Every finding on record at Canterbury Woods

Based on observation, interview, and record review conducted during a Complaint investigation (Complaint #NY00362317) completed on an Extended Recertification survey with an exit date of 1/8/2025, the facility failed to protect the residents rights to be free from verbal and physical abuse by a Companion Aide for one (Resident #22) of six residents reviewed for abuse. Specifically, a Companion Aide was witnessed by facility staff being verbally and physically abusive towards Resident #22. The facility did not review/revise abuse processes/protocols since 2016. In addition, the facility did not consistently implement their protocols regarding Companion Aides. They did not have an effective system to ensure background checks were verified as completed for all Companion Aides prior to starting at the nursing home; lacked an effective system to communicate with the residents/families, and Companion Aides the nursing home policy included Companion Aides were not to provide hands on care; lacked a system to monitor Companion Aides to ensure their specific policies were followed to ensure resident safety. This resulted in no actual harm with the potential for more than minimal harm with the likelihood to affect all residents and is substandard quality of care. The finding is: The policy and procedure titled, Abuse Prevention Program dated 11/28/16 documented the residents have the right to be free from abuse, neglect, mistreatment, corporal punishment. The facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to, staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, companion aides, legal guardians surrogates, friends, visitors, or any other individual. The policy and procedure titled Companion Aide with a revision date of 10/01/2020 documented the facility recognizes a resident's right to hire or engage the services of a Companion Aide. The Social Worker was listed as responsible for the implementation of this policy and the facility established guidelines. To ensure resident safety and security, Companion Aides must provide certain background information to the facility prior to beginning service, permit the facility to conduct a criminal background check and complete an Authorization for Release Information form. Companion Aides are subject to all the policies, guidelines, rules, and regulations in effect at the facility. Companion Aides providing services to residents residing in the Assisted Living & Skilled Nursing settings are not permitted to perform hands on care, this includes assisting residents with personal care or activities of daily living. An undated Private Hire Agreement provided by Social Worker #1, documented that all Companion Aides were to complete the agreement prior to their hire date. In consideration for access to the community for the purpose of performing personal care services to resident(s) they were to sign they understand and agree to the following: a criminal background check, validate any certifications or licenses as may apply or perform reference checks if deems necessary to ensure the safety of its residents. The form documents by signing they agree to assume all risks associated with or resulting from the performance of my services to residents. Additionally, by signing they agree to abide by all policies, procedures, rules, guidelines, and regulation of the community. Understands that our facility assumes no responsibility for supervising or monitoring the work of the companion aide engaged or employed by the resident. The Private Hire Agreement did not include the nursing home's specific policy which documented that Companion Aides were not to provide hands on care and they were subject to all to all the policies, guidelines, rules, and regulations in effect at the nursing home. 1. Resident #22 had diagnoses of Alzheimer's disease, heart failure, and displacement fracture of left femur. The Minimum Data Set (a resident assessment tool) dated 11/15/24 documented Resident #22 had severe cognitive impairments. Resident #22 required substantial/maximal assistance for toileting, toileting transfer, upper body dressing, lower body dressing, and for personal hygiene. The Comprehensive Care Plan dated 11/25/24 documented Resident #22 had severe dementia, was alert and oriented to person only. Interventions included to provide comfort and reassurance when resident was confused. Resident #22 had behavioral problems related to dementia which included resistive to hands on care, hitting/slapping/kicking staff members, verbally aggressive, and yelling at staff. Interventions included to give positive feedback and reinforcement for resident's compliance, reapproach resident as needed in a calm manner. The care plan did not address Resident #22 had a Companion Aide. The Accident and Incident Report signed by the Administrator and the Assistant Administrator documented on 11/26/24 between the hours of 8:00 AM and 9:00 AM Activities Aide #1 reported to the Licensed Practical Nurse Supervisors they heard screaming and thumping sounds coming from Resident #22's room. The Licensed Practical Nurse Supervisors went to Residents #22's room and the resident was receiving care at the bedside from CNA (Certified Nurse Aide #1) and a private companion aide. The report also documented the resident was restrained by Companion Aide#1, their arms were grabbed, crossed, and held to the resident's chest. The Accident and Incident Report included a Management Investigation Report that documented the event occurred because Resident #22 did not want to get out of bed and the hired Companion Aide #1 did not respect the resident's wishes. The Accident and Incident Report/ Management Investigation Report had four employee written statements, but did not include a written statement from Companion Aide #1 and Activities Aide #1. Review of Certified Nurse Aide #1's statement dated 11/26/24 revealed Resident #22 did not want to get up, so they stated to the resident they would come back later. The Companion Aide was in the room at the time and said they were going to get the resident dressed. The Companion Aide moved the resident's blanket and the resident hit the Companion Aide with their legs. The Companion Aide grabbed both of Resident #22's hands, crossed them and pushed their arms towards the resident's chest. The Companion Aide told Resident #22 to stop, and they were going to get dressed. Certified Nurse Aide #1 documented they told the Companion Aide to stop, that we don't do that. Certified Nurse Aide #1 also documented the resident was scared. Review of Licensed Practical Nurse Supervisor #1's statement dated 11/26/24 revealed they responded to the reported situation, upon entering Certified Nurse Aide #1 was providing care and Companion Aide #1 was attempting to clean the resident. The resident was agitated but calmed after the Companion Aide walked away. Review of Licensed Practical Nurse #3's statement dated 11/26/24 revealed Certified Nurse Aide #1 was doing care and Companion Aide #1 was assisting with care and Resident #22 was visibly agitated. During an observation on 1/6/24 at 8:01 AM Resident #22's room door was closed. Post knocking, Companion Aide #3 opened the door and Resident #22 was lying in bed resting with no distress noted. During an interview at this time Companion Aide #3 stated they provided hands on care for Resident #22 and they were also aware that Companion Aide #1 had provided hands on care. Companion Aide #3 stated the facility nurses and CNA's (certified nurse aides) were aware Companion Aides provided hands on care and were happy because it was less work for them. Companion Aide #3 also stated they were in charge of the hiring Companion Aides for Resident #22, and they performed the duties of a Case Manager for the family. Companion Aide #3 stated they were informed by Social Worker #1 of Companion Aide #1's inappropriate behavior towards Resident #22 that occurred 11/26/24 and that Companion Aide #1 no longer worked for the family and was not allowed in the facility. Companion Aide #3 stated Social Worker #1 did a background check on Companion Aide #1 but did not validate their licensure because Social Worker #1 told them (meaning themselves) Companion Aides were not allowed to perform hands on care. Companion Aide #3 stated the family representative was aware they were providing hands on care for Resident #22 in the nursing home and the staff in the nursing home never told them to stop. During an interview on 1/6/25 at 8:19 AM, Certified Nursing Aide #1 stated Resident #22 could be combative while providing care. They stated the morning of 11/26/24, Companion Aide #1 insisted that Resident #22 got up and dressed; and had stated they were tired of (facility) staff not getting the resident out of bed and would do it themselves. Certified Nurse Aide #1 stated they told Companion Aide #1 the resident could not be forced to get up. Companion Aide #1 insisted, pulled the residents blankets back and Resident #22 kicked Companion Aide #1. Companion Aide #1 then forcefully grabbed the residents' arms and crossed them across the resident's chest to restrain them as they yelled, Stop, you will get dressed now! Certified Nursing Aide #1 told Companion Aide #1 to stop. Resident #22 was screaming and crying. Licensed Practical Nurse Supervisor #1 and Licensed Practical Nurse #3 entered the room. Certified Nurse Aide #1 stated they would consider this abuse because they should not force a resident to do anything they don't want to. Certified Nurse Aide #1 stated they were aware Companion Aides were not allowed to provide hands on care and were to socialize with the residents only. They stated all facility staff were trained yearly on abuse but the Companion Aides were not employed by the facility, so they were not certain of what training they received. During an interview at 1/6/25 at 9:17 AM, Licensed Practical Nurse #3 stated Activities Aide #1 had told Licensed Practical Nurse Supervisor #1 they heard a thump and yelling in Resident #22's room, so they went to see what had happened. Certified Nurse Aide #1 was at the foot of the bed and Companion Aide #1 was trying to assist them with care, Resident #22 was screaming, distressed and agitated. They stated they did not see any bruises on Resident #22 and did not see Companion Aide #1 touch the resident, so they were not certain if this was abuse, but the resident was upset and agitated. During an interview on 1/6/25 at 9:24 AM, Licensed Practical Nurse Supervisor #1 stated Activity Aide #1 reported they had heard screams and a thump in Resident #22's room and they went to the Resident's room with Licensed Practical Nurse #3. Upon entering the room Certified Nurse Aide #1 and Companion Aide #1 were at the bedside, Resident #22 was screaming and agitated. Companion Aide #1 had blamed the resident's distress on the amount of people in the resident's room. Licensed Practical Nurse Supervisor #1 stated Companion Aide #1 overstepped their boundaries and were not to provide hands on care. There was no bruising noted on Resident #22, but they considered this abuse and reported the incident to the Assistant Administrator. During an interview on 1/6/25 10:27 AM, Activities Aide #1 stated during their rounds on the morning of 11/26/24, they passed Resident #22's room and heard a thump and someone yelled, Stop kicking me. They reported the concern Licensed Practical Nurse Supervisor #1 and Licensed Practical Nurse #3. They stated they were uncertain if the Companion Aides were allowed to perform hands on care. During a telephone interview on 1/6/25 at 11:06 AM, Companion Aide #1 stated they worked with Resident #22 on 11/26/24 until 9:00 AM and they worked for the family of Resident #22 not the facility. They stated Resident #22 was combative and their behavior had declined since their transfer to the nursing home from independent living. Resident #22 would call them trash, hit them. Companion Aide #1 stated they had to provide hands on care to Resident #22 because the facility aides would never come when they pressed the call bell, and facility staff did not like to provide care because Resident #22 was so behavioral. Companion Aide #1 stated on 11/26/24 they asked Certified Nurse Aide #1 if they needed help with care and they replied yes. Companion Aide #1 stated they did not yell at Resident #22; the resident did not have their hearing aide in and had to talk loudly. Companion Aide #2 stated they never grabbed the resident's arms or restrained them. They stated they were not asked to leave the facility, it was the end of their shift and that was why they left. They stated they no longer provided companion care for Resident #22 and was asked not to return to the building by the Case Manager (Companion Aide #3). During an interview on 1/6/25 at 11:38 AM, Resident #22's family member stated they were told by Certified Nurse Aide #1 that Companion Aide #1 physically grabbed their family member by the arms, put them across the resident's chest and yelled at them that they needed to get dressed. The family member stated they reported the incident to Social Worker #1. The family member stated Companion Aides were not allowed to perform hands on care, but were aware the Companion Aides would provide incontinent care and change Resident #22's brief when needed but deferred to the nursing home staff for anything else. They stated they were never provided the nursing home policy and procedures regarding Companion Aides. During an observation and an interview on 1/6/25 at 2:43 PM, Resident #22's room door was closed, Companion Aide #2 responded to the knock at the door. The resident was lying in bed and appeared comfortable without agitation. Companion Aide #2 stated their duties were to perform hands on care for Resident #22. Personal care included washing the resident and providing incontinence care, changing incontinence briefs, and providing oral care. They stated they shadowed Companion Aide #3 for a day, and this was what they were told to do. They stated they observed Companion Aide #3 perform a sponge bath, changed the residents' briefs, and applied zinc oxide to the residents' buttocks. They stated the only thing they were told not to do was to shower Resident #22. They stated the facility itself had not provided them information on what they could or could not do for residents and they had never met with Social Worker #1 prior to their hire date. During an interview on 1/6/25 at 2:59 PM and 1/7/25 at 10:31 AM, Social Worker #1 stated they were responsible for the Companion Aide program at the skilled nursing home level. Social Worker #1 stated they were uncertain how many Companion Aides were currently working within the nursing home and were uncertain how many current residents had Companion Aides. Social Worker #1 stated they were not verifying that background checks were completed for Companion Aides because they assumed if the resident was transferred from within the community (campus) it was completed at the other levels of care. They stated they had performed a background check on Companion Aide #1 prior to their hire date but did not check their licensure because they were not to perform hands on care. Social Worker #1 stated they had not completed a background check on Companion Aide #2 because they were unaware, they acted as both a Companion Aide and as the Case Manager for the family. During the interview Social Worker #1 reviewed the Private Hire Agreement and stated the agreement did not specify that hands on care could not be provided by the Companion Aide once a resident reached the skilled nursing level of care. Social Worker #1 stated the campus utilized the same Private Hire Agreement for Companion Aides across all levels of care throughout the campus even though the expectations were different. Social Worker #1 stated the nursing home does not provide education for the Companion Aides regarding the of rules and regulations they were expected to adhere to. The Companion Aides did not receive a copy of the nursing homes policy titled Companion Aide and they do not verbally tell the Companion Aides they cannot provide hands on care in the nursing home. Social Worker #1 stated to protect the resident's safety the facility monitored the Companion Aides the same way they would monitor any visitor; they relied on the staff to inform them of any inappropriate behavior. During an interview on 1/6/25 at 3:14 PM, the Administrator stated the Companion Aide program was the responsibility of the Social Worker in the nursing home; and Companion Aides were told they were not to perform hands on care verbally when they met with Social Worker #1. The expectations of the Companion Aide would include taking residents to the library, scheduling appointments, or anything the family would ask them to do as long as it was not hands on care. The Administrator stated the incident that occurred on 11/26/24 with Resident #22 would not be considered abuse because the police did not get involved, the resident did not get hurt, and there was no psychological harm. They stated it was an isolated event and it was wrong but would not consider this abuse. They stated the facility reported the incident; Companion Aide #1 was no longer allowed in the facility and this was an adequate resolution to the incident. The Administrator deferred to Social Worker #1 questions regarding how many residents had Companion Aides and how many Companion Aides were working within the nursing home. During a follow up telephone interview on 1/7/25 at 11:53 AM, Companion Aide #1 stated they did provide hands on care for Resident #22 all the time and usually with a staff member of the facility but did recall twice they had to do care themselves because no one came when they pressed the call bell. They stated they assisted Resident #22 with eating, made sure they were hydrated, assisted with dressing, helped them to the toilet, changed soiled briefs and applied zinc oxide to their buttocks. They stated they never met with anyone from the facility about orientation or training but did sign paperwork and dropped it off to the receptionist when it was completed. They stated all the facility staff were aware they provided hands on care for Resident #22 and liked that they did because the resident was behavioral, and it was less work for them. During an interview on 1/7/25 at 3:24 PM, Social Worker #1 stated the facility had a responsibility to ensure a resident was not being abused. They stated there was no formal process for monitoring the Companion Aides except as if they were any other visitor. Staff were to check in with the resident, observe and intervene if there was anything inappropriate happening. Social Worker #1 stated they were unaware that Resident #22's Companion Aides were providing hands on care. Social Worker #1 stated that from their understanding of the situation that occurred on 11/26/24, they felt Resident #22 was restrained by Companion Aide #1 and that would be considered abuse. During an interview on 1/8/25 at 10:44 AM, Companion Aide #3 stated they were not provided with the nursing home's Companion Aide policy. The Private Hire Agreement did not specify the different levels of care and restrictions on care in the nursing home. Companion Aide #3 stated the facility could not ensure the residents safety if the Companion Aides were not informed on what care they could or could not do for the residents. During an interview on 1/8/25 at 11:28 AM, the Administrator stated it was the facilities responsibility to provide a safe environment to protect the residents from abuse, and assumed the responsibility when a resident was admitted . They stated the facility management did not do any unannounced visits or monitoring of the Companion Aides before or after the incident that occurred on 11/26/24. They stated they monitored the Companion Aides the same way they would monitor any other visitor, they relied on staff to inform them of any inappropriate behavior. They stated no corrective actions were needed following the investigation because the alleged suspect was not permitted in the facility any longer. 10 NYCRR 415.4(d)(1)(vii)

