/13/23 at 9:57 AM, Resident #4 stated sometimes their insulin was given very late, not until almost midnight, they do not like to be woken up so late, and that it upsets them. During an interview on 11/17/23 at 11:29 AM, Licensed Practical Nurse (LPN) #1 stated medications can be given an hour before and up to an hour after their scheduled time listed on the MAR. LPN #1 stated they have been late with administering mediations to residents, and they have never called the physician about medications being administered late. LPN #4 stated the physician should have been notified. During an interview on 11/17/23 at 12:18 PM, LPN #2 stated nurses can give medications one hour before and one hour after the scheduled timeframe. If given out of the timeframe, then the supervisor should be called so that the physician could be notified. LPN #2 was never informed of medications being given late and stated if Levemir was given late it could mess with the blood sugar reading. During an interview on 11/17/23 at 2:22 PM, the Medical Director stated if there was a problem in the medication timing, then the physicians should be notified. If receiving Levemir late, there could be an issue because Levemir was an insulin and could cause blood glucose to go low and could make it look like the resident's blood glucose was managed better than it was. During an interview on 11/20/23 at 8:05 AM, the Acting Director of Nursing (DON) stated nurses can give medications an hour before and after their scheduled time. If out of the timeframe they should be notifying the provider and ideally it would be the Nursing Supervisor on that shift notifying the physician. If the physician was notified there should be a progress note written in the resident's electronic health record. The DON would expect nurses to document medications that were given right after administering them and would expect nurses to notify supervisors if meds are late so the providers could be called and orders received. 10 NYCRR 415.3(f)(2)(ii)(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed 11/20/23, the facility did not ensure that each resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain grooming and personal hygiene for one (Resident #72) of three residents reviewed for ADLs. Specifically, Resident #72 was observed with long dirty (dark debris) fingernails, had unkempt facial hair, and was not shaved or offered to be shaved during morning care. The finding is: The policy and procedure (P&P) titled Shaving Residents - Male and Female dated 11/14/11 documented it shall be the policy of this facility that residents shall have facial hair removed on a regular basis and/or per their request. The P&P titled Nail Care - Routine and Diabetic dated 2/14/13 documented it shall be the policy of this facility that resident nails will be kept neat, clean, and smooth to assist in injury prevention and to maintain proper hygiene. The P&P titled AM (morning) and PM (night) Care dated 7/23/13 documented every resident shall be provided with AM and PM care daily to provide cleanliness and comfort for the resident, to monitor skin, and to prevent odor. 1. Resident #72 had diagnoses that included depression, cognitive impairment (difficulty remembering, and making decisions that affect everyday life), and weakness. The Minimum Data Set (MDS- a resident assessment tool) dated 10/24/23 documented Resident #72 had severe cognitive impairment was always understood, and always understands. The MDS documented Resident #72 required moderate assistance for personal hygiene. The comprehensive care plan (CCP) dated 8/14/23 documented Resident #72 had an ADL self-care performance deficit related to activity intolerance and confusion. Interventions included to check nail length, trim and clean on bath day and as necessary. Additionally, the CCP documented Resident #72 was at risk for decline in ADLs and mobility due to muscle weakness. Interventions included extensive assist of one staff member for grooming. The [NAME] (a guide used by staff to provide care) dated 11/16/23 documented Resident #72 required extensive assist of one staff member for grooming. Review of the Treatment Administration Record (TAR) dated 11/1/23-11/30/23 documented Resident #72's skin and nails were checked on 11/1/23, 11/8/23 and 11/15/23. Review of the nursing progress notes from 10/15/23 through 11/15/23 revealed there was no documentation regarding refusal of nail care or shaving. During an observation and interview on 11/14/23 at 9:34 AM, Resident #72 had long nails on both hands with dark debris under the nails. Resident #72 had unkempt facial hair. Resident #72 stated they did not like the facial hair, and they wanted someone to shave it. During an interview on 11/14/23 at 10:21 AM, Resident #72's family member stated Resident #72 never had facial hair and in the past, they would remove their own facial hair daily. The family member also stated Resident #72 always kept their fingernails trimmed short. During an observation on 11/15/23 at 3:55 PM, Resident #72 had unkempt facial hair and long nails with debris underneath them. During an observation on 11/16/23 at 9:41 AM, Certified Nursing Assistant (CNA) #3 and Licensed Practical Nurse (LPN) #2 assisted Resident #72 with morning care. CNA #3 did not attempt or offer to assist Resident #72 with shaving and nail care, before, during or after the completion of morning care. During an interview on 11/16/23 at 9:55 AM, CNA #3 stated they noticed Resident #72's long nails and facial hair. CNA #3 stated they did not shave or do nail care for Resident #72 because they always refused. CNA #3 stated they did not know what was under Resident #72's nails. CNA #3 stated they would approach Resident #72 later about their facial hair and nails. During an interview on 11/16/23 at 10:08 AM, LPN #5 stated Resident #72 usually refused care but could be persuaded when staff talked to them. LPN #5 stated Resident #72 definitely needed some hand care. During a telephone interview on 11/16/23 at 3:24 PM, CNA #4 stated Resident #72 would refuse care unless they were approached using their preferred nickname. CNA #4 stated when staff used Resident #72's preferred nickname, they would be like jelly in your hands. CNA #4 stated, that meant Resident #72 would allow all care including nail care and shaving when staff used the right approach. During an interview on 11/16/23 at 3:54 