Every finding on record at Absolut Center for Nursing and Rehabilitation at A

Based on observation, interview, and record review conducted during the Standard survey completed on [DATE], the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, five ([NAME] 3, [NAME] 2, Willink A, Willink C, Willink Legacy Cove) of five unit Nourishment Room refrigerators contained undated, unlabeled, and out of date food and drink items and a staff member's personal food was stored with residents' food. The findings are: The policy and procedure titled Food Receiving and Storage, revised ,d+[DATE], documented potentially hazardous foods stored in the refrigerator will be labeled and dated and discarded after three days once opened. All non-potentially hazardous foods stored in the refrigerator will be labeled and dated and discarded after five days once opened. The policy and procedure titled Food(s) Brought in from Outside the Facility, revised ,d+[DATE], documented perishable foods brought in must be labeled with resident's name and dated and consumed promptly. The facility is responsible for storing food brought in by family or visitors in a way that is separate from or easily distinguishable from facility food. All foods are labeled/ dated and discarded after three days. 1a. Observation in the [NAME] 3 Nourishment Room on [DATE] at 9:10 AM revealed the following items were stored in the refrigerator: -One 8.8-ounce glass jar of raw wildflower honey, opened, not labeled with the date opened, and no manufacturer expiration date. -One poured applesauce cup with a facility sticker that stated, use by Saturday ,d+[DATE]. -One poured pudding cup with a facility sticker that stated, use by Saturday ,d+[DATE]. -One opened 32-ounce thickened lemon water, not labeled with the date opened, manufacturer instructions stated discard if not used with in four days of opening. -One opened 46-ounce thickened dairy beverage, not labeled with the date opened, manufacturer instructions stated after opening, may be kept for up to seven days under refrigeration. -Two opened 46-ounce thickened apple juices, not labeled with the date opened, manufacturer instructions stated discard if not used within ten days of opening. -One individual bottle of water, one individual bottle of iced tea, one individual bottle of blue electrolyte drink, all opened, not labeled with a resident name or date opened. During an interview at the time of the observation, Registered Nurse Unit Manager #1 stated Dietary staff maintained the refrigerators in the Nourishment Rooms, but Nursing staff was responsible for dating the items when they were opened. 1b. Observation in the [NAME] 2 Nourishment Room on [DATE] at 10:15 AM revealed the following items were stored in the refrigerator: -One commercially prepared individual container of ready to eat oats, manufacturer best by' date [DATE]. -Two opened 32-ounce nectar and honey consistency beverages, not labeled with the date opened, manufacturer instructions discard if not used within four days of opening. During an interview at the time of the observation, the Director of Environmental Services stated the ready to eat oats needed to be discarded because its manufacturers best by date had passed. 1c. Observation in the Willink A Nourishment Room on [DATE] at 11:15 AM revealed the following items were stored in the refrigerator: -One plastic storage container of cut vegetables labeled with a resident's name, but no date. -One tray of food labeled with a resident's name, but no date. -Two unopened commercially prepared individual turkey meals labeled with a resident's name; manufacturer instructions stated keep frozen. -Two unopened commercially prepared individual scrambled egg cups, labeled with a resident's name, manufacturer 'best by' date 24Nov24. Additional observation revealed a sign was posted on the Willink A Nourishment Room refrigerator that read, All items in this refrigerator must be dated and labeled. During an interview at the time of the observation, Certified Nurse Aide #2 stated resident foods needed to be dated. They stated the resident that the individual turkey meals and scrambled egg cups belonged to was no longer at the facility. At this time, Certified Nurse Aide #2 voluntarily discarded the turkey meals and stated manufacturer's instructions to keep frozen were not followed. Certified Nurse Aide #2 also voluntarily discarded the scrambled egg cups and stated they should not be eaten because they were past the manufacturer's 'best by' date. 1d. Observation in the Willink Legacy Cove Nourishment Room on [DATE] at 12:00 PM revealed the following items were stored in the refrigerator: -A plastic container of chicken and pasta, labeled with a name, but no date. -A purple plastic container with pasta and crackers in a black bag, no name or date appeared on the black bag or the items inside the black bag. -A pitcher of lemonade with a facility sticker that stated, Use by Sunday ,d+[DATE]. -One opened 46-ounce thickened apple juice, not labeled with the date opened, manufacturer instructions stated discard if not used within ten days of opening. During an interview at the time of the observation, Licensed Practical Nurse #5 stated food in this refrigerator was supposed to be labeled and dated. When juice containers were opened, it was the responsibility of whoever opened it to date it at that time. They further stated the container of chicken and pasta was their own personal lunch and it was brought in today. Licensed Practical Nurse #5 stated staff were not supposed to keep their personal food in the Nourishment Room refrigerators, but there was no other nearby refrigerator. 1e. Observation in the Willink C Nourishment Room on [DATE] at 12:25 PM revealed an opened 32-ounce cardboard box of tomato soup was stored in the refrigerator. It was labeled with a resident's name, but not labeled with the date opened. Manufacturer instructions stated refrigerate after opening. During an interview at the time of the observation, Nurse Aide Trainee #1 stated food brought in from residents' families should be labeled with the date it was opened. The tomato soup belonged to a resident whose family brought in food frequently and usually the family labeled the items with the date they were opened but did not write the opened date on this container of tomato soup. During an interview on [DATE] at 1:00 PM, Dietary Aide #1 stated Dietary staff performed a daily check of each Nourishment Room refrigerator. The daily checks occurred seven days per week and included temperature, number of nourishments, and dates on all items in each refrigerator. Dietary Aide #1 stated foods brought into the facility from residents' families should be labeled with the resident's name and date and whoever put the food in the refrigerator was responsible for labeling it. All foods were to be discarded after three days, except large items such as containers of coffee creamer or salad dressings, which could be kept until the manufacturer's date on the package. Once thickened beverage containers were opened, they needed to be dated, and were kept in the refrigerator for four to five days. Dietary Aide #1 stated if any thickened beverages were not dated when opened, at the end of each week, they would get rid of any opened containers that they had been noticing in that refrigerator throughout the week. During an interview on [DATE] at 1:10 PM, the Food Service Director stated a member of the Dietary staff checked each Nourishment Room refrigerator seven days per week. They would check for expired product and unlabeled product. They stated any opened product needed to be discarded after three days. Foods brought in by residents' families needed to be labeled and dated by Nursing staff, as family members and residents did not have access to the Nourishment Rooms, they needed to ask Nursing staff for access. During Dietary staff's daily rounds of Nourishment Room refrigerators, if something was found without a name or date, it should be discarded. The Food Service Director stated thickened juices needed to be dated when opened, otherwise Dietary staff would not know when to discard, as Dietary staff followed manufacturer instructions on how many days thickened beverages could be stored after opening. They stated this past weekend, the Dietary department was short-staffed, and they were not sure if anyone performed the daily rounds of Nourishment Room refrigerators. Additionally, the Food Service Director stated staff food needed to be kept in the Breakroom, not Nourishment Rooms. NYCCR 415.14 (h) Subpart ,d+[DATE] Food Service Establishments ,d+[DATE].31(c), ,d+[DATE].40, ,d+[DATE].43(e)

Based on interview and record review conducted during a Complaint investigation (#NY00347404) during a Standard survey completed on 12/20/2024, it was determined the facility did not protect residents from sexual abuse for two (Resident #165 and Resident #151) of seven residents reviewed. Specifically, residents who lacked ability to consent were observed undressed and in bed together. The policy and procedure titled Abuse Prohibition dated 02/2023 documented that residents have a right to be free from abuse including sexual abuse. The policy and procedure titled Abuse Prohibition Staff Responsible for Coordinating and Implementing dated 11/19/2021 documented that the Administrator is responsible for preventing abuse of the residents. The findings are: 1. Resident #165 was admitted to the facility with diagnoses of Alzheimer's disease and dementia. The Minimum Data Set (a resident assessment tool) dated 5/30/24 documented Resident #165 was severely cognitively impaired and had wandering behaviors. The comprehensive care plan dated 5/24/24 documented Resident #165 had wandering behaviors and displayed promiscuous behaviors at times. Resident #165 was alert and oriented to person only and could ambulate independently in their room and in the hall. The Patient Resident's Rights and Responsibilities dated 5/29/24 documented that Resident #165 was unable to give consent due to cognitive capacity. The Determination of Capacity dated 5/31/24 documented Resident #165 lacked the capacity to make health care decision and the reason for this lack of capacity was due to Alzheimer's disease. The Mini Mental State Examination dated 6/4/24 documented Resident #165 scored a 13 out of 30 which indicates that Resident #165 severely cognitively impaired. Review of a progress note written on 6/3/2024 at 4:35 PM by the Director of Social Work documented that capacity determination was signed by provider and the concurring provider stated that Resident #165 does not have capacity to make their own medical decisions. Resident #151 was admitted to the facility with diagnoses of dementia and Parkinson's disease. Review of the Minimum Data Set, dated dated dated [DATE] documented Resident #151 was moderately cognitively impaired and had wandering behaviors. The comprehensive care plan dated 5/21/2024 documented Resident #151 had an alteration in decision making skills related to dementia. The comprehensive care plan documented the resident encourages others behavioral tendencies at times. Additionally, it documented a potential for alteration in mood and behavior patterns related to dementia and adjustment difficulties. Review of the patients' rights and responsibilities dated 5/21/2024 documented Resident #151 does not have capacity to give consent. Review of the determination of capacity dated 5/23/2024 documented that Resident #151 lacks the capacity to make health care decisions. It documented that the lack of capacity was due to dementia. An incident report dated 7/6/2024 at 4:45 PM completed by Licensed Practical Nurse Supervisor #2 documented while doing their medication pass, Licensed Practical Nurse #4 walked into Resident #151's room and found Resident #151 sitting on their bed with Resident #165 without clothes on. Resident #151 stated at this time, that it had been [AGE] years since I had sex, and they (Resident #165) were willing. The incident report documented that Resident #165 was dressed and escorted from the room. It documented that both residents were assessed for injuries, and none were found. Review of an investigation statement dated 7/6/2024 documented that Licensed Practical Nurse #4 walked into Resident #151's room to pass medications and found Resident #151 and Resident #165 unclothed in Resident 151's bed. The statement documented that Licensed Practical Nurse #4 instructed Resident #165 and Resident #151 to get dressed. Licensed Practical Nurse #4 then notified Licensed Practical Nurse Supervisor #3 and other staff. An investigation report dated 7/11/2024 documented that Resident #165 was last seen by staff at 3:15 PM on 7/6/2024. Resident #165 was found close to the genital area of Resident #151 by Licensed Practical Nurse #4 on 7/6/2024 at 4:45 PM. The investigation documented the residents were noted to be unclothed in Resident #151's room. Resident #165 was dressed by staff and re-directed out of the room. Resident #151 stated they did not have sex with Resident #165 but Resident #165 did perform oral sex on them. The conclusion of the investigation documented the residents' cognitive status, they were unable to give consent for sexual activities and this was reported to the New York State Department of Health. Review of a progress note from the Psychiatric Nurse Practitioner dated 7/16/2024 documented that Resident #165 was seen for sexual inappropriateness. The progress noted documented that Resident #165 had poor insight, poor memory, and poor judgement due to dementia. During an interview on 12/18/2024 at 1:22 PM, Certified Nurse Aide #1 stated that staff were looking for Resident #165 prior to the incident, but they did not witness anything between Resident #165 and Resident #151. During an interview on 12/19/24 at 9:27 AM, Social Worker #1 stated Resident #151 does not have the capacity to consent. They stated residents with dementia cannot consent to anything. During an interview on 12/19/24 at 9:36 AM, the Director of Social Work stated that non-consenting adults having sex would be considered abuse. They stated that Resident #151 does not have capacity to consent. During an interview on 12/19/2024 at 10:33 AM, the Assistant Director of Nursing stated because there was no psychosocial harm between Resident #165 and Resident #151, there was no abuse. They stated that Resident #165's going into other residents' rooms was a new behavior and that's why Resident #165 was put on one-to-one supervision to prevent Resident #165 from repeating this wandering behavior. During an interview on 12/19/2024 at 1:11 PM, Resident #151's responsibility party stated visited Resident #151 right after the incident occurred. They stated that Resident #151 told them that Resident #165 had performed oral sex on them. The Responsible Party stated they spoke to Resident #151 about informed consent and that other residents might not be able to consent to sex. During an interview on 12/19/2024 at 1:21 PM, Licensed Practical Nurse #4 stated they stand by what was in their statement. They stated that if two residents do not have the ability to consent to sex, then it was considered abuse. During an interview on 12/19/2024 at 3:58 PM, Resident #165's responsible party stated they were not aware that Resident #165 was unclothed and in bed with Resident #151. The facility informed them that Resident #165 was fully clothed, and that Resident #151 only had their pants down. They stated the facility informed them they couldn't find Resident #165 for over an hour and that the security cameras were not working on the memory unit. During an interview on 12/19/2024 at 4:33 PM, the Medical Director stated that if residents cannot consent to sex, then it was considered abuse. They stated that they do not believe Resident #165 could consent. During an interview on 12/20/2024 at 9:26 AM, the Psychiatric Nurse Practitioner stated that Resident #165 does not have the capacity to consent. Two residents who don't have the capacity to consent; can't consent to sex so they would consider this abuse. During an interview on 12/20/2024 at 12:08 PM with local law enforcement, they stated that they were called to the facility concerning an incident between two residents. They stated that the facility told them the contact was consensual and they did not initiate an investigation because of what the facility told them. During an interview on 12/20/2024 at 12:23 PM, Licensed Practical Nurse Supervisor #3 stated that Resident #165 does not have the ability to say yes or no. Resident #165 was put on one to one supervision after the incident because they did not want Resident #165 to wander in and out of other residents' rooms to protect them and other residents from possible abuse. They stated they had contacted the local police department because they thought it may have been abuse. During an interview on 12/20/2024 at 1:21 PM, the Director of Nursing stated that what happened between Resident #151 and Resident #165 was not abuse because nothing was witnessed. The Director of Nursing stated that a reasonable amount of time to do a Registered Nurse assessment for an incident between two residents was 12 to 24 hours after the incident. During an interview on 12/20/2024 at 1:36 PM, Licensed Practical Nurse #2 stated that confused residents do not have the ability to consent. They stated that two residents unclothed in a room together would be considered abuse and should be reported right away to the Director of Nursing or Administrator. During an interview on 12/20/2024 at 1:44 PM, Registered Nurse Supervisor #2 stated they started their shift at 7:00 PM on 7/6/2024. They had assessed Resident #151 a little after 7:00 PM when they started their rounds, and they did not find any injuries on the resident at that time. Registered Nurse Supervisor #2 stated they did not assess Resident #165 right away because the resident was sleeping. They stated they assessed Resident #165 around 1:00 AM when Resident #165 was receiving a medication and they did not observe any marks or injuries at that time. Registered Nurse Supervisor #2 stated at the time of the incident, there didn't seem to be a sense of urgency, so they assumed there was no abuse involved. During an interview on 12/20/24 at 2:06 PM Licensed Practical Nurse Inservice Coordinator #1 stated, if two residents who lacked capacity to consent were found naked in bed together it would be considered abuse. 10 NYCRR 415.4(b)(1)(i)

Based on observation, interview, and record review conducted during the Standard survey completed on 12/20/24, the facility did not maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for one (Resident #10) of three residents reviewed. Specifically, staff placed linens soiled with urine and fecal matter and soiled incontinence briefs directly on the floor and on the resident's bed headboard and footboard while providing care. The finding is: The policy and procedure titled Incontinent Care revised 3/2022 documented to remove brief, clothing and bed linen and place on a soiled barrier. Wash perineum, anus, buttocks, abdomen, hips, and thighs. Rinse if using soap. Pat dry with a towel. Remove gloves, wash hands, apply new gloves and apply a thin layer of protective skin barrier per care plan. Apply one glove before leaving room to place linen in hamper. The policy and procedure titled Infection Prevention and Control General Statement revised 11/2024 documented the primary purpose of this facility's infection prevention and control program is to establish guidelines to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Establish guidelines to follow in implementing Standard and Transmission Precautions for handling of blood, body fluids, secretions, excretions, mucous membranes, and non-intact skin. Resident #10 was admitted with diagnoses of depression, anxiety, and paranoid schizophrenia. The Minimum Data Set (a resident assessment tool) dated 10/23/24 documented Resident #10 was usually understood, usually understands and was cognitively intact. Additionally, Resident #10 required partial/moderate assistance from staff for personal hygiene. The comprehensive care plan dated 7/29/24 documented Resident #10 had a self-care performance deficit related to Parkinson's Disease and was incontinent of bowel and bladder. The resident required maximal assist for bathing and incontinent care. The Visual/Bedside Kardex Report (a guide for staff to provide care) dated 12/19/24 documented incontinent care was to be provided every 2-3 hours and the resident required maximum assist of two people. During an observation of morning care on 12/19/24 at 8:13 AM, Certified Nurse Aide #4 and Certified Nurse Aide #5 performed hand hygiene and donned gloves. Certified Nurse Aide #4 wet a washcloth at the sink in the room and then began to cleanse Resident #10's face. Certified Nurse Aide #4 placed the washcloth that was used on Resident #10's face on top of the headboard of the bed. Certified Nurse Aide #5 placed a barrier for soiled items at the foot of the bed and stated to Certified Nurse Aide #4 that the dirty barrier was placed at the foot of the bed. Certified Nurse Aide #4 cleansed Resident #10's chest and then placed the used washcloth directly on the footboard of the bed, away from the soiled barrier. Certified Nurse Aide #4 provided urinary incontinent care with another washcloth and then placed that washcloth on the footboard of the bed, away from the soiled barrier. Prior to rolling Resident #10 on their side and removing the urine soiled brief, Certified Nurse Aide #4 stated to Certified Nurse Aide #5 that Resident #10 was usually incontinent of urine whenever they were rolled and then placed a rolled clean towel between Resident #10's legs. They rolled Resident #10 onto their right side and Certified Nurse Aide #4 removed the urine soiled brief and placed it directly on the floor. They used the washcloth to cleanse the buttocks and anus. There was a small amount of brown debris on the washcloth after Certified Nurse Aide #4 cleansed the anus. Certified Nurse Aide #4 dropped the washcloth to the floor near the brief that was on the floor. Certified Nurse Aide #4 cleansed the anus again with another washcloth, there was a small amount of brown debris on the washcloth and Certified Nurse Aide #4 placed the washcloth directly on the floor. The Certified Nurse Aides rolled Resident #10 onto their left side after placing a clean brief under them. The Certified Nurse Aides rolled Resident #10 onto their back and Certified Nurse Aide #4 removed the towel from between Resident #10's legs and placed it on the bed alongside Resident #10's left hip. Certified Nurse Aide #5 asked if the towel was wet and Certified Nurse Aide #4 held it up and stated Yes, [Resident #10] peed on it. The towel was visibly wet. Without changing their gloves and performing hand hygiene Certified Nurse Aide #4 then took the towel that was next to the resident's hip, the washcloths and the brief from the floor, walked over to the door and placed their hand on the door handle. Certified Nurse Aide #5 stated to Certified Nurse Aide #4 to stop what they were doing and to place the soiled items in a bag before leaving. Certified Nurse Aide #4 then placed all items directly on the floor. Certified Nurse Aide #5 stated to Certified Nurse Aide #4 to place items on the dirty barrier and wash their hands. Certified Nurse Aide #4 picked the soiled items off the floor, placed them on the dirty barrier, removed their gloves, washed their hands, and then left the room. They returned with bags and placed the soiled items into the bags. During an interview on 12/19/24 at 8:54 AM, Certified Nurse Aide #5 stated Certified Nurse Aide #4 should have used a dirty barrier for the washcloths and brief because without the barrier they were contaminating the surfaces in the room. During an observation and interview on 12/19/24 at 8:56 AM, Certified Nurse Aide #4 stated that the floor was the correct place to put the soiled brief and washcloths because there was fecal matter on the washcloths. They stated if they would have placed the soiled brief and washcloths on the barrier that was on the bed then they would have contaminated the bed. They stated that placing the used washcloths and towel on the headboard, footboard and alongside Resident #10 contaminated those areas of the bed. During an interview on 12/19/24 at 8:58 AM, Registered Nurse Unit Manager #3 stated Certified Nurse Aide #4 should have used the barrier that was placed by Certified Nurse Aide #5 from the start of care. They should not have placed the soiled washcloths, towel, or brief on the headboard, on the footboard, along the side of Resident #10, or on the floor because that was an infection control risk. During an interview on 12/19/24 at 9:43 AM the Registered Nurse Assistant Director of Nursing Infection Preventionist stated Certified Nurse Aide #4 needed to be re-educated regarding the use of dirty barriers. They stated it was expected that certified nurse aides used proper hand hygiene including glove changes and used dirty barriers and bags to handle soiled linen during morning care and routine incontinent care. They stated the nurses, unit managers, and in-service coordinators were responsible to make sure the certified nurse aides were educated on infection control. During an interview on 12/20/24 at 10:49 AM, the Director of Nursing stated they expected Certified Nurse Aide #4 to follow the correct procedure during care and follow infection control guidelines because it was for the protection of the resident. They stated it was everyone's responsibility to follow infection control guidelines including certified nurse aides, licensed practical nurses, unit managers, the director of nursing and in-service coordinators. They stated ultimately, the Director of Nursing was responsible for the nursing staff on the units. 10 NYCRR 415.19(a)(1)(c)