Based on interview, and record review conducted during a Complaint investigation (Complaint #NY00362317) completed on an Extended Recertification survey with an exit date of 1/8/2025, the facility did not ensure that all alleged violations involving abuse, neglect, and mistreatment, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to the administrator and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for one (Resident #22) of six reviewed. Specifically, the facility did not report to the State Agency allegations of abuse within the two-hour required time frame. In addition, the facilities abuse reporting protocols have not been reviewed/revised since 2016. The finding is: The policy and procedure titled Abuse Reporting revised 11/28/16 documented the Director of Nursing and Administrator will be called and notified immediately, but not later than two hours after the allegation is made if the events of the allegation involve abuse or result in serious bodily injury. Verbal/written notices to agencies will be made within 24 hours of the occurrence and such notice may be submitted electronically via the NYSDOH (New York State Department of Health) Health Commerce System. The policy did not include the required 2-hour timeframe. 1. Resident #22 had diagnoses of Alzheimer's disease, heart failure, and displacement fracture of left femur. The Minimum Data Set (a resident assessment tool) dated 11/15/24 documented Resident #22 had severe cognitive impairments. Resident #22 required substantial/maximal assistance for toileting, toileting transfer, upper body dressing, lower body dressing, and for personal hygiene. The Accident and Incident Report signed by the Administrator and the Assistant Administrator documented on 11/26/24 between the hours of 8:00 AM and 9:00 AM Activities Aide #1 reported to the Licensed Practical Nurse Supervisors they heard screaming and thumping sounds coming from Resident #22's room. The Licensed Practical Nurse Supervisors went to Residents #22's room and the resident was receiving care at the bedside from CNA (Certified Nurse Aide #1) and a private companion aide. The report documented the resident was restrained by Companion Aide #1, their arms were grabbed, crossed, and held to the resident's chest. The Accident and Incident Report included a Management Investigation Report that documented the event occurred because Resident #22 did not want to get out of bed and the hired Companion Aide #1 did not respect the resident's wishes. The report documented the event was suspected abuse/mistreatment/neglect of the resident and the Regulatory Agency was notified on 11/27/24. Review of Social Worker #1's written statement attached to the Accident and Incident report dated 11/26/24 documented that Resident #22's family member reported to them at 2:00 PM on 11/26/24 that Certified Nurse Aide #1 reported to the family member that Companion Aide #1 was using inappropriate behavior towards Resident #22. During an interview on 1/6/25 at 8:19 AM, Certified Nursing Aide #1 stated on the morning of 11/26/24, Companion Aide #1 insisted that Resident #22 got up and dressed; they pulled the residents blankets back and Resident #22 kicked Companion Aide #1. Companion Aide #1 then forcefully grabbed the resident's arms and crossed them across the resident's chest to restrain them as they yelled, Stop, you will get dressed now! Resident #22 was screaming and crying. Licensed Practical Nurse Supervisor #1 and Licensed Practical Nurse #3 entered the room. Certified Nurse Aide #1 stated they would consider this abuse because they should not force a resident to do anything they don't want to. During an interview at 1/6/25 at 9:17 AM, Licensed Practical Nurse #3 stated Activities Aide #1 had told Licensed Practical Nurse Supervisor #1 they heard a thump and yelling in Resident #22's room, so they went to see what had happened. Resident #22 was screaming, distressed, and agitated. They stated they did not see any bruises on Resident #22 and did not see Companion Aide #1 touch the resident, so they were not certain if this was abuse. During an interview on 1/6/25 at 9:24 AM, Licensed Practical Nurse Supervisor #1 stated Activity Aide #1 reported they had heard screams and a thump in Resident #22's room. Upon arrival to the room, Resident #22 was screaming and agitated. Licensed Practical Nurse Supervisor #1 stated Companion Aide #1 overstepped their boundaries and were not to provide hands on care. There was no bruising noted on Resident #22, but they considered this abuse and reported the incident to the Assistant Administrator. During an interview on 1/6/25 10:27 AM, Activities Aide #1 stated during their rounds on the morning of 11/26/24, they passed Resident #22's room and heard a thump and someone yelled, Stop kicking me. They reported the concern to Licensed Practical Nurse Supervisor #1 and Licensed Practical Nurse #3. During an interview on 1/6/25 at 11:38 AM, Resident #22's family member stated they were told by Certified Nurse Aide #1 that Companion Aide #1 physically grabbed their family member by the arms, put them across the resident's chest and yelled at them that they needed to get dressed. The family member stated they reported the incident to Social Worker #1 in the afternoon on 11/26/24. During an interview on 1/6/25 at 3:14 PM, the Administrator stated the incident that occurred on 11/26/24 with Resident #22 would not be considered abuse because the police did not get involved, the resident did not get hurt, and there was no psychological harm. They stated it was an isolated event and it was wrong but would not consider this abuse. The Administrator stated the facility reported the incident. During an interview on 1/7/25 at 3:24 PM, Social Worker #1 stated based on their understanding of the situation that occurred on 11/26/24, they felt Resident #22 was restrained by Companion Aide #1 and that would be considered abuse. Review of an email provided by the Administrator on 1/8/2025 dated 11/27/24 at 3:07 PM revealed the email was addressed to the Administrator and documented the Nursing Home Facility Incident Report was successfully submitted on 11/27/24 at 15:06 (3:06 PM). The report was not submitted within two hours of the alleged abuse. NYCRR 415.4(b)(4)