PM, LPN #2 stated shaving and nail care were part of morning care. LPN #2 stated they noticed Resident #72 had long nails that were dirty. LPN #2 stated CNA #3 should have at least offered to shave Resident #72 and should have attempted to clean Resident #72's fingernails because it was unknown what was underneath them. LPN #2 stated just because a resident might be known to refuse care, it did not mean the staff should stop attempting to complete care. LPN #2 stated each day was a new day, and residents should at least be approached daily, for shaving and nail care. During an interview on 11/17/23 at 9:20 AM, Registered Nurse (RN) #1 stated they expected staff to shave and complete nail care for residents during morning care. RN #1 stated they expected staff to cut and clean long nails when they noticed residents had long nails, not only on shower days. RN #1 stated staff should have noticed if residents needed to be shaved or nail care done when they were doing care. RN #1 stated the LPNs oversaw the CNAs so they should have made sure the CNAs were completing care every day. During an interview on 11/17/23 at 11:13 AM, the Acting Director of Nursing (DON) stated during morning care, the staff should have at least offered to shave residents unless the resident was care planned to grow a beard. The Acting DON stated, the staff should have looked at the fingernails during care and address them in any way; if the nails needed to be cleaned, trimmed, or filed. The Acting DON stated it was standard to check the fingernails on shower days, but CNAs should always check during daily care if nail care was needed. NY10CRR 415.12 (a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review completed during the Standard survey completed on 1/28/22, the facility did not ensure that all alleged violations of abuse including injuries of unknown origin were reported immediately, but not later than 2 hours after the allegation is made to the State Survey Agency or not later than 24 hours if the event that cause the allegation do not involve abuse and do not result in serious bodily injury for three (Resident #4, #34, #226) of seven residents reviewed for alleged abuse. Specifically, a bruise of unknown origin (Resident #226) and an allegation of resident-to-resident abuse (Resident #4 and #34) were not reported to the New York State Department of Health (NYSDOH) within the two-hour timeframe as required. The findings are: The facility policy and procedure (P&P) titled Resident Abuse Prohibition revised 3/1/18 documented to prohibit resident abuse. Upon the receipt of a complaint, if there is reasonable case to believe abuse has occurred, Administration will be immediately notified, and the Department of Health will be notified as soon as possible, but not to exceed 24 hours. The P&P defined reasonable cause to include statements that physical abuse, mistreatment, or neglect occurred. An investigation shall be initiated immediately after administrative notification, staff will be interviewed, and written statements obtained. Section titled Resident to Resident documented that all resident complaints/concerns will be referred to Administration and upon the receipt of a complaint, Administration shall conduct an investigation into allegations. The facility P&P titled Accidents & Incidents (A&I) revised 7/31/17 documented that all accidents, potential accidents, incidents, reported abuse, suspected abuse shall be investigated and reported to the Administration. It is the responsibility of all staff members to report any accident/incident, potential accident/incident and any suspected abuse issues to the charge nurse immediately - including resident-to-resident altercations. When the floor nurse receives report of an accident/incident, they are to immediately notify the nursing supervisor and the floor nurse or supervisor is to complete the A&I report. The supervisor needs to immediately start the investigation. Once the A&I and all required paperwork has been reviewed by the supervisor, it shall be given to the DON or RN designee for review. 1. Resident #4 was admitted to the facility with diagnoses including dementia, down syndrome (disorder causing developmental and intellectual delays), and major depressive disorder. The Minimum Data Set (MDS- a resident assessment tool) dated 1/16/22 documented Resident #4 understood, understands and had moderate cognitive impairment. The resident had a history of verbal behavioral symptoms towards others. Resident #34 was admitted to the facility with diagnoses including dementia, hypotension, and heart failure. The MDS dated [DATE] documented Resident #34 understood, understands and had moderate cognitive impairment. The resident had no history of verbal or physical behavioral symptoms towards others. Review of the Progress Notes dated 11/4/21 at 7:44 PM documented that Director of Nursing (DON) was notified at 5:55 PM via phone by Registered Nurse (RN) #1 Nurse Supervisor that Resident #34 alleged that Resident #4 hit Resident #34 in the buttocks, and hit Resident #34 in the jaw earlier the same day. DON documented an assessment that revealed there was no injury to Resident #34 and statements from both residents and staff who were present at the time of the alleged abuse. The DON notified Resident #34's family and documented that after investigation of the allegations by Resident #34, there was not credible evidence that abuse occurred. Review of A&I reports provided by the facility revealed there was no documented A&I investigation into Resident #34's allegations of abuse reported on 11/4/21. Review of the NYS DOH Automated Complaint Tracking System Complaint/Incident Investigation Report revealed there was no documented investigation into Resident #34's allegations of abuse reported on 11/4/21. During a phone interview on 1/26/22 at 12:28 PM, RN #1 Nurse Supervisor stated that they were notified of the alleged incident between Resident #4 and Resident #34 later during the shift that it allegedly occurred and spoke to both residents regarding the allegation. RN #1 then spoke to the DON about the allegations, at which point RN #1 and the DON concluded that the allegation did not require an incident report or reporting to NYSDOH because Resident #34 was a bad historian, without injuries from alleged altercation and stated they were not fearful of Resident #4 when asked by RN #1. During an interview on 1/27/22 at 11:37 AM, the DON stated that there was no further investigation on the allegation made by Resident #34, beyond what was documented in the resident's progress notes. The DON stated that they were aware of alleged violation reporting requirement and the allegation was not reported to the NYSDOH because they investigated the allegation and ruled out that abuse occurred. 