Based on observation, interview and record review conducted during the Standard survey completed on 12/20/24, the facility did not ensure residents had the right to interact with members of the community and participate in community activities inside the facility for one (Resident #33) of two residents reviewed. Specifically, staff did not accommodate Resident #33's choice to attend the Resident Council Meeting on 12/17/24. The finding is: The policy and procedure titled Resident Rights and Responsibilities revised 4/2/24 documented the facility functions on the premise that the service it renders should demonstrate its belief in the dignity and worth of every individual. It is the objective of the facility to provide the Patient/Resident with optimal nursing and psychosocial care. Every effort is made by the staff to meet the Patient/Resident's individual needs and requirements. Resident #33 had diagnoses which included multiple sclerosis, paraplegia (paralysis of lower extremities) and anxiety. The Minimum Data Set (MDS, a resident assessment tool) dated 12/9/24 documented Resident #33 was cognitively intact. The Minimum Data Set, dated dated dated [DATE] documented it was very important for Resident #33 to participate in their favorite activities and with groups of people. The comprehensive care plan revised 9/18/24 documented Resident #33 would select daily activities of choice. The planned activities included Resident #33 enjoyed watching television, listening to music, playing bingo, attending resident council, and socializing with peers and staff. The Kardex (guide used by staff to provide care) with a print date of 12/18/24 documented Resident #33 required transport assistance to leisure time activities as needed. The December 2024 [NAME] 3 Activity Calendar revealed a Resident Council Meeting was scheduled at 10:30 AM on 12/17/24. During an observation on 12/17/24 at 10:30 AM the Resident Council Meeting took place in the [NAME] 3 dining room. During an observation and interview on 12/17/24 at 11:23 AM, Resident #33's call bell was activated and illuminated above their bedroom door. Resident #33 was lying in bed, and stated they were upset. They had their call light on for over an hour and no one had come to get them up and they had missed the Resident Council Meeting at 10:30 AM. Resident #33 stated they attended the Resident Council Meetings on a regular basis. They stated they told the Director of Activities that they had planned on attending the meeting this morning. Review of the Resident Council Meeting minutes from June 2024 through November 2024 revealed Resident #33 attended the Resident Council meetings regularly. During an interview on 12/18/24 at 9:33 AM, Certified Nurse Aide #6 stated Resident #33 actively participated and attended Resident Council meetings. During an interview on 12/18/24 at 9:34 AM, Registered Nurse #1 Unit Manager stated the Director of Activities should have informed Certified Nurse Aide #13 that Resident #33 wanted to attend the Resident Council Meeting on 12/17/24. During an interview on 12/18/24 at 9:50 AM, the Director of Activities stated Resident council meetings were held every third Tuesday of the month and were announced during the Daily Chronicle at 9:30 AM for a reminder. In addition, the Director of Activities invited Resident #33 to the Resident Council Meeting on 12/17/24 because they attended the meetings regularly. Resident #33 had told them that they were not feeling good and assumed that they did not want to attend. Resident #33 liked to be in the know of what's going on and that was their right and should not have assumed. During an interview on 12/18/24 at 10:50 AM, Certified Nurse Aide #14 stated they took over for Certified Nurse Aide #13 on 12/17/24 at 10:00 AM. Certified nurse aide #14 was sidetracked and couldn't provide care timely; there for Resident #33 missed the Resident Council Meeting. Certified Nurse Aide #14 stated attending the meeting was the resident's right and they should have prioritized their assignment and accommodated Resident #33's preference. During a telephone interview on 12/18/24 at 1:43 PM, Certified Nurse Aide #13 stated they provided care for Resident #33 at 9:00 AM on 12/17/24 and Resident #33 did not mention a thing about going to the Resident Council meeting. During an interview on 12/20/24 at 11:07 AM, the Director of Nursing stated the Director of Activities knows who wants to attend activities and should have let the nursing staff know. Attending the meeting was Resident #33's right and would have expected the staff to accommodate that right. I'm sure it was miscommunication. During an interview on 12/20/24 at 10:57 AM, the Administrator stated they would have expected Resident #33 to attend the meeting based on their preference. 10 NYCRR 415.5 (b) (1,3)

Based on observation, interview, and record review conducted during the Standard survey completed on 12/20/24, the facility did not ensure each resident was offered the pneumococcal and influenza immunizations and received education regarding the benefits and potential side effects of the immunizations for two (Residents #171 and #10) of six residents reviewed. Specifically, Resident #171 was not given the influenza vaccine after their responsible party consented to the vaccination nor were they offered and educated about the pneumococcal vaccination. Additionally, Resident #10 was not given the pneumococcal vaccination after their responsible party consented to the vaccination. The findings are: The policy and procedure titled Policy on Influenza Immunization revised 10/2020, documented the facility assures that all residents receive a flu vaccination, unless medically contraindicated, or the resident makes an informed choice of refusal. The resident is immunized once the influenza vaccine consent form has been signed. The policy and procedure titled Pneumococcal Vaccination Program Residents revised 10/2024 documented the facility assures that all residents receive a pneumococcal pneumonia vaccine, unless medically contraindicated, or the resident makes an informed choice of refusal. An immunization history will be obtained upon admission and the physician will be consulted regarding an order for vaccination. The vaccine will be offered to all residents and administered with consent, unless medically contraindicated or the resident has previously received the vaccination. All residents/responsible parties will be educated on the risks and benefits of the pneumococcal vaccine using the current CDC/ACIP (Centers for Disease Control/Advisory Committee on Immunization Practices) Guidelines as the basis for the education. If a resident/responsible party refuses the vaccine, a declination form is obtained by the nurse and filed in the medical record. 1. Resident #171 was admitted with diagnoses of pneumonia, necrotizing encephalopathy (a severe brain disease that can occur after a viral infection), and dementia. The Minimum Data Set (a resident assessment tool) dated 10/31/24 documented Resident #171 was sometimes understood, sometimes understands and was severely cognitively impaired. The Minimum Data Set documented the influenza vaccine was not received in the facility and the pneumococcal vaccination was not up to date and not offered. Review of the nursing progress notes dated 9/1/24 - 12/19/24 lacked documented evidence that Resident #171, or their responsible party were offered, declined, or were provided education regarding the pneumococcal immunization. Review of Resident #171's electronic medical record on 12/19/24 lacked documented evidence of the pneumococcal immunization consent/declination form. Review of the Influenza (Seasonal and H1N1) Vaccine Consent/Declination Form dated 9/26/24, completed by Licensed Practical Nurse Unit Manager #8, documented verbal consent was obtained from Resident #171's responsible party. Review of the nursing progress note dated 9/26/24 at 4:06 PM, Licensed Practical Nurse Unit Manager #8 documented they had spoken with the resident's responsible party regarding the resident receiving the influenza vaccine. Education was provided and the resident's responsible party gave consent for the resident to receive the vaccine. There was no documented evidence Licensed Practical Nurse Unit Manager #8 provided education or offered the pneumococcal vaccination. Review of the Medication Administration Records dated 9/1/24-9/30/24, 10/1/24-10/31/24, and 11/1/24-11/30/24 lacked documented evidence the influenza vaccination was given. Review of the Immunization Report dated 12/19/24 documented Resident #171 was not eligible for the influenza vaccination. Review of the Order Listing Report dated 12/19/24 lacked documented evidence of an order for the influenza vaccine. During an interview on 12/19/24 at 11:01 AM, Hospice Doctor #1 stated patients who were on the hospice program received the influenza vaccination based on their functional status and overall goals of care. They stated there were families and patients who requested the vaccine in order to avoid the burden of symptoms of the flu and they were welcomed to receive vaccinations. The only time they may have advised against vaccinations, as a Hospice Doctor, was when death was imminent. They stated Resident #171 had a prognosis of months, meaning death was not imminent. They stated, according to the medical record, there was no egg allergy that would make Resident #171 ineligible for the vaccination and the only other reason that would make Resident #171 ineligible was a history of an adverse reaction. However, they stated, if Resident #171's responsible party consented to the vaccination, then they would have assumed there was never an adverse reaction to the vaccination in the past. They stated, in their experience, there were many hospice patients throughout the area and many of them received the influenza vaccination, unless their death was expected within the next two weeks. During an interview on 12/19/24 at 11:07 AM, Resident #171's responsible party stated they consented to the influenza vaccination, but they were unaware if Resident #171 received it. Resident #171 received the vaccination in the past and never had any adverse reactions to it. They stated they remembered asking a staff member about the pneumococcal vaccination because they thought it would be a good idea since Resident #171 was admitted to the facility with pneumonia, but nobody had followed up with them. They stated they wanted Resident #171 to receive both vaccinations. During an interview on 12/19/24 at 11:19 AM, Licensed Practical Nurse Unit Manager #7 reviewed the electronic medical record, and stated they did not see any consent or declination for the pneumococcal vaccine. They stated it may have been documented in the nursing progress notes if it was offered. They stated the influenza consent form was in the electronic medical record and dated 9/26/24. Licensed Practical Nurse Unit Manager #7 stated the immunization documentation in the electronic medical record stated Resident #171 was not eligible to receive the influenza vaccination. They stated Resident #171 was a Hospice resident and a vaccination could be painful and that may have been why they were not eligible to receive the vaccination. They stated Resident #171 became a Hospice resident on 10/18/24 and they were not on the Hospice program at the time of the consent form. During an interview on 12/19/24 at 11:34 AM, Licensed Practical Nurse Unit Manager #8 stated there was not a pneumococcal consent/declination form in Resident #171's electronic medical record and if it was offered, the consent/declination form would have been completed and scanned into the electronic medical record. Resident #171 had a consent/declination form completed for the influenza vaccination and it was their responsible party who had consented to the vaccination. They stated in the electronic medical record, Resident #171 was ineligible for the influenza vaccination. Licensed Practical Nurse Unit Manager #8 stated that Resident #171 may have been on antibiotics at some point and that was why they were ineligible. Resident #171 was ordered to have antibiotics from 10/10/24-10/17/24. They stated they should have received the influenza vaccination at some point after 10/20/24. They stated the Unit Managers were responsible to ensure the residents on their units had consent/declination forms completed for vaccinations and that they received the vaccination if there was consent received. They stated Resident #171 should have received the vaccinations because the vaccinations could lessen the symptoms of influenza and pneumonia. The residents in the facility had the right to be offered a consent or declination to vaccinations. During a telephone interview on 12/19/24 at 4:30 PM, the Medical Director stated Resident #171 had severe dementia and their responsible party made medical decisions for them. They stated Resident #171 was not ineligible to receive the influenza vaccine and they should have received it. The Medical Director stated the pneumococcal vaccination should have been discussed with the responsible party and offered to the resident. 2. Resident #10 was admitted with diagnoses adult failure to thrive (a decline in physical and mental functioning), depression, and anxiety. The Minimum Data Set, dated dated dated [DATE] documented Resident #10 was usually understood, usually understands and was cognitively intact. Review of the Absolut Care Determination of Capacity dated 7/19/24 documented Resident #10 lacked the capacity to make health care decisions due to a diagnosis of dementia. Review of the Resident Consent/Declination of Immunizations and Health Screening form dated 11/21/24 documented Resident #10's responsible party consented to the influenza vaccine and the pneumococcal vaccine. Review of the nursing progress notes dated 11/1/24 through 12/19/24 lacked documented evidence that the pneumococcal vaccine was ordered, refused, or given. Review of the Medication Administration Record dated 11/1/24-11/30/24 lacked documented evidence the pneumococcal vaccination was given. Review of the Medication Administration Record dated 12/1/24-12/31/24 documented the pneumococcal vaccine was ordered for a one time administration from 12/19/24-12/21/24, but was not signed by a nurse as given or refused. Review of the Immunization Report printed on 12/19/24 documented the Prevnar-20 (pneumococcal vaccine) was refused. During an interview on 12/19/24 at 11:46 AM Registered Nurse Unit Manager #3 stated Resident #10 has not received the pneumococcal vaccine because it has not been given yet and there was no order for it. Registered Nurse Unit Manager #3 stated they spoke with Resident #10 in May 2024, and they refused because they had already received the vaccine but did not know when. Nurse Practitioner #1 completed the consent form with Resident #10's responsible party on 11/21/24 and they may have requested having the pneumococcal vaccine spaced apart from the influenza vaccine. They stated both the medical providers and unit managers were responsible to put orders into the electronic medical record; nurses and unit managers were responsible to ensure vaccines were given. During an observation and interview on 12/19/24 at 11:59 AM, Nurse Practitioner #1 stated they remembered discussing the risks and benefits of vaccinations with Resident #10's Responsible Party and they had consented to both the influenza and pneumococcal vaccination. They stated they preferred to space vaccinations out by two weeks instead of giving them all at once. They stated, Resident #10 should have had an order to receive the pneumococcal vaccine on 12/6/24, two weeks after they received the influenza vaccine on 11/22/24. They stated there was nothing in Resident #10's chart contraindicating them from receiving the pneumococcal vaccine. They stated there should have been an order in the electronic medical record because there needed to be an order for it to be given. They stated they preferred the Unit Managers put the orders in because they were not comfortable putting the orders into the electronic medical record. Resident #10 should have received the pneumococcal vaccine because older adults could become very ill and respiratory illnesses spread a lot faster in the communal setting. Registered Nurse Unit Manager #3 was observed requesting an order for the pneumococcal vaccine for Resident #10 from Nurse Practitioner #1. Nurse Practitioner #1 gave a verbal order for the pneumococcal vaccine for Resident #10, and it was entered into the electronic medical record by Registered Nurse Unit Manager #3. During an interview on 12/20/24 at 9:11 AM, the Registered Nurse Assistant Director of Nursing/Infection Preventionist stated Resident #171 should have received the influenza vaccination and should have been offered the pneumococcal vaccination. They stated both vaccinations were important because in the geriatric population the vaccinations could protect them from respiratory symptoms and illness. They stated because Nurse Practitioner #1 usually waited a couple weeks between vaccinations, they felt Resident #10 received their pneumococcal vaccination timely. The physicians were responsible for giving the order for vaccinations, but at the end of the day the Unit Managers were responsible to make sure the consent/declination form was completed, and if there was consent for the vaccination, they were responsible to make sure the vaccination was administered. During an interview on 12/20/24 at 10:49 AM, the Director of Nursing stated they expected the influenza and pneumococcal vaccinations to be offered to the residents or the responsible parties. They expected the unit managers or nurses on the unit to obtain the orders for the vaccination and to administer the vaccinations. 10 NYCRR 415.19(a)(1)