Based on observation, interview and record review conducted during the Extended Recertification survey completed on 1/8/25, the facility did not ensure that a resident with pressure ulcers (ulcers on the skin due to prolong pressure) received necessary treatment and services, consistent with professional standards of practice, to promote healing, and prevent infection for one (Resident #13) of one resident reviewed. Specifically, there were lack of consistent weekly pressure ulcer assessments and ongoing monitoring for Resident #13's left heel and left buttock pressure ulcers, the assessments did not consistently include staging, measurements of size (length x width x depth), or a description of the wounds. Additionally, the assessments had conflicting documentation of treatment instructions and wound measurements for the pressure ulcers. The finding is: The undated facility policy titled Pressure Ulcer Prevention and Treatment documented that a complete wound assessment and documentation will be done upon initial finding then weekly on all pressure ulcers until they are healed or if there was a deterioration in the ulcer by the Skin team or designees. The policy documented the criteria to be included were site/location; stage; size to include length, width, and depth in centimeters; appearance of the wound bed; undermining/tunneling; surrounding skin; drainage; pain; and signs and symptoms of infection. Resident #13 had diagnoses including dementia, coronary artery disease and chronic obstructive pulmonary disease. The Minimum Data Set (a resident assessment tool) dated 10/11/24 documented Resident #13 had moderate cognitive impairment, was understood, and usually understands. The assessment tool documented the resident had one stage II (partial-thickness skin loss into but not deeper than the dermis) pressure ulcer that was not present upon admission. The Comprehensive Care Plan dated 10/24/24 documented Resident #13 had actual altered skin integrity related to a partial thickness wound on their left heel. Interventions included to monitor skin per protocol, preventive skin interventions as per resident care guide, encourage meal/fluid consumption, skin team referral as needed, notify the medical doctor for adverse changes, and left heel bootie on at all times. There was no documentation regarding the left buttock pressure ulcer. Review of the Treatment Record from October 1, 2024-January 8, 2025, revealed Resident #13 had a treatment order with start date of 10/31/24 to apply optifoam (a foam dressing designed to absorb wound drainage) bandage to their pressure ulcer on left buttock after cleansing with normal saline daily in the evening. Review of the untitled medical provider progress notes from 9/20/24- 11/12/24 the Medical Director documented on: -9/20/24, Resident #13 had an acute visit due to a new onset of an ulceration on their left heel in the medial aspect (the part that is closest to the body's midline). It was documented that the area was about 2.5 x 1 centimeters and crescent shaped. -9/24/24, Resident #13 had an ulceration on their left heel, measuring 2 x 0.5 centimeters, a quarter moon type shape with a clean wound bed. -11/12/24, Resident #13 was seen for a 60-day visit and they had a very superficial ulceration area 3 x 4 centimeters to their left heel. There was no further Medical Director documentation in the medical record regarding Resident #13's pressure ulcer of their left heel or left buttock. Review of the Interdisciplinary notes from 9/20/24-1/7/25 revealed on: -9/20/24 at 10:14 AM, Registered Nurse Manager documented Resident #13 was seen by the Medical Director due to a pressure injury to their outer aspect of the left heel. The area measured 2.5 x 1 centimeters and was crescent shaped. There was no mention of stage or wound bed description. -10/30/24 at 10:18 PM, Licensed Practical Nurse #5 documented that Resident #13 had a small 2-centimeter open area noted to their left buttock. It was documented that a new order was received to place optifoam dressing daily. There was no documented description of the wound. -12/11/24 at 2:22 PM, Licensed Practical Nurse #4 documented that Resident #13 presented with a left heel pressure injury that measured 3.5 x 3.6 centimeters with eschar (dead tissue usually black, brown, or tan in color) and slough (non-viable yellow, tan, gray, green or brown tissue). -12/18/24 at 12:22 PM, Licensed Practical Nurse #4 documented that Resident #13 was seen for skin rounds and was observed to have a stage II pressure ulcer on their left lower buttocks with scant serous drainage measuring 1 x 1.5 centimeters. It was documented that the treatment was for a hydrocolloid dressing (a gel-like dressing that promotes healing) to be changed every three days and as needed. -12/26/24 at 2:27 PM, Registered Nurse Manager documented that Resident #13 was seen for skin checks, their left heel remained with pressure injury and the left lower buttock was resolving. -1/1/25 at 2:47 PM, Licensed Practical Nurse #4 documented that Resident #13 was seen for skin rounds and presented with a pressure ulcer to the lower buttocks. It was documented that Resident #13 had an unstageable pressure ulcer on the left heel that was 95% slough and 5% granulation tissue (red healing tissue). Review of Resident #13's Skin Evaluation form from 10/20/24-1/1/25 revealed on: -10/20/24 at 2:37 PM, Licensed Practical Nurse #4 documented the resident had an area to their left heel measuring 1.5 x 3 centimeters with 25% slough and serosanguineous drainage (drainage containing both blood and serum). There was no documented stage of the left heel pressure ulcer. -11/21/24 at 2:24 PM, Registered Nurse Manager documented the resident had a pressure injury to their left heel measuring 1.5 x 3 centimeters with 25% slough and moderate amount of serosanguinous drainage. It was documented that the stage needed further assessment. -12/11/24 at 12:08 PM, Licensed Practical Nurse #4 documented the resident had a left heel unstageable pressure injury measuring 3.5 x 3.6 centimeters with eschar and slough. Licensed Practical Nurse #4 documented on a second form at 12:09 PM that the left heel pressure injury measured 1.5 x 3 centimeters with 25% slough and 75% granulation tissue. The form documented that the stage needed further assessment. There were conflicting measurements documented on two different forms for the same area on the left heel. -12/18/24 at 12:16 PM, Licensed Practical Nurse #4 documented the resident had a stage II pressure injury to their left lower buttock measuring 4 x 3.9 centimeters with light serous drainage (clear or yellow fluid). The treatment was a hydrocolloid dressing every other day. There was no documented description of the wound. Licensed Practical Nurse #4 documented on a second form at 12:31 PM that the stage II pressure injury on the left lower buttock measured 1 x 1.5 centimeters with light serous drainage. The treatment was a hydrocolloid dressing every other day. There was no documented description of the wound. There were conflicting measurements documented on two different forms for the same area on the left lower buttock. Licensed Practical Nurse #4 documented a third form at 12:22 PM that the resident had a left heel unstageable pressure injury measuring 3.5 x 3.6 centimeters with eschar and slough. -12/26/24 at 2:25 PM, Registered Nurse Manager documented the resident had an unstageable pressure injury to their left heel that measured 5 x 3.9 centimeters with eschar and slough. At 2:26 PM Registered Nurse Manager documented the resident had a stage II pressure ulcer to their left lower buttock measuring 0.8 x 1 centimeters. There was no documented description of the wound and the treatment was a hydrocolloid dressing that was to be changed every other day. -1/1/25 at 2:57 PM, Licensed Practical Nurse #4 documented that Resident #13 had an unstageable pressure injury to their left heel that measured 6 x 4 centimeters with slough. The resident had a stage II pressure ulcer to their left lower buttocks measuring 1 x 1 centimeters. There was no documented description of the wound and the treatment was a hydrocolloid dressing to be changed every other day. There was no documented evidence that Resident #13's pressure ulcer to their left heel was monitored and/or observed by the skin team or Medical Director for the weeks of 10/27/24-11/2/24, 11/3/24-11/9/24 and 12/1/24- 12/7/24. There was no documented evidence that Resident #13's pressure ulcer to their left buttock was monitored and/or observed by the skin team or Medical Director from 11/1/24-12/17/24 (6 weeks missed). During an observation and interview on 1/8/25 at 8:11 AM, Registered Nurse Supervisor #1 performed wound care on Resident #13 per medical provider orders. Registered Nurse Supervisor #1 stated that they were unsure how long Resident #13 had a pressure ulcer to their left heel and left buttock, but it was longer than two weeks. They stated both wounds were chronic wounds. Resident #13 was observed to have a quarter size open area to their left buttock. Registered Nurse Supervisor #1 placed an optifoam dressing to the area. Registered Nurse Supervisor #1 stated they would describe Resident #13's left buttock wound as a stage II pressure ulcer that was open, had slough to the wound bed and did not have any drainage. Resident #13 was observed to have a large open area to their left heel. Registered Nurse Supervisor #1 cleansed the area with normal saline and applied Medi honey (wound care dressing that uses medical-grade honey) and a dry clean dressing. Registered Nurse Supervisor #1 stated they would describe Resident #13's heel as an unstageable pressure ulcer that had slough, dark eschar to the wound bed, was moist with drainage and had a foul odor. They stated the area also appeared macerated (skin that has been softened due to prolonged exposure to moisture). [NAME] drainage was observed on the outside of the old dressing prior to removal and on Resident #13 fitted bed sheet. Registered Nurse Supervisor #1 did not measure any skin areas because they stated they did not bring in anything in the room to measure them with and would have to do so later. During an interview on 1/8/25 at 9:16 AM, Registered Nurse Manager stated the process for resident pressure ulcer monitoring was the wounds were to observed weekly on Thursdays by themselves and/or Licensed Practical Nurse #4. They stated the Weekly Skin Care Report was the skin tracking log that was emailed to them weekly from the Administrator. The Registered Nurse Manager stated they completed the log after observation of the wound and emailed the log back to the Administrator. They stated they were notified over the summer that they were also to complete the Skin Evaluation Form in the electronic medical record, but it was hit and miss if they completed that form. Registered Nurse Manager stated it was the responsibility of Licensed Practical Nurse #4 or themselves to complete the Skin Evaluation Form. Registered Nurse Manager stated from October 2024 until December 23, 2024, Licensed Practical Nurse #4 was responsible for weekly skin monitoring and documentation because they had assumed the role of interim Director of Nursing. During an interview on 1/8/25 at 11:18 AM, Registered Nurse Manager stated on 9/20/24 they did document the initial skin note for Resident #13 pressure injury to their left heel. They stated they did not stage the wound because they were not comfortable staging any pressure ulcers. Registered Nurse Manager also stated that not all of their notes have descriptions of the wounds and/or staging because they needed more education on pressure ulcers. They stated upon hire and during their role of Registered Nurse Manager they had expressed their need to the Former Director of Nursing and the Administrator for more education and uncomfortableness of staging pressure ulcers. Registered Nurse Manager stated that Resident #13 should have had consistent weekly measurements, staging and description of their pressure ulcers because it was important for continual management of their wounds. After they reviewed the Skin Evaluation Form and the electronic Treatment record, Registered Nurse Manager stated they documented on the Skin Evaluation Form that Resident #13 was getting a hydrocolloid dressing to their left buttock pressure ulcer and that was inaccurate. They stated Resident #13 had an order to have optifoam to the left buttock daily and was unsure why they documented a hydrocolloid dressing every other day. A telephone interview was attempted on 1/8/25 at 11:43 AM, with Licensed Practical Nurse #4 and no return telephone call was received. During a telephone interview on 1/8/25 at 11:49 AM, the Medical Director stated Resident #13 had chronic pressure ulcers. The Medical Director stated their expectation for pressure ulcer documentation would be for staff to document Resident #13's wounds in their medical record and that the treatment information be accurate. They stated they would expect the wound documentation to include measurements with depth, description of the wound including what the surrounding tissue looked like and if there were any signs and symptoms of infection. During an interview on 1/8/25 at 2:48 PM, the Director of Nursing stated they expected that monitoring, and documentation of a pressure ulcer would be conducted weekly. They stated the documentation should be part of the medical record and include staging, measurements, and description of the wound. The Director of Nursing stated weekly skin monitoring was the responsibility of the Registered Nurse Manager and themselves. They stated that Licensed Practical Nurse #4 should have assessed Resident #13's pressure ulcers with a registered nurse present. The Director of Nursing stated they could not provide any further skin documentation for Resident #13 and the Weekly Skin Report was the facility's skin tracking log and was not part of a resident's medical record. The Director of Nursing reviewed Resident #13's treatment documentation on the Skin Evaluation Form and the electronic treatment records dated November 2024 and December 2024, and stated there was conflicting documentation. The Director of Nursing stated that optifoam and hydrocolloid were not a same treatment, and they were unsure what treatment Resident #13 should have had in place to their left buttock. They stated they would have followed the medical provider's order, but the documentation should be accurate. The Director of Nursing stated skin documentation should be descriptive and accurate for proper monitoring of improvement or worsening of a pressure ulcer. During an interview on 1/8/25 at 3:08 PM, the Administrator stated that their expectations for monitoring and documenting of pressure ulcers would be staff to follow the facility policy along with the regulatory requirements. They stated the skin team was handled by the Director of Nursing along with Registered Nurse Manager and Licensed Practical Nurse #4. The Administrator stated that they were unaware Registered Nurse Manager requested additional education for pressure ulcer staging and treatment. 10NYCRR 415.12(c)(2)

Based on observation, interview and record review conducted during an Extended Recertification Survey completed 1/8/25, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and a comfortable environment, to help prevent the development and transmission of communicable diseases and infections for one (Residents #13) of one resident reviewed. Specifically, enhanced barrier precautions (interventions designed to reduce transmission of multi-drug resistant organisms including gown and glove use during high contact resident care activities) were not initiated for a resident with pressure ulcers and staff did not wear appropriate personal protective equipment during pressure ulcer care. The finding is: The policy titled Enhanced Barrier Precautions dated 5/2024, documented enhanced barrier precautions are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms to residents. Enhanced barrier precautions employed targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. An example of high-contact resident care activity requiring the use of gown and gloves for enhanced barrier precautions would include wound care (any skin opening requiring a dressing). Signs were to be posted on the door or wall outside the resident room indicating the type of precautions and personal protective equipment required along with the personal protective equipment to be available outside of the resident room. Review of the enhanced barrier precaution signage (a sign used by the facility that was supposed to be posted outside a residents door to indicate they required enhanced barrier precautions) documented that providers and staff must wear gloves and a gown for the following high-contact resident care activities: wound care (any skin opening requiring a dressing). Resident #13 had diagnoses including dementia, coronary artery disease and chronic obstructive pulmonary disease. The Minimum Data Set (a resident assessment tool) dated 10/11/24 documented Resident #13 had moderate cognitive impairment, was understood, and usually understands. The assessment tool documented the resident had one stage II (partial-thickness skin loss into but not deeper than the dermis) pressure ulcer that was not present upon admission. The Comprehensive Care Plan dated 10/24/24 documented Resident #13 had actual altered skin integrity related to a partial thickness wound on their left heel. Interventions included to monitor skin per protocol, preventive skin interventions as per resident care guide, encourage meal/fluid consumption, skin team referral as needed, notify the medical doctor for adverse changes, and left heel bootie on at all times. The comprehensive care plan did not document that Resident #13 was on enhanced barrier precautions. During intermittent observations on 1/2/25 at 12:06 PM, 1/2/25 at 3:34 PM, 1/6/25 at 9:53 AM 1/6/25 at 3:16 PM and 1/8/25 at 8:11 AM, Resident #13 was in their room either in their recliner chair, wheelchair, or bed. There were no plastic precaution bins outside of their room and no enhanced barrier precaution signage on the door. During an observation and interview on 1/8/25 at 8:11 AM, Registered Nurse Supervisor #1 performed wound care to Resident #13 while the resident was in bed. Registered Nurse Supervisor #1 stated that they were unsure how long Resident #13 had a pressure ulcer to their left heel and left buttock, but it was longer than two weeks and they were chronic. The resident had an open area to their left buttock/hip area with slough (non-viable yellow, tan, gray, green or brown tissue) to the wound bed. Registered Nurse Supervisor #1 stated that they would describe the area as a stage II pressure ulcer that was open, had some slough to the wound bed but did not have any drainage. Registered Nurse Supervisor #1 cleansed the area with normal saline and applied any optifoam dressing. The resident had had a large open area to their left heel. Registered Nurse Supervisor #1 stated the area appeared to be an unstageable pressure ulcer that had slough with dark eschar (dead tissue usually black, brown, or tan in color) to the wound bed that was moist with a large amount of serosanguineous (blood mixed with yellow/clear drainage) drainage. [NAME] drainage was noted to the outside of the old dressing prior to removal and on Resident #13 fitted bedsheet. Registered Nurse Supervisor #1 did not wear a gown during this observation. During an interview on 1/8/24 at 10:43 AM, Registered Nurse Supervisor #1 stated that when a resident was on enhanced barrier precautions, plastic bins were placed outside of the resident's door, and a precaution sign was to be hung on their door. Registered Nurse Supervisor #1 stated the purpose of enhanced barrier precautions was to protect oneself from the possibility of spreading an infection to themselves or others. They stated that Resident #13 was not on enhanced barrier precautions, and they did not wear a gown when performing pressure ulcer care. Registered Nurse Supervisor #1 stated they were unsure if residents with a chronic pressure ulcer should be on enhanced barrier precautions and would need to look at the signage. After review of the facility's enhanced barrier precautions signage, Registered Nurse Supervisor #1 stated Resident #13 should have been on enhanced barrier precautions because the signage stated, wound care: any skin opening requiring a dressing. During an interview on 1/8/25 at 11:18 AM, Registered Nurse Manager stated that a resident with any skin wounds should be on enhanced barrier precautions. They stated that Resident #13 was not on enhanced barrier precautions, that they should have been, and there was no reason but it was not followed through. Registered Nurse Manager stated the purpose of enhanced barrier precautions was for the protection from the resident getting a further infection and protecting the staff as well. During an interview on 1/8/25 at 2:48 PM, the Director of Nursing stated they were the facility's Infection Preventionist and that enhanced barrier precautions should be utilized on residents that need wound care and when there was any high-risk contact with the area. They stated they were responsible for implementing and ensuring residents that needed them, had enhanced barrier precautions in place. The Director of Nursing stated they were unsure if Resident #13 had enhanced barrier precautions implemented and assumed they did because Resident #13 had chronic pressure ulcers for a while. The Director of Nursing stated the purpose of enhanced barrier precautions was to protect to the resident from obtaining an infection in their wound and protect other residents and staff. NYCRR 415.19(a)(2)

