Every finding on record at Avon Nursing Home L L C

Based on observations, interviews, and record reviews conducted during the Recertification Survey from 09/26/2024 to 10/02/2024, the facility failed to ensure services were provided to maintain acceptable parameters of nutritional status for one (Resident #27) of two residents reviewed for nutrition. Specifically, Resident #27 had multiple meal refusals and decreased intakes (less than 50%) for approximately two months resulting in a 31 pound (14.4%) unplanned, severe weight loss. The facility could not provide evidence that nursing leadership, dietary or the medical team had been notified or any supplemental interventions had been implemented. This resulted in actual harm to Resident #27 that was not Immediate Jeopardy and is evidenced by the following: The facility policy Nutritional (Impaired)/Unplanned Weight Loss - Clinical Protocol, dated September 2017, included nursing staff would monitor and document the weight and dietary intake of residents in a format which permits comparisons over time. Additionally, staff would report to the physician significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake. Resident #27 had diagnoses including a recent stroke (07/16/2024), depression, and adult failure to thrive. The Minimum Data Set Resident Assessment, dated 07/21/2024, revealed Resident #27 was cognitively intact and required setup assistance with eating. Review of Resident #27's Comprehensive Care Plan, dated 08/01/2024, revealed the resident was at risk for suboptimal nutrition and dehydration. Interventions included to provide the diet as ordered, supplements and snacks as needed or requested, and to monitor the resident's meal intakes and weights. During an observation on 09/26/2024 at 12:45 PM, a facility staff member entered Resident #27's room with a lunch tray and exited the room less than 60 seconds later with the untouched lunch tray. During an observation on 09/30/2024 at 12:50 PM, Resident #27 was lying in bed with their eyes closed. There was no lunch tray in the resident's room, and the lunch meal ticket, located on the nurses' desk counter, had refused handwritten on it. In the most recent dietary progress note, dated 07/27/2024, Registered Dietician #1 documented Resident #27's current weight was 206 pounds, down from 212 pounds a month ago, food intake averaged 76%-100%, and there were no nutritional issues at the time. Physician orders, dated 08/09/2024, documented a regular diet with consistency as tolerated. There were no further orders for nutritional supplements or any other interventions to prevent weight loss. Review of the Vitals Report forms used by staff for documentation of meal intakes from 08/07/2024 to 08/31/2024 revealed multiple meals not documented at all, and multiple meals documented with intakes of less than 50%, less than 26%, none (zero % of the meals consumed), or that the meal was refused. Review of the Vitals Report form of meals intakes from 09/01/2024 to 10/01/2024 revealed for 92 meal opportunities staff had documented the following: - Refused - 26 meals - None (0% meal consumed) - 20 meals - 1-25% - 17 meals - 26% -50% - 10 meals - Resident unavailable or no documentation at all - 8 meals Review of Resident #27's documented weights revealed on: - 07/03/2024 was 213 pounds - 7/16/2024 was 206 pounds - 08/06/2024 was 206 pounds - 09/03/2024 was 201 pounds Review of interdisciplinary team progress notes, dated 09/01/2024 to 09/29/2024, revealed nursing staff had documented on multiple occasions Resident #27 had refused a meal. There was no documented evidence nursing leadership, the dietician, or the medical team had been notified of the decreased intakes or the refusals. In a nursing progress note, dated 09/30/2024, the Acting Director of Nursing documented Physician #1 saw Resident #27 for their routine medical visit and was made aware the resident was not eating or drinking well. There were no new orders at that time. In a medical Visit Note, dated 09/30/2024, Physician #1 documented Resident #27 had a progressive decline with decreased oral intake and weight loss and the plan was to continue with current treatment. Review of Resident #27's electronic medical record revealed no documented evidence that the medical team had discussed any weight loss plans with the resident or their representative. During an interview on 10/01/2024 at 11:20 AM, Certified Nursing Assistant #2 said if a resident refused a meal, they would talk to the resident to try to identify the reason, offer alternatives, and notify the nurse. Certified Nursing Assistant #2 stated Resident #27 had been refusing most of their breakfast that week. During an interview on 10/01/2024 at 11:27 AM, Resident #27 said they did not eat breakfast that day and did not have an appetite. During an observation on 10/01/2024 at 12:49 PM, Resident #27's lunch ticket was observed on the nurses' desk counter with refused handwritten on it. During an interview on 10/01/2024 at 1:30 PM, Licensed Practical Nurse #1 said the Certified Nursing Assistants documented how much a resident eats and drinks and they would expect to be made aware if a resident refused a meal or had a low meal intake. Licensed Practical Nurse #1 said this information should be passed from nurse to nurse during report, and if a resident was refusing meals or having decreased intakes, it should be documented and reported to the nurse manager. Licensed Practical Nurse #1 said Resident #27 had a stroke not too long ago and they knew that a week or two ago, Resident #27 had been refusing quite a bit, mostly lunch, but they had not been told during morning report of any changes (meal refusals or decreased intakes) for Resident #27. During an interview on 10/01/2024 at 1:43 PM, the Acting Director of Nursing said the Certified Nursing Assistants should look at residents' meal trays and enter the intakes (amount consumed) into the electronic medical record for all meals. The Acting Director of Nursing stated if a resident refused a meal or had decreased intake, staff should encourage the resident, and notify the nurse who should check on the resident and try to find a reason why (refused a meal or decreased intake). The Acting Director of Nursing said the nurse should notify either nursing leadership or the medical provider if a resident had consumed less than 25% of one meal and refused the other two meals in one day. The Acting Director of Nursing stated Resident #27 had a stroke a few months prior with a change in personality and poor appetite and had been started on an antidepressant. The Acting Director of Nursing stated Resident #27 had not been eating for the past week or so, and the resident's representative was aware and said the resident would do what they wanted. During an immediate review of the documented meal intakes for Resident #27, the Acting Director of Nursing stated they were not aware of the extent that Resident #27 had been refusing meals. The Acting Director of Nursing stated they told Physician #1, who saw Resident #27 on 09/30/2024, but Physician #1 did not order any new interventions for Resident #27's nutrition status after the visit. The Acting Director of Nursing said residents' weights are done monthly unless otherwise ordered and was not aware if the resident had been weighed yet this month. On 10/02/2024 at 2:36 PM, a weight was obtained for Resident #27 that was 182 pounds or a 9.2% weight loss in one month and 14.5% over three months. During a telephone interview on 10/01/2024 at 3:40 PM, Registered Dietician #1 said they follow-up with residents' monthly weights and receive emails from the Acting Director of Nursing and Social Worker #1 to keep them in the know. Registered Dietician #1 stated they should be notified of a resident's meal refusals or decreased intakes, but this would depend on the resident (no standard number of refusals or intake values). Registered Dietician #1 said they usually reviewed residents' monthly weights around the 10th of the month, and they had not received any emails from the Acting Director of Nursing related to any issues with Resident #27. Registered Dietician #1 stated this was an unusual situation and they would definitely follow up with the resident and the Medical Director. During a telephone interview on 10/01/2024 at 4:17 PM, Physician #1 said their understanding was that residents' intake amounts were monitored at each meal and if there was a concern about weight loss or diminished oral intake, it would be escalated to a higher level of administration. Physician #1 said if a resident was frequently refusing meals, staff should notify (nursing) leadership, and if nursing leadership felt they had a concern they should notify the medical provider. Physician #1 said during their visit with Resident #27 the previous day, it was mentioned the resident had poor oral intakes and any information regarding this visit could be found in the resident's progress notes. 10 NYCRR 415.12(i)(1)

Based on observations, interviews, and record review conducted during the Recertification Survey from 09/26/2024 to 10/02/2024, the facility did not ensure residents were assessed by an interdisciplinary team to determine their ability to safely self-administer a medication for one (Resident #7) of six residents reviewed. Specifically, Resident #7 was observed with a prescribed inhaler kept at the beside with no documented evidence that an assessment had been completed to determine their ability to safely self-administer the medication or a physician's order for self-administration. This was evidenced by the following: Review of the facility policy Administering Medications, dated April 2019, revealed that medications are administered in accordance with prescribed orders. Residents may self-administer their own medications if the attending physician, in conjunction with the interdisciplinary care team, has determined the resident to have the decision-making capacity to do so. The facility education reference guide Self-Administration of Medications, reviewed September 2023, documented that nursing will obtain an order from the Medical Provider for which medications are approved for self-administering. Resident #7 had diagnoses that included Chronic Obstructive Pulmonary Disease (an ongoing lung condition caused by damage to the lungs that is characterized by breathlessness and cough), schizophrenia, and pneumonia. The Minimum Data Set Resident Assessment, dated 07/24/2024, documented the resident had moderately impaired cognition. During observations on 09/30/2024 at 9:08 AM, Resident #7 had an Anoro Ellipta inhaler in a plastic bin on their bedside table. During an interview at this time, Resident #7 stated they have had their inhaler a long time and that they kept their inhaler in the plastic bin on the bedside table and used it every day. Resident #7's Comprehensive Care Plan, revised 08/01/2024, did not include any information related to Resident #7 having been assessed for safe administration of inhalers. Resident #7 Physician's orders, dated 09/09/2024, included an Anoro Ellipta inhaler (used to prevent air flow obstruction in the lungs) one puff daily at 9:00 AM with special instructions to rinse the mouth after use. The orders did not include that resident could self-administer the inhaler or leave the inhaler at the bedside. During an interview on 09/30/2024 at 10:41 AM, Registered Nurse #1 stated in order for a resident to self-administer a medication an order (Physician) should be in the electronic medical record. Registered Nurse #1 said that they had talked to the acting Director of Nursing and the inhaler for Resident #7 was removed from Resident #7's room until an order could be obtained from the physician. During an interview on 09/30/2024 at 11:17 AM, the Registered Nurse Manager/Acting Director of Nursing stated that a resident should be evaluated by the physician for self-administration of a medication and there should be a note in the medication order for the Resident to keep the medication at their bedside and self-administer it. The Registered Nurse Manager/Acting Director of Nursing said that Resident #7 should not have had the inhaler in their room. During an interview on 10/02/2024 at 9:35 AM, the Registered Nurse Manager/Acting Director of Nursing stated that they had no knowledge that Resident #7 kept an inhaler at their bedside and should not have been. The Registered Nurse Manager/Acting Director of Nursing said that there should be an assessment and education provided by nursing for a resident to self-administer a medication. 10 NYCRR 415.3