Based on observation, interview, and record review conducted during a Standard survey completed on 6/28/23, the facility did not ensure that residents who receive a psychotropic medication have gradual dose reductions (GDR), unless clinically contraindicated, in an effort to discontinue these drugs for one (Resident #7) of six residents reviewed for psychotropic medication use. Specifically, there was a lack of a GDR attempt for a resident receiving an antipsychotic medication without adequate supporting evidence for its continued use. The finding is: The policy and procedure (P&P) titled Psychotropic Med Use Initiation and Gradual dose reduction dated revised 10/22 documented each resident is evaluated for the initiation/continued need of psychotropic medications and the determination of whether he/she is being maintained on the lowest effective dose. Each resident receiving psychotic medication(s) require a GDR unless deemed and documented as clinically contraindicated. A determination is made if GDR/discontinuation is appropriate based on evaluation of resident's target symptoms, effect of medication, clinical stability and/or resolution of underlying causes. GDR/tapering for psychotropic medication and antipsychotics must: Occur within the 1st year after initiation; GDR in 2 separate quarters, with at least one month between attempts unless contraindicated; After the 1st year, GDR must be attempted annually, unless clinically contraindicated. The requirements underlying guidance emphasize the importance of seeking an appropriate dose and duration for each medication and minimizing the risk of adverse consequences. The purpose of tapering a medication is to find an optimal dose to determine whether continued use of the medication is benefiting the resident. Clinical contraindication for resident receiving psychotropic medication to treat behavioral symptoms related to dementia, the GDR is considered clinically contraindicated if: The resident's target symptoms returned or worsened after the most recent attempt at a GDR within the facility; and the physician has documented the clinical rationale for why any additional attempted dose reductions at that time would be likely to impair the resident's function or increase distressed behavior. 1. Resident #7 had diagnoses including altered mental status (onset:8/31/21), unspecified dementia, with other behavioral disturbance (onset:10/3/22), and psychotic disorder with delusions due to known physiological condition (onset: 4/27/22). The Minimum Data Set (MDS- a resident assessment tool) dated 5/24/23 documented Resident #7 was cognitively intact, understands and was understood. Resident #7 had no hallucinations or delusions, and no behaviors were exhibited. The MDS documented Resident #7 received an antipsychotic medication on a routine basis. The Comprehensive Care plan (CCP) revised on 6/7/22, documented Resident #7 had potential for alteration in mood and behavior pattern related to anxiety, depression, psychotic disorder with delusions and disease process (AMS-altered mental status). Behaviors included accusatory statement toward staff and peers, refuses medications, refuses out of bed (OOB). Interventions included to respect and listen to expression of feelings, report changes, monitor mood/behavior for change, respond to behaviors with the following diversions/approaches: redirection, change tone of voice, offer activities, discuss clairvoyance abilities, and administer psychotropic medication per MD order. The facility Order Recap Report dated 9/1/21-6/30/23, documented a physician order by MD #1 on 9/3/21 for Haloperidol Decanoate Solution (anti-psychotic medication) 100 milligrams (mg) per millimeters (ml) inject 100 mg intramuscularly (IM) one time a day every 30 day(s) for psychosis with delusions. An order on 3/19/22 changed the indication for use to vascular dementia with behavioral disturbance. An order on 4/5/22 changed the administration to the 20th and ending on the 20th every month. An order on 4/28/22 changed the indication for use to psychotic disorder with delusions. Active order dated 5/20/22, with no end date, documents Haloperidol Decanoate solution 100mg/ml inject 100mg IM one time a day starting on the 20th and ending on the 20th every month for psychotic disorder with delusions. The SW (social worker) Psychotropic Medication Review dated 4/12/22, 7/2/22, 9/23/22, 10/7/22 and 4/12/23, reviewed at BMARC (Behavior Modification Assessment Record Committee), documented there was no psych eval (psychiatric evaluation) completed, psychotropic medication-Haldol and there was no specific reason documented as to why a GDR was contraindicated. The SW Review completed 7/15/22 through 5/23/23 revealed there was no documented history of a Haldol GDR and why a GRD had not been attempted. Review of the Resident #7's Physician Progress Notes revealed the Medical Doctor (MD) #1 documented the following: - 9/2/21, Medical History anxiety disorder-unspecified, Major Depressive Disorder-Single Episode-Unspecified, Vascular Dementia with behavioral disturbance and unspecified dementia without behavioral disturbance. Review of Systems (ROS) denies anxiety, insomnia, suicidal thoughts; positive for depression. Physical Exam (PE) mood & affect: upset, anxious; attention span & concentration: decreased; delusions: present. Mood is pleasant today, attention and concentration decreased, agitated today. Plan patient is still not taking medication, and, in my opinion, patient does not have capacity and therefore if they continue to not take medication, patient may have to be given Haldol injection to stabilize. - 8/11/22, Medical History included altered mental status-unspecified, communication deficit, and psychotic disorder with delusions due to known physiological condition. ROS denies insomnia, suicidal thoughts; positive for depression, anxiety PE distress: none; status: cooperative; judgement: appropriate; mood & affect: appropriate; attention span & concentration: intact; thoughts: normal; associations: normal. Plan continue behavioral counseling and gentle redirection therapy. Patient likely had some issues for which they were hospitalized however now stabilized and taking their medications appropriately. Patient was on Zoloft 50 mg but discontinued, also on Haloperidol 100mg injection once a month for their behavioral issues. - 4/12/23, Medical History included major depressive disorder-recurrent-severe with psychotic symptoms. ROS and PE- no changes from previous review 8/11/22. Plan continue haloperidol. Review of the Resident #7's Nurse Practitioner (NP) Progress Notes revealed NP #1 documented the following: -11/11/22, Member continues Haldol IM for depression with psychosis. Has been doing well with no adverse side effects. Follows with psychiatric NP. Hallucinations: negative; angry: negative; upset negative; socially appropriate, coherent and cooperative. GDR contraindicated and would exacerbate condition and decrease QOL (quality of life). Continue to follow with psychiatric provider. -1/27/23, Dementia is mild to moderate and complicated by their mental health disease. Depression and anxiety and schizoaffective disorder managed with Haldol IM monthly follows with psychiatric NP. Spoke to nursing denies concerns. Plan Member with dementia with behavioral disturbance/psychosis-sometimes will refuse care but less frequently on Haldol. Resident #7 is followed by psychiatric provider. GDR of Haldol is contraindicated and would decrease QOL and exacerbate current condition. -3/31/23, resident being seen for monthly visit and follow up dementia. Appears to have lost weight. Appetite has been poor, sleeps through most meals. Negative for hallucinations. GDR of Haldol is contraindicated and would decrease QOL and exacerbate current condition. -5/10/23, resident being seen for follow up depression, last month Remeron started for poor appetite and depression. No changes in behavior. Plan: Resident with major depression, recurrent with psychotic symptoms. Mood and behaviors stabilized Haldol 100mg IM monthly. GDR contraindicated and would exacerbate condition and decrease QOL also put member at risk. Continue to follow with psychiatric provider. Review of Geriatric Psychiatry Consultation Services dated 9/10/21 documented reason for consultation, Refuses medications-3 weeks, resistive to HOC (Hands on Care) at times-won't allow blood draw, thinks meds interfere with psychic abilities-tarot card reader. Recommendations: urinalysis (UA) and culture- foul smelling urine and difficulty urinating; discontinue Seroquel (anti-psychotic) to minimize meds and avoid use of 2 anti-psychotics; continue Zoloft (anti-depressant) 50 mg-could GDR in future; continue haloperidol 100mg monthly for delusions, paranoia; Psych follow up 3-4 weeks or as needed. There were no further psychiatry notes provided by the facility after initial consult on 9/10/21. Review of the CHE Behavioral notes from 1/24/22-3/25/22 documented that Resident #7 had no documented evidence of psychotic behaviors that were detrimental to the resident or others. CHE Behavioral note dated 3/25/22 documented Resident #7 denied symptoms and declined need for ongoing counseling services. Case closed on this date per Resident #7 request. There were no further psychological notes after 3/25/22. Review of Note To Attending Physician/Prescriber MRR (Medication Regime Review by Consultant Pharmacist on 3/18/22 suggested dose of haloperidol decanoate be reduced to 80 mg IM every (q) 30 days from current dose of 100mg IM q30 days for Resident #7. Physician/Prescriber Response dated 3/25/22 documented, disagree-stable, doing well. Followed by psych. Resident #7 was last seen by Psychiatry 9/10/21 and psychological services on 3/25/22. Review of Resident #7's progress notes 3/14/22 through 6/30/22 and 1/4/23 through 6/26/23 revealed there was documented evidence of hallucinations, agitation, anxiety and accusatory statements toward staff and peers. Adjusted well to room changes 4/26/22 and 5/2/22. During intermittent observations on 6/22/23 to 6/27/23 from 7:50 AM to 2:30 PM, Resident #7 had no anxiety, delusions, refusal of medications, and refusals to get out of bed, outbursts, striking out at staff or residents. Additionally, Resident #7 had tremors of their upper extremities and involuntary jaw movements while awake During an interview on 6/26/23 at 10:29 AM, Resident #7 stated it was hard for them to feed themselves because their arms shake like crazy and on 6/28/23 at 12:09 PM, Resident #7 stated the movement in their jaw bothers them and it had been occurring for years. On 6/27/23 at 7:54 AM during a mechanical lift transfer observation, Resident #7 displayed no negative behaviors, was pleasant and calm with care. During an interview on 6/28/23 at 9:35 AM, Certified Nursing Assistant (CNA) #3 stated Resident #7 has had no behaviors to their knowledge. CNA #3 stated Resident #7 hands shake and that they have a difficult time feeding themselves. They have noticed the resident's tongue moves, back and forth, in their mouth and had brought it to the attention of the nurse. During an interview on 6/28/23 at 9:42 AM, Licensed Practical Nurse (LPN) #3 stated Resident #7 has never displayed behaviors, had delusions, or made any accusations to their knowledge. LPN #3 stated Resident #7 had tremors to both of their hands. During an interview on 6/28/23 at 10:01 AM, Registered Nurse (RN) #1 stated Resident #7 has had no recent delusions or hallucinations and had not been seen by a psychiatrist in a while. Additionally, RN #1 stated that Resident #7 had tremors to their hands and wasn't sure when they started. During an interview on 6/28/23 at 10:56 AM, Director of Social Worker (SW) #1 stated Resident #7 was not currently receiving any services from psychiatry and was not aware of any recent displays of behaviors. Additionally, SW #1 stated they were not aware of any GDRs of Resident #7 Haloperidol. During an interview on 6/28/23 at 12:23 PM, Medical Doctor (MD) #1 stated the order for Haloperidol came from the psychiatrist. MD #1 stated they do not give orders for Haloperidol unless the psychiatrist gave the recommendation. The order may be signed by them but was prescribed by psychiatrist for delusional disorder. MD #1 stated Resident #7 has been on Haloperidol for a long time and would not change order unless recommended by the psychiatrist. MD #1 stated that they were not aware that Resident #7 had not been followed up by a psychiatrist since 9/2021. During an interview on 6/28/23 at 12:50 PM, NP #1 stated they would have expected Resident #7 to have been seen by the psychiatrist every three months and that GDR discussions occurred every month. Additionally, NP #1 stated the psychiatrist was involved in the GDR discussions but not sure if they were available at every meeting. During an interview on 6/28/23 at 1:43 PM, Director of Nursing (DON) stated their expectation was that a GDR would occur unless there is hard core evidence documented that a GDR failed, and documentation was provided by a medical provider to support why or why not a medication shouldn't be reduced. At 2:10 PM, the DON stated Resident #7 should have been seen by the psychiatrist as recommended, and that they have no additional evidence to support the resident was followed by psychiatry services to evaluate current order and use of Haloperidol. NY 10CRR 415.12(l)(2)(ii)

Based on observation, interview, and record review conducted during a Standard survey completed on 6/29/23, the facility did not ensure that each resident who was unable to carry out Activities of Daily Living (ADL's) received the necessary services to maintain grooming and personal hygiene for one (Residents #7) of four residents reviewed for ADL's. Specifically, Residents #7 had dark thick debris under their fingernails. The findings are: The policy and procedure (P&P) titled Nail Care revised 10/11 documented purpose was to ensure cleanliness and to prevent infection. Routine nail care is to be done following bath/shower whenever possible. The P&P titled Bathing and Grooming revised 2/2019 documented all residents are bathed as often as necessary to maintain cleanliness, refresh and stimulate circulation. Care of fingers and toenails is part of the bath. Be certain nails are clean and trim as needed. 1. Resident #7 had diagnoses that included unspecified dementia, type 2 diabetes mellitus, and peripheral vascular disease (PVD- poor circulation of lower extremities). The Minimum Data Set (MDS - a resident assessment tool) dated 5/24/23 documented Resident # 7 had intact cognition and did not exhibit rejection of care. The resident required extensive assistance of one person for personal hygiene. Resident #7's comprehensive care plan (CCP) revised 9/1/21 documented Resident #7 had a self-care performance deficit. Interventions included grooming-extensive assist of one (revised:5/26/23), and nail care on bath day and/or as needed (revised:6/27/23). Goal included will have optimal personal hygiene daily. Resident #7's Kardex (a guide used by staff to provide care) as of 6/28/23, documented nail care on bath day and/or as needed, anticipate needs, and skin and feet check with daily care. Review of the physician orders revealed an active order dated 9/13/21 that documented weekly skin and nail monitoring in the evening every Tuesday for skin integrity/hygiene. Review of the Treatment Administration Records (TAR) dated 5/8/23 -6/26/23 revealed no documented evidence the resident refused nail care. Resident #7's facility progress notes 5/8/23- 6/26/23 did not document any refusal of care. During an observation on 6/22/23 at 10:34 AM, Resident #7's right hand fingernails were long, over pads of fingers, with pink nail polish and dark debris under them. During an observation on 6/26/23 at 8:24 AM, Resident #7 was eating breakfast, utilizing right hand with spoon. Right hand fingernails with dark debris under them. Debris under nails able to be observed through painted nails extending over pads of fingertips. During an observation on 6/27/23 from 7:50-7:54 AM, Resident #7 was lying in bed, after receiving am care, waiting to be transferred out of bed for breakfast. Resident #7's right hand fingernails noted with dark debris under them through painted nails. During an interview on 6/22/23 at 10:34 AM, Resident #7 stated they liked their nails long, but it bothered them that they were dirty and would like them cleaned. Resident #7 stated the staff don't bother; they can't get staff to come in, so they don't ask anymore. During an interview on 6/27/23 at 11:34 AM, Certified Nursing Assistant (CNA) #1 stated the CNAs were responsible to perform nail care on residents. CNA #1 stated residents could have food or feces under their nails, and they always check residents' nails during care in the morning. Additionally, CNA #1 stated it was important to complete nail care for dignity. During an interview on 6/27/23 at 11:56 AM, CNA #2 stated the CNAs were responsible for nail care, so the residents look presentable. CNA #2 stated they usually check resident's fingernails before and after meals to make sure there is nothing caked up under them. CNA #2 stated bacteria can build up under nails and be a risk for infection. During an interview on 6/27/23 at 11:48 AM, Licensed Practical Nurse (LPN) #2 stated they would expect nail care to be done on the resident's shower day and any time as needed during the week. LPN #2 stated it was important nail care was completed to prevent infection and maintain cleanliness as stuff can get under nails. During a further interview and observation on 6/27/23 at 12:01 PM, CNA #2 stated Resident #7's nails definitely needed to be cleaned as it appeared they had food debris under all their nails on the right hand. During an interview and observation on 6/27/23 at 12:04 PM, CNA #1 stated they completed morning (AM) care today on Resident #7 and should have cleaned their nails because they have dark debris under their nails. During an interview and observation on 6/27/23 from 12:11 PM to 12:14 PM, Director of Nursing (DON) stated it was the resident's preference on when nail care was provided. DON stated nail care should be done on shower day, as needed and with AM care if needed for infection control reasons and fragile skin. DON observed Resident #7s right hand/fingernails and stated they absolutely needed to have their nails cleaned. 10 NYCRR 415.12 (a)(3)

Based on interview and record review conducted during a Complaint Investigation (NY00310847) during a Standard survey completed on 6/28/23, the facility did not ensure that residents, residents' representative, and the Office of the State Long Term Care Ombudsman receive a written notice of transfer or discharge must be made by the facility at least 30 days before the resident is transferred or discharged . Specifically, three (Residents #221, 220, 219) of four, their representatives, and the New_York State Ombudsman office did not receive a written transfer or discharge notices 30 days prior to being transferred to another facility. The findings are: The policy and procedure titled Discharge Notice dated 12/03 documented that a notice will be issued at least 30 days prior to the transfer/discharge unless there is an urgent medical need, the health or safety of the residents are endangered, or there is a sufficient improvement in the resident's health where the services of the skilled nursing facility is no longer needed. 1. Resident #220 was admitted to the facility with diagnoses of cancer and malnutrition. The Minimum Data Set (MDS - a resident assessment tool) dated 7/31/22 documented Resident #220 was cognitively intact, was understood, and understands others. Further review of the MDS documented there was not an active discharge plan in place for the resident. Resident #220's care plan dated 7/26/22 documented the resident did not express a return to the community and was a long-term placement. A Social Work (SW) progress note dated 1/10/23 documented that Resident #220's discharge plan was to remain in the facility. Review of a letter sent by the facility dated 1/13/23 documented that [NAME] and C units were closing temporarily with the intent to make upgrades to those units. Further review of the letter documented that the Social Work department was to contact families of all the residents to discuss their preferences to care. Review of the transfer/discharge notice dated 1/31/23 documented that Resident #220 was going to be discharged to another facility on 2/3/23 due the resident's unit closing. Further review of the transfer/discharge notice documented that Resident #220 family representative was verbally notified 1/30/23 and the notice was emailed to the NYS Ombudsman office on 1/31/23. During an interview on 6/22/23 at 1:11 PM, the Ombudsman stated they were concerned about the lack of proper notifications to residents for transfer or discharge. During an interview on 6/27/23 at 9:41 PM, the Discharge Planner Social Worker stated that they initiated calls to families that were on a list of residents who would consider going to another facility. They also stated the facility was downsizing and that the residents needed to a place to go. They stated they only knew of 30-day notice of discharge or transfer in cases of non-payment of bills. During an interview on 6/27/23 at 9:45 AM, the Director of Social Work, stated they called families to ask if there was another facility they wanted their family member to go to due to the unit closing. The Director stated that they were not aware of a written 30-day notice if a transfer was facility initiated. During a telephone interview on 6/27/23 at 10:54 AM, the former Administrator stated that the letter notifying families of the unit closure was sent in January 2023 as the facility was temporarily downsizing. The former Administrator stated the facility SW department initiated the phone calls to families about being transferred to another facility. During a telephone interview on 6/27/23 at 12:12 PM, Resident #220's representative stated they received a letter from the facility concerning their family member's unit closing at the facility. They also stated they did not receive in writing a notice of discharge or transfer from the facility. The representative stated that they, nor another representative did not request Resident #220 to be moved to another facility. The representative stated the facility called them and told them Resident #220 had to be moved as soon as possible. They were not aware they could appeal a facility-initiated discharge. During an interview on 6/28/23 at 8:58 AM, Registered Nurse Resident Care Coordinator (RN RCC) #1 stated they were covering [NAME] 2 and [NAME] 3 as the RCC. They stated they were notified about the unit's closing sometime around January 2023. They stated that the conversation about transfers and discharges between the facility and families were initiated by SW. They stated that they received phone calls from concerned families after the letters about units closing. During an interview on 6/28/23 at 9:35 AM, the Assistant Director of SW stated the family did not call to initiate the transfer. They verified that the dates on the transfer/discharge notice were correct. They also stated that Resident #220 and their representative were notified verbally on 1/30/23 and an email was sent to the Ombudsman on 1/31/23. During an interview on 6/28/23 at 9:57 AM, the SW Assistant stated they do not recall if they notified families about transfers or discharges prior to 1/31/23. The SW Assistant stated there were many families to be called by SW. They also stated they called families that had expressed prior interest in transferring to another facility. They do not recall any contact with Resident #220 or their family concerning discharge. They stated they would have documented it in the electronic medical record if they did. During an interview on 6/28/23 at 10:16 AM, Licensed Practical Nurse (LPN) RCC #1 stated they formerly worked on [NAME] 3 and recalled being notified about the unit's closing in January. They stated that around the same time, the letters notifying families about the unit closings went out. They stated that they do not recall Resident #220 nor the family initiating a transfer. During an interview on 6/28/23 at 10:30 AM, the Regional [NAME] President, stated the letters were sent out 1/13/23 to families and given to the residents in the facility. They stated that this letter would not be a notice of discharge. They stated that the facility initially asked families who had a previous interest in possibly transferring to another facility. They also stated that if a resident or their representative didn't want the resident to be transferred, they could have stayed in the facility. They stated they were not aware of any residents that wanted to stay at the facility. 2. Resident #219 was admitted to the facility with diagnoses of dementia and aphasia (a communication disorder that affects your ability to speak, write, or understand language). The MDS dated [DATE] documented that Resident #219 was severely cognitively impaired, usually understood by others, and usually understands others. The MDS also documented the resident was to remain in the facility. Resident's #220's care plan dated 8/5/22 documented the resident does not express an interest in returning to the community and is a long-term placement. Further review of the care plan documented the resident could not make independent decisions. Review of the transfer/discharge notice dated 1/31/23 documented that Resident #220 was going to be discharged to another facility on 2/3/23 due the resident's unit closing. Further review of the transfer/discharge notice documented that Resident #220 family representative was verbally notified 1/30/23 and the notice was emailed to the NYS Ombudsman office on 1/31/23. During an interview on 6/27/23 at 12:12 PM, Resident #219's representative stated they received a letter from the facility concerning their family member's unit closing at the facility. They also stated that they did not receive in writing a notice of discharge or transfer from the facility 30 days before the resident's move. During an interview on 6/28/23 at 9:35 AM, the Assistant Director of SW, stated the family did not call to initiate the transfer. They verified that the dates on the transfer/discharge notice were correct. They also verified that Resident #219 and their representative were notified verbally on 1/30/23 and an email was sent to the Ombudsman on 1/31/23. They stated that SW initiated the calls to families and residents to see if there were interested in transferring to another facility. 3. Resident #221 was admitted to the facility with diagnoses of aphasia, malnutrition, and diabetes mellitus. The MDS dated [DATE] documented Resident #221 was cognitively intact, usually understood by others, and usually understands others. The MDS documented that there was no active discharge plan in place for the resident. Resident #221's care plan dated 12/28/21 documented the resident does not express a return to the community and was a long-term placement. SW progress note dated 12/19/22 documented that Resident #221's discharge plan was for the resident to stay in the facility. SW progress note dated 1/20/23 at 11:07 AM documented that SW attempted to call the resident's spouse about a lateral transfer to another facility. SW progress note dated 1/20/23 at 11:11 AM documented that SW spoke with the resident's son to discuss a potential transfer to another facility. Further review of the progress note documented that the SW would reach out to another facility. SW progress note dated 1/24/23 documented that Resident #221 was notified that they were being transferred to another facility. Review of the transfer/discharge notice dated 1/24/23 documented that Resident #221 was verbally notified on 1/24/23 that they were to be transferred on 1/26/23. Further review of the notice documented that the Ombudsman was notified by email on 1/24/23. During an interview on 6/28/23 at 9:35 AM, the Assistant Director of SW stated, the family did not call to initiate the transfer. They verified that the dates on the transfer/discharge notice were correct. They also verified that Resident #221 and their representative were notified verbally on 1/24/23 and an email was sent to the Ombudsman on 1/24/23. They stated that SW initiated the calls to families and residents to see if there were interested in transferring to another facility. 10 NYCRR 415.3(i)(1)(iv)