Based on observation and interviews conducted during the Extended Recertification survey completed on 1/8/25, the facility did not ensure the nursing staff information was posted daily and contained the required information for three of five days reviewed. Specifically, the facility did not post daily the current resident census, the total number, and the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift in a prominent place readily accessible to residents and visitors. The finding is: The policy titled Direct Care Daily Staffing Numbers dated 2/03, documented the facility will post on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. Additionally, within two hours of the beginning of each shift, the number of licensed nurses and the number of unlicensed nursing personnel directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. Intermittent observations made on 1/2/25 at 8:40 AM, 1/3/25 at 8:25 AM, 1/6/25 at 9:46 AM and 1/6/25 at 3:05 PM, revealed there was no posting of the Report of Nursing Staff Directly Responsible for Resident Care form at the nurse's station of [NAME] Village, at the main reception area of the facility, or in any prominent place accessible to residents and visitors. The Skilled Nursing Assignment Sheet observed posted at the nurse's station on 1/2/25 at 8:40 AM, 1/3/25 at 8:25 AM and 1/6/25 at 9:46 AM, documented the current date, the name of the nursing supervisor, charge nurse, and certified nurse aides. The document did not include the resident census, or the total number and actual hours worked by licensed and unlicensed staff directly responsible for resident care. During an interview with Resident #18's family member on 1/3/25 at 2:30 PM, they stated that the actual staffing was never posted and was not visible to family members. Resident #18's family member stated that only the daily assignment sheet would be posted, and it did not accurately document what staff had showed up for work or who had called off. During an interview on 1/6/25 at 3:05 PM, the Staffing Coordinator #1 stated that they did not post the Report of Nursing Staff Directly Responsible for Resident Care form because they would post the daily Skilled Nursing Assignment Sheet. During an interview on 1/8/25 at 11:54 AM, the Staffing Coordinator #1 stated that it was the nursing supervisor's responsibility to complete the Report of Nursing Directly Responsible for Resident Care form within two hours of their shift starting and would be posted at the nurse's desk in a clear plastic stand next to the Daily Skilled Nursing Assignment Sheet. During an interview on 1/8/25 at 1:17 PM, Licensed Practical Nurse Supervisor #1 stated that the nursing supervisors were responsible to complete the Report of Nursing Staff Directly Responsible for Resident Care form each shift and would adjust with any staff changes that occurred during their shift. Licensed Practical Nurse Supervisor #1 stated this form had not previously been posted at the nursing desk until 1/7/25. They stated that prior to 1/7/25 this form would be completed and placed in a binder that was behind the nurse's desk not accessible to residents or family. Licensed Practical Nurse Supervisor #1 stated that it would be important to have it posted to provide transparency for residents and families so that they knew how many staff members were present in the building to provide resident care. They were not aware that it should have been posted in an accessible. During an interview on 1/8/25 at 11:58 AM, the Director of Nursing #1 stated that it was the nursing supervisor's responsibility to complete and post the Report of Nursing Staff Directly Responsible for Resident Care form daily. They stated they would expect this form to be updated every shift with any call offs to reflect the actual staff in the building. The Director of Nursing #1 stated it was important to have this posted so that residents and family members would know how many staff members were present in the building providing care. 10NYCRR 415.13

Based on interview and record review conducted during the Standard survey completed on 6/2/23, the facility did not implement written policies and procedures for screening employees that would prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for four (Employees A, B, D, and F) of six agency employees reviewed who were hired in the last four months and were subject to the New York State Nurse Aide Registry. Specifically, the facility did not ensure prospective employees were screened through the New York State Nurse Aide Registry prior to their employment. This affected two (North Unit and West Unit) of two resident units. The findings are: 1a. Review of the personnel file for Employee (A) (Agency Licensed Practical Nurse, (LPN)) revealed Employee (A) was hired on 5/15/23 and the New York State Nurse Aide Registry Verification Report for Employee (A) was dated 6/1/23. Review of Nursing Assignment Sheets revealed Employee (A) had worked at the facility for three days between 5/20/23 through 6/1/23. Additionally, the Nursing Assignment Sheets revealed Employee (A) had worked as the Charge Nurse on the North Unit and West Unit between 5/20/23 and 5/24/23. During an interview on 6/2/23 at 8:59 AM, the Human Resources Director stated Employee (A) was an agency employee, was working at the facility as a Licensed Practical Nurse (LPN), was hired by the facility on 5/15/23, and the Nurse Aid Registry Verification for Employee (A) was dated 6/1/23. 1b. Review of the personnel file for Employee (B) (Agency Licensed Practical Nurse, (LPN)) revealed Employee (B) was hired on 3/1/23 and the New York State Nurse Aide Registry Verification Report for Employee (B) was dated 6/1/23. Review of Nursing Assignment Sheets revealed Employee (B) had worked at the facility for two days between 3/21/23 through 6/1/23. Additionally, the Nursing Assignment Sheets revealed Employee (B) had worked as the Charge Nurse on the North Unit between 3/21/23 and 3/22/23. During an interview on 6/2/23 at 8:59 AM, the Human Resources Director stated Employee (B) was an agency employee, was working at the facility as a Licensed Practical Nurse (LPN), was hired by the facility on 3/21/23, and the Nurse Aid Registry Verification for Employee (B) was dated 6/1/23. 1c. Review of the personnel file for Employee (D) (Agency Licensed Practical Nurse, (LPN)) revealed Employee (D) was hired on 3/18/23 and the New York State Nurse Aide Registry Verification Report for Employee (D) was dated 5/31/23. Review of Nursing Assignment Sheets revealed Employee (D) had worked at the facility for five days between 3/18/23 through 5/31/23. Additionally, the Nursing Assignment Sheets revealed Employee (D) had worked as the Charge Nurse on the North Unit and West Unit between 3/18/23 and 5/14/23. During an interview on 6/2/23 at 8:59 AM, the Human Resources Director stated Employee (D) was an agency employee, was working at the facility as a Licensed Practical Nurse (LPN), was hired by the facility on 3/18/23, and the Nurse Aid Registry Verification for Employee (D) was dated 5/31/23. 1d. Review of the personnel file for Employee (F) (Agency Licensed Practical Nurse, (LPN)) revealed Employee (F) was hired on 5/27/23 and the New York State Nurse Aide Registry Verification Report for Employee (F) was dated 6/1/23. Review of Nursing Assignment Sheets revealed Employee (F) had worked at the facility for one day between 5/27/23 through 6/1/23. Additionally, the Nursing Assignment Sheets revealed Employee (F) had worked as the Charge Nurse for the North Unit and West Unit on 5/27/23. During an interview on 6/2/23 at 8:59 AM the Human Resources Director stated Employee (F) was an agency employee, was working at the facility as a Licensed Practical Nurse (LPN), was hired by the facility on 5/27/23, and the Nurse Aid Registry Verification for Employee (F) was dated 6/1/23. During the interview on 6/2/23 at 8:59 AM, the Human Resources Director stated the facility used three different agencies to provide Nurses and Certified Nursing Assistants for the facility's staffing. The agencies usually conducted the Nurse Aide Registry Verification for the agency employees, and they were not sure why the information was not in the employee's (A, B, D and F) personnel files. 415.4(b)(1)(ii)(a)(b)

Based on observation, interview, and record review conducted during a Standard survey completed 6/2/23, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, one of one main kitchen had issues with multiple food items in the walk-in coolers and a reach-in cooler that had been removed from the original (mother) container or had been opened and were not dated with the date opened. The reach-in freezer in the kitchen had loose French fries, onion rings and many crumbs of debris on the bottom. In addition, one of one servery, Cook #1 was observed serving food without changing gloves during the entire meal service. The findings are: The policy and procedure (P&P) titled Food and Cleaning Supply Storage with the revision date of 11/19/22 documented on the third day of any prepared food, the item will be disposed of or used. Gallon containers (i.e., dressings, mayonnaise, etc.) must be labeled on opening date and disposed on the tenth day. Predated items with an expiration date on package, need wrapped and dated on opening date. The P& P titled Infection Control Program, reviewed 6/2/23, documented the infection control nurse served as a resource for all staff and departments relating to the prevention of infections and that compliance is monitored and documented by observation of practices and the infection control nurse and appropriate department managers review the compliance monitoring and initiate appropriate actions. The P&P titled Sanitation and Control of Infection - Use of Disposable Gloves, prepared by the dining services director with a revision date of 6/1/23 documented that any time gloves in food service come in contact with uncooked product they may not be used to touch any cooked food and vice-versa. It also documented that any time gloves come in contact with allergens like shellfish or nuts, the gloves must be replaced with a fresh pair. Additionally, any time a cook switches food groups - cooked to uncooked - or - uncooked to cooked - the gloves must be discarded and replaced with new ones. An observation of the main kitchen on 5/30/23 between 9:07 AM and 9:45 AM revealed the following: -The walk-in coolers contained the following items of concern: 1 servery salad kit dated 5/15/23. -The following items were opened or portioned out and were not dated: 9 clear plastic cups containing 2 hard- boiled eggs and a lettuce leaf in each, bags of fresh cilantro, chives, green onions, shredded lettuce, avocados, 2 bags of fresh spinach, of which one had a Best by date of 5/22/23 stamped on the original bag, clam shell containers of sliced cake, a large container of strawberry topping, blue cheese dressing, stir fry sauce, a bag of sliced salami, a bag of fresh bacon pieces, and a servery salad kit. -A tray cart with 11 clam shell containers with pre-made salads and one large aluminum pan containing tossed salad ingredients that was full and not covered - these items were also not dated. -Multiple bags of fresh cut vegetables (mixed vegetables and several broccoli bags) with zip ties that had been removed from their original boxes and were stored on shelves in the walk-in coolers. They were not labeled or dated with Use by dates. - The reach-in milk cooler in the kitchen contained a partial half gallon of chocolate milk that was not dated with the date it was opened. - The bottom of the reach-in cooler near the stove was littered with loose French fries and onion rings and various other crumbs and debris. 2. During the dining observation on 5/30/23 from 12:00 PM to 12:25 PM, Cook #1 did not change their black latex food service gloves between placing lettuce leaves and sliced tomatoes on plates without a utensil, scooping hot foods from the steam table, going into the back of the servery station and getting a bagged loaf of bread and making a peanut butter and jelly sandwich, scooping more hot foods, handling meal tickets and plates, and cutting scallops while holding them down on the plate with one gloved hand and using the knife in the other hand to cut them in half. During an interview on 5/30/23 at 1:07 PM, Cook #1 stated their culinary school training had taught them to change gloves when moving between stations and they had not changed their gloves as often as they should have. During an interview on 5/30/23 at 1:17 PM, Executive Chef #1 stated they expected their staff to date opened food containers, so open fresh food items can be discarded three days after opening. If a food item was removed from the mother (original) container, it should be dated. Executive Chef #1 stated their expectation from staff would be that gloves should be changed when switching from hot food service to cold food service and any time a cook changes from one food preparation station to another. During an interview on 6/1/23 at 9:26 AM, the Dietician/Nutritionist #1 stated that gloves should be changed especially when handling seafood and peanut butter, to avoid adverse reactions for residents with allergies and to avoid cross contamination between different types of foods. During an interview on 6/1/23 at 9:44 AM, Director of Dining Services #1 stated that a cook not changing gloves between food stations can be a concern with allergies. The Director of Dining Services stated that the cooks working on 5/29/23 (Memorial Day) had been instructed to toss all leftover foods from the day's picnic at the end of the day and the cart and single serving packaged foods observed in the cooler on 5/30/23 had been from the picnic. There should have been a clear large bag placed over the cart and the preparation date would have been written on the bag. Since there was no bag over the cart, individual items should have been dated and marked. During an Interview on 6/1/23 at 11:50 AM, the Director of Nursing (DON)/Infection Preventionist stated food service gloves should be changed any time a cook changes from serving one area of food to another area and type of food to avoid cross contamination. They expected staff to use utensils, and not their gloved hands to place lettuce and sliced tomatoes on plates. The DON/Infection Preventionist stated it was the dining department's role to train cooks on infection prevention by hand hygiene and glove changing when appropriate. During an interview on 6/1/23 at 11:55 AM, the Administrator and the Campus Head of Food Service #1 stated that cooks should be changing gloves often, as there are cross contamination concerns, and they expected the Chef and the Dining Director to provide training regarding glove use and when they should be changed during food service. 10 NYCRR 415.14 (h)