Based on observation, interviews, and record review conducted during the Recertification Survey from 09/26/2024 to 10/02/2024, the facility did not develop and implement a comprehensive plan of care (including measurable goals and interventions) for one (Resident #14) of two residents reviewed for communication and sensory. Specifically, Resident #14's Comprehensive Care Plan did not include that the resident had profound hearing loss, used of an amplifier (hearing aid), or was able to read lips. This is evidenced by the following: The facility policy Resident-Centered Care Planning last reviewed February 2024, documented each resident will have a Comprehensive Resident-Centered Care Plan that is consistent with resident rights and person-centered care. Resident #14 had diagnoses that included a stroke, right sided hemiplegia and hemiparesis (weakness and/or paralysis on one side of the body), and hearing loss. The Minimum Data Set Resident Assessment, dated 09/20/2024, documented that Resident #14 was cognitively intact, had moderate difficulty with hearing (speaker has to increase volume and speak distinctly), and requires the use of hearing aids or other hearing appliances. Review of the current Comprehensive Car Plan revealed no information related to Resident #14's hearing loss, use of an amplifier, or any other interventions (such as lip reading) to assist the resident with communication needs. The Care Area Assessment included that Resident #14 triggered for hearing loss and that communication should be care planned for. During an interview on 09/26/2024 at 12:24 PM, Resident #14 stated they lost 80% of their hearing years ago and have used a left ear amplifier for more than [AGE] years. Resident #14 said that currently all employees were wearing masks and that they would prefer they wore clear masks so they could lip read. During an observation on 09/26/2024 at 12:30 PM, Certified Nursing Assistant #3 was in the resident's room wearing a surgical face mask. Resident #14 asked if Certified Nursing Assistant #3 was speaking to them and that they were unable to hear or read lips with the mask on their face. During an observation on 09/30/2024 at 10:02 AM, Resident #14 was in the therapy room working with Physical Therapy. Physical Therapist #1 was wearing a surgical face mask. During an interview on 10/01/2024 at 9:20 AM, Registered Nurse Manager/Acting Director of Nursing stated that hearing loss and use of an amplifier were not included in Resident #14 Comprehensive Care Plan. During an interview on 10/01/2024 at 9:50 AM, Certified Nursing Assistant #1 stated that Resident #14 had difficulty hearing them if they wore a surgical mask, and in order to communicate with the resident, they need to pull down their mask for Resident #14 to see their lips so they can read their lips in order to participate and communicate with them. During an interview on 10/01/2024 at 11:54 AM, Social Worder #1 stated that Resident #14 Comprehensive Care Plan did not include a plan for hearing loss or the need for the hearing amplifier and that the care plans should be more specific and tailored for individual resident care. 10 NYCRR 415.11(c)(1)

Based on observations, interviews and record review conducted during an Abbreviated Survey (#NY00313057) the facility did not ensure the resident environment remained free of accident hazards and each resident received adequate supervision to prevent accidents for one (Resident #1) of six residents reviewed for accidents and hazards. Specifically, the facility did not know at what operating temperatures the in-room heating system should function, had no system or policy in place to monitor operating temperatures or the distance of residents from the in-room heating units required to prevent injury. Subsequently, Resident #1 sustained multiple second-degree thermal injuries on bilateral legs, right shoulder, and right hand from falling out of bed and onto the baseboard heater in their room. This resulted in actual harm to Resident #1 that was Immediate Jeopardy and Substandard Quality of Care, with the likelihood of serious harm to the health and safety of 22 residents with cognitive deficits and/or diabetic neuropathy. The findings were: Resident #1 had diagnoses including unspecified dementia without behavioral disturbance, failure to thrive and muscle weakness. The Minimum Data Set Assessment, dated 2/13/23, documented that Resident #1 was severely impaired of cognitive skills for daily decision making and required extensive assist to total dependence on staff for all activities of daily living. Review of Resident #1's Comprehensive Care Plan revealed that Resident #1 required assistance with ADL's due to severe cognitive impairment and had a fall risk with interventions that included keeping their bed in lowest position with a mat on the floor. Review of the facility Report of Incident or Accident dated 3/19/23 at 5:00 a.m. revealed that Resident #1 had rolled out of bed and was found on the floor by staff on the resident's baseboard heater. Injuries (later identified as burns) were noted on the resident's right shoulder, right knee and leg and left leg. In an interdisciplinary progress note dated 3/19/23 Registered Nurse #1 documented that Resident #1 was found by staff in the early morning hours at approximately 5:00 a.m. with their lower body and right hand on the baseboard heater after falling out of bed. Resident #1 had thermal injuries on bilateral legs, right shoulder, and right hand. During removal of Resident #1 off the heater two blisters on residents' legs opened. In an interdisciplinary progress note dated 3/20/23 at 6:06 a.m., Licensed Practical Nurse #1 documented the resident's wound measurements as follows: right outside shin 12 centimeters (cm) by 6.4 cm, right inside shin 11 cm by 3.5 cm, right knee 14 cm by 9 cm, left shin 27 cm x4 cm, left inside shin 5 cm by 3 cm, left outside shin 5 cm x 3 cm and right middle finger 0.9 cm by 0.5 cm. In a medical progress note dated 3/21/23, the Physician documented that Resident #1 sustained second degree burns to both shin areas that required topical treatments and morphine every six hours for pain with additional morphine every two hours as needed for breakthrough pain. During observations and interview on 3/27/23 from 10:00 a.m., to 12: 00 p.m. all 24 resident rooms had the baseboard heaters. Thermostat setting knobs were on all heaters and set to medium or high except Resident #1's room (the knob was removed after incident). Temperatures taken at this time with an infrared laser thermometer that was calibrated on 3/27/23 at 9:00 a.m., revealed 5 of the 24 resident room baseboard heaters had a surface temperature greater than 125 degrees ( ) Fahrenheit (F) with the highest found in Resident #1's room [ROOM NUMBER] at 210 F. The temperature control knob had been removed following the incident, but the heater was still running. Surveyor could not ascertain at which setting the heater was on without the knob. During an immediate interview the Maintenance Director acknowledged that the surface temperature of the baseboard heater in the resident's room was over 210 F. The Maintenance Director stated that they had not checked the temperatures of the baseboard heaters and did not know what temperatures the heaters could reach or how to ensure the heaters did not get too hot. The Maintenance Director said that the thermostats for the heaters only had three settings of low, medium, and high. At 10:45 a.m., the Maintenance Director re-attached the knob to Resident #1's baseboard heater which revealed the temperature knob was at the high setting. In an interview on 3/27/23 at 10:30 a.m. the Director of Nursing (DON) stated Resident #1 had sustained second degree burns to their shins on both legs, right hand and shoulder from the baseboard heater in their room. The DON stated staff should not be adjusting the thermostats in the residents' rooms and that they had an in-service for all staff just that morning to instruct them In an interview on 3/27/23 at 10:55 a.m., Housekeeper #1 stated they have adjusted the baseboard heaters for the residents but did not know how hot the high setting reached. In an interview on 3/27/23 at 12:30 p.m. Certified Nursing Assistant #4 stated they had turned the thermostats too high for the residents in the past and that they have had concerns about the baseboard heaters because last week in another resident's room they had to throw a pillow away after it landed on the heater and melted. During an observation on 3/28/23 at 9:22 a.m. (after the facility investigation) in a resident room, the baseboard heater temperature remained greater than 125 F at 135 F. Review of resident medical history information provided by the facility revealed the facility currently had 18 residents with cognitive impairment (difficulty remembering, or making decisions that affect everyday life and safety) and 4 residents with diagnoses of diabetic neuropathy (numbness from nerve damage in the hands and feet) who had access to the heating units. During an interview on 3/28/23 at 4:30 p.m., the Administrator stated that the facility did not have any policies or procedures related to the monitoring or adjusting of temperatures of the baseboard heaters located in the residents' rooms. Review of the Owner's Manual for the baseboard heaters provided by the facility Maintenance Director revealed the following warnings: This heater is hot when in use. To avoid burns, do not let bare skin touch hot surfaces. Keep combustible materials such as furniture, pillows, bedding, papers, clothes, and curtains away from heater. For furniture maintain at least 6 inches space between furniture and heater. NYCRR 415.12 (h)(1) Immediate Jeopardy was identified, and the facility Administrator was notified on 3/28/2023 at 4:15 p.m. Removal of immediacy was accepted on 3/28/23 at 5:15 p.m., prior to the survey exit based on the following actions: a. All baseboard heaters have been turned off and the central air heater will be raised to 80 F. b. Corporate Maintenance Director will be in the building on 3/29/23 to reeducate the facility Maintenance Director and to evaluate a system to maintain a safe environment. c. All heater knobs have been removed from heaters and are in possession of the Maintenance Director so no other staff can adjust the resident room baseboard heat temperatures once the heating system is turned back on in the future (after re-evaluating the system). d. Facility policy and procedures regarding electric baseboard heaters was created and provided to surveyors. e. Spot checks of air temperatures in resident rooms will be monitored tonight to maintain proper resident room temperatures while utilizing the central heating and extra blankets will be available to any resident that requests them.