3. Resident #226 was admitted with diagnoses which included dementia, atherosclerotic heart disease and frequent falls. Brief Interview for Mental Status (BIMS) assessment documented on 1/10/22 by the Social Worker revealed Resident #226 had moderately impaired cognition. The Comprehensive Care Plan, (CCP) dated 1/24/22 documented Resident #226 was at risk for falls related to history of falling and confusion. Planned interventions included: Anticipate and meet the resident's needs, call light within reach and encourage to call for assistance, ensure non-skid footwear when out of bed (OOB), follow facility fall protocol, physical therapy evaluate and treat as ordered or as needed. On 1/25/22 at 10:38 AM Resident #226 was observed laying on their bed in their room with a purple bruise above the right eyebrow approximately 2 inches x 2 inches. During an interview at the time of the observation Resident #226 stated they didn't know how they got the bruise. Review of the Progress Notes revealed the following: - 1/19/22 at 8:39 PM Registered Nurse (RN) #4 documented, staff noted a bruise on right temple area. Resident #226 did not know where it came from or how it happened. The transport aide did not notice it yesterday. - 1/20/22 at 2:54 AM Registered Nurse (RN) #4 documented, HCP, daughter called and was with resident during the appointment and saw the bruise and was concerned. - 1/20/22 at 1:26 PM Licensed Practical Nurse (LPN) #2 documented, Aide notified writer that resident had a bruise on the right side of the forehead, 2 centimeters (cm) x 2.1 cm. Writer attended and noted the same, purple in color with red blood vessels in the middle. This was not present when resident left the facility with her daughter on 1/19/22 at 2:15 PM for an appointment. Resident didn't know what happened to cause it. - 1/20/22 at 2:04 PM the Director of Nursing (DON) documented, it was discovered by this resident's daughter while out of facility at medical appointment that resident has a quarter sized bruise over the right eyebrow. Review of the Facility Accident / Incident (A/I) Reports provided by the facility dated 1/20/22 at 1:20 PM documented It was discovered on 1/19/22 while out of facility at an appointment that resident had a quarter sized bruise above their right eye. Review of the on-line submission Health Emergency Response Data System (HERDS) documented the incident dated 1/19/22 with an incident time 3:00 PM, submitted on 1/20/22 at 2:39 PM. During an interview on 1/28/22 at 10:14 AM, LPN #1 Unit Manager (UM) stated they were not aware of the bruise above resident #226's eyebrow until interviewed by the DON on 1/20/22. LPN #1 UM stated when an injury of unknown origin was noted the DON should be notified immediately to rule out abuse. During an interview on 1/28/22 at 12:37 PM, the DON stated the Nursing Supervisor should have informed the covering DON on 1/19/22 when the staff reported the bruise above the resident's right eyebrow immediately to rule out abuse. The DON stated the were not aware of the bruise above Resident #226's right eyebrow nor was the covering DON until the morning of 1/20/22. The DON stated a report should have been filed within 2 hours of the noted bruise on 1/19/22 according to the regulations to New York State Department of Health (NYS DOH) because it was an injury of unknown origin on the resident's forehead. During an interview on 1/28/22 at 1:52 PM, the Administrator stated a report to NYS DOH should have been filed within 2 hours of the noted bruise on 1/19/22 because it was an injury of unknown origin on the resident's forehead. 415.4(b)(4)

Based on interview and record review conducted during the Standard Survey completed on 1/28/22, the facility did not ensure that all allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for one (Resident #226) of seven residents reviewed for abuse. Specifically, there was a lack of a thorough investigation to include the previous shifts staff members statements according to facility practices to rule out abuse, neglect or mistreatment when a bruise of unknown origin was identified above the resident's right eyebrow. The finding is: Review of a facility policy and procedure (P&P) titled Accident/Incidents revised date 7/31/2017 documented, all accidents, potential accidents, incidents, reported abuse, suspected abuse, unexplained bruising shall be investigated and reported to the administration as indicated (see P&P Abuse Prohibition). The supervisor needs to immediately start an investigation as to what happened and the cause, making sure all staff scheduled on the unit complete the staff observation sheet. The supervisor will also fill out observation/ investigative sheets for the past 72 hours for any injury of unknown origin or until area was not noted. Review of a facility P&P titled Resident Abuse Prohibition revised date 1/18/2017 documented the facility prohibit resident abuse, neglect by staff, volunteers, consultants, family members/friends/legal guardians or other individuals. Definitions included: injuries of unknown origin to be classified as an injury of unknown origin both of the following conditions must exist; the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident and the injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma). 