Based on observation, interview, and record review conducted during the Standard survey completed on 12/30/21, the facility did not ensure that a resident who is unable to carry out activities of daily living (ADL's) receives the necessary services to maintain good nutrition for one (Resident #29) of two residents observed for ADL's. Specifically, Resident #29 with a history of pneumonia (lung infection) and weight loss was not provided with extensive assist with eating at meals as required per their plan of care. The finding is: The policy and procedure (P&P) titled POC Charting and ADLs (undated) defined an extensive assist as resident helps/use muscle and one assist as one staff to help support ADL. 1. Resident #29 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- a resident assessment tool) dated 11/30/21 documented Resident #29 had severe cognitive impairment and required extensive assist with eating. The Care Plan (CP) revised 12/09/21 documented Resident #29 had decreased ability with ADL's. Interventions included to provide assist as per resident care guide. Effective 12/29/21, Resident #29 was at risk for altered nutrition related to poor appetite and intake. Interventions included to provide diet and consistency as ordered and observe intake. The Resident Care Guide (guide used by staff to provide care) effective 11/23/21 documented - Resident #29 required extensive assist of one with eating and altered food consistency of cut chop pea size solids and nectar thick liquids. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Dietary Notes dated 8/5/21, 10/6/21, and 12/15/21 documented Resident #29 had a weight loss trend related to poor appetite and intake. Intake of solids ranging from 0-50 percent (%), rarely consuming 50%. Resident #29 had an 11% weight loss over 6 months and 7% weight loss over the past 3 months. Resident #29 required much encouragement for improved intake and a request was made for the resident to be evaluated by SLP to determine if current diet consistency order was still appropriate. Review of Occupational Therapy assessment dated [DATE] documented Resident #29 required extensive assist with eating. Speech Therapy evaluation dated 12/16/21 documented Resident #29 had mild swallowing impairment with risk of aspiration on liquids. SLP goal was that Resident #29 would safely consume a cut/chopped pea size and nectar thick liquid diet without signs or symptoms of aspiration to optimize nutrition and hydration. During an intermittent breakfast meal observation on 12/27/21 at 10:46 AM revealed Resident #29 was seated upright in bed with a breakfast meal on a tray in front of them and was unassisted. The meal intake record dated 12/27/21 documented Resident #29 consumed 25% at breakfast. During a continual lunch meal observation on 12/28/21 at 12:52 PM revealed Resident #29 was provided lunch by dietary staff in a private bedroom and left unassisted. The resident's meal slip dated 12/28/21 documented Resident #29 was to receive extensive assist with lunch. Resident #29 was observed eating lunch independently, closing eyes between bites and coughing twice after consuming thickened liquids from straw in cup. At 12:58 PM Licensed Practical Nurse (LPN) #3 entered Resident #29's room and asked if the resident wanted help eating. Resident #29 stated I am trying, and LPN #3 stated I will be back to check on you, and exited the room without providing assistance. Resident #29 was observed to take six bites of lunch. At 1:34 PM, dietary staff entered the resident's room and removed the lunch tray. LPN #3 did not returned to assist the resident before their tray was removed. The meal intake record dated 12/28/21 documented Resident #29 consumed 25% at lunch. During an intermittent breakfast meal observation on 12/29/21 at 9:40 AM revealed Resident #29 eating breakfast in bed with the Occupational Therapist (OT) providing extensive assistance. The meal intake record dated 12/29/21 documented Resident #29 consumed 75% at breakfast. During an interview on 12/29/21 at 10:41 AM, CNA #6 stated Resident #29 required extensive assist with feeding and staff was to stay in the resident's room until the resident was done eating. During an interview on 12/29/21 at 12:10 PM, LPN #3 stated Resident #29 was an extensive assist with feeding and did not typically eat unless fed. LPN #3 stated that Resident #29 needed to be supervised with meals and have a staff member remain with them during meals. A CNA or nurse were responsible for providing extensive assist with feeding. LPN #3 stated they did not know why Resident #29 was not provided extensive assist during continuous lunch observation on 12/28/21. During an interview on 12/29/21 at 12:21 PM, the Diet Technician stated that they expected staff to sit down and assist Resident #29 for safety and to achieve the best nutritional intake possible as an extensive assist. During an interview on 12/30/21 at 8:23 AM, the OT stated that staff were expected to remain with residents who require extensive assist with feeding for the entirety of the meal to assist with continuing nutritional intake whether the resident was in a private room or communal dining area. The OT stated that Resident #29's participation in dining and nutritional intake had declined. The OT stated that they looked at the resident's needs for optimal intake of nutrition and that Resident #29 was increased to extensive assist to get nutrition into the resident. The OT further stated that Resident #29 fatigued quickly, and staff had be present to keep them awake and to help feed. During a follow up interview on 12/20/21 at 11:42 AM, the OT stated Resident #29 consumed 75% of breakfast meal while provided continuous extensive assist with dining. The OT stated that they had to provide extensive assist with breakfast for Resident #29 to consume 75% of nutrition. 415.12(a)(3)(iv)

Based on observation, interview, and record review during the Standard survey completed on 12/30/21, the facility did not ensure that each resident received, and the facility provided food prepared by methods that conserve nutritive value, flavor and appearance, and food that was palatable. Specifically, for six of six residents reviewed for pureed food preparation, the recipe for the pureed lunch meal on 12/29/21 was not followed and it affected the nutritive value, flavor, appearance, and palatability of the food. The finding is: According to the facility's undated document titled, Puree Consistency Diet, the puree diet provides a nutritionally adequate diet for the resident with difficulty in swallowing, pureed foods are altered to form a consistency between liquid and soft, and care should be taken to serve pureed food in a colorful, attractive manner. Review of the recipe provided by the Executive Chef titled, Pureed Vegetable Recipe revealed it included the following steps: [NAME] (brand of food maker/blender) cooked vegetables for one and a half minutes, add hot liquid until blended, and add thickener just until incorporated. Review of the recipe provided by the Executive Chef titled, Pureed Meat Recipe revealed it included the following steps: [NAME] (brand of food maker/blender) cooked meat until paste consistency, add hot liquid until blended, and add thickener just until incorporated. Review of the facility's Week at a Glance Menu revealed the lunch meal for 12/29/21 was Oriental stir fry over rice, with shrimp and soy sauce. During an observation on 12/29/21 at 11:04 AM, the Cook poured approximately three cups of a mixture of cooked shrimp, vegetables, and sauce into a food processor. This mixture contained approximately twelve to fifteen shrimp and was in a thin liquid sauce that splashed when being poured. At this time, the Cook also added approximately two cups of water and four measured tablespoons of thickener powder. The Cook then blended the ingredients for approximately one minute, checked its consistency with a spoon, then added two additional measured tablespoons of thickener. The Cook blended the mixture for approximately 30 additional seconds, checked its consistency with a spoon, then added two additional measured tablespoons of thickener. The Cook blended the mixture for approximately 30 additional seconds, checked its consistency with a spoon, then added two additional measured tablespoons of thickener. At this time, the mixture contained a total of ten tablespoons of thickener and appeared the consistency of gravy. The Cook stated that they wanted the consistency of pureed food to be formed and defined formed as able to stay in the scoop shape after being scooped onto a plate and added that the current consistency of this mixture was still too runny. The Cook continued to add two more measured tablespoons of thickener to the mixture and briefly blended it, then transferred it to a pan to keep it hot until service. When this mixture was transferred to the pan, it was a gravy-like consistency. At the end of the puree process at 11:15 AM, the final pureed product contained approximately three cups of the regular meal of shrimp and vegetables in sauce, plus approximately two cups of water, plus twelve measured tablespoons of thickener. During an interview on 12/29/21 at 11:15 AM, the Cook stated they started with about three cups of the shrimp and vegetable meal in the food processor, the shrimp content of it was about one and a half cups, and the amount pureed was six servings. The Cook further stated they used water at the start of the puree process, so the shrimp and vegetables did not get clumpy. On 12/29/21 at 11:20 AM, Surveyor #1 tasted the final pureed product and noted it tasted like broth, with unidentified seasonings, and had no shrimp flavor. At this same time, Surveyor #2 also tasted the final pureed product and noted it smelled like shrimp, had a vegetable aftertaste, but did not taste like shrimp. After tasting the final product, the Cook stated the puree tasted like vegetables and shrimp. During an interview on 12/29/21 at 11:30 AM, the Executive Chef stated there is a recipe for this meal and the Cook should have followed the recipe when preparing the purees. The Executive Chef further stated they typically salt the food after puree, but not with this dish because the sauce in this dish was honey teriyaki, which already had a high sodium content. At this time, it was noted by Surveyor #1 and Surveyor #2 that the final pureed product that was tasted at 11:20 AM had no honey or teriyaki flavors. Observation at the Skilled Nursing Facility's Servery on 12/29/21 at 12:00 PM revealed the Cook took the temperature of the pureed shrimp and vegetables mixture and a separate pureed rice mixture on the steam table and they both appeared to have a gravy-like consistency. At the time of the observation, the Cook stated the puree meal consistency was fine, and if it was any thicker, the residents might not like it. Continued observation on 12/29/21 at 12:10 PM revealed the Cook placed four ounces of regular consistency shrimp and vegetables mix on a plate, with four ounces of regular consistency rice, and four ounces of regular consistency plain steamed vegetables on top, and a side cup of soy sauce on a regular diet plate. At this time, the Cook stated they were making sure each regular diet plate received four shrimp. When preparing a puree diet plate, the Cook placed four ounces of the pureed shrimp and vegetables mixture and four ounces of pureed rice on the plate and added a side cup of soy sauce. After being scooped onto the plate, the pureed food items spread out into two flat circles that extended almost to the edge of the plate. Observations of the lunch meal on 12/29/21 revealed the twelve to fifteen shrimp at the start of the puree process were divided by six servings, giving each resident on a pureed diet two to two and a half shrimp per serving, while residents on a regular consistency diet received four shrimp per serving. During an interview on 12/29/21 at 3:05 PM, the Executive Chef stated the Cook should have blended the shrimp and vegetables mixture first, then poured liquid into the blender a little at a time, which is the procedure on the recipe. The Executive Chef also stated there was no specific recipe for the pureed version of the honey teriyaki shrimp and vegetables meal, only the generic recipe for pureed vegetables and the generic recipe for pureed meat. The Executive Chef further stated when using two generic recipes, they should be combined, and they would suggest adding more vegetables and protein at the start of the puree to get the right consistency. Additionally, they stated adding water and thickener could affect the food's flavor. During a telephone interview on 12/29/21 at 3:25 PM, the Consultant Dietitian stated when preparing pureed food, they would expect the recipe to be followed, and if thickener and water were added, then the portion size must be adjusted so the food would not be watered down. Additionally, the Consultant Dietitian stated the thickener is flavorless and would not affect the flavor of the pureed food but adding too much water could affect the flavor of pureed food. Pureed food should be a pudding-smooth consistency, depending on the food, and when scooped onto a plate, it should somewhat hold its shape. 415.14(d)(1)(2)