Based on interviews and record review conducted during the Recertification Survey conducted 2/13/23 to 2/17/2023, it was determined that for four Residents (#9, #11, #19, #31) of four residents reviewed for Baseline Care Plans (BCP), the facility did not consistently develop and implement a BCP within 48 hours of admission that included the minimum healthcare information necessary to properly care for the immediate needs of the resident and did not provide the resident and/or resident representative a written summary of the BCP. Specifically, for Resident #11, the facility was unable to provide documented evidence that a BCP was created, or any summary of care provided to the resident or resident representative. For Residents #9, #19 and #31, the facility could not provide documented evidence that a BCP contained the necessary information or that any information regarding the residents' care was reviewed with the resident and/or resident representative. This is evidenced by, but not limited to, the following: The facility policy, Baseline Resident Care Plan, dated 11/28/17, revealed a BCP will be developed within 48 hours of admission for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The BCP will contain the minimum healthcare information necessary to properly care for a resident and will be utilized by appropriate staff. The BCP will contain at a minimum: initial goals based on admission orders and after discussion with appropriate members of the interdisciplinary team, Physician orders, dietary orders, therapy services, and social services. The BCP will be provided to the resident and/ or their representative by the nurse (or designee) developing the care plan. Resident and/or resident representative will be given the opportunity for questions and input. 1.Resident #11 was admitted [DATE] with diagnoses that included dementia with agitation, heart failure, chronic kidney disease stage 4, and anxiety. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was severely impaired cognitively. Review of Resident #11's Electronic Health Record (EHR) revealed no documented evidence that a BCP had been created and no evidence that any summary of the resident's care, including medications, diet, therapy, physician orders or activities of daily living was provided to or reviewed with Resident #11 or their representative. Additionally, the facility was unable to provide any paper version of a baseline care plan or summary. 2. Resident #19 was admitted [DATE] with diagnoses that included dementia, depression, and anxiety disorder. The MDS assessment dated [DATE] documented the resident was severely impaired cognitively. Review of Resident #19's EHR revealed a BCP was created on 9/2/22 that included a goal that Resident #19 have their needs met and remained content at the facility. Approaches included to see the Certified Nursing Assistant (CNA) care plan and the Physician orders. The area under BCP presented by and BCP presented to were both blank. There was no documented evidence that any type of summary of the resident's care was provided or reviewed with Resident #19 or their representative or were given any input regarding their care. 3. Resident #31 was admitted [DATE] with diagnoses that included Alzheimer disease, high blood pressure and obesity. The MDS assessment dated [DATE] documented the resident was cognitively intact. Review of Resident #31's EHR revealed that a BCP was created on 12/2/22 that included a goal that the resident had their needs met and remained content at the facility. Approaches included to see the CNA care plan and the physician orders. The area under BCP presented by and BCP presented to were both blank. There was no documented evidence that any type of summary regarding the resident's care was provided or reviewed with Resident #31 or their representative or given any input regarding their care. In an interview on 2/16/23 at 2:15 p.m., Resident #31 stated they could not remember having any meeting with facility staff members to review their care after admission. During an interview on 2/17/23 at 9:11 a.m., the Social Worker (SW) stated that when a resident is admitted they usually go over the BCP with the resident and their family representative verbally. The SW stated that once the comprehensive care plan is done the BCP is resolved in the computer but that it was not an actual document (summary) that could be printed. The SW stated that there should be documentation in the progress notes that it was reviewed but that they do not always do this. The SW was unable to provide any documentation that a BCP or summary was reviewed with the residents or their family members. During an interview on 2/17/23 9:24 a.m. and again at 11:02 a.m., the Administrator stated that in their small facility communication with residents and families was usually done immediately and that the SW was working on trying to find any documentation that this was done but was unable to provide. 10 NYCRR 415.11

Based on interviews and record reviews conducted during a Recertification Survey, completed on 9/30/21, it was determined for 1 (Resident #7) of 14 residents, the facility did not ensure that staff who have the skills and qualifications to assess relevant care areas and who are knowledgeable about the resident's status, needs, strengths and areas of decline, accurately complete the resident assessment. Specifically, Resident #7's Minimum Data Set (MDS) Assessments, dated 5/7/21 and 7/6/21, were incorrectly coded or did not include the resident's Level II Preadmission Screening and Resident Review (PASRR) conditions. This was evidenced by the following: The MDS Assessment manual, dated October 2019, documented that all individuals who are admitted to a Medicaid certified nursing facility must have a Level I PASRR completed to screen for possible mental illness (MI), intellectual disability (ID), developmental disability (DD) or related conditions. Individuals who have or are suspected to have MI or ID may not be admitted to a Medicaid certified nursing facility unless approved through Level II PASRR determination. A resident with MI or ID/DD must have a Resident Review conducted when there is a significant change in the residents' physical or mental condition. The manual instructs if the MDS Assessment is an admission, annual or significant change Assessment, to review the Level I PASRR to determine whether a Level II was required. Resident #7 was admitted to the facility 11/22/17 and readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The annual MDS Assessment, dated 5/7/21 and the Significant Change MDS Assessment, dated, 7/6/21, documented that Resident #7 had moderately impaired cognition and did not have any level II PASRR conditions coded as per the regulations. Review of Resident #7's Admission PASRR, dated 10/2/17, documented that Resident #7 did have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 9/30/21 at 10:03 a.m. the MDS Coordinator stated that Resident #7's MDS Assessments were not accurate and should include [CONDITION(S)] and moderate ID in the PASRR section. The MDS Coordinator stated a modified MDS needed to be completed to accurately reflect the resident. During an interview 9/30/21 at 11:08 a.m. the Administrator stated they were not aware of issues with MDS accuracy. 10NYCRR 415.11(b)

Based on interviews and record reviews conducted during a Recertification Survey, completed on 9/30/21, it was determined for 1 (#7) of 14 residents reviewed the facility did not ensure that preadmission screening for an individual identified with an intellectual disability (ID) was completed prior to admission in order to receive care and services in the most integrated setting appropriate to their needs as per the regulations. Specifically, the Pre-Admission Screen Resident Review (PASRR) for Resident #7, dated 10/2/17, was not completed by a qualified screener and did not accurately determine the need for a Level II screen (to assess for additional services). In addition, the facility did not reassess Resident #7 following a significant change in condition. This was evidenced by the following: The Minimum Data Set (MDS) Assessment manual, dated October 2019, documented that all individuals who have or are suspected to have mental illness (MI) or ID/developmental disability (DD) or related conditions may not be admitted to a Medicaid certified nursing facility unless approved through Level II PASRR determination. Those residents covered by Level II PASRR process may require certain care and services provided by the nursing home and/or specialized services provided by the state. A resident with MI or ID/DD must have a Resident Review (RR) conducted when there is a significant change in the resident's physical or mental condition. A facility policy, Screen Policy, dated 11/10/06, documented that a Social Worker (SW) must determine that the PASRR screen has been properly completed upon admission. If not, they must contact the hospital and request one. Resident #7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was readmitted to the facility on [DATE] following an acute stay for a leg fracture. The MDS Assessment, dated 7/6/21, revealed Resident #7 was moderately impaired cognitively. No Level II PASRR conditions were coded on the MDS Assessment in the PASRR section per the regulations. Review of the PASRR, dated 10/2/17, revealed questions to determine if a Level II screen was required were not answered and the individual completing the form lacked the screeners identification number. (which qualifies screener by training to complete the PASRR form) making the form invalid. The facility was unable to produce evidence that a Level II referral was completed since admission or since a significant change in condition. In an interview on 9/30/21 at 8:34 a.m. the SW stated PASRRs' were reviewed by a SW prior to resident's admission. The SW reviewed Resident #7's PASRR form of 10/2/17 and stated all required questions had not been answered including the Level II referral. The SW stated they would have to complete a new screen and reach out to the division of Mental [CONDITION(S)] and Developmental Disabilities to go forward. In an interview on 9/30/21 at 11:08 a.m. the Administrator stated the Quality Assurance Committee reviewed admissions and had not identified the issue. 10NYCRR415.11(e)