1. Resident #226 was admitted with diagnoses which included dementia, atherosclerotic heart disease and frequent falls. Brief Interview for Mental Status (BIMS) assessment documented on 1/10/22 by the Social Worker revealed Resident #226 had moderately impaired cognition. Review of the Facility Accident/Incident (A/I) Report provided by the facility dated 1/20/22 at 1:20 PM documented It was discovered on 1/19/22 while out of facility at an appointment that resident had a quarter sized bruise above their right eye. Witness statements included were Resident 226's daughter, Transport Aide, Training Nurses Aide (TNA) #7 and Licensed Practical Nurse (LPN) #1 Unit Manager (UM). Review of the investigation provided by the Director of Nursing (DON) revealed there was no documented evidence staff members working the day shift on 1/19/22, or the previous night and evening shift were interviewed to rule out abuse. During an interview on 1/28/22 at 10:14 AM, LPN #2 stated the bruise noted above the resident's right eyebrow was an injury of unknown origin and should have been thoroughly investigated. LPN #2 stated she doesn't know how the resident obtained the bruise. During an interview on 1/28/22 at 11:25 AM, LPN #1 UM stated a bruise of unknown origin should be thoroughly investigated to rule out abuse, including obtaining statements from all staff working on the day shift on 1/19/22 and does not know if previous shift employees should have been interviewed. LPN #1 UM stated the DON investigated the bruise. During an interview on 1/28/22 at 11:25 AM, the DON stated they had stopped interviewing staff after two staff members stated they had not seen the bruise on 1/19/22 on the day shift. The DON stated a bruise could appear hours after an incident and they should have interviewed the previous shifts to rule out abuse. The DON stated they had not completed a thorough investigation. During an interview on 1/28/22 at 1:52 PM, the Administrator stated they had stopped interviewing staff when a staff member stated they had not seen it on the day shift of 1/19/22 but should have continued to interview staff on the previous shift to rule out abuse. 415.4(b)(3)

Based on observation, interview, and record review conducted during the Standard survey completed on 1/28/22, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, one (Resident #36) of one resident reviewed for quality of care of prosthetic eye did not receive eye care as ordered by the physician and was inaccurately documented in the treatment record. The facility policy and procedure (P&P) titled Maintenance of Prosthetic Eye dated 2/4/21 documented that routine cleaning of prosthetic eye is to be performed in effort to maintain comfort, reduce secretions, extended life of prosthetic eye and aide in the prevention of conjunctivitis (eye infection). Any licensed nursing staff is able to perform maintenance of prosthetic eye. All residents possessing a prosthetic eye shall have it removed, cleansed and inserted once monthly unless otherwise specified by a doctor. Equipment included: Sterile water, clean gloves, baby shampoo, prosthetic eye suction cup and a clean towel. The finding is: 1. Resident #36 was admitted to the facility with diagnoses that included dementia, major depressive disorder and anxiety disorder. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 11/29/21 documented Resident #36 was severely cognitively impaired with short-term and long-term memory problems. The facility's physician Order Summary Report documented an order dated 1/24/21 as follows: Remove and clean right eye prosthetic weekly then replace. Rinse with sterile saline and replace with the use of suction adaptor. Check eye for any discoloration, drainage or redness everyday shift on Thursday. The facility's Treatment Administration Record (TAR) dated 12/1/21 through 1/28/22 revealed an order: Remove and clean right eye prosthetic weekly then replace. Rinse with sterile saline and replace with the use of suction adaptor. Check eye for any discoloration, drainage or redness ever day shift every Thursday for right eye prosthetic. The following was documented: -12/2/21, 12/30/21, 1/13/22 and 1/27/22 the treatment was initialed as completed -12/9/21 and 1/6/22 was blank, with no documented evidence the prosthetic eye was removed and cleaned -12/16/21, 12/23/21 it was documented that Resident #36 refused the treatment to their prosthetic eye -1/20/22 documented as NA Review of Referral and Consult Report Resident #36 for prosthetic eye dated 3/1/21 documented, Patient came in with ocular prosthesis upside down, checked socket and polished ocular prostheses. There is no crack or chip in prostheses. Attached to consult, Artificial Eyes - Eye maintenance instructions included how to remove the eye and cleaning of the eye. Review of the Comprehensive Care Plan dated 2/4/21 documented Resident #36 has an artificial right eye. Interventions included: treat eye prosthetic as ordered, provide eye care as ordered, notify physician of any eye concerns, monitor for eye drainage, arrange consultation with eye care practitioner as required, follow up with eye specialists as indicated, and monitor for discomfort or pain in eyes and notify physician. During an interview on 1/24/22 at 10:47 AM, the resident's daughter-in-law stated the prosthetic eye remover was missing for approximately 4 weeks. During an interview and observation on 1/28/22 at 10:18 AM, Licensed Practical Nurse (LPN) #2 stated the resident has not allowed her to remove and clean the eye in a long time, months. LPN #2 identified they had documented the resident refused eye care on the TAR dated 12/23/21. LPN #2 stated the suction cup adapter to remove the prosthetic eye should be in the top drawer of the treatment cart and had not seen it in a while. LPN #2 searched for the prosthetic suction cup adapter in treatment cart, both unit medication carts and in the resident's room; unable to locate it. During an interview on 1/28/22 at 10:48 AM, LPN #3 reviewed the TARs 12/2021 and 1/2022 and identified they documented the resident refused eye care on 12/16/21 and the resident received eye care on 12/2/21, 12/30/21, 1/13/22 and 1/27/22. LPN #3 stated she had not seen the suction cup adaptor, had not removed and cleaned the resident's prosthetic eye as ordered. The LPN documented in the TAR inaccurately. LPN #3 stated they should have asked the Unit Manager, a nursing supervisor or the Director of Nursing (DON) where to obtain the adaptor and informed them they were unable to follow the physician's order. During an interview on 1/28/22 at 11:32 AM, LPN #1 Unit Manager stated they were unaware the prosthetic eye suction cup adapter to remove the glass eye was missing and the glass eye was not being cleansed as ordered. LPN #1 stated they would have expected the staff nurses to report the adaptor was missing and it would have been ordered. During an interview on 1/28/22 at 12:52 PM, the DON stated they were unaware the prosthetic eye suction cup adapter to remove the glass eye was missing and would have expected the staff nurses to inform the UM to ensure the treatment of the prosthetic eye was completed. The DON stated they expect the staff nurses to document appropriately on the TAR indicating the task was unable to be completed. During an interview on 1/28/22 at 2:51 PM, the Medical Director stated it is very important to follow the orders, it was a clinical recommendation to remove and clean the prosthetic eye. The Medical Director stated they expect the nurses to document accurately and notify the DON to obtain the adaptor and if necessary, notify medical personnel. 