Based on observation, interview, and record review conducted during the Standard survey completed on 10/31/19 the facility did not ensure that residents who use psychotic drugs receive gradual dose reductions (GDR), and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for one (Resident #25) of four residents reviewed for antipsychotic medications. Specifically, the facility did not attempt a gradual dose reduction (GDR) for the antipsychotic medication [MEDICATION NAME] since 7/2018. In addition, lacked the supporting behavioral documentation and [DIAGNOSES REDACTED]. The finding is: A policy and procedure (P&P) entitled [MEDICAL CONDITION] Medications, Definitions and Guidelines for Use dated 1/18/17 documented a [MEDICAL CONDITION] medication is any drug that affects brain activities associated with mental processes and behavior. These medications include but are not limited to anti-psychotics; anti-depressants; anti-anxiety; and hypnotics. [MEDICAL CONDITION] medications are ordered by the physician as indicated by the following: specific behaviors as quantitatively (number of episodes) and objectively documented by the facility which cause the resident to present a danger to self, present a danger to others or, or interfere with staff's ability to provide care. The facility supports the involvement of the resident and family members in the development of guidelines relative to the use of [MEDICAL CONDITION] medications and makes recommendations to the physician if indicated. A P&P entitled [MEDICAL CONDITION] Medication Routine Documentation dated 1/18/17 revealed physician documentation, requested every 60 days is monitored by the RN (Registered Nurse) Nurse Manager and or designee. Monthly BMARC (Behavior Modifying Agent Review Committee) meetings are held to review and make recommendations regarding [MEDICAL CONDITION] medications. [MEDICAL CONDITION] medications per MD order will be initiated if non-pharmacological interventions have been determined to not be effective, except in emergency situations. The BMARC committee will review for appropriateness and non-pharmacologic interventions utilized. Other possible underlying causes will be assessed by the Interdisciplinary Team. 1. Resident #25 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated 8/30/19 documented the resident was severely cognitively impaired and was usually understood and usually understands. Section N: documented the resident received antipsychotic medications during on a routine basis. GDR was attempted 7/25/18 and GDR has not been documented by a physician as clinically contraindicated. Review of the Resident Care Guide (guide used by staff to provide care) dated 8/23/17 documented the resident can be critical of staff. Interventions included: to provide cues, re-orientation and reminders as needed, educate on inappropriate verbalizations, re-approach as needed. Additionally, the resident has delusions at times and to reorient if allows, otherwise live in delusion and problem solve as needed. Review of the Physicians Orders dated 8/8/18 revealed Quetiapine 25 mg (milligrams) ½ tablet 12.5 mg once daily for BPSD (Behavioral Psychological Symptoms of Dementia) after a failed GDR from 7/24/18 through 8/7/18. The comprehensive care plan (CCP) dated 9/12/19 documented periods of [MEDICAL CONDITION] and hallucinations at times related to BPSD. Interventions included to maintain calm, safe environment. Provide reality orientation yet if not live in his [MEDICAL CONDITION], emotional support as needed; make a consistent daily routine; rule out acute illness if delusions exacerbate; psych consults as needed. The CCP further documented alteration in mood/behaviors as evidence by sarcastic negative statements towards staff with anger episodes. The plan included activity programs; medications per MD order; determine frustrations through 1:1 visits and enjoys meals in café. Review of the physician progress notes [REDACTED]. Review of the physician progress notes [REDACTED]. [MEDICATION NAME] has helped him quite a bit. Review of the certified nurse aide (CNA) Daily Charting Behavior Tracking dated 12/1/18 through 1/22/19 revealed there was no documented behaviors. Review of Treatment Record Behavior, Intervention, and Outcomes document revealed there was no documented behaviors from 12/22/18 through 1/22/19. Review of the Nursing Progress Notes dated 12/20/18 and 12/21/18 documented Resident #25 was admitted to the hospital and returned to the facility on [DATE] with a [DIAGNOSES REDACTED]. Further review of the Nursing Progress Notes dated 12/21/18 through 1/22/19 revealed there was no documented behaviors. Review of the MDS dated [DATE] Section E- Behavior revealed there was documented hallucinations, delusions, or [MEDICAL CONDITION]. Section N: documented the resident received antipsychotic medications during on a routine basis only. GDR was attempted 7/25/18 and GDR has not been documented by a physician as clinically contraindicated. Review of the Behavior Modifying Agent Review (BMARC) dated 1/16/19 documented resident has been in very good spirits. No expressions or reports of hallucinations. He does however over react to small incidents. For instance, yelling out in the dining room because he did not have his sneakers on. Staff retrieved his sneakers, he was fine then. Further review of the BMARC documented Resident #25 becomes upset if another resident wanders into his room. Staff is able to intervene. Resident is stable at this time and becomes easily fixated on topics. In addition, the recommendation documentation revealed symptoms continue, therefore no changes. Further review of the Physicians Progress Notes dated 1/22/19 documented staff stated resident had been becoming belligerent and nasty. In addition, the Physicians Progress Notes documented status [REDACTED]. The physician progress notes [REDACTED]. Review of the Physician order [REDACTED].½ tablet),12.5 mg once daily for BPSD and obtain urinalysis (UA) and culture and sensitivity (C&S, laboratory test to determine the presence of bacteria and the appropriate antibiotic treatment if an infection identified). Continued review of the Nursing Progress Notes dated 1/1/19 through 1/22/19 revealed there was no supporting documentation of non-pharmacological interventions or behaviors prior to the increase in Quetiapine ([MEDICATION NAME]). Review of the Medication Administration Record [REDACTED]. Review of the Urine Culture and Sensitivity Bacteriology Results dated 1/24/19 revealed colony count greater than 100,000 CFU/ml (colony-forming unit/millilter) Escherichia coli (ESBL). Review of the Physicians Orders dated 1/28/19 documented a Physicians Order [MEDICATION NAME](antibiotic) 250 mg twice daily x 7 days for UTI. Review of the MAR indicated [REDACTED]. Review of the 24-hour Nurse Report Sheets dated 1/2/19 through 1/31/19 revealed there was no documented evidence of behaviors. Review of the Behavior Modifying Agent Review (BMARC) dated 1/16/19 documented resident has been in very good spirits. No expressions or reports of hallucinations. He does however over react to small incidents. For instance, yelling out in the dining room because he did not have his sneakers on. Staff retrieved his sneakers, he was fine then. Further review of the BMARC documented Resident #25 becomes upset if another resident wanders into his room. Staff is able to intervene. Resident is stable at this time and becomes easily fixated on topics. In addition, the recommendation documentation revealed symptoms continue, therefore no changes. Review of the Consultant Pharmacist Interdisciplinary Notes dated the following: - 12/12/18 documented no behaviors, on [MEDICATION NAME], failed a GDR in the past. - 1/22/19 documented decline noted, increase in [MEDICATION NAME] (Quetiapine) noted. - 2/6/19 documented ESBL UTI noted, cultures reviewed. Review of the BMARC form dated 3/26/19 documented Resident #25 in good spirits, assertive with conflict with peers at times and recommended to decrease AM [MEDICATION NAME] dose to 12.5 mg. On 5/1/19 the Physician declined the decrease and documented stable on medication, GDR in past without success. Review of the Physicians Orders dated 1/22/19 through 10/30/19 revealed Quetiapine 25 mg once daily and Quetiapine 12.5 mg once daily for BPSD. During observation and interview on 10/30/19 at 8:40 AM Resident #25 was at the breakfast table, drinking coffee, and responded appropriately with his answers. His behavior was pleasant and friendly. During an observation on 10/30/19 at 2:46 PM was actively engaged with music entertainment. Resident #25 showed no signs of behaviors. During an observation and interview on 10/31/19 at 8:38 AM Resident #25 was eating breakfast in bed and stated he was not feeling well. Resident #25 was calm, and pleasant. During an interview on 10/30/19 at 2:33 PM, LPN (Licensed Practical Nurse) #3 stated Resident #25 had no behaviors, Maybe just confused at times, but easily redirected. The nurses place their behavior charting in the progress note section in the electronic medical record and document on the TAR (treatment administration record). CNAs record the behaviors under the daily charting part of the electronic medical record. During an interview on 10/30/19 at 2:38 PM, CNA #3 stated Resident #25 could get agitated and snarky when he's asked questions. The resident tends to get us aides mixed up and can cause him to be more confused, I think it bothers him. Typically, she would re-approach him and he would be fine. During an interview on 10/30/19 at 2:43 PM, RN (Registered Nurse) #2 stated the resident's behaviors are due increased confusion and was aggressive with hands on care in the past. RN #2 stared it was his responsibility to audit the electronic medical record and assure behaviors are reflected in the documentation. It must have been overlooked. During interview on 10/31/19 at 9:40 AM, the Director of Social Work (DSW) stated the resident had no current behaviors but may become fixated and dwell on a certain topic. She would provide diversion and listening would calm him down. In the past the resident would have periods of delusions and anger, feeling that somebody did him wrong. The DSW does not review the CNA behavior documentation, instead she will talk with the CNA's who provide care and review her assessments during the BMARC review. The DSW does not review the nursing documentation and expected it would reflect behaviors. During a telephone interview on 10/31/19 at 9:50 AM, the Consultant Pharmacist stated the resident had a failed GDR in (MONTH) of (YEAR) and was aware of the Quetiapine increase in 1/2019. The Consultant Pharmacist stated she was more concerned the UTI was treated appropriately, was not concerned with the Quetiapine at the time, overlooked the increase in the Quetiapine until (MONTH) when she had requested a GDR in the medication. The Consultant Pharmacist then stated the Physician declined the decrease in the Quetiapine. During an interview on 10/31/19 at 10:16 AM, RN #1 Unit Manager stated the resident can be combative during hands on care, make false statements that aren't necessarily true, and may yell at other residents in the dining room when they sit at his spot at the table. They will typically direct the staff to re-approach the resident. She would expect documentation in the medical record to reflect behaviors. During a telephone interview on 10/31/19 at 11:05 AM, the Medical Director stated the nursing staff had communicated with him the resident had been delusional in the past, seeing people in his room and objects outside of his window that weren't there. Those symptoms could be present with a urinary tract infection as well and he would expect the documentation in the electronic medical record to reflect what the staff related to him. In addition, the Medical Director stated he was aware of the Federal Regulations. We should try to do GDR's to see what's fit, based on what the resident's needs are. It's always in the patient's best interest to do a GDR and would consider it. During an interview on 10/31/19 at 12:14 PM, the Director of Nurses (DON) stated CNA's are expected to document behaviors in the daily charting section of the electronic medical record. Nurses are expected to document behaviors in the TAR section and the Nursing Progress Notes. If the behavior is known to the resident, the expectation would be to document behaviors in the resident care plan with specific non-pharmacological interventions pertaining to the resident. Resident #25 behaviors are episodic and would expect documentation to support an increase in medication. In addition, the DON stated GDR's should be attempted at least annually after a resident has been on the medication for a while and would expect supporting evidence of why something was or was not done and what the outcome was. 415.12(1)(2)(ii)

Based on interview and record review during a Standard Survey completed on 11/6/18, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility did not conduct or complete a Legionella risk assessment, to identify where Legionella and other opportunistic pathogens could grow and spread in the facility's potable water system and the facility did not have a water management plan in place for the facility to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in the building's potable water system. This affected the entire building including two (North and West Units) of two resident units. The finding is: During an interview with the Chief Operating Officer on 11/6/18 at 10:54 AM, the Chief Operating Officer stated the facility had no documentation a Legionella risk assessment had been conducted for the building's potable water system and the facility had no documentation a Legionella water management program was in place for the building's potable water supply. A Legionella risk assessment had not been conducted for the building's potable water system and a Legionella water management program was not in place for the building's potable water supply. The Administrator, Environmental Services Director and the Facility Manager were present during this interview. Review of a cooling tower and treatment inspection form dated 7/5/18, a water supply of cooling tower report dated 7/5/18, and a water analysis report dated 7/6/18 for the building's cooling tower revealed these reports contained no documentation that a Legionella risk assessment had been conducted for the building's potable water system or a Legionella water management program was in place for the building's potable water supply. Further review of the reports revealed the water supply for the cooling tower was in a closed system and it was not connected to the building's potable water supply. Review of the Centers for Medicare & Medicaid Services Survey and Certification Letter S & C 17-30 subject: Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD) dated 6/2/17 revised 6/9/17 with an effective date of Immediately on 1/16/18 revealed: Healthcare Facilities must conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system. Healthcare Facilities must have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in the building water systems. 415.19(a)(1)

Based on interview and record review conducted during the Standard Survey completed on 11/6/18, the facility did not ensure that the Pharmacist reported any irregularities to the attending physician and the facility's Medical Director and Director of Nursing (DON). Specifically, one (Resident #1) of five residents reviewed for drug regimen reviews had issues involving the lack of Consultant Pharmacist's identification of the continued use Rexulti (anti-psychotic medication) without a gradual dose reduction (GDR) attempt in efforts to reduce or discontinue the medication. The finding is: The policy and procedure (P&P) entitled Medication Regimen Review dated 12/9/16 documented each resident's medication regimen is reviewed at least monthly by a licensed pharmacist. The interdisciplinary note will be noted as a Pharmacist Review Note and the appropriate notation that the drug regimen review was performed noting irregularities or that no irregularities were observed. The P&P dated 1/29/14 entitled Behavior Modification Agent Review Committee (BMARC) revealed the committee will consist of the Director of Nursing and/or Nurse Manager, Director of Activities, Director of Social Services, Social Worker, and Consultant Pharmacist. Recommendations made will utilize Federal and State Regulations/Guidelines for behavior modifying medication use and reduction as well as review of each resident's individual care plan and current status. 1. Resident #1 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-a resident assessment tool) dated 10/8/18 documented the resident was severely cognitively impaired, was understood and understands. Section E documented there were no indicators of [MEDICAL CONDITION] and no behavioral symptoms. Section N documented the resident received an antipsychotic medication on a routine basis and that no GDR had been attempted. The comprehensive Care Plan dated 10/18/18 documented the use of [MEDICAL CONDITION] medications secondary to major [MEDICAL CONDITION]. Interventions included to administer medications per the MD order. Monitor the effectiveness and side effects of medication, community psychiatrist, provide support and allow resident to vent feelings and BMARC as indicated. Review of the physician's orders [REDACTED]. Review of the Medication Administration Records (MAR) dated (MONTH) (YEAR) through (MONTH) (YEAR) revealed the resident was administered Rexulti 1.5 mg daily as ordered. Review of the pharmacist Interdisciplinary Notes dated 7/26/17 through 10/29/18 revealed there were no irregularities documented and there were no recommendations made by the pharmacist to address the continued use of Rexulti without an attempt of a GDR in efforts to reduce or discontinue the medication. During an interview on 11/6/18 at 9:54 AM, the Director of Nurses (DON) stated the Pharmacist will make recommendations for a gradual dose reduction during her monthly reviews or during BMARC. During a telephone interview on 11/6/18 at 9:36 AM, the Pharmacy Consultant stated residents on antipsychotics are reviewed every three months. Prior to the resident's last psychiatric appointment, she had requested the Social Worker to complete a current depression scale. The results scored normal, meaning no depression. The Rexulti should have been decreased based on no depressive symptoms but returned from the psychiatric appointment with no recommended changes in the treatment plan. 415.18 (c)(2)