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for 1 (Resident #26) of 33 residents reviewed for advanced directives, the facility did not ensure that there was an organized, effective system to ensure that residents' wishes regarding Cardiopulmonary Resuscitation (CPR) and Do Not Resuscitate (DNR) are initiated and implemented according to their wishes. Specifically, the resident was sent to the hospital for evaluation and returned with a change in her advance directives that was not identified or implemented by the facility. This is evidenced by the following: Review of the current facility policy, Medical Orders for Life Sustaining Treatment (MOLST) and Advanced Directives, dated (MONTH) 2010, directs that end of life medical decisions of all residents will be honored. The resident's care and treatment choices will be recorded on the MOLST form and the form will be presented to the attending physician. The physician signed MOLST form becomes the physician's orders [REDACTED]. Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated [DATE], revealed the resident had moderately impaired cognition. Physician orders, dated [DATE], revealed that the resident was a Full Code status. There was a MOLST in the chart, dated [DATE], that was signed by the physician, and directed to attempt CPR. Section B, Consent for Resuscitation Instructions was blank. There was no signature from the resident, decision-maker, or witness. Additionally, Section E, Orders for Other Life-Sustaining Treatment and Future hospitalization When the Patient has a Pulse and the Patient is Breathing was all blank. No treatment decisions were identified or selected. There was a second MOLST in the chart, dated [DATE], that was completed at the hospital and included a DNR order. The form had signatures from the Health Care Proxy, witness, and physician. Additionally, Section E was entirely filled out with resident life sustaining treatment options. Interviews conducted on [DATE] included the following: a. At 11:25 a.m., the Registered Nurse Manager (RNM) said the resident does not wear her name band on her wrist so her name band is taped to the head of her bed. The RNM said the resident's name band was white which means the resident is a Full Code. b. At 11:33 a.m., Licensed Practical Nurse (LPN) #1 and LPN #2 both said they would check the color of the resident's name band to determine a resident's code status. They said a white name band means the resident is a full code and a blue one means DNR. They said they would send another staff member to check the medical orders and the MOLST in the chart. c. At 11:36 a.m., the RNM said she would follow the physician order [REDACTED]. Interviews conducted on [DATE] included the following: a. At 11:27 a.m. by telephone, the Medical Director said the most current, signed MOLST, dated [DATE], should be followed. He said the resident's status changed from a full code to DNR. b. At 2:58 p.m., Registered Nurse (RN) #2 stated that she does not remember seeing a MOLST. RN #2 said she does not think the MOLST was in the packet of information she reviewed from the hospital. She said if their was a change in the MOLST, she would have notified the physicians and verifed the information with the Health Care Proxy. (10 NYCRR 415.3(e)(1)(ii))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for two of four residents reviewed for falls and one of one resident reviewed for abuse, the facility did not investigate skin injuries or an allegation of abuse to rule out abuse, neglect or mistreatment. The issues involved the lack of investigation for an allegation of physical abuse (Resident #20) and a lack of investigation for injuries of unknown origin (Residents #21 and #28). This is evidenced by the following: 1. Resident #20 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED].>spinal stenosis, anxiety, and [MEDICAL CONDITION]. The Minimum Data Set (MDS) Assessment, dated 3/1/19, revealed the resident had moderately impaired cognition, was understood and understands, and had no behaviors or mood indicators. The Comprehensive Care Plan (CCP), dated 3/11/19, revealed that the resident's orientation varies as does her short-term memory. Approaches include to observe for changes in her mental status. A Nursing Progress Note, dated 3/18/19 for the evening shift, revealed the resident had increased confusion and stated she had been raped during the night. The 24-hour Report Sheet, dated 3/18/19, revealed that the resident had increased confusion on the evening shift, and no issues for the night shift. A late-entry evening, nursing note written on 3/20/19 for 3/18/19, documented that no male caregivers, residents or visitors were in the resident's room all shift. The nurse spoke with the night shift workers from 3/17/19, and they all stated that no male caregiver, residents, or visitor were in the resident's room on their shift. A Nursing Progress Note, dated 3/19/19, for the day shift revealed that the resident exhibited increased confusion, and a physician order [REDACTED]. A 3/20/19 Nursing Progress Note revealed that a urine sample was obtained. The resident stated that there was a man sitting on top of the dresser. She said he never does anything but just sits and watches her, but she was not afraid. Staff explained that there was no man there. An antibiotic was started for a urinary tract infection [MEDICAL CONDITION] on 3/24/19. Review of the resident's record and facility documents did not include any mention of the resident's allegation of rape on 3/18/19 or any investigation. A Physician Note, dated 3/28/19, revealed that the resident was oriented to person, place, and time and her memory was intact. The resident was presently on an antibiotic for a UTI. There was no mention of the resident's confusion, allegation of rape on 3/18/19, and no documentation that a physical exam of the genitalia was completed. When interviewed on 4/22/19 at 3:29 p.m. and 3:49 p.m., the Director of Nursing (DON) said she remembered the resident being confused, but an investigation was not initiated because no one reported to her the resident's allegation of rape. She said that the resident did not have a physical exam. During an interview on 4/23/19 at 9:05 a.m., the DON said she spoke with the evening nurse who reported that she parks her medication cart outside of the resident's room and that is how she knows that no one went into the resident's room that evening. She said that the resident's son did visit her that evening. The evening nurse reported that the resident had been confused. The evening nurse said she asked the staff that worked the day before and no one had seen anyone go into the resident's room. The DON said that she told the evening nurse, even though she took those steps the allegation still needs to be reported to the DON. The DON said that she explained to the evening nurse that it was the DON's responsibility to investigate the allegation and determine a conclusion. The DON said the physician was only notified that the resident was confused and hallucinating. The DON said if she had known about the allegation of rape, she would have made sure an investigation was done. 2. Resident #21 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assessment, dated 3/1/19, revealed the resident had moderately impaired cognition, was usually understood, sometimes understands, has no behaviors and no skin conditions. The CCP, dated 7/5/18, included to report any signs of changes in the resident's skin condition. During an observation on 4/18/19 at 10:34 a.m. and on 4/19/19 at 10:35 a.m., the resident had a reddened abrasion that was beginning to scab in the middle of her forehead. The resident was unable to say what happened. Review of the progress notes, physician notes, and Incident/Accident Reports for the past six months did not include an abrasion on the forehead. Interviews conducted on 4/19/19 included the following: a. At 10:44 a.m., the resident's primary Certified Nursing Assistant (CNA) said she had been taking care of the resident that day and that past weekend. She said the resident had the abrasion on her forehead that past Saturday (4/13/19). She said that she thought she told the nurse but could not remember which one. b. At 10:53 a.m., the Licensed Practical Nurse (LPN) said she worked that past weekend and did not believe the resident had the abrasion on the weekend. She said the resident's abrasion was not reported to her. She said the resident has dry skin on the back of her neck and staff apply cream. She said the resident may have picked at her forehead. The LPN said the abrasion should have been documented. c. At 11:00 a.m., the Registered Nurse Manager (RNM) said she had been working both the night shift and part of the day shift, she did not notice the resident's abrasion, and no one reported it. The RNM said that she did not know when the abrasion occurred and guessed it may be from the hairdresser. She said the resident sometimes has a reaction after going to the hairdresser and her skin gets dry. The RNM said the resident was not someone who picks at herself. She said the abrasion should have been reported and documented. After assessing the area, the RNM said she would call it an abrasion. She said the area measured 1/4 inch x 1/4 inch and would be considered an injury of unknown origin. When interviewed on 4/24/19 at 10:10 a.m., the DON said the RNM told her about the resident's abrasion and she started an Incident/Accident Report to investigate. She said she did not notice the abrasion on the resident's forehead. 3. Resident #28 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assessment, dated 3/25/19, revealed the resident was cognitively intact, required the extensive assistance of two staff for bed mobility and toileting, and did not walk in either the room or corridor during the lookback period. Physician orders, dated 4/10/19, included [MEDICATION NAME] (prevents the release of substances in the body that cause inflammation) 10 milligrams (mgs) daily and Aspirin (to reduce pain and swelling) 81 mgs every day. The Incident and Accident Report, dated 12/17/18, revealed the resident had a bruise on the right rib and abdomen that measured 12 centimeters (cms) x 5 cm. The resident stated it was from when he fell . The second page of the Incident and Accident Report included the same bruise as well as a second bruise above the resident's right eye that measured 1 cm x 0.5 cm. The Incident and Accident Report did not include who reported the bruises, the color or sizes of the bruises, treatment given, or the date or time when the bruises were reported to the physician. The area for Physician's Report of Examination was blank. Review of the 12/8/18 Incident and Accident Report revealed that the resident said he went to stand to use the urinal, got dizzy and fell , hitting his arm on the stand. Injuries were identified as three skin tears and a bruise to the right arm and one skin tear and bruise to the left arm. When interviewed on 4/23/19 at 2:15 p.m., the DON reviewed the Incident and Accident Report from 12/17/18. The DON then stated that the resident bruises almost immediately so the bruise below the right rib and abdomen most likely did not occur on 12/8/18 and should have been investigated as a new injury. She said the resident was on two medications ([MEDICATION NAME] and Aspirin) which contributes to his fragile skin. The DON said that even though the resident said the bruises were from the last fall, staff interviews should have been done and additional information on the bruises should have been documented. The DON said the investigation was incomplete. (10 NYCRR 415.4(b)(3))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for two (Residents #29 and #34) of eight residents reviewed for Baseline Care Plans, the facility did not provide the resident or resident representative with a written summary of the resident's Baseline Care Plan. This is evidenced by the following: 1. Resident #29 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 2/5/19, revealed the resident was cognitively intact. There was no documentation that a summary of the Baseline Care Plan (BCP) was provided to either the resident or representative. 2. Resident #34 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 3/12/19, revealed that the resident had severely impaired cognition. There was no documentation that a summary of the BCP was provided to the resident or representative. Interviews conducted on 4/22/19 included the following: a. At 10:35 a.m., the Registered Nurse Manager (RNM) said the Director of Nursing (DON) was responsible for developing all care plans, including the BCP. b. At 11:55 a.m., the MDS RN said she was responsible for completion of the Care Area Assessments but the DON writes all the Care Plans. During an interview on 4/24/19 at 8:07 a.m., the DON said it was her responsibility for developing and presenting the BCP to the resident and or representative. The DON that she does not document that a summary of the BCP was provided.