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 1/28/22, the facility did not ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for three, (Resident #47, #56, & #224) of four residents observed for pressure ulcers. Specifically, there was a lack of treatment initiation for residents with pressure ulcers (#47, #224), treatments were not completed as recommended by the Wound Consultant Physician (#56), a wound culture was not obtained as ordered (#224), and pressure reducing devices were not provided as recommended by the Wound Consultant Physician (Resident #56 & 224). The findings are: The facility policy and procedure (P&P) titled Pressure Ulcer Prevention and Treatment Protocol revised July 2013 documented any resident entering the facility without pressure ulcers will remain free from pressure ulcers unless the residents' clinical condition demonstrates that it was unavoidable. Any resident having a pressure ulcer will receive the necessary treatments and services to promote healing, prevent infection and prevent new ulcers from developing. Floor staff will follow the following preventative procedures: Use positioning devices such as, but not limited to, pillows, foam wedges, bolster rolls, etc. to prevent bony prominences from contact with each other: Use pressure relieving devices such as, but not limited to, foam pads, air or gel cushions, and pressure relieving mattresses. Review of Mattress Systems for Pressure Management provided by the facility document; Group 2 support surfaces can prevent pressure ulcers, and help treating existing pressure sores while helping control pain, enhance the quality of sleep and life, and make care giving for bed-bound patients easier. Group 2 support surfaces include: alternating - pressure, low-air loss, lateral-rotation, mattress overlays. 1. Resident #47 was admitted to the facility with diagnoses that included quadriplegia, (paralysis of all four limbs) depression and anxiety. The Minimum Data Set (MDS- a resident assessment tool) dated 12/13/21 documented Resident #47 was understood, understands and was at risk for the development of pressure ulcers. Review of the Order Summary Report dated 11/4/20 revealed an active Physician's Order for skin checks once per week on Tuesday. The Comprehensive Care Plan dated 12/20/21 documented Resident #47 was at risk for pressure skin breakdown. Interventions included to administer treatments as ordered, educate resident on causes of skin breakdown, follow facility policies and procedures for the prevention/treatment of skin breakdown, wound consults as needed, encourage protein sources, and a low loss air mattress (specialty mattress to help prevent pressure ulcers). During a range of motion (ROM) observation on 1/27/22 at 2:39 PM, the PTA (Physical Therapy Aide) #2 completed ROM. Resident #47's right heel was observed to be red and there was a small stage 2 pressure ulcer with surrounding redness was on the bottom of the left heel. Resident #47 requested the PTA to apply lotion to the left heel and Resident #47 stated both heels had been sore for over one month and that Certified Nurse Aide (CNA) #4 was aware and notified Licensed Practical Nurse (LPN) #6. During interview on 1/27/22 at 3:00 PM, the PTA #2 stated they informed LPN #6 one month ago of potential skin breakdown to Resident 47's heels and LPN #6 instructed the PTA to apply barrier cream to the heels. Review of Resident #47's Medication/Treatment Administration Record (MAR/TAR) dated 1/1/22 through 1/27/22 revealed there was no documented evidence a treatment was ordered for the resident's the right and left heels. Further review of the Order Summary Report dated 1/2022 revealed there were no Physician's Order for a treatment to Resident #47's right and left heels. During an interview on 1/27/22 at 3:40 PM, LPN #6 stated nurses were responsible to visually inspect resident's skin once weekly on bath days. LPN #6 stated they signed the weekly skin check on 1/25/22 in the TAR without visually inspecting Resident # 47's skin. During observation on 1/27/22 at 4:05 PM, Registered Nurse (RN) #2, Unit Manager in the presence of LPN #6 measured the reddened area (stage 1, red, non-blanchable area) to Resident's #47 right heel as 1.5 cm (centimeter) x 1 cm and stated it was boggy (soft). The left heel was staged at a 2 (superficial shallow crater) and measured 0.5 cm x 0.5 cm x 0.1 cm and was boggy. During an interview on 1/27/22 at 4:10 PM, RN #2 Unit Manager stated that the nurses were expected to visually inspect the resident's skin on bath days. When concerns were identified the nurses were to inform the unit manager or RN supervisor. RN #2 stated they were not aware Resident #47 had pressure ulcers to their heels. During a telephone interview on 1/28/22 at 12:00 PM, CNA #4 stated that Resident #47 heels had been red for over a month and had informed LPN #6 and RN #2 Unit Manager. CNA #4 was instructed by LPN #6 to apply barrier cream to Resident #47 heels. CNA #4 applied lotion to the heels during morning care as resident requested. During an interview on 1/28/22 at 1:35 PM, the Director of Nurses (DON) stated it was not in the scope of practice for CNA's to be performing skin assessments. The CNAs should notify the nurse on duty of the skin concern and then nurse should notify the RN. The RN would then assess and notified the provider for an appropriate treatment. 