Based on interview and record review, conducted during a Standard survey completed 6/28/23, the facility did not ensure the resident has a right to a safe, clean, comfortable, and homelike environment. The facility did not exercise reasonable care for the protection of resident's property from loss or theft for one (Resident #43) of 3 reviewed. Specifically, Resident #43 reported to the facility in February 2023 that their cell phone went missing during a room change from one unit to another. The facility did not investigate and follow up on the missing property report. The findings are: The policy Loss/Misappropriation of resident Property, dated/revised 11/4/2021 documented that reports of misappropriation of resident property are promptly and thoroughly investigated. The facility does not request or require residents to waive potential facility liability for losses of personal property. All Lost Property/Damaged Property Reports are filed in a file found in the Administrator's/Designee's office. This shall service as the log of allegations and subsequent investigations as required by the New_York State Code of Rules and Regulations. The procedure section documented that upon notification of lost or damaged property, the informed employee is to immediately notify the Team Leader/designee on the unit. The team leader is to initiate a search of the resident's room and other areas where the resident has been during the past several hours. The Lost or Damaged Property Report is to then be initiated by Nursing or Social Work. If the investigation concludes that misappropriation of resident property has occurred, the appropriate police agency is notified by the administrator. Depending on the nature and circumstance of the loss, the administrator may act to replace the item with a comparable product. 1. Resident #43 was admitted to the facility with diagnoses including multiple sclerosis, paraplegia (paralysis of the legs), and narcolepsy (sleep disorder that makes people extremely drowsy during the day) without cataplexy (sudden loss of muscle tone while a person is awake). The Minimum Data Set (MDS - a resident assessment tool) dated 6/6/23 documented Resident #43 was cognitively intact, was understood and understands. During a Resident Council meeting on 6/23/23 at 10:45 AM, Resident #43 stated that their cell phone went missing when they were moved from one unit to another. During an interview on 6/26/23 at 9:47 AM, Resident #43 stated the facility moved them from a unit they were closing to their current unit. During the move, Resident #43's stated that their cell phone, which they had received as a gift from their father, went missing. The resident also stated the cell phone was given to them to have a way to communicate with family members. Resident #43 stated that a purse had also gone missing, but the purse was located by facility staff and returned to them. Resident #43 stated they had left a voicemail for the social work office about the missing items and that they had reported the missing phone and purse to Unit Manager (LPN #4). Resident #43 stated that LPN #4 investigated on the unit and was able to return the purse to them but was not able to locate the cell phone. During telephone interview on 6/27/23 at 8:45 AM, LPN #4 stated they were aware of the missing phone, had completed a Missing Property Form and submitted the form to the Social Work department after searching the unit with no success. LPN #4 stated they had located the missing purse and returned that to Resident #43. LPN #4 stated the facility process was to conduct a search, if unsuccessful, complete a Missing Property Form, get as much information as possible, and submit the form to social work. Social Work takes it from there. During an interview on 6/27/23 at 9:35 AM, SW (Social Worker) #2 stated they were not aware of the missing cell phone until yesterday (6/26). They stated they did not remember any voicemail from Resident #43 regarding a missing cell phone, nor had they seen any Missing Property Form for the cell phone. SW #2 stated the completed Missing Property forms were kept in the DON's (Director of Nursing's) office. During an interview on 6/27/23 at 9:56 AM with the DON, the DON provided a Missing Property Report for Resident #43's missing cell dated 6/26/23. Review of the Missing Property Report dated 6/26/23 documented that Resident #43 was missing a phone and a purse and that the date missing was unknown. The purse was documented as having been found and the person taking the report was documented as LPN #7. The form documented that room searches had been completed and that housekeeping, and laundry had been checked and the facility and resident were negotiating reimbursement at this time. During an interview on 6/27/23 at 10:48 AM, LPN #7 stated they had found out about the missing cell phone, as Resident #43 had talked about that and the missing purse at a mealtime on 6/26/23. LPN #7 stated resident #43 had stated that the purse had been recovered and the cell phone was still missing. When asked about the Missing Property Report, LPN #7 stated they did not know what it said, as it was completed by SW #2 and they only put their name on it. Review of an email dated 2/28/23 at 7:32 AM (provided by LPN #4) revealed Nursing Supervisor #1 sent an email to SW #1, SW #2, and LPN #4. The email documented that Resident #43's cell phone had been reported missing by a family member on 2/27/23 and that a missing property report had already been completed and was about to be submitted. Review of an email dated 3/16/23 at 12:55 PM (provided by LPN #4) sent from LPN #4 to SW #2 that documented LPN #4 following up on Resident #43's request for a landline until they got another cell phone and that Resident #43 had reached out to SW #2 about this. Further review of the email revealed SW #2 responded they had received the voicemail on 3/15/23 and meant to come over to talk to Resident #43 and completely forgot. It also stated that family would have to bring in a phone and set the service up. A record review of Resident #43's progress notes from 2/10/23 through 6/26/23 revealed that Resident #43 was moved to their current room on 2/14/23, and SW #4 documented on 2/20/23 that Resident is adjusting well to room change. No concerns at this time. SW will remain available. During an interview on 6/28/23 at 11:50 AM, the DON stated that either the Unit Manager or the Social Worker of a unit should be completing a Missing Property Report for any resident property that was not found during a search. They expect family contacts and resident contacts to be documented by the social work department in progress notes and emails to document communications between facility staff/departments. During an interview on 6/28/23 at 11:50 AM, the Director of Social Work SW #1 stated they did not recall an email in February regarding a missing cell phone and that Missing Property Reports would either be received by the being handed to Social Work staff or they can be left in the Social Work mailbox. SW #1 stated they would expect social work staff to document any resident and family contacts to be documented in progress notes under Social Work. 10 NYCRR 415.5 (h)(1)

Based on observation, interview, and record review during the Standard survey completed on 6/28/23, the facility did not operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes. Specifically, the facility was not in compliance with Section 915 of the 2020 Fire Code of New_York State, which requires carbon monoxide detection in buildings with fuel-burning appliances and on-going preventative maintenance of carbon monoxide detectors. This affected three ([NAME], [NAME], Willink) of three resident use buildings. The finding is: The policy and procedure called, Carbon Monoxide Detectors, effective 5/2019, documented carbon monoxide detectors shall be installed, tested and cleaned as per manufacturer's recommendations. Testing of carbon monoxide detectors will occur on a weekly basis and carbon monoxide detectors will be vacuumed monthly to remove any accumulated dust. Observations during the building tour on 6/22/23 from 8:36 AM through 3:24 PM and 6/23/23 from 10:00 AM through 1:54 PM revealed fuel-burning appliances were located on the ground floor of the [NAME], [NAME], and Willink buildings. At these times revealed two brands (Brand A and Brand B) plug-in style single-station carbon monoxide detectors were located in each of the three buildings. Continued observation during these times revealed Brand A, Brand B, or both brands of carbon monoxide detectors were located on the First, Second, and Third floors of the [NAME] building, the First, Second, and Third floors of the [NAME] building, and on Unit A, Unit C, and Vintage Cove in the Willink building. Review of Brand A carbon monoxide detector manufacturer's User's Manual revealed to keep the alarm working properly, test it every week and vacuum its cover at least once a month. Review of Brand B carbon monoxide detector manufacturer's User Guide revealed to keep the alarm in good working order, test it once a week by pressing the test/ reset button and vacuum the alarm cover once a month to remove accumulated dust. Review of the facility's log called, Carbon Monoxide Monthly Test Log, Test Per Manufacture Specifications revealed it included 21 carbon monoxide detectors located in three of three buildings. The log included columns for monthly testing and monthly cleaning. The logs dated 4/14/23, 5/12/23, and 6/9/23 had checkmarks in the testing column for all 21 carbon monoxide detectors and nothing in the cleaning column. During an interview on 6/26/23 at 8:45 AM, the Maintenance Assistant/ Transportation Coordinator stated they tested the facility's carbon monoxide detectors every month. They further stated they cleaned them each month too, even if it was not marked on the log. The Maintenance Assistant/ Transportation Coordinator also stated they usually followed the manufacturer's recommendations for the maintenance of equipment, and they did not know the carbon monoxide detector manufacturers recommended weekly testing. During an interview on 6/28/23 at 8:45 AM, the Environmental Services Director stated carbon monoxide detectors have always been tested monthly, which was the direction in the ESM (Environmental Services Manager) report. They further stated they were not aware that the policy and procedure indicated it was a weekly task. 42 CFR 483.70(b) 10NYCRR: 415.29(a)(2), 711.2(a)(1) 2020 Fire Code of New_York State, Section 915: 915.3.1, 915.6

Based on interview and record review conducted during an Abbreviated survey (Complaint #NY00313656) completed 4/5/23, the facility did not ensure the resident environment was free of accident hazards as possible for one (Resident #1) of three residents reviewed. Specifically, staff did not follow the residents plan of care which resulted in a fall. The finding is: The policy and procedure (P&P) titled Accidents/ Incident Continuous Quality Improvement Summary Investigation and Prevention revised 4/15 documented the facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. An accident was defined as any unexpected or unintentional incident, which may result in injury to a resident. A fall was defined as an intentional change in position coming to rest on the ground, floor or onto the next lower surface. The P&P titled Interdisciplinary Care Planning revised 2/23 documented the comprehensive resident-centered care plan is developed by the Interdisciplinary Team upon admission and reviewed/updated on a regular basis throughout the resident's length of stay. 1. Resident #1 had diagnosis including chronic obstructive pulmonary disease (COPD, diabetes mellitus, and dyspnea (difficulty or distress in breathing). The Minimum Data Set (MDS-a resident assessment tool) dated 3/27/23 documented Resident #1 was cognitively intact, was understood and understands. The MDS documented the resident did not ambulate (walk). The Comprehensive Care Plan (CCP) dated 3/21/23 documented Resident #1 was non-ambulatory (did not walk). The Physical Therapy (PT) Evaluation & Plan of Treatment dated 3/22/23 documented Resident # 1 was non-ambulatory. The Kardex (guide used by staff to provide care) dated 3/27/23 documented Resident #1 transferred with an extensive assist of one staff member with the use of a gait belt and a rolling walker, and that Resident #1 was non-ambulatory. The investigation report dated 3/27/23 at 7:30 AM, completed by License Practical Nurse (LPN #1) Resident Care Coordinator documented Resident #1 was found lying on their back between the bed and the privacy curtain. Resident #1 was short of breath and unable to state what happened. The investigation report documented Resident #1 was walking out of the bathroom with their rolling walker and Certified Nurse Aide (CNA) #1. Resident #1 lost their balance and fell . There were no injuries were noted. The report documented that CNA #1 did not follow Resident #1's plan of care. During an interview on 4/5/23 at 10:37 AM, Registered Nurse (RN) #1 stated Resident #1 had a fall on the floor on 3/27/23. Resident #1's legs gave out and fell to the floor. Resident #1 was non- ambulatory. During a telephone interview on 4/5/23 at 12:14 PM, CNA #1 stated during the breakfast tray pass on 3/27/23, Resident #1 stood up unassisted from their wheelchair. CNA #1 intervened and ambulated Resident #1 using a rolling walker to and from the bathroom. While walking back to the wheelchair from the bathroom Resident #1 fell backwards onto the floor. CNA #1 stated Resident #1 did not have a gait belt on, was unaware Resident #1 was non-ambulatory and never checked Resident #1's Kardex. During an interview on 4/5/23 at 1:45 PM, LPN #1 Resident Care Coordinator stated CNA #1 did not follow Resident #1's care plan. CNA #1 should have redirected Resident #1 to sit in the wheelchair, kept Resident #1 safe, checked the Kardex, and then transferred the resident to and from the toilet using the wheelchair and a gait belt. The Kardex documented Resident #1 was non ambulatory, therefore Resident #1 should not have been walking. The fall could have been prevented. During an interview on 4/5/23 at 2:12 PM, the Director of Nursing (DON) stated residents could get injured when care plans were not followed. The expectation was for the Kardex be reviewed to adequately provide safe care. During an interview on 4/5/23 at 2:43 PM, the Administrator stated CNA #1 walked a resident that was not supposed to walk which resulted in a fall. Reading the plan of care could have prevented the fall on the floor. 10 NYCRR 415.12(h)(2)

Based on observation, interview, and record review conducted during a Standard survey completed on 8/11/21, the facility did not maintain all essential mechanical, electrical, and patient care equipment in a safe operating condition. Specifically, one ([NAME]) of two kitchens in use had issues with sub-optimal dish machine water temperatures for proper cleaning and sanitizing of dishes. The findings are: Review of facility dish machine Installation and Operation Manual dated 2013 provided by vendor documented, in the hot water sanitizing mode the temperature gauge labels must specify 160°F (degrees Fahrenheit) minimum wash temperature and 180°F minimum rinse temperature. Observation of the [NAME] kitchen on 8/10/21 at 12:30 PM revealed Dietary Aide #2 sent three racks of dishes (trays, bowls, and juice cups) through the hot water sanitizing mode dish machine. The wash cycle temperature gauge did not go above 150 °F and the rinse cycle did not go above 110 °F. Review of the thermostat instructions posted on the dish machine revealed the wash cycle temperature should be a minimum of 160 °F and the rinse cycle temperature should be a minimum of 180 °F. During an interview on 8/10/21 at 12:40 PM, Dietary Aide #2 stated temperatures of dish machine were checked by the supervisors. Dietary Aide #2 was not aware of any problems with the dish machine and stated, usually, the temperatures are up to par. Dietary Aide #2 further stated they were unaware of how to verify the dish machine wash and rinse cycle temperatures. During an interview on 8/10/21 at 12:52 PM, the Assistant Food Service Director (AFSD) stated it was sometime after breakfast the Food Service Director (FSD) made them aware the dish machine was not reaching proper hot water temperatures during the wash and rinse cycles. The AFSD stated that they did not notify dietary support staff of the issue, and the dish machine should not have been used until a low temperature sanitizer could be set up or the problem was fixed with the machine. Observation of the [NAME] Kitchen on 8/10/21 at 1:45 PM revealed the Assistant Food Service Director ran a dish cycle through the hot water sanitizing mode. The wash cycle temperature did not go above 152 °F and rinse cycle temperature did not go above 120 °F. The chlorine test stripe revealed 0 (zero) ppm indicating the machine was not utilizing a chemical sanitizer. Review of a facility document titled Dish Machine/Pot Washing Log dated August 1 through 10, included instructions to record the wash and rinse temperatures when washing the dishes prior to utilizing the dish machine to ensure the wash and rinse temperatures are properly monitored and controlled. If chemical sanitizers are in use, log the PPM (parts per million) of the sanitizer prior to each use for both the dish machine and/or the pot sinks. The log should be initialed by those directly involved in the dishwashing process. Additionally, the log documented the breakfast on 8/10/21 wash temperature as 160, the rinse temperature was 179 and the PPM was documented as 200. There were no temperatures logged for the dinner check. During an interview on 8/10/21 at 2:00 PM, Dietary Aide #1 stated that no one had informed them the dish machine was not working properly. During an interview on 8/10/21 at 2:00 PM, the Dietary Supervisor stated the dish machine temperature checks were done three times daily (breakfast, dinner and super). The opening supervisor completed the temperature check in the morning. The Dietary Supervisor stated they were not aware the dish machine was not reaching the proper temperatures until about 15 minutes ago. The Dietary Supervisor further stated that the wash cycle temperature should be at least 150° F and the rinse cycle temperature should be at least 180°F with the hot water sanitizing mode. During an interview on 8/10/21 at 2:20 PM, the Food Service Director (FSD) stated they checked the dish machine temperatures around 6:00 AM, and the dish machine was working properly. The FSD stated that they could not recall who told them, but in passing was told the dish machine wash not reaching the proper temperature. The FSD stated the facility did not have the sanitizing detergent available to use with the low temperature rinse. The FSD stated the facility does not have a policy for the dish machine. Additionally, at the time of the interview the facility was unable to provide an operation manual for the dish machine. During a follow up interview on 8/11/21 at 8:59 AM, the FSD stated the technician from vendor who serviced dish machine on 8/10/21 indicated that the booster heater (utilized to achieve required temperature for rinse) needed to be replaced. During an interview on 8/11/21 at 9:41 AM, the Administrator stated there should have been prompt communication between the FSD and the dietary support staff regarding the dish machine issue. The FSD should have verified chemical back up and ensured the dish machine was up and running properly. 415.29 (b) Sub part 14-1 14-1.113 (b)(c) 14-11.115