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for two (Residents #19 and #28) of seven residents reviewed for pharmacy recommendations, the facility did not ensure that the services provided met professional standards of practice. Specifically, the nurse wrote physician orders [REDACTED]. This is evidenced by the following: 1. Resident #19 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 2/27/19, revealed the resident had moderately impaired cognition. Physician orders [REDACTED]. The Pharmacy Consultant Sheet, dated 3/22/19, revealed the resident complained of loose stools and [MEDICATION NAME] has a 5 to 15 percent incidence of diarrhea which is dose dependent. The recommendation included to consider a dose reduction to 5 mg and monitor for a change in the resident's symptoms. The physician response, dated 4/10/19, included to reduce the [MEDICATION NAME] to 5 mg daily and monitor for any change in bowels. There were several orders written by the physician on 4/10/19 but not for [MEDICATION NAME]. an order written [REDACTED]. There was no documentation as to whether the order was a verbal or a telephone order from the physician. A progress note, dated 4/13/19, revealed that the RNM documented based on recommendations made by the pharmacy consultant, the physician decreased [MEDICATION NAME] from 10 mg to 5 mg every evening for dementia. 2. Resident #28 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assessment, dated 3/25/19, revealed the resident was cognitively intact. Physician orders [REDACTED]. The pharmacy consultant sheet, dated 3/22/19 recommended that the physician please evaluate the need for multivitamin supplementation in this well nourished patient. If not needed, we could discontinue to decrease the medication pass and avoid unnecessary medication. The physician response, dated 4/10/19, included to discontinue the multivitamin. There were several orders written by the physician on 4/10/19 but not for the multivitamin. An order, written by the RNM and dated 4/12/19, included to discontinue the multivitamin. There was no documentation as to whether the order was verbal or a telephone order from the physician. A progress note, dated 4/12/19, revealed that the RNM documented based on the pharmacy consult recommendation, the physician discontinued the multivitamin. Interviews conducted on 4/22/19 included the following: a. At 2:01 p.m., the RNM said she discontinued or changed the medications because the physician agreed with the pharmacy recommendations. The RNM said that she had not received a verbal or telephone order but copied the information from the pharmacy sheets, and documented in the chart. She said the physicians are busy and that may be why they do not write the orders themselves. The RNM said that she did not know if the pharmacy consultant sheet was a permanent part of the resident's record or if it was an order for [REDACTED]. b. At 2:08 p.m., the DON said the pharmacy consultant sheets are not part of the resident's medical record and they are not order forms. She said the physicians are not in the facility often so it is difficult to obtain all the orders needed. She said the physicians may have to start writing orders themselves. She said the nurses will need to start documenting if orders are verbal or telephone orders. (10 NYCRR 415.11(c)(3)(i))

Based on an interview and record review conducted during the Recertification Survey, it was determined that for one (Resident #36) of one resident reviewed for discharge, the facility did not ensure a discharge planning process was in place which addressed the resident's discharge goals and needs, including care giver support and referral to local agencies as appropriate, and involved the resident and the interdisciplinary team in developing the discharge plan. This is evidenced by the following: Resident #36 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessments, dated 11/1/18 and 11/26/18, revealed the resident expected to be discharged to the community and an active discharge plan was occurring. The MDS Assesment, dated 1/14/19, revealed the resident was cognitively intact, required the limited assistance of staff for transfers and ambulation, and extensive assistance of staff for bathing and dressing. The Baseline Care Plan, dated 10/26/19, revealed that the resident's goal was to get stronger and return home. Interventions included Therapies and Social Services to assist the resident in achieving her goal and discharge. The Comprehensive Care Plan reviewed on 11/14/18 and 12/5/18 did not demonstrate progression towards discharge or address the discharge plan. The facility could not provide documentation of services to be provided after discharge. During an interview on 4/23/19 at 12:34 p.m., the Director of Nursing (DON) stated she was responsible for the development of the Care Plan for discharge planning. The DON stated therapy was responsible for the resident's physical abilities, nursing for the resident's abilities to manage and understand medications and the teaching of any precautions. The DON stated Social Work would set up home services. The DON stated that the resident did not have a care plan that addressed discharge planning, goals and or needs. (10 NYCRR 415.11(d)(3))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #36) of one resident reviewed for discharge, the facility did not provide a discharge summary to the resident that included a recapitulation of the resident's stay and a post discharge plan of care. This is evidenced by the following: Resident #36 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessments, dated 11/1/18 and 11/26/18, revealed the resident expected to be discharged to the community and an active discharge plan was occurring. The MDS Assessment, dated 1/14/19, revealed the resident was cognitively intact, required the limited assistance of staff for transfers and ambulation, and extensive assistance of staff for bathing and dressing. The physician progress notes [REDACTED]. There was no documentation regarding the plan for the resident's discharge home on 2/4/19. A Licensed Practical Nurse documented on 2/4/19 that the resident was given discharge instructions and medications were sent home with the resident. The Transfer Discharge Summary, dated 2/4/19, included the physician's name, the resident's allergies [REDACTED]. The section History and [DIAGNOSES REDACTED]. The Discharge Medications form, dated 2/4/19, included a list of medications and was signed by the resident and nurse acknowledging the resident's acceptance of the medications. The Physical Therapy (PT) Discharge Summary, dated 2/4/19, revealed the resident would receive assistance with transportation, shopping, and bathing at home. The resident was to be discharged home with necessary assistance. A Registered Nurse note, dated 2/5/19, revealed that a medication list and discharge paperwork was faxed to the resident's primary care physician for review. When interviewed on 4/23/19 at 12:34 p.m., the Director of Nursing stated the physician's discharge summary was incomplete. She stated there was no care plan developed for discharge to home and no documentation of services to be provided after discharge. (10 NYCRR 415.11(d)(1)(2))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #28) of four residents reviewed for nutrition, the facility did not ensure that a resident maintained acceptable parameters of nutritional status, such as body weight, unless the resident's clinical condition demonstrated that was not possible. The issues involved the lack of a timely reweight for a resident identified with a severe weight loss. This is evidenced by the following: Resident #28 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 3/25/19, revealed the resident was cognitively intact, had no weight loss or gain, was on a therapeutic and mechanically altered diet, and required one personal physical assistance for eating. Review of the Weight Monitoring Guidelines, revised (MONTH) 2010, revealed that weight monitoring will be done as indicated by the resident's condition or as requested by the Registered Dietitian (RD) based on the resident's medical and nutritional status. Weights are done at approximately the same time of the day, in the same attire, with shoes on, and on the same scale as able. After the weight is obtained, the nurse will compare the current weight to the last weight. If there is a loss of weight equal to or greater than five pounds or a gain of weight equal to or greater than five pounds, further discussion is indicated including repeating the weight at that time or on the following day. The Monthly Weight Record in the dietary section of the medical record revealed that the resident weighed 188 pounds (lbs) on 3/3/19, and 174 lbs on 4/3/19, and 166.5 lbs on 4/6/19. The resident was reweighed on 4/23/19 and weighed 162.2 lbs. An e-mail, dated 4/7/19 from the Registered Dietician (RD) to the Director of Nursing (DON), Registered Nurse Manager (RNM), Director of Food Service (DFS), and Administrator revealed that the RD was requesting a reweight due to a significant weight change. A Nursing Progress Note, dated 4/9/19, revealed that two attempts were made to reweigh the resident. The resident said that he would get weighed when he felt better. The Medical Assessment Form completed by the RNM on 4/10/19 revealed that the resident had a weight loss, weighed 174 lbs, and they were awaiting a reweight. The section for the percentage of weight loss or gain of five percent or more in the last 30 days or weight loss or gain of ten percent or more in the last 180 days was blank. Interviews conducted on 4/22/19 included the following: a. At 2:27 p.m., Licensed Practical Nurse (LPN) #1 said that staff identified a weight loss and a reweight needed to be done. She said she discussed it with the resident, and he agreed to be reweighed on 4/26/19 with his shower and haircut. b. At 2:43 p.m., the DFS said that the RD reviewed the monthly weights, and on 4/7/19, she identified a significant weight change for the resident and requested a reweight. The DFS said she was not involved in reweights. When interviewed on 4/23/19 at 1:56 p.m., the DON said if a resident has a significant weight loss, staff are to reweigh the resident within 24 hours. She said if the resident refuses to be weighed, then it should be documented, and the nurse should be notified. She said that the medical form, dated 4/10/19, should have included how much weight the resident lost and over what time. Interviews conducted on 4/24/19 included the following: a. At 8:30 a.m., the RNM said she was not told that the resident declined to be reweighed. b. At 9:12 a.m. by telephone, the RD said that reweights are normally done the same day. The RD said she sent an e-mail to the team requesting a reweight. (10 NYCRR 415.12)