2. Resident #56 was admitted to the facility with diagnoses that included diabetes mellitus type 2 with foot ulcer, peripheral vascular disease (PVD, decreased circulation of lower extremities), and chronic kidney disease. The MDS dated [DATE] documented Resident #56 was cognitively intact, at risk for the development of pressure ulcers (PU) and had one stage 3 (full thickness tissue loss) PU. The Comprehensive Care Plan dated 12/31/21 documented Resident #56 had a stage 3 PU to the right heel. Interventions included to follow facility policies and procedures for the prevention/treatment of skin breakdown, and follow with wound consultant MD as indicated. The Order Summary Report dated 1/27/22 documented an order dated 1/6/22 to cleanse right heel with wound cleanser, pat dry, apply nickel thick dab of Santyl (sterile ointment used to remove dead tissue) and to apply alginate, gauze, foam dressing and kerlix. The Wound Evaluation & Management Summary documented by the wound physician dated, 10/2/21 11/4/21, 12/2/21, 12/23/21, 1/6/22, 1/13/22, and 1/20/22 revealed a recommendation for a Group 2 bed mattress and air boot for the right heel. In addition, a recommendation to add collagen powder to the treatment was documented on 12/23/21, 1/6/22, 1/13/22, and 1/20/22. Intermittent observations on 1/24/22 through 1/27/22 between 8:09 AM and 1:35 PM revealed Resident #56 was in bed and did not have a Group 2 bed mattress and did not have an air boot as recommended from the Wound Consultant Physician. During an observation and interview on 1/26/22 at 10:54 AM LPN #2 completed the treatment as written in the orders with LPN #1 Unit Manager present. Observation and interview on 1/27/22 at 8:26 AM Wound Consultant Physician completed the treatment to resident's right heel as followed; cleansed with wound cleanser, pat dry, mixed collagen powder into the Santyl ointment, applied nickel thick dab to right heel, applied alginate, and covered with a foam dressing. Wound Consultant Physician stated the nurses should be adding collagen powder to the Santyl to assist with the healing process as recommended. Upon review of the physician orders, the Wound Consultant Physician verified collagen was not in the treatment order and stated the nurse manager was responsible review their recommendations and write the treatment orders according to their recommendations. Additionally, a Group 2 bed mattress and air boot was also recommended, and they expected their recommendations to be followed. During an interview on 1/28/22 at 10:03 AM, LPN #2 stated they do not review the wound consultant recommendations, did not know collagen was recommended in the treatment order and does not know what a Group 2 bed mattress is. LPN #2 stated it is the responsibility of the Unit Manager to review the recommendations and write the orders. During an interview on 1/28/22 at 11:03 AM, LPN #1 UM stated they were responsible to review the recommendations from the wound consultant and write the orders. LPN #1 stated they did not see the recommendation for the air boot or Group 2 bed mattress. LPN #1 stated they did not write the order for the collagen powder because the pharmacy said it was not available and did not inform the Director of Nursing (DON) and should have because it was a recommendation. 3. Resident #224 was admitted to the facility with diagnoses that included pressure ulcer (PU) of sacral region stage 4 (full thickness tissue loss with exposed bone, tendon or muscle) diabetes mellitus type 2, and dementia. The MDS dated [DATE] documented Resident #224 was moderately cognitively impaired and was at risk for the development of pressure ulcers. The Comprehensive Care Plan dated 1/5/22 documented Resident #224 admitted with an unstageable (slough and/or eschar (black tissue) unable to be stageable due to coverage of wound bed) PU to their sacrum, the sacral PU had been debrided and the cultures were positive for infection. After debridement the PU was restaged at Stage 4, and the resident follows with the Wound Consultant Physician in house for wound care. Interventions included to follow facility P&P for the prevention/treatment of skin breakdown, administer treatments as ordered and monitor for effectiveness, obtain and monitor lab/diagnostic work as ordered. The Order Summary Report dated 1/27/22 documented an order dated 1/5/22 to consult with the wound specialist, off-loading boots to both heels when in bed every shift for red boggy heels with breakdown. There was no documented evidence of a treatment to the right heel. Review of the Treatment Administration Record dated 1/1/22 through 1/31/22 revealed an order dated 1/21/22 to obtain a sacral wound culture. There was no evidence the sacral wound culture was obtained as ordered. There was no evidence of a treatment to the right heel. Review of Wound Evaluation & Management Summary documented by the Wound Physician dated, 1/6/22, 1/13/22, and 1/20/22 revealed a recommendation for a Group 2 bed mattress. Intermittent observations on 1/25/22 through 1/27/22 between 8:14 AM and 2:54 PM revealed Resident #224 was not on a Group 2 bed mattress as recommended from the wound consultant physician. During a morning care observation and interview on 1/26/22 at 10:33 AM with the DON present; CNA #6 stated Resident #224 did not have any pressure ulcers on their heels. CNA #6 removed the resident's bilateral heel booties, and their right heel had a black unstageable ulcer that measured approximately 1 centimeter (cm) x 1 cm area. During an observation and interview on 1/27/22 at 9:03 AM, the Wound Consultant Physician stated Resident #224 was wearing heel float booties for protection and the resident's heels were intact without skin breakdown. The Wound Consultant Physician observed Resident #224's right heel and stated the resident's right heel had a black area measuring 1 cm x 1.1 cm and stated they would have expected the nursing staff to have identified the area and obtained an order for treatment. In addition, the Wound Consultant stated Resident #224 should have a low air loss mattress as recommended and would have expected the staff to follow their recommendations. During an interview on 1/28/22 at 7:39 AM, CNA #6 stated they didn't know Resident #224 had a black area on their right heel and didn't look at the resident's heels during care on 1/26/22 and should have. During an interview on 1/28/22 at 10:03 AM, LPN #2 stated they were not aware there was a blackened area on Resident #224's right heel. LPN #2 stated they rely heavily on the CNAs to inform them of skin changes. During an interview on 1/28/22 at 11:21 AM, LPN #1 Unit Manager stated they were responsible to review the recommendations from the Wound Consultant and write the orders. LPN #1 stated they did not see the recommendation for the Group 2 bed mattress. In addition, LPN #1 stated CNAs should be observing