Based on observation, interview and record review conducted during the Standard survey completed 11/6/18, the facility did not ensure that residents who use [MEDICAL CONDITION] drugs receive gradual dose reductions (GDR) and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. One (Resident #1) of four residents reviewed for antipsychotic medication use received Rexulti (anti-psychotic medication) since 8/10/17 with no GDR attempt. In addition, there was no documentation to support the continued use of the medication and/or that non-pharmacological interventions were being utilized. The finding is: A policy and procedure (P&P) entitled [MEDICAL CONDITION] Medications, Definitions and Guidelines for Use dated 1/18/17 documented that a [MEDICAL CONDITION] medication is any drug that affects brain activities associated with mental processes and behavior. These medications include but are not limited to anti-psychotics; anti-depressants; anti-anxiety; and hypnotics. [MEDICAL CONDITION] medications are ordered by the physician as indicated by the following: specific behaviors as quantitatively (number of episodes) and objectively documented by the facility which cause the resident to present a danger to self, present a danger to others or, or interfere with staff's ability to provide care. The facility supports the involvement of the resident and family members in the development of guidelines relative to the use of [MEDICAL CONDITION] medications and makes recommendations to the physician if indicated. A P&P entitled [MEDICAL CONDITION] Medication Routine Documentation dated 1/18/17 revealed physician documentation, requested every 60 days is monitored by the RN (Registered Nurse) Nurse Manager and or designee. Monthly BMARC (Behavior Modifying Agent Review Committee) meetings are held to review and make recommendations regarding [MEDICAL CONDITION] medications. [MEDICAL CONDITION] medications per MD order will be initiated if non-pharmacological interventions have been determined to not be effective, except in emergency situations. The BMARC committee will review for appropriateness and non-pharmacologic interventions utilized. Other possible underlying causes will be assessed by the Interdisciplinary Team. 1. Resident # 1 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a resident assessment tool) dated 10/8/18 revealed the resident is severely cognitively impaired, understands, and is understood. Section E of the MDS documented there were no indicators of [MEDICAL CONDITION] and no behavioral symptoms. Section N revealed the resident received an antipsychotic medication on a routine basis and no GDR has been attempted. The Physician documented GDR as clinically contraindicated on 9/25/18. The Comprehensive Care Plan (CCP) dated 10/18/18 documented the use of [MEDICAL CONDITION] medications secondary to major [MEDICAL CONDITION] and anxiety with the following approaches: - Administer/monitor effectiveness/side effect of medication per MD order - Community psychologist and psychiatrist - Provide support and allow resident to vent feelings - BMARC as indicated. Review of the Resident Daily Care List dated 3/13/17 revealed the section entitled Behavior/Approach documented Flat affect. Provide cues, reminders and reorientation as needed. physician's orders [REDACTED].½ by mouth once daily for depression. Review of the Medication Administration Records (MARs dated (MONTH) (YEAR) through (MONTH) (YEAR) revealed the resident received Rexulti 1.5 mg daily. Nursing Treatment Records for Behavior Monitoring dated 11/2017 through 11/2018 revealed there was no documentation of behaviors to support the use of an antipsychotic medication. A Psychiatric Evaluation dated 3/27/18 documented a plan to continue Rexulti. At this time, we will not make any medication adjustments as the patient continues to endorse remission of depressive symptoms with no current issues or concerns and re-evaluate in six months. There was no documentation of a [DIAGNOSES REDACTED]. A Social Work Interdisciplinary Note dated 9/24/18 documented that a geriatric depression scale for the assessment of mood was completed (9/21/18) as a resource for an upcoming psychiatry appointment. The resident scored a 4/10 indicating no significant depression. A Psychiatric Evaluation dated 9/25/18 documented the following: - Continue Rexulti - The patient reports continued stability - Will continue current medication regimen to manage as a stable chronic illness requiring continued monitoring and prescription drug management Additional review of the 9/25/18 Psychiatric Evaluation revealed there was no documentation of a clinical contraindication for a GDR of Rexulti. Review of Behavior Modifying Agent Review (BMARC) Notes dated 11/21/17 through 10/9/18 revealed the resident's major [MEDICAL CONDITION] continued to be managed by the resident's community psychiatrist, with recommendations to continue to follow recommendations. The BMARC Notes documented that a GDR was clinically contraindicated because the resident has symptoms of self-isolating self in room at times. Review of Nursing Interdisciplinary Notes dated 10/2/18 through 11/4/18 revealed there was no documented evidence of behaviors to support the use of an antipsychotic medication. Physician's Progress Notes dated 12/12/17 through 10/30/18 revealed the resident had a long history of depression and sees a psychiatrist on the outside. There were no behaviors documented. Twenty-four Hour Nurse Report Sheets dated 8/1/18 through 11/4/18 revealed no behaviors. During an interview on 11/6/18 at 8:46 AM, the Registered Nurse (RN #1) Unit Manager stated the resident was followed for years by her community psychiatrist and typically follow's the recommendations. The RN Unit Manager stated she could not recall any behaviors. During interview on 11/6/18 at 8:50 AM, the Social Worker stated the resident had a flat affect, occasionally will request to stay in her room, and typically does not exhibit behaviors. In addition, the depression scale on 9/21/18 was normal and the Social Worker expected recommendations to decrease the Rexulti. During an interview on 11/6/18 at 9:10 AM, a Certified Nurse Aide (CNA #1) stated Resident #1 was sweet and always smiles. When interviewed on 11/6/18 at 9:52 AM, the Unit Attendant stated the resident always smiles and she did not recall any behaviors. During a telephone interview on 11/6/18 at 9:36 AM, the Consultant Pharmacist stated residents on antipsychotics are reviewed every three months (BMARC). Prior to the last psychiatric evaluation appointment, she requested that the Social Worker complete a current depression scale. The results scored normal, meaning no depression. The Consultant Pharmacist further stated the Rexulti should have been decreased based on no depressive symptoms, but she returned from her psychiatric appointment with no recommended changes in the treatment plan. In addition, the Consultant Pharmacist stated because the resident is seen by the community psychiatrist, the IDT felt they were unable to suggest changes and stated, He's the expert. During interview on 11/6/18 at 9:54 AM, the Director of Nursing (DON) stated that Resident #1 is followed by her community Psychiatrist and recommendations are followed because he knows her best. During a telephone interview on 11/6/18 at 10:20 AM, the Community Psychiatrist's RN stated the physician was unavailable and she could not provide any information. During interview on 11/6/18 at 11:06 AM, the Medical Director stated he was no psychiatrist or mental health specialist. He refers his residents to specialists with a background in [MEDICAL CONDITION] medications and always follows the professional's recommendations. 415.12(1)(2)(ii)

Based on observation and interview during the Standard survey completed on 11/6/18, the facility did not maintain all essential mechanical, electrical and patient care equipment in safe operating condition. Issues included, shower plumbing devices and hoses that did not have vacuum breakers to prevent backflow, and there was an open plumbing pipe. This affected two (North and West Units) of two resident units. The findings are: 1) a. Observation on the West Unit on 11/1/18 at 10:46 AM, revealed the shower and shower wand in the West Spa (shower room) located near Resident room [ROOM NUMBER] did not have a vacuum breaker. The shower had a shower wand, attached to it by a hose, that allowed the wand to lie flush with the shower floor. The length of the hose allowed the shower wand to be submerged if the shower did not drain properly. During the observation the Environmental Services Director and the Facility Manager stated, they were not aware the shower's plumbing did not have a vacuum breaker. b. Observation on the North Unit on 11/1/18 at 10:51 AM, revealed the shower and shower wand in the North Spa (shower room) located near Resident room [ROOM NUMBER] did not have a vacuum breaker. The shower had a shower wand attached to it by a hose that allowed the wand to lie flush with the shower floor. The length of the hose allowed the shower wand to be submerged if the shower did not drain properly. During the observation the Environmental Services Director and the Facility Manager stated, they were not aware the shower's plumbing did not have a vacuum breaker. 2) Observation on the West Unit on 11/1/18 at 11:06 AM, revealed a one-inch plumbing pipe, located in the storage room inside the conference room, was open and uncapped. Further observation revealed paper was sticking out of the pipe. During the observation, the Environmental Services Director stated the room was previously used as a bathroom and she was not aware the pipe was open and uncapped. 415.29(d)(f)(4)

Based on interview and record review during the Standard survey completed on 11/6/18, the facility did not implement written policies and procedures for screening employees, that would prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. The facility did not provide documentation that verified one (Agency Licensed Practical Nurse) of six employees that worked in the facility, during the last four months, and were subject to the New York State Nurse Aide Registry, had not been screened through the New York State Nurse Aide Registry prior to their employment. The finding is: A review of the facility's policy for Licensing, Certification and Credentialing with a revision date of 7/16/10 revealed: Certification records will be completed and maintained as per Human Resource Department procedures. Certified Nursing Assistant certificates will be verified through the New York State Aid Registry. Observations on 11/2/18 between 11:45 AM and 12:15 PM revealed the West Unit was a 24-bed unit and 22 residents were residing on the unit. On 11/5/18, reviews of facility staff and agency staff employee files, for compliance with the New York State Nurse Aide Registry regulations, revealed the following: Agency Employee #1A, (Agency Licensed Practical Nurse), started working at the facility on 10/6/18. The employee's Nurse Aide Registry Verification Report supplied to the facility from the agency the employee worked for was dated 11/5/18. The employee worked at the facility for 13 days, between 10/6/18 and 11/5/18 without a Nurse Aide registry check. During an interview on 11/5/18 at 2:00 PM, the Director of Nursing (DON) stated Agency Employee #1A was at general orientation on 10/6/18 and started providing care to residents on 10/19/18. The DON further stated Agency Employee #1A worked on the North Unit. During an interview on 11/5/18 at 3:09 PM, the Human Resources Director stated the facility conducted a Nurse Aide Registry Verification Report on all of its employees prior to their employment at the facility. A Nurse Aide Registry Verification Report was not conducted for Agency Employee #1A because the employee was not an employee of the facility. The facility was relying on the agency to conduct a Nurse Aide Registry Verification Report. The Human Resources Director had contacted the agency Employee #1A worked for and a representative of the agency told her the agency was not obligated to conduct a Nurse Aide Registry Verification Report on its employees. The facility was currently using one agency to supply the building with Licensed Practical Nurses, the facility had just started using agency nurses as of 10/6/18, and only one agency LPN was currently working in the building. 415.4(b)(1)(ii)(a)(b)

Based on observation, interview and record review conducted during an Abbreviated survey (complaint #NY 613) completed on 2/5/18, the facility did not ensure the resident's right to be free from neglect. One (Resident #1) of three residents reviewed for neglect sustained an injury when the care plan was not followed. Specifically, the Resident Care Guide dated 12/28/17, instructed that the resident requires the extensive assistance of one person to transfer. A certified nurse aide (CNA #1) neglected to implement the Resident Care Guide. The CNA left the resident unattended during transfer from the bathroom to the chair. This negligence resulted in the resident falling during the transfer, sustaining bruises and an abrasion around the right eye. The finding is: Review of a facility policy and procedure (P&P) entitled Abuse Prevention Program dated 11/28/2016 revealed its purpose is to ensure residents have the right to be free from abuse, neglect, mistreatment, misappropriation of property, corporal punishment and involuntary seclusion. The P&P documented that no one may subject residents to abuse including but not limited to facility staff, other residents, consultants, volunteers, staff or other agencies servicing the resident, family members or legal guardians, friends or other individuals. It also states that the facility maintains systems to prevent instances of abuse, neglect or mistreatment of [REDACTED]. The section entitled Signs of Actual Physical Neglect included Leaving someone unattended who needs supervision. 1. Resident #1 is [AGE] years old and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS- a resident assessment tool) dated 1/8/18 revealed that the resident has moderate cognitive impairment and requires the extensive assistance of one person for transfers. Review of a Physical Therapy Screen/ assessment dated [DATE] revealed recommendations to transfer the resident with the extensive assist of one. Review of the Resident Care Guide (used by staff to provide care) dated 12/28/17 revealed Transfers Level of Assist: 1 Ex (extensive). Review of an Accident/Incident (A/I) Report, completed by a Registered Nurse (RN), dated 1/13/18 revealed the resident was found on the floor in her room at approximately 5:15 PM. CNA #1 left the resident standing alone in her room without providing the extensive assist of one per the care plan. An assessment by the RN revealed the resident sustained [REDACTED]. The A/I documented that CNA #1 was counselled. Review of CNA #1's verbal statement dated 1/13/18 and written statement dated 1/15/18 revealed after ambulating the resident from the bathroom to the recliner, the CNA realized she did not have a chair pad. As the resident held on to the arm of the chair unattended, the CNA left the room to obtain the pad. While the CNA was in the linen room, the resident lost his balance and fell on the floor. Review of the 2:00 PM to 10 PM staffing sheet dated 1/13/18 revealed the facility staffing included: one RN supervisor, two Licensed Practical Nurses, and six CNAs. Review of the Employee File/ Records for CNA #1 revealed in-services and attendance sheets dated 8/16/17 included but were not limited to the following topics: Specialized Dementia Program, Resident Rights and Responsibilities, Abuse/ Neglect/ Mistreatment, Accident Prevention, Wheelchair / Ready Lift (mechanical) transfer procedure, Elopement procedure, and Body Mechanics. Review of a CNA Orientation sheet dated 8/18/17 revealed that CNA #1 demonstrated the following tasks: Follows Care Plan Guidelines provided in the resident room and Demonstrates all levels of resident transfers were signed off by the RN instructor. Review of all required employment paperwork for CNA #1, including criminal background check and certifications revealed the CNA had no prior history of any disciplinary actions or abuse. During an interview on 1/19/18 at approximately 12:00 PM, the Administrator stated that upon interview with the CNA, she did not seem to appreciate the gravity of her action and/or use of poor judgement. The CNA felt if the resident could hold on to a grab bar in the bathroom then holding on to the recliner was the same. The Administrator stated that the CNA was informed that the resident is an extensive assist of one which means you must remain with him at all times even if there is a bar or chair to hold. The Administrator stated that the CNA was terminated on 1/15/18. Observation on 1/19/18 at approximately 12:30 PM revealed the resident was seated in the dining room, eating lunch with his wife. The observation revealed the resident had bruises remaining around both eyes. 415.4(b)(1)(i)