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #13) of four residents reviewed for nutrition, the facility did not ensure the medical care of each resident was supervised by a physician. Specifically, the physician did not evaluate the resident's significant weight loss. This is evidenced by the following: Resident #13 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 1/15/19, revealed the resident had severely impaired cognition, required the limited assistance of staff for eating, weight was 143 pounds, and the resident did not have a weight loss of five percent in one month or ten percent or more in six months. Review of the weight record revealed that the resident weighed 143 pounds in (MONTH) 2019 and 131 pounds in (MONTH) 2019 (a weight loss of 8.65 percent in one month). The resident's weight was 148.8 pounds in (MONTH) (YEAR) and 131 pounds in (MONTH) 2019 ( a weight loss of 11.96 percent). The Comprehensive Care Plan (CCP), dated 4/17/19, revealed the resident was on a therapeutic diet with a history of mild weight loss. The physician Medical Assessment Form, dated 2/13/19, did not address the resident's weight and or weight loss. The Registered Dietician (RD) note, dated 2/21/19, revealed that the resident had a weight loss over the past six months. The resident's weight was 149 pounds in (MONTH) (YEAR) and 131 pounds in (MONTH) 2019. The resident received health shakes and was started on fortified foods. The physician Medical Assessment Form, dated 3/8/19, documented a weight of 133 pounds but did not address weight loss. Interviews conducted on 4/22/19 included the following: a. At 9:55 a.m. the Registered Nurse Manager (RNM) stated she completes the Medical Assessment Form for the physician's review and she documents the resident's current weight on the form. The RNM stated she does not calculate weight loss. The RNM stated the Director of Nursing (DON) and RD meet weekly to review the resident's weights. The RNM stated the DON or RD notify the physician of weight loss. She said that sometimes she may ask to notify the physician. b. At 12:06 p.m. the DON stated either she or the RNM notify the physician of a resident's significant weight loss. The DON stated the RD notified her of the resident's weight loss. At 12:47 p.m., the DON stated the RNM would notify the physician of a resident's weight loss. The DON said that she could not provide documentation that the physician was or was not notified of the resident's weight loss. The DON stated a significant weight loss would be 5 percent in 30 days or 10 percent in 180 days. During an interview on 4/23/19 at 3:37 p.m., the physician stated that the RNM documents on the Medical Assessment Form to inform him of a weight change. He stated the only time the resident had a weight change that he recalled was when he adjusted the resident's [MEDICAL CONDITION] medication. (10 NYCRR 415.15(b)(1)(i)(ii))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #13) of five residents reviewed for unnecessary medications, the facility did not ensure that residents who have not used [MEDICAL CONDITION] drugs are not given theses drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record. Specifically, there was a lack of documented non-pharmacological behavioral interventions prior to the implementation and or increase of an antipsychotic medication, and the plan of care did not specify which behaviors were being targeted by the antipsychotic and specific non-pharmacological interventions to be attempted. This is evidenced by the following: Resident #13 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 1/15/19, revealed the resident had severely impaired cognition. Behavior Documentation Flow Sheets, from 6/7/18 through 7/2/18, revealed that the resident was agitated on 10/78 shifts. The progress notes did not consistently document the specific behaviors exhibited and or non-pharmacological interventions attempted. Physician orders, dated 7/3/18, included to start [MEDICATION NAME] (an antipsychotic) 12.5 milligrams (mg) twice a day for dementia with agitation. Behavior documentation, from 7/4/18 through 7/10/18, revealed the resident was agitated on 2/30 shifts. The progress notes did not consistently document the specific behaviors exhibited and or non-pharmacological interventions attempted. The Comprehensive Care Plan (CCP), dated 7/5/18, revealed the resident received an antipsychotic medication related to a behavioral disturbance. Interventions included to provide non-pharmacological interventions as able, behavior log as needed, and to observe for verbal and non-verbal signs of distress. The psychiatric consultation, dated 7/6/18, revealed the resident had been admitted to the facility on [MEDICATION NAME] in (YEAR) and was successfully tapered off the [MEDICATION NAME]. The resident has increased agitation and was striking out, had an altercation with another resident, and was yelling that she wanted to leave the facility. The resident was observed to take off her white gloves and pick at her face. Recommendations included restarting the [MEDICATION NAME] and timing the doses to precede periods of increased agitation if predictable. Physician orders, dated 7/10/18, included to discontinue the current [MEDICATION NAME] order and start [MEDICATION NAME] 12.5 mg in the morning and 25 mg at bedtime for dementia with agitation. The Medical Assessment Form, dated 7/18/18, revealed the resident had increased behaviors both physical and verbal. Psychoactive medications included [MEDICATION NAME] (an antidepressant). The Medical Assessment Form, dated 9/12/18, revealed the resident was receiving [MEDICATION NAME] 12.5 mg in the morning and 25 mg at bedtime. The physician documented the resident has dementia and agitation and was doing better. Review of Behavior Flow Sheets, dated 10/21/18 through 11/3/18, revealed there was no documentation of resident behaviors. Physician orders, dated 11/1/18, included to increase the [MEDICATION NAME] to 25 mg twice a day for dementia with agitation and obtain a urine for culture and sensitivity. Physician orders, dated 11/6/18, included to start [MEDICATION NAME] for a urinary tract infection [MEDICAL CONDITION]. The Medical Assessment Form, dated 11/7/18, included the resident exhibited behaviors at times. The [MEDICATION NAME] had been increased to 25 mg twice a day on 11/1/18 due to increased behaviors. The pharmacy consultant documented on 11/12/18 that the resident's [MEDICATION NAME] was increased due to behavioral symptoms, a urine culture was done, and the resident was treated for [REDACTED]. Consider reducing the [MEDICATION NAME]. The physician disagreed and documented it had been tried several times. The Psychiatric Consultation, dated 12/7/18, had information written by the nurse on 11/9/18 that revealed the resident had been increasingly agitated, picking at her face, and scratched another resident's hand. The psychiatrist agreed with increasing the [MEDICATION NAME] and recommended timing the doses to be given 30 to 60 minutes before the resident becomes agitated. Review of the Behavioral Care Plan, revised 8/14/18 and reviewed 10/29/18, revealed the resident's behaviors included consuming nonfood items when participating in an activity or during meals and requests to go home. The resident believes she is on a bus, may scream to get off the bus, and she is known to reach out and grab others when agitated. When interviewed on 4/19/19 at 1:43 p.m., the Certified Nursing Assistant (CNA) stated the resident did not exhibit any behaviors and did not refuse cares. During an interview on 4/22/19 at 11:57 a.m. and 3:00 p.m., the Director of Nursing (DON) stated she was responsible for developing and revising the CCP and the behavioral care plan. She said the resident's care plans have been reviewed periodically without revisions. Interviews conducted on 4/23/19 included the following: a. At 9:11 a.m., the DON stated the nurse should document behaviors as reported by the CNAs. She said the documentation should include specific behaviors exhibited, approaches implemented to stop the behavior, and if the behavioral plan was successful. After reviewing the resident's progress notes, the DON stated there was no documentation of the targeted behaviors and or the non-pharmacological approaches attempted before the implementation and or increase of the [MEDICATION NAME]. b. At 3:27 p.m., the physician stated the resident was having agitated behaviors and staff had been able to manage the resident's behaviors utilizing techniques. The physician stated staff were very good about trying methods and he would expect that. He said the staff should document specific behaviors exhibited and non-pharm interventions attempted. (10 NYCRR 415.12(l)(2)(i))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of one main dining room, the facility did not ensure that a safe, clean, comfortable and homelike environment was maintained. Specifically dining room chairs and tables were stained, or had torn upholstery, and some tables and chairs were wobbly. This is evidenced by the following: Review of Resident Council Minutes, dated 2/4/19, revealed that residents stated the dining room tables were very wobbly and needed to be fixed or replaced. The tables shake all over when food is being cut. The chairs need a good cleaning or to be reupholstered as some are ripped or very dirty. Issues noted for Environmental Services include dining room tables and chairs. Resident Council Minutes, dated 3/5/19, revealed that the chairs were cleaned and down the road some may be replaced. The tables were worked on, and the facility was looking into replacement or fixing the tables too. Issues noted for Environmental Services include dining room tables and chairs. Resident Council Minutes, dated 4/2/19, documented that chairs were cleaned and down the road some may be replaced. During a Resident Council meeting on 4/19/19 at 1:46 p.m., the four residents (Resident #5, #8, #9, and #15) said the dining room chairs had been cleaned, but were still stained and the staff cannot get the stains out. They also said the tables were still wobbly even though the facility fixed some. The Resident Council President said she thinks six new tables were ordered. When interviewed on 4/19/19 at 3:15 p.m., the Director of Environmental Services said there was no order for any new tables. During an interview on 4/23/19 at 10:00 a.m., the Director of Food Service said that the tables were purchased eight to ten years ago and because of the pedestal the tops wobble. She said the Director of Environmental Services looked at them again, within the last month or two, trying to get them fixed, but they are just worn out. Interviews conducted on 4/24/19 included the following: a. At 8:07 a.m and 8:28 a.m., the Director of Environmental Services said they have a preventive maintenance program and go through the furniture several times a year. He said an evening staff person goes through the chairs and washes them. He said it was brought to his attention that the stains were not coming out approximately two years ago and the chairs are eight years old now. He said they reupholstered a couple of the chairs about two years ago and he tries to keep up. The Director of Environmental Services said he had been dealing with the wobbly tables for about six months now. He said that the pedestal was the problem. He said they have tried to repair the tables. He said he was aware and had a copy of the notes from the Resident Council regarding the chairs and tables. He said nothing had been ordered, but they do have some quotes for the chairs and the tables. He said he has an e-mail from the man who did the initial remodeling, and they would reupholster a little at a time. b. At 8:12 a.m., the Administrator said the chairs and tables are not old. He said they were about eight years old. They have tried a lot of things to fix them. He said the Resident Council only complained two months ago. He said the facility plans to replace them, but they have to figure out what fabric to use. c. At 8:42 a.m., Resident #33 said she was at the facility for rehabilitation and noticed the stains on the chairs and had seen some with tears. She said she would not sit in a chair like that at home and if it was in a restaurant she would leave. d. At 8:45 a.m., Resident #5 said the chairs have had stains for a long time. She said it was not homelike. She said if it were her home she would buy another chair. e. At 8:47 a.m., Resident #8 said she always sits in her wheelchair in the dining room, but she can see the stains and tears in the fabric on the chairs. She said they have been like that for a couple of years. She said she would not have something like that in her home. She said she does not like the wobbly tables because when residents are eating things can spill. f. At 8:52 a.m., Resident #15 said it was not homelike to have stains on the chairs. She said the chairs need to be reupholstered. She said she has not had any of her food spill while sitting at a wobbly table; however, it does move sometimes when she is trying to get her food. g. At 8:55 a.m., the Administrator provided a copy of an undated invoice for pedestal bases with handwritten costs for 11 tables. h. At 9:06 a.m., the Director of Environmental Services told the surveyor he had an e-mail from the furniture vendor. Review of the e-mail, dated 3/8/19, revealed that a question was asked about the stripes on the chairs being original. (10 NYCRR415.5(h)(2))