all areas of the resident's skin every shift during care for changes and would have expected the nursing staff to observe and report the blackened area on Resident #224's right heel and a treatment to be initiated immediately. During an interview on 1/28/22 at 1:04 PM, the DON stated LPN #1 Unit Manager was responsible to read the Wound Evaluation & Management Summary and follow the recommendations. The DON stated Resident #56 and #224 should have had a Group 2 bed mattress. Resident #56 should have had an air boot for their right heel, pressure reducing devices, and the collagen order should have written and completed according to the recommendations. The DON stated they would have expected LPN #1 Unit Manger to have informed them if the pharmacy was unable to provide the collagen, so they could have called other suppliers to obtain the collagen. Additionally, the DON stated the wound culture was not obtained as ordered on 1/21/22 and should have been. The nurses were expected to follow the physician orders. During an interview on 1/28/22 at 1:35 PM, the Administrator stated they would have expected the wound consultant to have identified the pressure reducing devices were not in place according to their recommendations and follow up with LPN #1 Unit Manager. During an interview on 1/28/22 at 2:46 PM, the Medical Director stated it was important the facility follow the Wound Consultant Physician's recommendations. 415.12 (c)(1)(2)

Based on interview and record review conducted during a Standard survey completed on 1/28/22, it was determined that the facility did not arrange for the provision for physician services 24 hours a day, in case of emergency. Specifically, one (Resident #124) of one resident reviewed for hospitalization the facility did not ensure the provider responded promptly to notification for resident with critically high and high laboratory values. The finding is: 1. Resident #124 had diagnoses of dementia, aphasia (the inability to communicate) and chronic kidney disease. The Minimum Data Set (MDS - a resident assessment tool) dated 10/17/21 documented Resident #124 was moderately cognitively impaired, understands and was understood. An undated facility document titled Team Health documented that staff are to call the on call medical provider between the hours of 8:00 AM and 5:00 PM and to use option #2 unless it is a code situation then staff are to press option #1. Additionally, staff are to contact the Medical Director after hours. A review of chronological nursing progress notes dated 12/11/21 documented the following: 9:19 AM - Resident #124 was observed slurring their words, not using words but saying letters, and confusion. A phone call was made to the on call medical provider service at 8:30 AM to report the issue with the resident. A second phone call was made to the on call medical provider at 9:00 AM to report the same issue. The on call medical provider returned the phone call and ordered labs including basic metabolic panel (BMP blood test including basic chemistry studies of the blood), complete blood count (CBC), urinalysis (U/A a test of urine, that provides important clinical information on kidney function), and a COVID-19 test. The COVID-19 test was negative. 12:45 PM - a phone call from the lab who performed the tests reported that Resident #124 had critical lab values of potassium (high potassium level can cause muscle weakness, tiredness, and heart rhythm issues) of 6.2 (normal range 3.2 to 5.2) and a BUN level of 100 (normal range 7 to 21 milligrams per deciliter; a high value can indicate possible kidney failure). A phone call was made to the on call medical provider and a message was left. 3:05 PM - a phone call from the lab reported that the resident had high white blood cells (WBC) of 17 (normal range 4.5 to 10) and the mean platelet volume of 12 (normal range 7.2 to 10.2). A phone call was made to the on call medical provider, a message was left, and waiting for a return call. 5:06 PM - Resident #124 was observed to be moving slow, confused, and removing clothes. A call was placed to the on-call medical provider at this time and return call was pending. The Director of Nursing (DON) was notified of the concerns. 5:33 PM - The family of Resident #124 was notified about the resident's condition. They agreed to send the resident to the hospital. 6:40 PM - The Medical Director of the facility was notified by phone of Resident #124's condition. The Medical Director gave the order to send the resident to the hospital. The ambulance service was called at 6:11 PM and arrived at 6:30 PM to transfer Resident #124 to the hospital. During an interview on 1/26/22 at 11:26 AM, LPN #2 Unit Manager stated that they left messages for the on-call provider to receive direction for Resident #124 but did not receive any return calls. During an interview on 1/26/22 at 12:41 PM, RN #4 stated that nursing staff must notify someone before sending a resident to the hospital. RN #4 stated that Resident #124 didn't look right, and they were concerned and contacted the DON. RN# 4 stated residents the labs were concerning, and they called the family to ask if the resident could be sent to the hospital. RN #4 stated that they asked the DON for permission to call the Medical Director. Once the Medical Director was contacted an order was obtained and Resident #124 was sent to the hospital. During an interview on 1/26/22 at 1:07 PM, the Nurse Practitioner stated that if staff couldn't get a hold of the on-call medical provider then yes, the resident should be sent to the hospital for evaluation. During an interview on 1/27/22 at 8:21 AM, the DON stated that they expected their nurses to keep calling the on-call provider, if they do not hear back from them. The DON stated that they expect their nurses to trust their instincts and, after 60 minutes if they have not gotten a hold of the on-call provider, to call the Medical Director. During an interview on 1/27/22 at 9:07 AM, the Medical Director stated that the expectation was for the nurses to call them if they were not able to get a hold of the on-call provider. The Medical Director stated that the expectation was for the nurses to send a resident to the hospital for an evaluation if they feel the resident needs to be sent, and they cannot get a hold of the on-call provider. 