Based on observation, interview, and record review conducted during a Standard survey completed on 8/11/21, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (Resident #6) of six residents reviewed for non-pressure related skin issues. Specifically, a nurse did not complete the wound treatment as ordered by the physician and there was a lack of hand hygiene and glove change, during wound treatment. The finding is: The facility policy and procedure (P&P) titled Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility P&P titled Dressing-Clean Technique effective 3/1/20 documented a clean dressing technique is used to provide and appropriate and safe environment conducive to wound healing. Procedure included following: -Verify order -Wash hands and don (put on) gloves -Remove soiled dressing and discard into a clear plastic bag. Change gloves, washing hands prior to donning new gloves. Review of facility P&P titled Policy on Hand Washing effective 3/2020 documented proper handwashing technique is used for prevention of transmission of infectious diseases. All personnel working in the long- term care facility is required to wash their hands in the following situations, but not limited to: -Before and after direct resident contact -Before and after change a dressing -After contact with a resident's mucous membranes and body fluids or excretions -After removing gloves or aprons. 1. Resident #6 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- a resident assessment tool) dated 6/7/21 did not document the number of venous and arterial ulcers. The MDS dated [DATE] documented Resident #6 had two. Resident #6 was cognitively intact. The Comprehensive Care Plan (CCP) dated 6/15/21 documented Resident #6 was at risk for skin injury related to PVD and had impaired skin integrity, and infection risk related to cellulitic ulcer of left knee, vascular ulcer to right calf, left shin and left plantar (sole) foot. Interventions included treatment per MD order. Review of Physician Re-admission History-Physical dated 6/19/21 documented the resident went to the hospital with history of [CONDITION(S)] secondary to lower extremity (LE) [CONDITION(S)] and came back to the facility on [DATE]. Review of systems documented LE ulcers. Plan documented resident regularly getting wound care by the wound care team and ulcers in different stages of healing. Continue current care. Review of facility document Other Ulcer and Injury Tracking Sheet dated 7/29/21 to be reviewed 8/12/21 documented Resident #6 had vascular wounds on L lateral shin, L plantar foot, right calf/shin and a cellulitic ulcer of L knee. Documented under Treatment was xeroform for L lateral shin, right calf/shin and Santyl (sterile ointment to remove dead tissue and advance wound healing) for L plantar foot and L knee wounds. Review of nursing progress note Nrsng: Wound-Weekly RN assessment dated [DATE] through 8/4/21 revealed the following ulcers: -Left lateral shin- vascular- 7.0 centimeters (cm) x 4.5 cm x 0.1 cm depth -Right shin-vascular- 2.0 cm x 2.0 cm x 0.1 cm -Right calf- vascular- 1.0 cm x 1.0 cm x 0.1cm -Left Knee- cellulitic- 1.6 cm x 1.6cm -Left plantar foot- vascular- 1.5 cm x 1.5 cm x 0.1 cm Review of physician Order Summary Report dated 8/10/21 revealed the following orders: -6/15/21 Cleanse left (L) lateral shin wound with NS (normal saline), apply xeroform gauze and dry clean dressing (DCD), secure with kerlix every day- shift for wound care -6/15/21 Cleanse right shin/calf wound with NS, apply xeroform gauze with DCD and secure with kerlix every day (QD) -6/15/21 Santyl ointment apply to L knee topically QD shift for wound, cleanse with NS, apply nickel thick Santyl and cover with DCD -6/15/21 Santyl ointment apply to L plantar foot topically QD shift for wound, cleanse with NS, apply nickel thick Santyl and cover with DCD During an observation of wound care on 8/10/21 at 10:37 AM, Licensed Practical Nurse (LPN) #5 and Clinical Regional QA Registered Nurse (RN) both washed hands, and donned (applied) clean gloves. LPN #5 removed the soiled dressing from the Resident #6's L knee. LPN #5 doffed (removed) gloves, washed hands, and donned a new pair of clean gloves. LPN #5 opened a container of NS placed clean 4x4 gauze on top of the container and tipped it upside down to moisten the gauze. LPN #5 cleansed the L knee wound bed with the NS moistened gauze and patted dry with a new gauze pad. A small amount of blood was observed on both gauze pads. Without changing gloves, the LPN opened a tube of Santyl, labelled with the resident's name, and squeezed some on to their gloved fingers tips and rubbed the ointment onto the residents wound. Without changing gloves or performing hand hygiene the LPN placed a clean island dressing (an all- in one dressing that conforms around wound and seals on all four sides) to the L knee wound. Two small spots of bright red blood were observed on the top of the island dressing. LPN #5 removed gloves and washed hands. During continued observation at 10:44 AM, Clinical Regional QA RN assisting, LPN #5 donned new clean gloves and removed the soiled dressing from the resident's L lateral leg. The wound bed was red with granulation tissue (tissue that forms on surface of a wound during healing) and had fresh blood dripping from the wound onto the bed linens beneath. Without changing gloves LPN #5 placed clean gauze on top of the NS container and tipped it upside down to moisten the gauze, then cleansed the wound. Fresh red blood was observed on the moistened gauze. With the same gloved hands LPN #5 placed dry gauze to the wound bed and went over to the resident's bedside table to grab a chux (disposable, fluid impervious) pad to place on the bed, beneath the resident's left leg. LPN#5 doffed their gloves. Clinical Regional QA RN rested the resident's LLE on the chux pad and left the room to retrieve a new box of gloves for LPN #5. Without washing hands LPN #5 opened the xeroform (non- adherent gauze with petrolatum) and island dressing to be used for the treatment. LPN#5 labelled the island dressing with initials and date. Continued observation at 10:49 AM, QA RN returned with a new box of gloves and both washed their hands and donned clean gloves. With QA RN holding the residents LLE, LPN #5 removed the bloody gauze from the wound, placed clean 4x4 gauze on top of the container to moisten with NS and proceeded to re-cleanse the wound with fresh blood observed on the moistened gauze. With the same gloved hands, LPN #5 then placed xeroform gauze to the wound bed followed by island dressing. LPN #5 doffed their gloves and donned a new pair of clean gloves without washing hands. At 10:54 AM LPN #5 removed the soiled dressing from Resident #6 L plantar foot wound that was pink and appeared to be healing. Without washing hands or changing gloves LPN #5 placed clean 4x4 gauze on top of the NS container, tipped it over to moisten, then cleanse the wound, followed by xeroform and small island dressing. LPN #5 folded the slightly bloody barrier beneath the resident's LLE, and QA RN rested the leg on the folded barrier. During an observation on 8/10/21 at 10:56 AM, with QA RN assisting, LPN #5 washed hands and donned new clean gloves. LPN #5 removed the soiled dressing from Resident #6 right shin/calf wound revealing 2 small wounds with granulation tissue. LPN #5 doffed their gloves and donned a new, clean pair without washing hands. They placed 4x4 gauze to the NS container and tipped to moisten, cleansed the wound, and repeated the process for the two wounds followed by patting dry with a new 4x4 gauze for the two wounds. LPN #5 doffed the gloves and donned new clean gloves without washing hands. LPN #5 then placed xeroform to the wounds followed by island dressing. During an interview on 8/10/21 at 12:10 PM, LPN #5 stated they were very familiar with Resident #6 and their treatment orders. They reviewed them prior to the treatment and had written the treatment orders on scrap paper prior to completing the treatments. LPN #5 stated they used xeroform, instead of Santyl for the L plantar foot because they thought the wound appeared to be healing and did not need Santyl any longer. LPN #5 stated they should have completed the treatment as ordered by the physician and informed RN Resident Care Coordinator (RCC) #1 if improvement or decline is noted in a wound so it can be reassessed. They stated they did not realize they didn't wash hands, at times, after removing soiled dressings and between glove changes, but they should have because there could be contamination after cleansing the wound prior to applying new treatment. LPN #5 stated they had never been told Santyl should be applied with an applicator and that they always applied it with gloved fingers. LPN #5 stated they did not see the blood on the new dressing applied to the L knee or they would have changed it. LPN #5 did not say why they used island dressing as opposed to kerlix wrap, as ordered by the physician. During an interview on 8/10/21 at 1:26 PM, RN RCC #1 stated they would expect to be informed by staff, of any signs of infection, improvement or decline in a wound so it could be assessed for physician update, and new orders if required. Additionally, RN RCC #1 stated gloves should be changed, and hands washed when removing a soiled dressing, and after cleansing a wound because the wound is considered dirty. Gloves should be changed, and hands washed for infection control purposes, so the wound is not contaminated. During an interview on 8/11/21 at 10:39 AM, Clinical Regional QA RN stated LPN #5 should have followed the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On follow up interview on 8/11/21 at 10:54 AM, RN RCC #1 stated the expectation was that Santyl should be applied to a wound with some type of applicator, Q-tip, gauze, or tongue blade, not a gloved hand for infection control purposes. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . If the resident refuses it would be OK to substitute a different dry, clean dressing but I would expect that to be documented and that I be notified so the physician could be updated and order adjusted, per the resident preference. I am not aware that Resident #6 had refused kerlix gauze wrap to the lower legs. During an interview on 8/11/21 at 1:58, the acting Director of Nursing (DON) stated they would expect staff to remove gloves and wash hands after removing a soiled dressing prior to application of a new/clean treatment. Best practice would be to apply Santyl using a clean product or applicator not gloved hands. Hands should be washed after wound cleansing as to not contaminate the new dressing. I would expect staff to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 8/11/21 at 2:21 PM, the Assistant Director of Nursing (ADON)/ Infection Preventionist (IP) stated the expectation for wound care was that hands should be washed prior to starting a treatment, after a soiled dressing was removed, after cleansing a wound and between glove changes so not to cross contaminate the wound when applying a new treatment. If a dressing was soiled or contaminated by infectious material it should be changed. 415.12

Based on observation, interview, and record review conducted during the Standard survey completed on 8/11/21, the facility did not ensure that each resident who is unable to carry out Activities of Daily Living (ADL's) receives the necessary services to maintain grooming and personal hygiene. Specifically, one (Resident # 205) of four residents reviewed for ADL's had long jagged fingernails. The finding is: A facility policy and procedure (P&P) titled Activities of Daily Living dated 3/20 documented that each resident will receive, and the facility will provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care. A facility P&P titled Nail Care dated 3/2020 documented the purpose was to ensure cleanliness and prevent infection, routine nail care is to be done following bath/ shower whenever possible and report pertinent observations. 1. Resident #205 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - a resident assessment tool) dated 7/9/21 documented Resident #205 was understood and understands and does not exhibit behavior of reject of care. In addition, Resident #205 required extensive assistance of one for personal hygiene, Review of a Visual/Bedside Kardex Report (guide used by staff to provide care) with a print date of 8/11/21 revealed the Resident #205 required extensive assist of one person for bathing of upper extremities. Review of the comprehensive care plan (CCP) dated 4/27/21 revealed Resident #205 had a bathing self-care performance deficit related to confusion, limited mobility, limited range of motion (ROM) and [CONDITION(S)] (OA) and required extensive assistance of one for upper extremities. Review of the Progress Notes dated 7/25/21 through 8/11/21 for Resident #205 revealed there was no documented evidence of nail care provided or the resident refused care. During intermittent observations on 8/5/21 at 9:41 AM, 8/9/21 at 8:30 AM, revealed Resident #205's fingernails were long (past the fingertips) and jagged. During an observation on 8/9/21 at 9:33 AM of morning (AM) care provide by certified nursing assistant (CNA) #5 and CNA #6 with Clinical Regional Quality Assurance (QA) Registered Nurse (RN) present AM care was completed, and the CNAs did not trim or offer to trim Resident #205's fingernails. During additional intermittent observations 8/10/21 at 8:19 AM and 8/11/21 at 7:31 AM revealed Resident #205's fingernails were still long (past the fingertips) and jagged During an interview on 8/11/21 at 7:31 AM, Resident #205 stated their fingernails were long and wanted them cut. During an interview on 8/11/21 at 7:31 AM, CNA #7 stated Resident #205 AM care was completed. CNA #7 observed Resident #205's fingernails and stated the resident's fingernails were long, jagged and should have been trimmed with morning care. During an interview on 8/11/21 at 7:37 AM, Registered Nurse (RN) #5 observed the Resident #205's fingernails and stated the resident's fingernails were long and jagged. RN #5 stated fingernails should be trimmed and filed to maintain cleanliness and appropriate length to prevent self-scratches. During an interview on 8/11/21 at 7:56 AM, the Clinical Regional QA RN stated they had not observed the length of the resident's fingernails during the observation of AM care on 8/9/21 at 9:33 AM and would expect the CNAs and Nurses to make observations during daily routine care and offer fingernail trimming on shower day or as needed. The Clinical Regional QA RN stated fingernails should be maintained trimmed and filed for infection control purposes, dignity, and safety to prevent potential self-injury related to self-scratching. 415.12 (a)(3)

Based on interview and record review conducted during a Standard Survey completed on 8/11/21, the facility did not ensure that each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment for five (Residents #'s 14, 60, 88, 205 and 210) of forty residents reviewed for Minimum Data Set 3.0 (MDS, a resident assessment tool) accuracy. Specifically, the facility did not ensure that the MDS Assessments accurately reflected the residents' status. The findings are but not limited to: The facility policy and procedure titled, Minimum Data Set (MDS) dated ,d+[DATE], documented the nurse obtains information to complete the MDS by the following means: Resident observation and communication/interview. Oral, written communication and via the electronic health record with direct care staff from all shifts, as well as with licensed professionals from all disciplines who have recently observed, evaluated, or treated the resident. Resident family/significant others; Resident's physician and the resident's medical record. 1. Resident #210 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident #210 was usually understood, usually understands, and had moderate cognitive impairments. The MDS documented the resident had an indwelling catheter and was always incontinent (no episodes of continent voiding). The Comprehensive Care Plan (CCP) dated 5/11/21 documented Resident #210 had a urinary catheter related to obstructive [CONDITION(S)]. During an interview on 8/10/21 at 1:35 PM, Certified Nursing Assistant (CNA) #8 stated that Resident #210's foley did not leak. If Resident #210 was wet, due to urine; it was because Resident #210 would forget to clamp the foley. During an interview on 8/10/21 at 3:59 PM, Registered Nurse (RN) #1 stated, that Resident #210 was not incontinent of urine and that their foley catheter does not leak urine. RN #1 stated, that if Resident #210 was wet from urine it was because they unclamp the foley clip or fidget with the catheter bag. During an interview on 8/11/21 at 9:53 AM, RN #2 stated, they were responsible for completing section H (Bladder and Bowel) on the MDS dated [DATE] for Resident #210. RN #2 stated that Resident #210 had an indwelling catheter, and that Resident #210 should have not been coded as always incontinent. RN #2 stated that they coded urinary incontinence in error and should had coded the question as not rate due to resident having an indwelling catheter. 2. Resident #88 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident #88 was rarely/never understood, rarely/never understands, and had severe cognitive impairments. The MDS documented the resident had a feeding tube and was a total assist of two staff for eating. The Comprehensive Care Plan (CCP) dated 3/10/21 documented Resident #88 had an alteration in nutrition related to dysphagia and gastrostomy. The CCP documented Resident #88 was a total assist with the peg, and to have nothing by mouth, and to administer enteral nutrition as ordered. During an interview on 8/11/21 at 1:44 PM, RN #1 stated Resident #88 had a feeding tube and does not require two staff members to provide care for feeding. During an interview on 8/11/21 at 10:12 AM, RN #4 stated, they were responsible for completing section G (Functional Status) on the MDS dated [DATE] for Resident #88. RN #4 stated that Resident #88 had a feeding tube and that they coded eating of two staff assistance in error and should have coded the resident's eating status as a staff assist of one. 3. Resident #60 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident #60 was usually understood, usually understands, and had mild cognitive impairments. The MDS documented Resident #60 received seven days of anticoagulant medication. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 8/11/21 at 9:52 AM, RN #3 stated, they were responsible for completing section N (Medications) on the MDS dated [DATE] for Resident #60. RN #3 stated that Resident #60 was receiving [MEDICATION(S)] ([MEDICATION(S)], antiplatelet). RN #3 stated that [MEDICATION(S)] was not an anticoagulant and they should not have coded Resident #3 as receiving an anticoagulant. During an interview on 8/11/21 at 10:12 AM, the Acting Director of Nursing (DON) stated that the medication [MEDICATION(S)] was an antiplatelet and should not have been coded on the MDS as an anticoagulant. The DON stated that they were unsure how incontinence was to be coded for a resident with an indwelling catheter. The acting DON stated that Resident #88 has not been combative and would have only needed a one staff member assist for feeding. The acting DON stated that coding errors occurred due to poor documentation. During an interview on 8/11/21 at 11:14 AM, the Administrative stated the MDS's were not in compliance. 415.11(b)

Based on observation, interview, and record review conducted during the COVID-19 Focus Infection Control Survey (Complaint # NY 083) completed on 6/9/20, the facility did not establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections for 1 of 7 units reviewed. Specifically, the facility did not discontinue communal dining as required in the Health Advisory issued by the New York State Department of Health dated March 13, 2020. In addition, the facility did not appropriately social distance (at least 6 feet apart) resident's as required. The findings are: The Executive Order #202.1 dated March 12, 2020 documented the following: Any guidance issued by the New York State Department of Health related to prevention and infection control of COVID-19 at nursing homes and adult care facilities, including but not limited to guidance on visitation, shall be effective immediately and shall supersede any prior conflicting guidance issued by the New York State Department of Health and any guidance issued by any local board of health, any local department of health, or any other political subdivision of the State related to the same subject. The Health Advisory issued by the New York State Department of Health dated March 13, 2020, documented At this time NHs (Nursing Homes) are required to take the following actions: - If there are confirmed cases of COVID-19 in a NH cancel group activities and communal dining. The facility policy and procedure (P&P) titled Coronavirus (COVID-19) revised 5/14/20 documented it shall be the policy to utilize accepted infection control measures to prevent and control the spread of a respiratory illness caused by Novel Coronavirus (Covid-19). The primary goals of COVID-19 prevention and control in long term care facilities are preventing the transmission of COVID-19 to residents. Large gathering areas will be closed. There will be no communal dining. Residents will eat meals in rooms or on units with at least 6 feet between other residents. Review of an undated facility document titled Watch List revealed there were 26 residents in the facility that tested positive for COVID-19. During an observation on 6/4/20 at 12:05 PM, Residents # 1 ,2, 3, 4, 5, 6, 7, 8, 9,10, 11,12,13,14,15,16,17 and 18 were seated in the station A lounge. Some of the residents were already eating their meal. There were nine 4- foot by 4-foot tables observed with two residents sitting at each table. The residents were not socially distanced (6 feet apart) or wearing face masks. During an interview on 6/4/20 at 12:43 PM, Licensed Practical Nurse (LPN #2) Unit Manager stated residents who required assistance and supervision started eating in the unit A lounge two weeks ago. According to LPN#2, the residents weren't eating well in their rooms and eighteen residents go to the lounge regularly to eat. LPN#2 further stated the residents in the lounge at lunch were not 6 feet apart. During an interview on 6/4/20 at 5:21 PM in the presence of the Administrator, the Director of Nurses (DON) stated, initially they tried keeping residents in their rooms for meals and the mealtimes were staggered but didn't work. The DON added the residents were losing weight and not only had been isolated from family but from other residents on the unit as well and the residents need socialization. During an interview on 6/4/20 at 5:27 PM, the Administrator stated she was aware of the Executive Order and communal dining was suspended on 3/11/20 then resumed on 5/26/20. The elimination of communal dining had affected residents quality of life as residents were losing weight. The team opted to avoid negative effects and promote normal nutrition. In addition, the Administrator stated she directed Unit Manager, LPN #2 to seat 2 residents at each table and residents were not 6 feet apart. The Administrator further stated, Since the unit was all COVID positive residents, I did not feel it was an issue. 415.19 (b)(1)

Based on record review and interviews conducted during the Standard survey completed on 10/24/19, the facility failed to develop and implement an effective discharge planning process that focuses on a resident's discharge goals. Specifically, one (Resident #5) of two residents reviewed for discharge planning lacked a referral to the New York Association for Independent Living when a desire to return to the community was expressed. In addition, the facility did not develop a care plan that included the resident's discharge planning needs to address his desire to return to the community. The finding is: The facility's undated social worker (SW) job description documented job responsibilities included completing a social service plan including discharge plan within 14 days of admission and maintaining a current social service plan and discharge statement on the resident care plan. 1. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a resident assessment tool) dated 6/29/19 documented the resident was cognitively intact. Section Q of the MDS documented there was no active discharge plan to return to the community, the resident would like to talk to someone about returning to the community, and a referral to the local contact agency was not needed. The admission MDS dated [DATE] documented the resident expected to be discharged to the community, would like to talk to someone about returning to the community, and a referral to the local contact agency was not needed. During an interview on 10/17/19 at 2:38 PM, the resident stated his goal was to be discharged , and that he's had some setbacks. The social worker had things going on now, but the other social worker didn't submit some paperwork for an apartment he had lined up, so he lost that apartment. The resident stated they are working on getting him into assisted living facility. Review of the comprehensive care plan last revised 10/18/19 did not include the resident's discharge plan including goals or interventions in place to address discharge needs. Review of Social Work (SW) Progress Notes dated 10/24/18 through 10/24/19 revealed: - 10/24/18 resident admitted to the facility and was here short term until he can get his apartment. He previously lived at home with family. He had aide services, home care nurses, wound care, MD (Medical Doctor), and NP (Nurse Practitioner) that all came to his home. - 11/28/18 SW called the (formal name) Homeless program and left a message re: housing. SW was made aware that resident lost the apartment he had set up d/t (due to) the fax not going through. No one picked up the phone when SW called the apartment complex (on numerous occasions) so SW did not know they never received it. SW did fax again when resident said he got a phone call from them saying they didn't receive it, but by then the paperwork was late. SW in process of helping resident find another place to live. - 4/25/19 visit with resident today to update the resident on process of moving out of facility. SW informed resident that his Medicaid had to be approved first before his application could be approved for community accessible housing. Discussed options available to him and helped resident to understand he needs 24-hour care and to have two person assist to support his move. Informed resident of OPWDD (Office for People with Developmental Disabilities) options out in the community that were available for people in his condition. - There was no documentation that a referral to New York Association for Independent Living was made. Review of the Social Service Progress Notes dated 11/27/18 through 10/1/19 revealed there was no documentation of any referrals made to address the resident's desire to return to the community. During an interview on 10/22/19 at 1:22 PM, Social Worker #1 stated the resident had some complications with his health and the plan was when he feels healthy enough, will move forward with discharge. When a resident does express desire for discharge, they talk about options and ideas and then submit them to the discharge planners and then they discuss what actually goes on from there. The SW stated he didn't know what the open-door program was but has heard about it. If he had made any referrals, he would have documented it in the medical record. When asked if any referrals have been made for this resident the SW stated, it's been a while since I checked into him. The SW stated that he knows the resident has an interest in going back to the community and was currently waiting for his Medicaid application to be approved. Additionally, the resident does not have a discharge plan on his care plan. During an interview on 10/24/19 at 8:44 AM, the Director of Social Services stated residents are asked about returning to the community regardless of being long term or short-term stays. They have a discharge planner that they recently have working on long term care discharges, as she was only involved with short term stays. The director stated she's not sure if there were any referrals made for this resident and she would expect a discharge plan to be included on the care plan. During an interview on 10/24/19 at 11:09 AM, the Director of Nursing (DON) stated she would expect social workers to document in their progress notes or care plan any referrals made when a resident expresses desire to return to community. During an interview on 10/24/19 at 2:20 PM, the Discharge Planner stated she was mostly doing rehab unit discharges prior to a month ago but now they have a strong Social Work team, so she was able to help with long term care residents. The Discharge Planner stated she hasn't done anything specific with this resident (#5), but SW #1 told her yesterday that the resident would like to be discharged to the community, so she plans to see him today. 415.11(d)(3)