Based on observations, interviews and record reviews conducted during the Recertification Survey it was determined that for one (Resident #17) of two residents reviewed for non-pressure related skin conditions, the facility did not investigate a skin injury to rule out abuse, neglect or mistreatment. The issue involved the lack of an investigation of an injury of unknown origin. This is evidenced by the following: The facility Standards of Practice, dated July 2016, included to observe skin with cares and report changes. Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 10/20/17, revealed the resident had moderately impaired cognition and required the extensive assistance of staff for personal hygiene. The Certified Nursing Assistant Assignment Sheet, dated 11/30/17, documented that the resident required minimum assistance with upper body cares and extensive assistance with lower body cares. The Assignment Sheet for grooming assistance was incomplete. The Nursing Measures Record, dated November 2017, instructed to complete a full skin check once weekly on shower day (Friday). The entry was not signed as completed on 11/10/17, 11/17/17 and 11/24/17. Review of the Incident/Accident Reports, from 7/1/17 through 11/30/17, revealed no reports of an injury to the resident's nose. Review of Nursing Progress Notes, from 11/1/17 through 11/30/17, revealed no documentation of a skin injury to the resident's nose. During observations conducted on 11/28/17 at 10:50 a.m., on 11/29/17 at 11:04 a.m. and on 11/30/17 at 8:53 a.m., the resident had a small (.25 centimeter) scabbed area on the top of the tip of his nose. Interviews conducted on 11/30/17 included the following: a. At 8:53 a.m., the resident stated that he broke his nose years ago and he had a bump. The resident stated when he shaved he hit the area. He said staff had not shaved him yet that day. b. At 1:40 p.m., the Director of Nursing (DON) stated nursing staff observe the resident's skin every day with cares. She stated if a skin injury was observed staff would report the issue to a nurse. The DON stated that if it was a non-pressure related skin injury an Incident/Accident Report and investigation would be completed. The DON stated if a resident had a new skin issue, there would be documentation in the Progress Notes. c. At 1:42 p.m., the Licensed Practical Nurse (LPN) stated the resident had a skin issue on his shin. The LPN said she did not recall any other skin issues. She stated an Incident/Accident Report should be completed as soon as an issue/injury is reported. The LPN stated she was not aware of the scabbed area on the resident's nose. At that time, the Registered Nurse Manager stated she was not aware of the scabbed area on the end of the resident's nose. (10 NYCRR 415.4(b)(3))

Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for 3 (Residents #17, #28 and #30) of 19 residents reviewed for development of a Comprehensive Care Plan, the facility had not developed a thorough care plan based on the resident's assessment to ensure the services were provided to maintain the resident's highest practicable physical well-being. Specifically, there was no Comprehensive Care Plan for oxygen (Residents # 28 and #30) and risk for skin injury (Resident #17). This is evidenced by the following: 1. Resident #28 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 11/3/17, revealed the resident was mildly cognitively impaired and received oxygen therapy. The physician order, dated 10/5/17, included oxygen at 2 liters per minute via nasal cannula at bedtime for [MEDICAL CONDITION] hypertension. The Certified Nursing Assistant (CNA) Assignment Sheet, dated 11/12/17, included oxygen at 2 liters per minute at bedtime. The current Comprehensive Care Plan (CCP) did not include the resident's respiratory status or the need for continuous oxygen at bedtime. When interviewed on 12/1/17 at 12:07 p.m., the Director of Nursing (DON) stated that the resident uses oxygen and it is her expectation that the CCP included the use of oxygen. 2. Resident #30 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Comprehensive MDS Assessment, dated 11/4/17, revealed the resident was moderately cognitively impaired and received oxygen therapy. The Care Area Assessment (CAA) Sheet, dated 1/13/17, documented the Activity of Daily Living (ADL)/Rehabilitation potential triggered due to the resident's fluctuating ADL needs in relation to the resident's respiratory status. The CAA Sheet, dated 11/15/17, documented the decision to proceed to care planning. The CNA Assignment Sheet, dated 11/14/17, included oxygen continuously at 2 liters per minute via nasal cannula. The current CCP did not include the resident's respiratory status or the need for continuous oxygen. During intermittent observations, from 11/28/17 through 12/1/17, the resident was receiving oxygen via nasal cannula at 2 liters per minute continuously. During an interview 11/29/17 at 2:25 p.m., the CNA stated she exchanges the resident's oxygen tanks when they are empty and regulates the liters to be delivered. When interviewed on 12/1/17 at 11:43 a.m., the DON stated she was responsible for the development of the CCP in conjunction with the Interdisciplinary Team. She stated that oxygen therapy would be addressed on the CCP if it was an issue for the resident. The DON stated the CCP should address actual and potential issues for the resident. 3. Resident #17 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The MDS Assessment, date 10/20/17, revealed the resident was moderately cognitively impaired and required the extensive assistance of staff for personal hygiene. The current CCP identified the resident's risk for skin breakdown and a current heel ulcer. Observations conducted on 11/28/17 at 10:50 a.m., on 11/29/17 at 11:04 a.m., and on 11/30/17 at 8:53 a.m., the resident had a small (.25 centimeter) scabbed area on the top of the tip of his nose. When interviewed on 12/1/17 at 9:26 a.m., the DON stated the resident picked and scratched his skin resulting in skin injuries. She stated the resident had a skin injury to his hand in October 2017. The DON stated the resident's CCP should include the risk of skin injuries. After review of the resident's CCP, the DON said the CCP does not address the resident's risk for skin injury. (10 NYCRR 415.11 (c)(1))

Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for 1 (Resident #1) of 18 residents reviewed for professional standards, the facility did not provide services consistent with professional standards of quality. The issue involved the improper application of Ace wraps. This is evidenced by the following: Resident #1 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 8/17/17, revealed the resident was severely cognitively impaired. The physician orders, dated 10/19/17, included to apply Ace wraps to both lower extremities every morning for [MEDICAL CONDITION] and remove at bedtime. The Certified Nursing Assistant Assignment Sheet, dated 11/14/17, included Ace wraps to both lower extremities, applied in the morning and removed at bedtime. During an observation on 11/28/17 at 2:20 p.m., the resident was sitting in a wheelchair in the hallway, and she had Ace wraps on both lower extremities ending mid-calf. There was slight swelling between the Ace wraps and the knees. The resident's legs were not elevated. Review of the Nursing Progress Notes and the Comprehensive Care Plan revealed there was no documentation related to the resident's refusal or preferences related to the application of the Ace wraps. During an observation of care on 11/30/17 at 9:26 a.m., the Licensed Practical Nurse (LPN) applied an Ace wrap to the resident's lower extremities, wrapping the foot and ankle of each extremity. The resident was cooperative and non-verbal throughout the procedure. At that time, the LPN stated staff just wrap the resident's feet because if you go up any further the resident becomes upset. The LPN stated the resident developed fluid in her feet and the Ace wraps assist in keeping the fluid down. The LPN stated the Director of Nursing (DON) instructed her on the application of Ace wraps. During an interview on 11/30/17 at 9:58 a.m., the DON stated she had provided education and competency evaluations on Ace wraps for the nursing staff. She stated Ace wraps are applied from the toes to the knees or the resident's preference. She stated the purpose of Ace wraps was to increase circulation and decrease [MEDICAL CONDITION]. (10 NYCRR 415.11 (C)(3)(i))