415.15(b)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for nine ( Residents #9, #17, #28, #33, #34, #37, #50, #58 and #220) of ten residents reviewed for Baseline Care Plans, the facility did not develop a Baseline Care Plan within 48 hours of admission that included the minimum required information, and/or the resident and/or resident's representative were not provided with a written summary of the plan. This is evidenced by, but not limited to, the following: The facility policy, Baseline Care Plan, revealed a Baseline Care Plan (BCP) will be developed for each resident within 48 hours of admission. The interdisciplinary team will review the physician orders and implement a BCP to meet the resident's immediate needs including, but not limited to, initial goals based on admission orders, physician orders, dietary orders, therapy services and social services. The resident and their representative will be provided a summary of the BCP that includes, but is not limited to, the initial goals, a summary of the medications, dietary instructions, and any services or treatments to be administered. 1. Resident #33 was admitted to the facility on [DATE] with diagnoses including urinary tract infection, diabetes, and recurrent falls. The Minimum Data Set (MDS) Assessment, dated 4/5/19, revealed the resident had moderately impaired cognition and clear comprehension. 2. Resident #9 was admitted to the facility on [DATE] and had diagnoses that included respiratory failure, chronic obstructive pulmonary disease, and obstructive sleep apnea. The MDS Assessment, dated 11/19/18, revealed the resident had moderately impaired cognition, clear comprehension, and used oxygen and a BIPAP (Bilevel Positive Airway Pressure) machine. 3. Resident #17 was admitted to the facility on [DATE] and had diagnoses that included cerebral vascular accident with left sided hemiplegia (paralysis on one side of the body), atrial fibrillation, and anxiety. The MDS Assessment, dated 7/4/18, revealed the resident was cognitively intact and used oxygen. Review of the medical records for each resident revealed an undated BCP which did not include the minimum healthcare information necessary to properly care for the resident immediately following admission including initial goals, dietary orders, therapy services, social services, physician orders, and/or instructions to provide person centered care. There was no documented evidence that the BCP was reviewed and/or a copy was provided to the resident and/or their representative. Interviews conducted on 5/28/19 included the following: a. At 2:08 p.m., the Registered Nurse Manager (RNM) said that the BCP was developed by the interdisciplinary team and each discipline (Nursing, Social Work, Dietary, and Therapy) was responsible for completing their own section. She said the BCP should be completed within 48 hours of admission. The RNM said she was not aware of the minimum requirements that should be included in the BCP. The RNM said she did not know who was responsible for providing a summary of the BCP to the resident and/or representative. b. At 3:15 p.m., the Social Worker (SW) stated she was responsible for reviewing the BCP with the resident and/or their representative. The SW said she would ask the resident and/or representative if they wanted a copy of the BCP. She stated there was a place on the BCP for the resident and/or representative to sign that the BCP had been reviewed with them. She stated if it was not signed, then it was not done. When interviewed on 5/29/19 at 11:00 a.m., the Director of Nursing stated the BCP was developed within 48 hours of admission, and a summary of the BCP and medication list was supposed to be provided to the resident and/or representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #28) of eight residents reviewed for unnecessary medications, the facility did not ensure orders for as needed psychotropic medications were limited to 14 days. This is evidenced by the following: Resident #28 was admitted to the facility on [DATE] and has diagnoses including insomnia, incomplete quadriplegia, and anxiety. The Minimum Data Set Assessment, dated 4/1/19, revealed that the resident was cognitively intact. The facility policy, Psychotropic Medication, dated 4/17/17, revealed that no resident will remain on an as needed psychotropic medication greater than 14 days without the prescribing practitioner documenting the rationale. Time frames for continued as needed psychotropic medication use must be documented in the medical record. Pharmacist will send a written report to Medical Director, Director of Nursing (DON), and attending physician listing the resident's name, relevant drug, and irregularity identified. The physician will document in the medical record the review of the irregularity and what if any action has been taken to address it. If no action is taken, document rationale in the medical record. Physician orders, dated 5/15/19, included Ambien (hypnotic used as a sleep aid) 10 milligrams (mg) at bedtime as needed. The medication was originally ordered on admission [DATE]). Review of the medical record since admission revealed that the physician documented the resident's diagnosis of insomnia. There was no documentation that the as needed Ambien was renewed or reviewed every 14 days or a rationale was documented for the extended use and duration of the medication. The Consultant Pharmacist Medication Regimen Review forms, dated 3/26/19, 4/27/19, and 5/22/19, revealed that the resident had been receiving Ambien since December 2018. Recommendations had been made to re-evaluate the use of Ambien, document the rationale for using the Ambien for more than 14 days in the medical record, and possibly adding a maintenance hypnotic due to frequent use. When interviewed on 5/29/19 at 9:41 a.m., the Registered Nurse Manager (RNM) stated that the resident has had an order for Ambien since admission. She said the resident used the medication at home for a long time. At 1:28 p.m., the RNM stated that she believed the resident used the Ambien almost daily. She said there was discussion with the physician regarding making medication changes, but nothing had changed with the Ambien order. During an interview on 5/29/19 at 2:14 p.m., the DON stated that the physician's signature and date on the 4/27/19 Monthly Summary Consultant Pharmacist Medication Regimen confirmed that the physician had reviewed the pharmacist recommendation. [10 NYCRR 415.12]