Based on interview and record review conducted during the Standard survey completed on 10/24/19, the facility did not ensure that a written summary of the baseline care plan, that included initial goals, a list of current medications, dietary instructions, and services/ treatments to be administered by facility personnel acting on behalf of the facility, was provided to the resident or the resident's representative. Specifically, 7 (Residents #102, 104, 115, 165, 249, 288, 297) of 27 admitted residents reviewed for baseline care plans had no documented evidence that a written summary of the baseline care plan was provided to the resident and/ or the resident's representative by completion of the comprehensive care plan. The findings are but not limited to: Review of a policy and procedure (P&P) titled Comprehensive and Baseline Care Plan Development and Care Area Assessments (CAA's) dated 10/1/18 revealed the resident and designated representative shall be notified of content of baseline care plan within five days of admission. Notification shall be completed by the Social Worker (SW) and will be documented in the progress note in the electronic medical record (EMR). 1. Resident #104 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a resident assessment tool) dated 8/26/19 documented the resident was severely cognitively impaired, never/ rarely made decisions. Review of a comprehensive Care plan (CCP) 3/8/18 revealed there was no evidence the care plan was reviewed and provided to the resident or resident's representative. Review of the interdisciplinary Progress Notes dated 3/8/18 through 4/4/18 revealed there was no documented evidence that a written summary of the baseline care plan was provided to the resident or the resident's representative. During an interview on 10/23/19 at 9:09 AM, Licensed Practical Nurse (LPN) #4 Resident Care Coordinator (RCC) stated baseline care plans are done on new admissions. The Registered Nurse (RN) opens the care plan, then we put all the treatment modalities in. We then share that with the Resident. If the resident is not cognizant, we share with the responsible party. Our baseline care plans are not separate from our comprehensive care plans, we start one and share the one that was started. We have a heading with baseline care plan note that is where we document that we have gone over it with the Resident or the responsible party. I don't see a note here for Resident #104, it would be my assumption that it would be here in the plan of care notes and it is not here, so I am assuming it was not shared with the Resident or the responsible party. During an interview on 10/23/19 at 10:33 AM, RN #3 Corporate Quality Assurance Nurse stated baseline care plans are completed when a resident gets admitted . The comprehensive care plan is started, all the baseline care plan components are then addressed and shared with the Resident or family. If the Resident is not cognitively intact, we share it with the family over the phone or if in the facility we give them a copy of it. The RCC or the Social Worker (SW) then document in a progress note. I don't see that either of them has completed a note on Resident # 104, so it is my assumption it was not completed. 2. Resident #249 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident was cognitively intact, was understood and understands. Review of the undated CCP revealed there was no evidence the care plan was reviewed and provided to the resident or resident's representative. Review of the interdisciplinary Progress Notes dated 9/26/19 through 10/16/19 revealed there was no documented evidence the care plan was reviewed or provided to the resident or resident's representative. During an interview on 10/23/19 at 10:34 AM, LPN #3 RCC stated when a resident is admitted the RN starts the CCP and the Baseline Care Plan (BCP) is the CCP. The BCP is printed and reviewed with the resident and/ or family (resident's representative) and any questions are answered. Whomever completes the baseline care plan review would be the one expected to document that the BCP was initiated and reviewed with the resident or family within the first 48 hours of admission. This used to be nursing responsibility but now we have a big Social Work (SW) team and they do it now. During an interview on 10/24/19 at 10:29 AM, the SW stated she just started at the facility two and a half weeks ago and she took over the responsibility of BCP's. She keeps a calendar of admissions and notes when they need to be completed. She prints the BCP and reviews it with the resident, if able. If unable to review with the resident she will call the family and review via telephone. Additionally, she stated I don't know who was doing them before I came. Resident #249 should have been done by 9/28/19, or at least the following Monday. I don't see her documentation of her BCP. When her son was here, we had an informal meeting and he asked for a copy of the CP medication list, but it wasn't the BCP. During an interview on 10/24/19 at 10:50 AM, the Director of Nursing (DON), after reviewing the progress notes in the electronic medical record (EMR), stated she did not see the BCP documentation for Resident #249 in the progress notes that is was reviewed with the resident or representative. 3. Resident #288 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident was severely cognitively impaired, was understood and understands. Review of the undated CCP revealed there was no evidence the care plan was reviewed and provided to the resident or resident's representative. Review of the interdisciplinary Progress Notes dated 10/3/19 through 10/23/19 revealed there was no documented evidence the care plan was reviewed or provided to the resident or the resident's representative. During an interview on 10/22/19 at 10:46 AM with the Licensed Practical Nurse (LPN) #2 Resident Care Coordinator (RCC) revealed the MDS Coordinator opens the CCP on admission, the Baseline Care Plan is the CCP. The interview further revealed the CCP is reviewed with the resident and/or representative, documented in the progress notes and the resident and/or representative are offered a copy of the CCP. She was unsure if the CCP was signed by the resident or representative and would have to check with her supervisor. During an additional interview on 10/22/19 at 11:31 AM with RCC LPN #2 revealed the CCP is reviewed with the resident and/or representative and documented in the progress notes but it does not get signed. During an interview on 10/24/19 at 10:50 AM with the Director of Nursing (DON) revealed the RN opens the CCP on admission and the RCC updates the CCP when needed. Nursing was responsible for a while to review the CCP with the resident or representative because there was a shortage of social workers, the social workers are responsible now. The interview further revealed after reviewing the Progress Notes in the electronic medical record (EMR) she was not seeing the baseline care plan documentation for Resident #288 in the progress notes that it was reviewed with the resident and or representative. 415.12(i)(1)

Based on observation, interview, and record review conducted during an Abbreviated survey (Complaint #NY 916) completed on 5/3/19, the facility must ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, and the comprehensive person-centered care plan for one (Resident #1) of three residents reviewed for respiratory care. Specifically, the resident was not provided with oxygen (O2) as per the physician's orders [REDACTED]. The finding is: The policy and procedure entitled Oxygen Therapy with a revised date of 1/2011 documented O2 is administered to promote adequate oxygenation and to provide relief of symptoms of respiratory distress. The procedure documented to change O2 tubing weekly, date tubing when changed weekly and nebulizer tubing and mask are also changed weekly. 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated 3/8/19 documented the resident was moderately cognitively impaired, was understood, and understands. Review of section O of the MDS documented the resident received O2 therapy in the last 14 days. Review of the comprehensive Care Plan with a revision date of 9/17/18 revealed the resident has altered respiratory status and difficulty breathing related to (r/t) a history of [MEDICAL CONDITION] and frequent upper respiratory infections (URI). Interventions included O2 via nasal cannula (N/C) at 3L (liters) and to monitor and report signs and symptoms (S&S) of respiratory distress or abnormal breathing patters to the medical doctor (MD). Review of the Medication Review Report dated 5/1/19 through 5/31/19 revealed an MD order for O2 at 3L via N/C every shift for [MEDICAL CONDITION] (O2 deficiency in the tissues) and [MEDICATION NAME] Solution (medication, respiratory treatment to open bronchus in the lungs and increases airflow to the lungs) 0.5-2.5 3mg (milligrams) per 3ml (milliliters) inhale every 8 hours for shortness of breath (SOB) and wheezing. During an observation on 5/2/19 at 9:00 AM the resident was in the hallway near her room in a Geri chair, with O2 N/C tubing in her nose. The oxygen tubing extended to her lap blanket and the tubing was not connected to either an O2 concentrator or a portable O2 source. The resident was sleeping and showed no S&S of respiratory distress. Additionally, the N/C tubing in the resident's nose was not labeled or dated. The observation further revealed a nebulizer machine with a mask and tubing attached on the night stand next to the resident's bed. The nebulizer tubing was labeled 3/21/19. During an interview on 5/2/19 at 9:08 AM, Licensed Practical Nurse (LPN #1) stated the resident wears O2 continuously. The nurses are responsible for applying the residents O2. The aid will let the nurse know when the resident goes to bed or gets up in the chair to reconnect the tubing. The tubing is changed weekly on Sundays by the night shift or as needed and the tubing is dated. Additionally, LPN #1 was unsure of how often the nebulizer tubing and masks are to be changed but thought it was every three days. During an interview on 5/2/19 at 10:13 AM, the Assistant Director of Nursing (ADON) stated nurses will change over the O2 when needed. The O2 tubing is to be changed every 7 days, usually on Sundays. The ADON was unsure how often the nebulizer tubing was to be changed. During an observation on 5/2/19 at 12:15 PM the resident was in the dining room for lunch assisted by staff with eating. The O2 tubing remained in resident's nose and was not attached to either an oxygen concentrator or portable O2 source. During the observation the resident showed no S&S of respiratory distress. The observation further revealed the N/C tubing in the resident's nose was not labeled or dated. During an observation on 5/2/19 at 2:30 PM the resident was in bed sleeping and the O2 was on at 3L via N/C via O2 concentrator. The O2 tubing was unlabeled or dated. Review of the Medication Administration Record [REDACTED]. During an observation on 5/3/19 at 8:30 AM the nebulizer machine with a mask and tubing attached was on the resident's night stand, the tubing was still labeled 3/21/19. During a telephone interview 5/3/19 at 1:04 PM, the Certified Nurse Aide (CNA #1) stated he was the aide for Resident #1 yesterday (5/2/19) and the resident wears O2 all the time. The nurses change the O2 over when the resident gets out of bed, he believed he told the nurse to hook the O2 back up in the morning but was not certain. He did not witness the nurse hook the O2 back up when the resident was gotten out of bed. During an interview on 5/3/19 at 2:00 PM, LPN #1 stated she changed the nebulizer tubing because it was on the floor and dated from March. During an interview on 5/3/19 at 2:20 PM, the Director of Nursing (DON) stated the O2 and nebulizer tubing is changed every Sunday throughout the facility for resident's that use it routinely. 415.12 (k)(6)

Based on interview and record review conducted during an Abbreviated survey (Complaint #NY 974) completed on 4/15/19, the facility did not ensure that all alleged violations including abuse, neglect, exploitation or mistreatment including injuries of unknown origin source, are reported immediately, but not later than two hours later after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator of the facility and to other officials (including to the State Survey Agency and the Adult Protective Services where state law provides for jurisdiction in long-term care facilities) in accordance with State Law through established procedures. Specifically, one (Residents #1) of three residents reviewed for reporting of alleged violations of abuse were involved in incidents not reported to the New York State Department of Health (NYSDOH) as required. The finding is: Review of a facility policy entitled Abuse prohibition Policy and Procedure dated 8/1/17 revealed residents have the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, and misappropriation of their property. Residents will not be subjected to such events by anyone including but not limited to facility staff, other residents, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends or other individuals. The facility shall comply with all federal and state requirements to screen, train, prevent, identify, investigate, protect and report, if applicable, any event not consistent with the usual operation of nursing facility or the standard care for certain residents. Abuse was defined as willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse may be resident-to-resident, staff-to-resident, family-to-resident, or visitor-to-resident. Federal and State regulations require the facility to report alleged violations of mistreatment, neglect and abuse, immediately to the administrator of the facility and to other officials in accordance with State Law as soon as possible, but not to exceed 24 hours after discovery of the incident. 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated 3/1/19 documented the resident had severe cognitive impairment. Additionally, the MDS documented the resident required a one- person physical assist for activities of daily living (ADL). Review of the Interdisciplinary Care Plan dated 10/4/18 revealed the resident had a behavior problem as she will become weepy at times. Interventions included: attempt to determine triggers that caused behavior, explain all procedures to the resident, allow time for the resident to adjust to changes and use diversional distraction items as needed. Additionally, the care plan dated 10/3/18 and updated 2/22/19 documented the resident was at risk to receive and/ or be the aggressor of physical aggression due to residing on a dementia unit, aggressive actions towards peers and staff, may have swift unpredictable episodes of aggressive behavior. Interventions included to redirect the resident as needed. Review of a facility investigation dated 4/4/19 revealed the Activities Aide reported to Human Resources that she witnessed physical and verbal aggression on that day (4/4/19) to Resident #1 by Certified Nurse Aide (CNA) #1. She was also informed by CNA #2 that CNA #1 told him about things he did to Resident #1 that constituted abuse. CNA #2 had also witnessed CNA #1 being verbally and physically aggressive with the resident on other occasions. Further review of the facility investigation revealed that during the investigation, the Director of Nursing (DON) learned that CNA #1 was transferring residents who required mechanical lifts by himself, without the mechanical lift with no injury to the residents. After interviews with staff, the DON concluded that CNA #1 did violate care plans and made inappropriate jokes about Resident #1 to staff regarding things he thought were funny. However, she was unable to substantiate abuse due to the variation and conflict in statements from staff. CNA #1 was suspended for one day. When he returned to work, he was re-assigned to another unit where alert and oriented residents resided. Upon investigation of the allegations by the New York State Department of Health (NYS DOH) on 4/12/19, CNA #1 was terminated. Interview with the DON on 4/12/19 at 11:15 AM revealed she did not believe this case was substantiated as abuse because of the conflicting statements from staff regarding the way CNA #1 treated Resident #1. There was a camera in the hallway, but the cameras have not been working. The DON stated she did not believe it was reportable to the NYS DOH because the allegation was inconclusive. She believed re-assigning him to another unit with alert and oriented residents who could speak for themselves was safe. Interview with the Administrator on 4/12/19 at 4:30 PM revealed after review of the investigation, she concluded the information did not rise to the level of abuse and was not reportable to the NYS DOH. She was aware the CNA had been suspended and re-assigned to another unit. She stated she was going to attempt to review the camera footage again from 4/4/19 and previous days when CNA #1 had worked. On 4/15/19 at 9:00 AM the Administrator stated she was not able to review any camera videos. Review of the Complaint/Incident Investigation Reports reported to the NYS DOH Centralized Complaint Intake Program (CCIP) for the facility revealed there were no facility reported incidents involving CNA #1 or Resident #1. 415.4(b)(2,4)

Based on observation, interview and record review conducted during an Abbreviated survey (complaint #NY 180) completed on 9/29/16, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents. One (Resident #1) of three residents reviewed for accidents had issues involving the improper use of a sling and the use of the wrong size sling during multiple mechanical lift transfers. The sling broke during a transfer and the resident fell to the floor from the lift and sustained a fractured right ankle. This resulted in actual harm that is not immediate jeopardy. The finding is: 1. Resident #1 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 3/30/16 revealed the resident has severe cognitive impairment. The resident is 5 feet tall and weighs 241 pounds. Review of the resident's Care Guide (used by certified nurse aides (CNAs) to provide care) dated 2/17/16 revealed under transfers, the resident requires a mechanical total lift with the assistance of two. Sling Color: BLUE TRIM SLING (extra-large) Loop Color: Top, Mid and Bottom: GREEN. Review of the mechanical lift manufacturer's Patient Sling Reference Guide revealed the large sling is for weights between approximately 150 - 275 pounds and the extra-large sling is for weights between approximately 200 - 400 pounds. Sling size and fit can vary significantly depending on patient weight and girth. Consult Physician before sling selection. Review of the New York State Department of Health ACTS Complaint/ Incident Investigation Report dated 3/24/16 reported by the Director of Nursing (DON) revealed an incident that had occurred on 3/20/16 at approximately 6:45 PM was identified as resident neglect. The facility reported that the certified nurse aide (CNA) #1 transferred the resident via mechanical lift with a sling that was already under the resident in her chair (placed by CNA #3). As CNA #1 with the assistance of a second CNA (CNA #2) transferred the resident and the mechanical lift started to raise, the sling strap gave way and the resident fell to the floor. The resident was assessed by the Registered Nurse (RN) and initially did not appear to have any visible injury however complained of left hip pain. ROM (range of motion) was normal for the resident and neurological checks were at baseline. The Physician was notified. An x-ray of the left hip (performed on 3/20/16, reported on 3/21/16) was negative for fracture. The next morning (3/22/16) the resident's right lower extremity was noted to be swollen and tender to the touch. An x-ray (performed on 3/22/16) revealed a non-displaced bi-malleolar (ankle) fracture. The resident was sent to the hospital where an immobilizer was placed. Resident returned to the facility. Further review of the complaint intake revealed that the sling used in the transfer was the wrong size and the loop that broke was not a loop to be used for transfers. The facility identified that CNA #1 did not check the sling size and loop color that was ordered. CNA #1, an agency CNA, will not be scheduled to work at the facility in the future. Review of the facility Incident Documentation Tool dated 3/20/16 at 6:45 PM revealed that the resident was being transferred with two assist when the mechanical lift sling broke. RN #1 documented that the resident's neurological checks were within normal limits (WNL), the resident's ROM was WNL except that the resident complained of left hip pain with abduction (movement away from the body) and palpation (exam by touching with hands). RN #1 documented that staff education was provided to check the condition of slings. The Plan of Prevention Implemented/ Steps Taken to prevent re-occurrence included: a new sling was provided, the x-ray was negative, and employee education. There was no documentation for a plan to address that the loop that broke was not a loop to be used for transfers and there was no documented evidence that nursing staff were educated on proper use of slings. Review of an undated, written and signed statement by RN #2 Unit Manager revealed that the resident was being transferred via a lift into bed. There was a sling break while the resident was in the air. An x-ray of the left hip and pelvis were obtained and were negative for fracture. RN #2's statement revealed that when she inspected the used sling it was noted to be the incorrect trim color and the broken loops were the incorrect colored loops per the plan of care. Review of a written and signed statement by CNA #1 on 3/20/16 revealed that while CNA #1 and CNA #2 were putting the resident to bed at approximately 6:45 PM the lift pad broke and the resident fell out of the lift, hit her chair, then hit the floor landing on her head. CNA #1's statement revealed that the lift pad was broken and worn out. Per the statement the nurse and Supervisor were called to assess the resident. Review of a written and signed statement by CNA #2 dated 3/20/16 revealed that while transferring the resident to bed from the chair; while the resident was up in the air, the straps broke and the resident fell face first on the chair. The resident bounced off the chair and hit her face on the floor, and the resident was still on the sling and the straps just broke. Review of a written and signed statement by the Licensed Practical Nurse (LPN) #1 dated 3/20/16 revealed that she was called into the room by a CNA. The resident was on the floor and stated to LPN #1, I want to go to bed. The CNAs told her that the resident fell from the lift to the floor and hit her head. LPN #1 did not witness any apparent injury. There was no written statement or interview obtained by the facility for CNA #3. Review of a Progress Note dated 3/21/16 at 2:29 AM written by RN #3 Supervisor revealed the resident states right side of leg sore, staff nurse medicating with APAP (Tylenol) as needed. The left hip x-ray was negative for fracture. Review of a Progress Note dated 3/21/16 at 12:03 PM, written by RN #2 revealed that the resident denied pain or discomfort, ROM is baseline to the resident, limited to the left side. There was no pain with ROM, neurological status was at baseline without changes noted. No injuries were noted. The resident was noted with intermittent behaviors and was refusing to get out of bed in the AM. Much 1:1 encouragement needed. Review of a Progress Note dated 3/22/16 at 8:38 AM written by RN #2 revealed that the resident's right lower extremity (RLE) was noted to have increased swelling and tenderness with touch especially around ankle area. The note documented that there is a new onset of soft tissue swelling around the ankle with ecchymosis (purplish patch caused by blood under the skin). The Physician was updated and a stat (immediate) x-ray was to be obtained. Review of a Progress Note dated 3/22/16 at 8:55 PM written by LPN #1 revealed that the resident's right ankle was wrapped in an ace wrap, the resident's right ankle was tender to the touch and the resident was sent to the hospital via ambulance at 3:30 PM. Review of a Progress Note dated 3/22/16 at 11:40 PM written by RN #3 revealed that the resident returned from the emergency room , Right lower foot/ ankle has splint intact (status [REDACTED]. The toes were warm and mobile and the RLE was elevated on a pillow. The resident denied complaints of pain or distress. The resident was observed in her room in her wheelchair on 5/20/16 at approximately 11:30 AM. The resident stated that a couple months ago she fell out of the lift and broke her ankle. She could not remember details of the accident. The resident stated that her ankle is now healed and no longer hurts. During a telephone interview on 7/7/16 at approximately 11:00 AM, RN #2 Unit Manager stated that the resident's fall occurred on Sunday 3/20/16 and that RN #1 saved the sling involved in the accident. RN #2 stated that when she inspected the sling on 3/21/16 she noted that it was a green trimmed sling (large) and the resident is care planned to use a blue trimmed sling (extra-large). RN #2 also stated that the broken loops on the sling were not the green loops that the resident is care planned for but were black loops that are not supposed to be used to hook to the mechanical lift. During a telephone interview on 7/11/16 at approximately 10:00 AM, CNA #1 stated that on 3/20/16 she worked the 2:00 PM - 10:00 PM shift and was assigned to the resident. CNA #1 stated that earlier in the shift the resident was given a shower by the shower aide (CNA #3) who originally put the sling under the resident in the chair. CNA #1 stated that after dinner the resident requested to go to bed. CNA #1 stated that she assumed the sling that was already under the resident was the correct sling since CNA #3 put it under the resident. CNA #1 stated that she does not recall if she checked the resident's care plan for the sling trim or loop colors needed before the transfer. CNA #1 stated that while she and CNA #2 were transferring the resident via the mechanical lift the sling broke and the resident fell to the floor. CNA #1 stated that she immediately called the nurse to assess the resident. Multiple unsuccessful attempts were made to contact CNA #3 by telephone for an interview. A request by the Regional Office for written statement from CNA #3 was obtained by the DON and faxed to this office on 8/11/16. Review on 8/11/16 of the written and signed statement by CNA #3 revealed that on 3/20/16 CNA #3 was the shower aide from 2:00 PM until dinner time. CNA #3 wrote that the sling used earlier in the day was soiled and sent to laundry. CNA #3 went to laundry to get another sling for the resident because the resident is care planned for an extra-large (blue trimmed) sling however laundry only had large slings (green trimmed) available. CNA #3 wrote that he informed LPN #2 that he could only find a large sling in laundry. CNA #3 wrote that LPN #2 told him that the resident needed to get her shower so CNA #3 used the large sling to lift the resident for the shower and to get the resident up for dinner that evening. CNA #3 stated that he was not present at the time of the resident's fall. The DON stated during a telephone interview on 9/22/16 at approximately 11:00 AM that CNA #1 is an agency aide. The DON stated that all agency aides receive education during their initial orientation to the facility on the need to follow the resident's care plan. In addition, CNAs are educated on using the correct sling trim and loop color for mechanical lift transfers. During a telephone interview on 9/22/16 at approximately 11:15 AM the Physician stated that he would expect the facility staff to follow the resident's care plan regarding the correct size sling and loop color to be used during mechanical lift transfers. During a telephone interview on 9/23/16 at approximately 11:00 AM, LPN #2 stated that on 3/20/16 he worked the 2:00 PM to 10:00 PM shift. LPN #2 stated that CNA #3 went to laundry to get a clean sling for the resident. LPN #2 stated that CNA #3 did not ask him for direction prior to using the large sling. LPN #2 stated after CNA #3 returned from laundry the next thing he knew the resident was already showered. LPN #2 stated that he would never advise a CNA to use the wrong sling size because the slings are rated for weight. LPN #2 stated that after the resident fell he was called to the room and noted that three straps and two loops of the sling were ripped. He stated that the resident fell into the Geri-chair then onto the floor. LPN #2 stated that he checked the resident then called the RN Supervisor to assess the resident. In summary, facility staff did not transfer the resident via the mechanical lift according to the resident's care plan. Staff did not follow the resident's care plan regarding the correct size sling or loop color to be used during mechanical lift transfers. This resulted in a fall to the floor during the transfer when the sling broke and the resident sustained [REDACTED]. 415.12(h)(1)