Based on observations, interviews, and record reviews conducted during an Abbreviated Survey (complaint #NY 752) completed on 9/6/13, it was determined that for 2 (Residents #1 and #2), of 45 residents reviewed for accidents, the facility failed to ensure that the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistive devices to prevent accidents. Specifically, the facility failed to have systems in place to ensure hot foods and beverages were served to residents at safe temperatures to limit the potential for burns. This resulted in actual harm to Resident #1 and has the potential for serious harm that is IMMEDIATE JEOPARDY to resident health and safety and SUBSTANDARD QUALITY OF CARE that is widespread. This is evidenced by the following: 1. Resident #1 is a [AGE] year-old female who is wheelchair bound and has [DIAGNOSES REDACTED]. Documentation on a "Report of Incident/Accident," dated 8/16/13, shows that the resident spilled soup in her lap while eating supper, and this resulted in second degree burns on both of the resident's inner thighs. Review of a "Hazard Analysis Critical Control Point Daily Food Temperatures and Taste Chart," temperature log, dated 8/16/13, revealed that at 4:30 p.m. that day the facility recorded the temperature of the Manhattan Clam Chowder at 204 degrees (*) Fahrenheit (F). The serving temperature for soups was listed to be 165*F or greater. A notation on this chart directs staff to record food temperatures at the beginning and the end of the service period. There were not end of service temperatures recorded on this log on 8/16/13. Review of temperature logs, dated from 8/17/13 through 9/4/13, revealed that for 11 of 11 meals with soup served at the supper meal, the temperatures recorded were between 173*F and 206*F. In an interview on 9/5/13 at 12:04 p.m., the Director of Food Service (DFS) said temperatures of the food are taken around 4:30 p.m. while setting up the tray line. Also, resident trays go to the unit at approximately 4:45 p.m. and dietary staff do not take any additional food temperatures, including after the tray line is finished. In an observation of the lunch meal on 9/5/12 at 12:34 p.m., Resident #1 was seated at a table in the middle of the dining room. Certified Nursing Assistant (CNA) #1 sat next to her. CNA #1 felt the sippy cup (special cup with lid), took off the lid, and added approximately 2 ounces of milk to the coffee. CNA #1 told the resident to be careful because the coffee was hot. At 12:50 p.m., CNA #1 felt the cup and told the surveyor, "It still feels hot and that is after I added milk." The surveyor asked Cook #1 to take the temperature of the coffee. CNA #1 said she had thought about removing the lid to the sippy cup to help cool the coffee but had not done that. At that time, Resident #1 picked up the sippy cup, brought it to her lips, may have taken a sip, and quickly set the cup down. Interviews conducted on 9/5/13 include the following: a. At 12:52 p.m., Cook #1 reported that the coffee temperature taken at approximately 11:30 a.m. was 176*F. Cook #1 said that specification for temperatures of coffee may be listed at the bottom of the temperature log. There was no serving temperature for coffee listed on the temperature log. b. At 1:06 p.m., Cook #2 verified that she had been the evening cook on 8/16/13. Cook #2 said that the food truck to the unit is usually delivered at 4:50 p.m., then food trays are delivered to the library. When there is a nurse in the dining room, she starts the supper service. Cook #2 also said that the dining room service started at approximately 5:15 p.m. that evening. Cook #2 said that she shuts the stove burners off when she starts serving at approximately 4:40 p.m. to 4:45 p.m.; the burner is not on for 30 to 45 minutes. Cook #2 reported that she turns the soup off sooner now, and places this resident's soup in a sippy cup to cool even more. c. At 2:21 p.m., the Director of Nursing (DON) explained that immediately following the incident, the resident was treated for [REDACTED]. The resident's care card revision included the use of finger foods, hot beverages in cups with lids, and monitoring her closely at mealtimes. d. At 3:14 p.m., Cook #2 said that on 8/16/13, the ambient kitchen temperature was about 100*F, so even though the burner under the soup was turned off, it would have taken awhile to cool. e. At 3:22 p.m., Licensed Practical Nurse (LPN) #1 said that once in awhile residents will say the coffee is too hot and that they need ice cubes to cool it. f. At 3:32 p.m., CNA #2 verified that she was in the dining room the night Resident #1 got burned because the soup was hot. She said there have been a couple of other times that the food was too hot, usually the soup or coffee, and that most of the residents are able to tell them. CNA #2 stated that she had to add ice cubes to the soup the previous night because it was too hot. On 8/16/13, when the resident was burned, they did tell the kitchen that the soup was too hot. g. At 3:41 p.m., LPN #2 said that some residents had complained that the coffee and tea were too hot. They asked for and were given ice cubes. The residents were cautioned to be careful. LPN #2 said she told staff in the dining room that the soup was very hot and to be very careful. Also, after this incident, she did put the soup into a cup with a lid for another resident. h. At 3:43 p.m., when asked what was being done to prevent another burn from hot food, the DON said she had spoken with the DFS because she did not know what the exact food temperatures should be. The DON said the DFS told her they took the temperature of the soup at 4:30 p.m. and that the soup was 204*F. The DFS told her that the soup was served to Resident #1 about 30 to 40 minutes later. The DON said she asked the DFS if dietary staff check the food temperatures again, and the DFS told her that this is not done. The DON said she had spoken with the Administrator about food temperatures, but he was not aware of any specific regulations about food temperatures. She said that staff put Resident #1's hot beverages in cups with lids. The DON also stated that the facility needs to determine what actions could be taken to prevent future burns. i. At 4:40 p.m., the DON and Cook #2 said that soup was not on the supper menu that night. Cook #2 said the coffee temperature taken at 4:30 p.m. was 176*F. j. At 4:44 p.m., Cook #2 and the surveyor took a second temperature of the coffee; both thermometers read 171*F. k. At 4:48 p.m., the temperature was 156*F. l. At 4:49 p.m., the temperature of the hot water was taken, and it was 181*F (facility's thermometer) and 183*F (surveyor). At that time, the DON said that for the supper meal that night, hot beverage cups, coffee and tea were to only be half filled and put at the back of the food tray away from the resident. Residents in the dining room were to have hot beverages and soup placed on the table in front of the food plate at a distance away from the resident. m. At 4:59 p.m., both CNA #1 and LPN #3 said they would check the hot water and coffee for "heat," stir it if needed to help cool, and add ice if needed before giving it to a resident. n. At 5:01 p.m., Resident #4 asked to eat in her room and requested hot tea and toast. Staff said they had already ordered the tea and toast. o. At 5:04 p.m., the Registered Nurse/Nurse Manager (RN/NM) received the supper tray for Resident #4. She took the top off of the hot water and said, "Oh, that's hot!" When asked what she would do, the RN/NM said, "Well it's steaming, I'm going to take it off the tray and stir it, and then take it to the resident." p. At 5:08 p.m., Cook #2 said that residents who eat in the library get their trays first and eat in the library without a nurse because they are independent. Cook #2 said she was sending two cups of cocoa and a cup of green tea to the library. q. At 5:11 p.m., Resident #5, who had cocoa, said she had not tried it yet, but if it was too hot, she would pour some water into it. r. At 5:15 p.m., Cook #2 said she had sent two bowls of soup to residents in the library but had not taken the temperature. s. At 5:22 p.m., both residents in the library who got the soup said that the soup was not too hot. 2. Resident #2 has [DIAGNOSES REDACTED]. Review of a food temperature log, dated 5/11/13, revealed the temperature of the turkey noodle soup served at supper was 204.4*F. Review of a "Report of Incident/Accident," dated 5/11/13, revealed that when moving a soup bowl to get a drink, the resident's left pinky finger came into contact with the soup. Ice was applied to the area and redness declined. On 9/6/13 the facility presented a letter alleging that the immediacy of the issue had been removed. The facility presented the following corrective actions: a. A new policy, "Hot Foods and Beverages, Precautionary Measures," was developed and implemented. b. As of 9/6/13 at 4:45 p.m., 38 of 75 staff members were inserviced. This included all nursing supervising staff. c. The remaining employees would be inserviced as they arrived for the next shift or by telephone if they were not currently scheduled. d. The Administrator planned to be onsite on the weekend of 9/7/13 and 9/8/13 to further inservice and monitor compliance with the new policy. e. The DFS implemented a new procedure and food temperature log system that included monitoring of food temperatures at the point of service. Corrective actions would be implemented based upon specified temperature parameters. f. Inservicing was planned to be at 100 percent by 9/10/13. Observations, interviews, and record review completed on 9/6/13 between 7:48 a.m. and 4:05 p.m. to verify that the facility's actions removed the immediacy included the following: a. review of the Hot Foods and Beverages policy, b. review of completed inservice records, c. review of revised food temperature log system, d. observations and interviews with residents and staff. (10 NYCRR 415.12(h)(1)(2))