THIS IS A REPEAT DEFICIENCY FROM THE LAST STANDARD SURVEYS COMPLETED ON 1/30/14 AND 1/22/15. Based on observation, interview and record review conducted during an Abbreviated survey (Complaint #NY 987) completed on 7/17/15, the facility failed to ensure that a resident having pressure sores received necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Two (Residents #1 and 2) of three residents reviewed for pressure sores had issues. The facility failed to monitor and assess (including measurement of size) by a Registered Professional Nurse, an area on Resident #1's sacrum (area above the tail bone on right and left buttocks) from 5/25/15 through 6/8/15. This resulted in the area on the sacrum progressing from a Stage 1 to a Stage 3 during this two week period. In addition, Physician documentation revealed the resident experienced pain related to the wound on the sacrum that necessitated an order for [REDACTED]. Resident #2 had an issue with the lack of notifying the Registered Dietician of the presence of a pressure sore in a timely manner. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy. The findings are: 1. Resident #1 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 5/8/15 revealed the resident has severe cognitive impairment. Review of a Comprehensive Physician order [REDACTED]. Review of a Weekly Skin Monitoring Sheet (utilized by the facility to check the for skin abnormalities on bath days) dated 5/25/15 and signed by a Licensed Practical Nurse (LPN) revealed that a skin abnormality was noted with a description of sacrum/ buttocks moisture. Review of the Medical Record including Interdisciplinary Progress Notes, 24 Hour Nursing Services Reports, and Wound Evaluation Flow Sheets from 5/25/14 through 6/8/15 revealed no documentation of a Registered Nurse (RN) assessment of the sacrum. Review of a Weekly Skin Monitoring Sheet dated 6/1/15 revealed the skin monitoring sheet was blank and had no nurse signature. Review of the Weekly Skin Monitoring Sheet dated 6/8/15 and signed by the LPN revealed a skin abnormality was noted. The description stated a pressure ulcer was noted to the sacrum area measuring 5 centimeters (cm) by 3.5 cm with a depth of 1.5 cm. Review of the Wound Evaluation Flow Sheet dated 6/8/15 and signed by the RN documented the presence of a Stage 3 pressure ulcer to the sacrum that measured 5 cm x 3.5 cm L x W (length x width), with a depth of 1.5 cm. The description of the wound stated the peri-wound (surrounding) was red. There was 90% [MEDICATION NAME] (skin) tissue and 10% necrosis (dead tissue). Review of the Comprehensive Physician order [REDACTED].after cleansing with normal saline, apply Santyl (topical [MEDICATION NAME] ointment) and a foam dressing to the sacrum ulcer area, change every day and as necessary until resolved. Review of a Wound Evaluation Flow Sheet dated 6/22/15 revealed the pressure sore to the sacrum had changed from a Stage 3 to an unstageable area that measured 4.5 cm x 2.5 cm (L x W) with a depth of 1.7 cm. The peri-wound was described as beefy red with moderate purulent and bloody drainage. There was 20% [MEDICATION NAME] tissue, 50% slough (dead tissue), and 20% necrosis. The description revealed the area has 1.7 cm tunneling at the 5:00 PM position. Review of the Physician's Telephone Orders dated 6/22/15 revealed orders to discontinue the previous treatment to the sacrum and to cleanse the wound with wound cleanser, pack tunneling with 4 cm to 5 cm of Derma granite AG rope (wound dressing with antibacterial silver for wounds with moderate to high drainage) and cover with a 4 x 4 cm foam dressing, change every three days and as necessary. Review of the Comprehensive Physician order [REDACTED]. Review of an Interdisciplinary Progress Note written by a LPN dated 6/25/15 at 11:50 PM revealed a new order for [MEDICATION NAME] 5 ml SL (sublingual- under the tongue) every four hours as necessary for pain related to the wound on the sacrum. Review of a Physician Acute Visit note dated 6/26/15 revealed the Physician was called to see the patient because it appears that the sacral decubitus that was categorized as a Stage 1 in the end of May 2015 has apparently progressed and worsened and is now deemed unstageable. The note further documented that yesterday the patient was started on sublingual [MEDICATION NAME] because of pain. Review of the Wound Evaluation Flow Sheet dated 7/15/15 revealed the pressure sore on the sacrum is designated as Stage 4/ unstageable. The measurement is 3.2 cm x 1.5 cm (L x W) with a depth of 1.3 cm. The peri- wound is described as pink. The note documented the area on the sacrum has signs of healing and no slough or eschar (dead tissue) was noted. There was a scant amount of drainage without odor. Granulation (new tissue) was noted. The current treatment is Santyl with a tender wet (moist) dressing. Observation of the resident's sacral dressing change was conducted on 7/16/15 at approximately 10:30 AM. The LPN performed the dressing change using proper aseptic technique in accordance with the physician's orders [REDACTED]. Tunneling was noted. The wound appeared to be the size as stated on the 7/15/15 Wound Evaluation Flow Sheet; 3.2 cm x 1.5 cm (L x W) with a depth of 1.3 cm. The wound bed appeared pink and clean with some granulating tissue and scant amount of drainage. The resident appeared to tolerate the treatment well. Review of the facility's policy and procedure entitled Dermal Wound and Stage 1 Pressure Ulcers dated 8/08 revealed there is to be an RN assessment and documentation completed weekly on the Wound Evaluation Flow Sheet. Review of the Exceptional Care Plan dated 5/19/15 revealed no specific interventions were added to the care plan on 5/25/15 related to the area found on the resident's sacrum and buttocks on that date. During an interview with the RN Charge Nurse on 7/15/15 at approximately 2:00 PM revealed the last time she observed the resident's sacrum was at the end of May 2015. The RN Charge Nurse stated the area appeared to be a Stage 1 with some redness and excoriation. The RN Charge Nurse stated an order was received in May to apply Dermamed ointment to the area. The RN Charge Nurse stated she did not document anything in the Nurse's Notes in May regarding the area. The RN Charge Nurse stated during further interview on 7/16/15 at approximately 11:00 AM that she did not start a Wound Evaluation Flow sheet for the resident's wound on 5/25/15. The RN Charge Nurse stated I realize I was supposed to initiate it but forgot to do it. The RN Charge Nurse stated no staff reported to her between 5/25/15 through 6/8/15 that the area had worsened and on 6/8/15 neither the CNAs (certified nurse aide) nor LPN reported the area to her. The RN Charge Nurse stated she assessed the area on 6/8/15, started a Wound Evaluation Flow Sheet and obtained new orders for Santyl ointment and a dressing to the area. In addition, the RN Charge Nurse stated the entire unit was moved to a different area of the building on 6/3/15. The Director of Nursing (DON) stated during an interview on 7/16/15 at approximately 12:00 PM the facility policy is to start a weekly Wound Evaluation Flow Sheet for a Stage 1 pressure sore and the RN Charge Nurse should have started one on 5/25/15 when the area was first discovered. During an interview with the Physician on 7/16/15 at approximately 12:30 PM, the Physician stated it is concerning that the resident's Stage 1 area was not assessed by an RN for a two week period and had progressed from a Stage 1 to an unstageable area. The Physician stated I was not aware of any wounds on the resident prior to ordering [MEDICATION NAME] for pain on 6/25/15. The Physician stated the nurse's told her the resident was in a lot of pain and could not swallow the [MEDICATION NAME] ([MEDICATION NAME] and [MEDICATION NAME]-used to relieve moderate to severe pain) so she ordered the sublingual [MEDICATION NAME] for the resident. 2. Resident #2 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has severe cognitive impairment. Review of the Wound Evaluation Flow Sheet dated March, 2015 revealed the stage 1 pressure sore to the sacrum had resolved. Review of the Wound Evaluation Flow Sheet dated 5/25/15 revealed the resident was assessed as having a Stage 2 pressure ulcer on her sacrum. Review of the Comprehensive Physician order [REDACTED]. Review of a Caloric Protein Worksheet (For Pressure Sores) completed on 6/16/15 by the Registered Dietitian (RD) revealed the resident's sacrum was now a stage 3 pressure sore and the resident's nutritional needs were re-assessed. Review of a Wound Evaluation Flow Sheet dated 6/17/15 revealed the sacrum assessed to be a Stage 2 pressure sore measuring .08 cm x .05 cm and continued to be treated with [MEDICATION NAME]. Review of a Wound Evaluation Flow Sheet dated 6/24/15 revealed the sacrum assessed to be a Stage 3 pressure sore measuring 1.5 m x 1.0 cm and the treatment was changed to Santyl. Review of the Comprehensive Physician order [REDACTED]. Review of the Treatment Administration Record (TAR) for June, 2015 revealed the resident continued to receive [MEDICATION NAME] treatments to the sacrum every other day. Review of the TAR for July, 2015 revealed the Santyl treatment was initiated on 7/3/15 due to the treatment continued to be scheduled for every other day instead of daily. Interview with the RD on 7/16/15 at 10:00 AM revealed she is usually informed about pressure sores during morning report, during skin rounds or by any nurse in passing. The RD stated she could not remember what date she was informed about the pressure sore worsening for Resident #2 but she usually re-assesses the resident as soon as she can after being informed. The RD stated when she is informed that a pressure sore has become worse, she changes the protein supplement that is provided with medication pass. She tries to re-evaluate as soon as she is informed so that the protein supplement is correct. During an interview with the RN Unit Manager (UM) on 7/16/15 at approximately 1:00 PM, the RN UM revealed the nurse that takes the new order for pressure sore treatment is the nurse who transcribes the new order to the TAR. In addition, when there is a new skin area or worsening of the skin area, the RD is to be informed either in report or when she is on the unit. The RN UM could not remember when Resident #2's pressure sore was assessed as being a Stage 3 and stated the treatment should have been started on 6/29/15 every day instead of every three days. 415.12(c)(1)

Based on observation, interview and record review conducted during an Extended Survey completed on 1/30/14, the facility failed to ensure that the resident environment remains as free of accident hazards and each resident receives adequate supervision and assistance devices to prevent accidents. Specifically, one (Willink Building) of three buildings involving three (Willink A, Vintage Cove, Station C) of seven resident units observed for hot water temperatures had issues involving unsafe water temperatures. Hot water temperatures in resident use areas ranged from 122 degrees Fahrenheit (F) to 131.9 degrees F. The facility was unaware of the hot water temperatures over 120 degrees F and review of the facility's water temperature logs revealed no water temperatures were tested from 1/20/14 to 1/26/14. Additionally, the facility did not have a policy and procedure to address checking water temperatures in the facility or to calibrate the thermometers in use. Residents #69, 79, 111, 125, 158, 191, 199, 205, 209, 211, 256, 281, 286, 297, 322, 329, 348, 350, and 354 were potentially affected. This resulted in a pattern of no actual harm with potential for serious harm, that is IMMEDIATE JEOPARDY AND SUBSTANDARD QUALITY OF CARE TO RESIDENT HEALTH AND SAFETY. In addition, one (Resident #156) of four residents reviewed for accidents had a [DIAGNOSES REDACTED]. Resident #156 had no actual harm with potential for more than minimal harm that is not immediate jeopardy. The Immediate Jeopardy was removed on 1/29/14, prior to completion of the survey. The findings are: 1a). During the initial environmental tour on 1/26/14 from 10:35 AM to 12:30 PM, water temperatures in the Willink Building were tested using a Taylor 9840N digital thermometer. Water temperatures in resident use rooms were as follows: Station C Unit (locked dementia unit): - Room #146 - 129.7 degrees Fahrenheit ?F - Room #164 - 128.8 ?F - Room # 165 - 130.3 ?F - Shower room - 126.7?F Vintage Cove Unit (locked dementia unit): - Room #124 - 129.1?F - Room #125 - 128.5?F - Room #127 - 123.6?F - Room #129 - 120.0?F - Room #140 - 123.0?F - Room #142 - 126.7?F - Room #143 - 128.5?F Willink A Unit: - Room #103 - 130.1?F - Room #104 - 125.9?F - Room #108 - 128.7?F - Room #109 - 131.9?F - Room #111 - 130.2?F - Room #113 - 129.0?F - Shower Room - 128.7?F Observation in the Willink Building Boiler room on 1/26/14 at approximately 11:42 AM revealed the domestic hot water control valve was set between 125?F and 130?F. The observation revealed that the thermometer at the mixing valve (a valve that mixes hot water with cold water, supplied to the Willink Building) read a little over 130?F. Interview with the Maintenance Director on 1/26/14 at approximately 11:57 AM revealed he has been working at the facility for three years and during that time, the mixing valve had not been replaced or worked on. The Maintenance Director stated he was not sure when the mixing valve was installed in the Willink Building's water system. Observation in the Willink Boiler Room on 1/26/14 at approximately 11:42 AM revealed the Maintenance Director lowered the domestic hot water control valve setting from "125?F to 130?F" to approximately 118?F. Observation on 1/26/14 at approximately 11:58 AM revealed the thermometer at the mixing valve still read a little over 130?F. Interview with the Maintenance Director on 1/26/14 at 11:58 AM revealed he believed the thermometer at the mixing valve was broken and he was not sure when the thermometer was installed. Interview with CNA #3 on 1/27/14 at approximately 12:17 PM stated the water does get hot sometimes she tests it on herself first and adjusts it before doing care. She has no idea how hot and she tells the nurse. b). Interview with the Vintage Cove and Station C Units Registered Nurse (RN) Resident Care Coordinator (RCC) on 1/26/14 at approximately 12:30 PM revealed both of the units are locked, dementia units. The RN RCC stated there are eight residents (#111, 158, 205, 281, 297, 322, 348, 354) on the Vintage Cove Unit and 11 residents (#69, 79, 125, 191, 199, 209, 211, 256, 286, 329, 350) on Station C who are cognitively impaired and wander. Review of Accident and Incident (A&I) Reports dated 8/2013 through 1/2014 revealed there were no incidents and/or injuries related to hot water temperatures. c). Review of Water Temps Check logs for the Hamlin, Hubbard and Willink Buildings for January 2014 revealed the following: - Water temperatures for the Hamlin 2 and Hamlin 3 units were written on the log from 1/16/14 through 1/20/14 but there was no information regarding where those temperatures had been obtained. There was no documentation of room numbers or location. The water temperatures ranged from 112 to 113 degrees F. - Water temperatures for Hubbard 2 and Hubbard 3 were written on the log from 1/16/14 through 1/20/14. There was no information regarding where the temperatures had been checked. The water temperature ranged from 112 to 113 degrees F. - Water temperatures for the Willink A unit were written on the log from 1/13/14 through 1/20/14. There was no information regarding where the temperatures were obtained. The water temperatures ranged from 111 to 113 degrees F. - Water temperatures for the Willink B unit were written on the log from 1/16/14 through 1/20/14, and there were no room numbers identified on the log. The water temperatures ranged from 112 to 113 degrees F. - Water temperatures for the Willink C unit were written on the log from 1/17/14 through 1/20/14 and there were no room numbers identified on the log. The water temperatures ranged from 112 to 113 degrees F. - The Water Temps Check logs were blank for all units from 1/20/14 through 1/26/14. Interview with the Maintenance Director on 1/26/14 at approximately 1:15 PM revealed that maintenance staff check water temperatures throughout the Hamlin, Hubbard, and Willink Buildings every day. The Maintenance Director stated he was not sure why water temperatures were not checked by maintenance staff in the Hamlin, Hubbard, and Willink Buildings from 1/20/14 through 1/26/14. Further interview with the Maintenance Director revealed he does not check the Water Temperature Check logs until the end of each month and then he sends copies of them on to the corporation that owns the facility. During the interview, the Maintenance Director stated that the facility had no written policy and procedure for taking water temperatures throughout the Hamlin, Hubbard, and Willink Buildings. Interview with the Administrator and Director of Nursing (DON) on 1/26/14 at approximately 2:05 PM revealed the facility had no written policy and procedure for taking water temperatures throughout the Hamlin, Hubbard, and Willink Buildings. Additional interview with the DON on 1/26/14 at approximately 2:15 PM revealed she was unaware that water temperatures in the residents' rooms were over 120.0?F. The DON stated that water temperatures are checked daily and if there are any issues, she should be notified immediately. In addition the DON stated that if water temperatures are not checked daily, she should be informed. Interview with the Administrator on 1/26/14 at approximately 2:30 PM revealed she was unaware that water temperatures in the residents' rooms were elevated beyond 120?F. The Administrator stated water temperatures are checked daily and if there are any issues, she should be notified immediately. In addition, the Administrator stated that if water temperatures were not checked daily, she should have been informed. d). Observation on 1/26/14 at approximately 3:00 PM, in the presence of the Maintenance Director, revealed the water temperature in resident room #146 measured 129?F using the surveyor's thermometer. The Maintenance Director measured the water temperature at 120?F using the facility's Bi-Metal "pocket test" thermometer (dial/ stem type thermometer). Observation in the Willink Boiler Room on 1/26/14 at approximately 3:44 PM revealed the hot water holding tank for the Willink Building domestic water was set at 130?F. Interview with the Maintenance Director at the time of the observation revealed the mixing valve was not functioning properly and water at approximately 130?F was going from the hot water holding tank through the mixing valve and directly into the Willink Building's domestic water supply. The Maintenance Director stated he was contacting an outside contractor to have them come to the facility and evaluate the Willink Building's water system. Interview with a Mechanic from the outside contractor who evaluated the Willink Building's water system on 1/27/14 at approximately 12:00 PM revealed that the thermostatic element (the mechanism that controls the mixing valve) for the mixing valve was broken; the mixing valve was not functioning properly; and water at approximately 130?F was going from the hot water holding tank through the mixing valve and directly into the Willink Building's domestic water supply. During an observation on 1/27/14 at approximately 4:01 PM, the surveyor and the Maintenance Director tested water temperatures in the sink located in resident room #146. The surveyor placed her thermometer in the stream of water coming out of the faucet in the bathroom sink, while the Maintenance Director placed three of the facility's thermometers in the sink basin and completely immersed the thermometers in approximately two inches of water. The water temperature on the surveyor's digital thermometer was 118.3 degrees F. The water temperatures recorded by the facility's stem thermometers were 110 degrees F, 111 degrees F, and 110 degrees F. During observation in the Willink Building on 1/27/14 at approximately 4:10 PM, the surveyor and the Maintenance Director tested water temperatures in the sink located in resident room #164. The surveyor placed her thermometer in the stream of water coming out of the sink, while the Maintenance Director placed three of the facility's thermometers in the sink basin, completely immersing the thermometers in approximately two inches of water. The water temperature displayed on the surveyor's digital thermometer was 118.2 degrees F. The water temperatures recorded by the facility's stem thermometers were 110 degrees F, 110 degrees F, and 109 degrees F. Review of the instructions on the box for the facility's "Pocket Test" thermometers on 1/27/14 at approximately 4:20 PM revealed "Immerse thermometer stem a minimum of two inches (5.08 cm) into a 50/50 ice and water slush bath (without touching the sides or bottom of the container), until indicator stabilizes." Interview with the Administrator, Maintenance Director, Food Service Director and the Chief Operating Officer on 1/27/14 at approximately 5:30 PM revealed the following: - The Food Service Director checks all of the facility's thermometers, using an ice water bath, before the thermometers are given to the facility's staff for use within the facility. - No re-checks are conducted on thermometers once they are give to the staff to ensure that the thermometers a functioning properly. - Thermometers that appear to be functioning improperly are thrown out. - All departments in the facility use the same type of thermometer (Bi-Metal Pocket Test Thermometer). - The facility has no written records that show when thermometers are checked. - The facility has no written policy and procedure for calibrating the accuracy of their thermometers and for taking water temperatures throughout the Hamlin, Hubbard, and Willink Buildings. e). Review of documentation signed by the Administrator and provided to the New York State (NYS) Department of Health (DOH) on 1/27/14 revealed the Director of Maintenance made immediate adjustments to the boiler to lower the water temperature, on 1/26/14 after elevated water temperatures were identified. All resident shower rooms and three resident rooms per unit were "temped" every two hours throughout the evening, night and day shifts and there were no further water temperatures over 120 degrees F in the facility. On 1/27/14, an outside vendor inspected the boiler and the mixing valve in the Willink boiler was "rebuilt". Review of documentation provided to the NYS DOH and signed by the Administrator dated 1/29/14 revealed the facility continued to monitor water temperatures in the facility every two hours. The Administrator documented that a policy for monitoring domestic water temperatures was developed and 95 percent of all facility staff had been inserviced. In addition, a policy for the calibration of thermometers was developed and dietary and nursing supervision and maintenance staff were inserviced. Observation and interviews from 1/27/14 to 1/29/14 revealed the following actions were taken to remove the Immediate Jeopardy situation in the facility involving hot water temperatures: - Interview with a mechanic from the outside contractor that evaluated the Willink Building's water system on 1/27/14 at approximately 3:00 PM revealed the thermostatic element (the mechanism that controls the mixing valve) was replaced and the mixing valve was functioning properly. The Mechanic stated that the domestic hot water control valve, the mixing valve and the hot water holding tank for the Willink Building were set at 116?F and the thermometer at the mixing valve was replaced and reading at 116?F. - Intermittent observations on 1/27/14 from approximately 3:00 PM to 1/29/14 at 10:00 AM revealed that random samples of hot water measured in resident use areas on the Willink A, Vintage Cove and Station C Nursing Units in the Willink Building ranged from 110.3?F to 118.6?F . - Interviews with three members of the Maintenance Staff on 1/29/14 at approximately 2:42 PM revealed the staff were aware and understood the facility's newly developed policy and procedure for checking water temperatures throughout the Hamlin, Hubbard and Willink Buildings. - Interviews with three LPNs and three CNAs in the Willink building on 1/29/14 from approximately 1:00 PM to 2:30 PM revealed staff were aware and understood the facility's policy to report hot water to maintenance and nursing supervision. Interview with the Administrator on 1/29/14 at approximately 1:30 PM revealed staff education on Water Safety Precautions was completed by 1/29/14. 2. Resident #156 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident has severe cognitive impairment, sometimes understands, is understood and has short and long term memory problems. The MDS documented that the resident requires extensive staff assistance with activities of daily living (ADLs) including personal hygiene. Review of an Initial SLP (Speech/ Language Pathology) assessment dated [DATE] revealed the resident had mild swallowing impairment; was at risk for aspiration on liquids; had mild oral residue; and may need meats ground or chopped; cueing and supervision. The Assessment documented that the resident was placed on a mechanical soft/ ground regular diet with thin liquids and would receive skilled ST (speech therapy) services for treatment of [REDACTED]." Review of a Speech Screening dated 7/30/13 revealed Resident #156 has impaired swallowing and receives a pureed diet with honey thick liquids. Review of the current Exceptional Care Plan printed 11/19/13 revealed the resident has an identified problem with nutritional status. The Care Plan documented that the resident has variable intakes, refuses meals, and has a history of weight loss trends with planned approaches to follow the Nutrition/ Hydration Standard of Care and provide fortified shakes and whole milk at meals for increased calories. The Care Plan also documented that the resident has a history of pneumonia (onset date 8/26/13). Review of the Care Guide, used by certified nurse aides (CNAs) to provide care, dated 1/27/14 revealed the resident is a "Total Feed", receives a pureed diet and honey thick fluids, requires the use of a nosey cup and has "Special Feeding Instructions" to alternate bites with sips. Observation on 1/28/14 at approximately 8:30 AM revealed that CNA #1 was feeding the resident, who was extremely somnolent (sleepy/drowsy). For approximately three minutes, the CNA attempted to feed the resident with no success. The CNA was observed to inform the Registered Nurse (RN) Resident Care Coordinator (RCC) who was in the dining room and another CNA took over feeding the resident. For the next 10 minutes, CNA #2 was observed feeding the somnolent resident by repeatedly calling her name and placing food/ liquid in the resident's mouth, while it took the resident approximately 4 to 45 seconds to swallow. Once the resident had a bolus of food in her mouth, she was observed to keep her mouth open and breath with the bolus of food in her mouth. At approximately 8:40 AM, CNA #2 stated that the resident was "too tired today", removed the resident's clothing protector, and placed the resident in a semi-fowler's (a back lying position with the head up at 30 degrees) position in the "Tilt-in-Space" wheelchair (reclining wheelchair). Three small to large boluses of food were visible in the resident's mouth. Once the task of feeding was completed, the resident remained asleep and was breathing through her open mouth. CNA #2 transported the resident from the dining room to her room; transferred the resident to her bed; and provided incontinence care to the resident as she was lying flat in the bed. During the entire observation, the resident remained asleep, she did not respond to her name, and she continually breathed through her open mouth. When the CNA was done with care, she took a Toothette (disposable oral swab) and removed the food from the resident's mouth. Interview with CNA #2 on 1/28/14 at approximately 8:55 AM revealed she knew that Resident #156 had food in her mouth in the dining room and she did not remove it because she had nothing with her in the dining room to remove it with. During an interview on 1/28/14 at approximately 8:56 AM, the RN RCC, who was in the resident's room for the transfer and incontinence care, stated that Resident #156 has dysphagia (difficulty swallowing), and receives a pureed diet with honey thick liquids. The RN RCC stated that staff are to alternate sips and bites during feeding, and ensure that the resident swallows. The RN RCC stated that she was aware the resident was sleepy during breakfast and did not wake up to stimuli. The RN RCC stated that she was not aware that the resident had a bolus of food in her mouth and stated that the CNAs are instructed to immediately remove the food if the resident does not swallow. Interview with the Speech Pathologist on 1/28/14 at approximately 11:30 AM revealed that Resident #156 has advanced dementia which affects her ability to eat. The Speech Pathologist reviewed the resident's speech therapy notes and stated that the resident was initially treated with speech therapy and was "on program" for some time for dysphagia. The Speech Therapist stated that he evaluated the resident on 10/10/12 because she had right sided pneumonia, which is often is an indication of aspiration (inhalation of foreign matter into the lungs) and this warranted a speech language evaluation. In October 2013, the resident received additional speech language therapy for impaired swallowing and has remained on a pureed diet and honey thick liquids. The Speech Pathologist stated that staff are taught to feed the resident with proper posture, provide alternating sips and bites and notify the nurse and/or speech pathologist for problems. The Speech Pathologist stated that if the resident is continually not swallowing, she is at risk for aspiration pneumonia, which is a common problem for end-stage dementia resident's. 415.12(h)(1)(2)

Based on observation, interview and record review conducted during an Extended Survey completed on 1/30/14, it was determined that the governing body failed to establish and implement policies regarding the management and operation of the facility to ensure that the facility was managed in a manner that protected the health and safety of its residents. The facility did not ensure that the resident environment remained as free of accident hazards as possible. Specifically, one (Willink Building) of three buildings involving three (Willink A, Vintage Cove, Station C buildings) of seven resident units observed for hot water temperatures had issues involving unsafe water temperatures over 120 degrees Fahrenheit (F). The facility failed to ensure that policies were developed and implemented related to monitoring water temperatures in resident use areas. The lack of oversight by the governing body resulted in a deficiency which was determined to constitute SUBSTANDARD QUALITY OF CARE. This resulted in a pattern of no actual harm with potential for serious harm, that is IMMEDIATE JEOPARDY TO RESIDENT HEALTH AND SAFETY. Refer to F323 - scope and severity - K The Immediate Jeopardy was removed on 1/29/14, prior to completion of the survey. The findings are: 1. During the initial environmental tour on 1/26/14 from 10:35 AM to 12:30 PM, water temperatures in the Willink Building were tested using a Taylor 9840N digital thermometer. Water temperatures in resident use rooms were as follows: Station C Unit (locked dementia unit): - room [ROOM NUMBER] - 129.7 degrees Fahrenheit ?F - room [ROOM NUMBER] - 128.8 ?F - Room # 165 - 130.3 ?F - Shower room - 126.7?F Vintage Cove Unit (locked dementia unit): - room [ROOM NUMBER] - 129.1?F - room [ROOM NUMBER] - 128.5?F - room [ROOM NUMBER] - 123.6?F - room [ROOM NUMBER] - 120.0?F - room [ROOM NUMBER] - 123.0?F - room [ROOM NUMBER] - 126.7?F - room [ROOM NUMBER] - 128.5?F Willink A Unit: - room [ROOM NUMBER] - 130.1?F - room [ROOM NUMBER] - 125.9?F - room [ROOM NUMBER] - 128.7?F - room [ROOM NUMBER] - 131.9?F - room [ROOM NUMBER] - 130.2?F - Room #113 - 129.0?F - Shower Room - 128.7?F Observation in the Willink Building Boiler room on 1/26/14 at approximately 11:42 AM revealed the domestic hot water control valve was set between 125?F and 130?F. The observation revealed that the thermometer at the mixing valve (a valve that mixes hot water with cold water, supplied to the Willink Building) read a little over 130?F. Observation in the Willink Boiler Room on 1/26/14 at approximately 11:42 AM revealed the Maintenance Director lowered the domestic hot water control valve setting from "125?F to 130?F" to approximately 118?F. Observation on 1/26/14 at approximately 11:58 AM revealed the thermometer at the mixing valve still read a little over 130?F. Interview with the Maintenance Director on 1/26/14 at 11:58 AM revealed he believed the thermometer at the mixing valve was broken and he was not sure when the thermometer was installed. Review of Water Temps Check logs for the Hamlin, Hubbard and Willink Buildings for January 2014 revealed the following: - Water temperatures for the Hamlin 2 and Hamlin 3 units were written on the log from 1/16/14 through 1/20/14. There was no information regarding where those temperatures had been obtained. There was no documentation of room numbers or location. The water temperatures ranged from 112 to 113 degrees F. - Water temperatures for Hubbard 2 and Hubbard 3 were written on the log from 1/16/14 through 1/20/14. There was no information regarding where the temperatures had been checked. The water temperature ranged from 112 to 113 degrees F. - Water temperatures for the Willink A unit were written on the log from 1/13/14 through 1/20/14. There was no information regarding where the temperatures were obtained. The water temperatures ranged from 111 to 113 degrees F. - Water temperatures for the Willink B unit were written on the log from 1/16/14 through 1/20/14, and there were no room numbers identified on the log. The water temperatures ranged from 112 to 113 degrees F. - Water temperatures for the Willink C unit were written on the log from 1/17/14 through 1/20/14 and there were no room numbers identified on the log. The water temperatures ranged from 112 to 113 degrees F. - The Water Temps Check logs were blank for all units from 1/20/14 through 1/26/14. Interview with the Maintenance Director on 1/26/14 at approximately 1:15 PM revealed that maintenance staff check water temperatures throughout the Hamlin, Hubbard, and Willink Buildings every day. The Maintenance Director stated he was not sure why water temperatures were not checked by maintenance staff in the Hamlin, Hubbard, and Willink Buildings from 1/20/14 through 1/26/14. Further interview with the Maintenance Director revealed he does not check the Water Temperature Check logs until the end of each month and then he sends copies of them on to the corporation that owns the facility. During the interview, the Maintenance Director stated that the facility had no written policy and procedure for taking water temperatures throughout the Hamlin, Hubbard, and Willink Buildings. Interview with the Administrator and Director of Nursing (DON) on 1/26/14 at approximately 2:05 PM revealed the facility had no written policy and procedure for taking water temperatures throughout the Hamlin, Hubbard, and Willink Buildings. Additional interview with the DON on 1/26/14 at approximately 2:15 PM revealed she was unaware that water temperatures in the residents' rooms were over 120.0?F. The DON stated that water temperatures are checked daily and if there are any issues, she should be notified immediately. In addition the DON stated that if water temperatures are not checked daily, she should be informed. Interview with the Administrator on 1/26/14 at approximately 2:30 PM revealed she was unaware that water temperatures in the residents' rooms were elevated beyond 120?F. The Administrator stated water temperatures are checked daily and if there are any issues, she should be notified immediately. In addition, the Administrator stated that if water temperatures were not checked daily, she should have been informed. Interview with a Mechanic from an outside contractor who evaluated the Willink Building's water system on 1/27/14 at approximately 12:00 PM revealed that the thermostatic element (the mechanism that controls the mixing valve) for the mixing valve was broken; the mixing valve was not functioning properly; and water at approximately 130?F was going from the hot water holding tank through the mixing valve and directly into the Willink Building's domestic water supply. Interview with the Administrator, Maintenance Director, Food Service Director and the Chief Operating Officer on 1/27/14 at approximately 5:30 PM revealed the following: - The Food Service Director checks all of the facility's thermometers, using an ice water bath, before the thermometers are given to the facility's staff for use within the facility. - No re-checks are conducted on thermometers once they are give to the staff to ensure that the thermometers a functioning properly. - Thermometers that appear to be functioning improperly are thrown out. - All departments in the facility use the same type of thermometer (Bi-Metal Pocket Test Thermometer). - The facility has no written records that show when thermometers are checked. - The facility has no written policy and procedure for calibrating the accuracy of their thermometers and for taking water temperatures throughout the Hamlin, Hubbard, and Willink Buildings. These deficiencies and the potential serious impact they represent to the quality of care and the quality of life of facility residents, demonstrate a failure on the part of the governing body to ensure effective management and operation of the facility. 415.26(b)(2)(3)

Based on observations and staff interviews conducted during an Abbreviated survey (complaint #NY 307) completed on [DATE], the facility did not ensure that the resident environment remained as free of accident hazards as is possible; and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, one (Resident #1) of five residents reviewed for accidents was allowed to go to an unsafe area outside of the facility without supervision. This was actual harm that is not immediate jeopardy. The findings are: 1. Resident #1 had [DIAGNOSES REDACTED]. Review of the facility Inhouse Investigation dated [DATE] revealed the resident was admitted to the facility on [DATE] with a Mini Mental score of ,[DATE] after hospitalization for respiratory failure and he was independent with an electric wheelchair. On [DATE] the resident was assessed by the Occupational Therapy (OT) Department and deemed to have good safety awareness of parked and moving cars and was independent in the chair on the facility property. Review of the Occupational Therapy (OT) Consultation Form dated [DATE] revealed the resident was able to push the handicap buttons to enter and exit a specific building on the facility's grounds. Resident instructed if he does not notify the nurse and use specific building for entrance or demonstrate unsafe driving, outside privileges will be revoked. A reflector was applied to the power wheelchair to increase safety while outside. The resident was also instructed not to leave the facility grounds alone. Resident with understanding of stipulation for independence with power wheelchair outside. OT to monitor and consult as needed. Review of a social work Interdisciplinary Progress Note dated [DATE] revealed the director of physical therapy was consulted regarding the resident's safety in the parking lot related to use of his motorized scooter and concerns that he was riding too close to the backs of parked cars. The note documented that the Social Worker spoke with the resident and educated him on riding further away from parked cars. Review of a social work Interdisciplinary Progress Note dated [DATE] revealed the Social Worker was informed the resident was behind one of the facility buildings, out of his motorized chair, near the creek, picking up black walnuts. The Social Worker spoke with the therapy director regarding safety awareness and a decision was made to set specific limits on the (facility) property in order to maintain the resident's safety. The Social Worker spoke to the resident and set parameters and informed him if he violated the rules, his motorized chair would be taken away due to safety concerns. Review of a social work Interdisciplinary Progress Note dated [DATE] revealed the Social Worker was called outside by a staff member who witnessed the resident in an unsafe spot in the parking lot sitting close to the back of a construction truck. Further review of the facility "Inhouse Investigation" dated [DATE] revealed that on Thursday [DATE] at 12:20 PM the resident was found down the embankment of the nearby creek in his motorized chair. When the Assistant Director of Nursing (ADON) approached the resident she noted that the resident had expired. The area where the resident was found on [DATE] was observed on [DATE] at approximately 10:30 AM. Observation revealed there was a small overflow of the parking lot in a shaded area next to the creek. The pavement ended and a small patch of brush and trees approximately 8 inches wide ended in a drop of approximately ,[DATE] feet into the creek. Interview with the Director of Nursing (DON) and the Administrator on [DATE] at 10:00 AM revealed neither was aware of the three incidents involving the resident and the motorized chair documented by the Social Worker. The DON reported the resident liked to sit in the area of the parking lot next to the creek because it was shaded and he could watch the activity in the parking lot. She reported no other residents sat in this spot and the resident was alert and oriented and enjoyed his independence on his motorized chair. Interview with the Social Worker on [DATE] at 10:15 AM revealed the resident did display behaviors that questioned his safety awareness but he was alert and oriented and once instructed not to repeat the behavior, he was good about complying. She stated he was also compliant with returning to the unit for medications and meals and his daily routine was the same every day. Interview with the RN Unit Manager (UM) on [DATE] at 10:30 AM revealed the unit has a log for residents to sign when they leave the unit. However, the resident did not sign the log because his routine was pretty much the same every day and he would verbally inform staff of his whereabouts. The UM stated the resident would inform staff that he was going outside but he always returned on time for his medications and meals. She reported that the resident never left the grounds of the nursing home and if he was needed, staff knew where to look for him and he could be located within ? hour time. Interview with the Nurse Practitioner on [DATE] at 10:45 AM revealed the resident was alert and oriented and very mobile. She reported he was very well suited to the motorized chair that he used. She reported he was competent to make decisions and he was cooperative with instructions that he was given. Review of the resident's Exceptional Care Plan dated [DATE] showed no documented evidence of the resident's lack of safety awareness or safety measures in place with the use of his motorized chair. Review of the Care Guide modified [DATE] and used by the Certified Nurse Aides (CNAs) to provide care revealed the resident used a personal power wheelchair independently on and off the unit and on facility grounds. Review of the resident's entire medical record revealed no documented evidence that safety measures including supervision or specific property limits were in place for use of the motorized chair. 415.12(h)(1)(2)