Based on observation, interview, and record review conducted during the Standard survey completed on 9/8/17, the facility did not ensure that the resident environment remains free from accidents hazards as is possible. Specifically, two (West and North Units) of two resident care units had issues with hot water temperatures exceeding 120 degrees Fahrenheit (F) in resident use areas. The finding is: 1. During an observation of the resident's environment on 9/5/17 at 1:00 PM revealed Resident Room #109's water temperature was observed at 122 degrees Fahrenheit using a Taylor 9842 digital thermometer. On 9/5/17 at 1:10 PM the New York State Department of Health (NYS DOH) Team Member's thermometers (Taylor 9842 digital stem-type and Atkins Aqua Tuff 351) were calibrated using an ice water method. Observations on 9/5/17 between 1:00 PM and 2:00 PM revealed the following unsafe water temperatures on the West Unit: Resident Room #104 - 125.1 degrees F Resident Room #109 - 122 degrees F Resident Room #110 - 124.4 degrees F Resident Room #111 - 124.5 degrees F Resident Room #116 - 122.1 degrees F Observations on 9/5/17 between 1:00 PM and 2:00 PM revealed the following unsafe water temperatures on the North Unit: Resident Room #125 - 122.4 degrees F Resident Room #130 - 124.7 degrees F Resident Room #131 - 124.3 degrees F Resident Room #133 - 123.2 degrees F Resident Room #135 - 121.9 degrees F Resident Room #137 - 122.2 degrees F Resident Room #144 - 122.0 degrees F Observation on 9/5/17 at 2:25 PM in Resident Room #101 obtained by NYS DOH Sanitarian (SAN) and Facilities Director revealed a temperature of 124.7 degrees F. Observation inside the Third Floor Boiler Room on 9/5/17 at approximately 2:16 PM revealed there were two boilers and one hot water tank. Further observation revealed the digital thermometer on the hot water tank fluctuated between 118.9 and 125.0 degrees Fahrenheit and the thermometer on the outgoing hot water line read 124 degrees Fahrenheit. Interview with the Facilities Director on 9/5/17 at the time of the observation revealed the two boilers and the hot water tank in the Third Floor Boiler Room supply hot water to the Skilled Nursing Facility located on the First Floor of Oxford Village. The Facilities Director also stated there have been no changes to this system in the last year. Review of the document entitled Water Temperature Log Oxford Village revealed hot water temperatures are taken from approximately five locations daily. Review of the last three months of the water temperature logs revealed the following documented water temperatures above 120 degrees Fahrenheit on the First Floor of Oxford Village (SNF): 6/29/17 - Oxford 1 Restroom 1(located on the resident care unit) - 125.4 degrees Fahrenheit 7/01/17 - Oxford North Common (located on the resident care unit) - 120.9 degrees Fahrenheit 7/04/17 - Oxford West Common (located on the resident care unit) - 121.7 degrees Fahrenheit 7/04/17 - Oxford North Common - 122.5 degrees Fahrenheit 7/12/17 - Oxford West Common - 121.0 degrees Fahrenheit 7/28/17 - Oxford West Common - 121.0 degrees Fahrenheit Interview with the Facilities Director on 9/5/17 at approximately 3:05 PM revealed a Maintenance Assistant takes the temperatures daily and records them in the log, and he was unaware of any hot water temperatures exceeding 120 degrees Fahrenheit. The Facilities Director further stated, he expects the Maintenance Assistant to notify him if any hot water temperatures exceed 120 degrees Fahrenheit. Telephone interview with the Maintenance Assistant who was assigned to take water temperatures on 9/6/17 at approximately 7:35 AM revealed he takes water temperatures on the overnight shift and he did not receive any instruction for this task other than to take the temperatures and record them in the log. The Maintenance Assistant stated he was not aware of a written policy or procedure regarding hot water temperatures and he never told anyone about the temperatures he obtained, he just wrote them in the log book as instructed. Continued interview with the Maintenance Assistant revealed he had never calibrated either of the two thermometers used for this task. Interview with the Facilities Director on 9/6/17 at approximately 11:45 AM revealed he did not personally receive any training on hot water temperatures and he did not provide any training to the Maintenance Assistant who was assigned to take hot water temperatures. Additionally, the Facilities Director stated he did not routinely review the water temperature log. Review of the facility's policy entitled Hot Water Temperatures with a revision date of 1/26/10 revealed temperatures of hot water will not exceed 120 degrees Fahrenheit. The policy further stated temperature readings that exceed 120 degrees Fahrenheit will require an investigation and solution by maintenance personnel and the area affected will be closed for use until the problem is resolved. 415.12(h)

Based on observation, interview, and record review during the Standard survey completed on 9/8/17, the facility did not properly store, prepare, distribute and serve food under sanitary conditions. One of one Main Kitchen, and one of one Unit Servery had issues including undated and outdated foods, potentially hazardous foods in cold holding above 41 degrees Fahrenheit, and floors and walls that were not maintained in a clean condition. The findings are: 1. a) Observation in the Main Kitchen on 9/5/17 from approximately 9:00 AM to 9:35 AM revealed the following refrigerated food items were outdated or undated: - An unopened, ten-pound cardboard carton of commercially prepared macaroni salad with a manufacturer's use by date 8/21/17 - An opened, half-full, ten-pound cardboard carton of commercially prepared macaroni salad with a manufacturer's use by date 9/3/17 - Three bags of sliced corned beef, each approximately two pounds, dated 8/24/17, 8/26/17, and 8/30/17 - An approximate three-pound ham in clear plastic wrap with no date - An approximate three-pound salami in clear plastic wrap with no date - Approximately four gallons of green pepper soup in a bucket with no date - Approximately five pounds of cut watermelon on a tray with no date - Approximately two pounds of cooked angel hair pasta in a plastic bin dated 8/29/17 - Approximately four pounds of cooked angel hair pasta in a plastic bin dated 8/31/17 - A plastic bin labeled angel hair 8/30 contained approximately eight pounds of cut fruit - Approximately three quarters of a pound of sauerkraut dated 8/26/17 - Approximately three pounds of cherry filling dated 8/31/17 - Approximately three pounds of cherry filling with no date - Approximately three pounds of blueberry filling with no date - Approximately three quarters of a pound of cooked onions and peppers with no date - Six unopened 32 ounce containers of vanilla yogurt with a manufacturer's best by date 9/1/17 1. b) Observation in the Skilled Nursing Unit Servery on 9/5/17 at approximately 10:10 AM revealed one opened half-full 32-ounce container of plain yogurt with a manufacturer's best by date 9/2/17 was stored in the refrigerator. Interview with the Food and Beverage Director at the time of the observations revealed it is the facility's policy to discard commercially prepared macaroni salad two days after opening, to discard lunch meats three days after opening/ slicing, and to discard sauerkraut five days after preparation. Continued interview with the Food and Beverage Director revealed he does not keep any food item beyond the manufacturer's best by or use by date. Additional interview revealed a Chef is responsible for checking dates on all foods daily and a Supervisor performs a weekly audit. Interview with the Executive Chef on 9/6/17 at approximately 10:15 AM revealed he and the other Chefs check dates on all food items on a daily basis and every three to four days, a purge/ cleanse is done in each cooler. He further stated he expected dates to be on all food items and the undated and outdated food items must have been overlooked during the daily checks. Review of the most recent Supervisor weekly audit dated 9/3/17 revealed food items dated and labeled and food items discarded after 72 hours both had a check in the yes column. Interview with the Food and Beverage Director on 9/6/17 at approximately 10:15 AM revealed he personally filled out the Supervisor weekly audit on 9/3/17 and he checked yes, that food items were dated and labeled and discarded after 72 hours, because all foods were good in the line coolers and he did not check the walk-in coolers because the Chefs check them daily. Review of the facility policy titled Refrigerated Storage, revised 3/09, revealed all cooked foods must be labeled and dated. Additionally, the policy stated thawed meats and leftover cooked meats have a recommended maximum storage period of three days. Review of the facility policy titled Usage and Storage of Leftovers, revised 3/09, revealed leftover foods must be used within three days of the original cooking date. 2. Observation in the Main Kitchen's Production Walk-in Cooler from approximately 9:20 AM until 9:40 AM revealed the following potentially hazardous foods were above 41 degrees Fahrenheit: - Approximately three pounds of cooked sliced ham 43.8 degrees Fahrenheit - Approximately three pounds of cooked meatloaf 44.0 degrees Fahrenheit - Individual carton of milk 46.7 degrees Fahrenheit (approximately 50 cartons in this cooler at this time) - Approximately three pounds of noodle salad 42.6 degrees Fahrenheit - Approximately three quarters of a pound of sauerkraut 42.2 degrees Fahrenheit - Approximately three quarters of a pound of cooked onions and peppers 43.3 degrees Fahrenheit - 32-ounce unopened container of vanilla yogurt 43.8 degrees Fahrenheit (six 32-ounce containers in this cooler at this time) - Approximately six pounds of cooked turkey breast 42.8 degrees Fahrenheit - Individual cup of blueberry yogurt 46.5 degrees Fahrenheit (96 5.3-ounce containers in this cooler at this time) Observation in the Main Kitchen on 9/5/17 at approximately 9:20 AM revealed the air temperature of the Production Walk-in Cooler was 50.5 degrees Fahrenheit according to the digital thermometer on the outside of the unit, 32 degrees Fahrenheit according to the portable dial thermometer on the inside of the unit, and 49 degrees Fahrenheit according to this Surveyor's digital food type thermometer. Interview with a Chef at the time of the observation revealed the Production Walk-in Cooler was re-stocked this morning at approximately 7:30 AM which might have allowed the air temperature in this cooler to rise, and all of the foods identified with temperatures above 41 degrees at this time have been stored in this cooler for greater than 24 hours. Interview with the Food and Beverage Director on 9/6/17 at approximately 3:45 PM revealed the Cook checks air temperature of all coolers at approximately 7:00 AM daily and one of the Chefs later double checks it. Review of the Refrigerator Temperature Log revealed an X in the column for Pantry #1 Large Cooler, which the Food and Beverage Director identified as the Production Walk-in Cooler, for 9/1/17 through 9/6/17. Interview with a Cook on 9/8/17 at approximately 11:18 AM revealed when she takes the temperatures, she records an X on the Refrigerator Temperature Log, not the actual temperature. Further interview revealed an X means the air temperature was below 40 degrees Fahrenheit and if the air temperature was above 40 degrees Fahrenheit, she would keep rechecking it for one hour, and if it did not go below 40 degrees Fahrenheit after one hour, she would tell her supervisor. Additionally, the Cook stated she uses the portable dial thermometer on the inside of this cooler when checking air temperature. 3. Observation in the Main Kitchen on 9/5/17 at approximately 9:55 AM revealed the floors and walls around the automatic dishwasher were soiled with a moist gel-like black substance. At this time, eight live cockroaches, three dead cockroaches, and one dead fly were observed on the floor in the dish wash area. Interview with the Food and Beverage Director at the time of the observation revealed floor cleaning is a daily task assigned to the Dishwashing Attendants, but it does not appear as if it has been getting done daily. Interview with a Dishwashing Attendant at the time of the observation revealed he cleaned the area under the dishwasher approximately two weeks ago and no one else does this task. Interview with the Food and Beverage Director on 9/5/17 at approximately 10:15 AM revealed a Supervisor performs a weekly audit of the kitchen. Review of the most recent weekly audit dated 9/3/17 revealed the question, Dishwasher area is clean was answered with a check in both the yes and no columns. Interview with the Food and Beverage Director on 9/6/17 at approximately 10:15 AM revealed he personally performed the most recent weekly audit and he checked both yes and no because it was not clean, but they were working on cleaning it at the time. Observation in the Main Kitchen on 9/6/17 at approximately 10:00 AM revealed the black substance remained in the corner under and behind the automatic dishwasher and nine dead cockroaches were observed in the area. At this time, this Surveyor wiped the floor and wall surfaces with a paper towel and the black substance easily came off onto the paper towel. Interview with the Food and Beverage Director at the time of the observation revealed the daily cleaning should have covered this area. Interview with a Dishwashing Attendant at this same time revealed he cleaned the dish wash area last night, but he did not get all the way into the corner or the wall behind the dish washer. 483.35(i)(2), 415.14(h) 14-1.170 14-1.171(a)

Based on interview and record review conducted during a Complaint investigation (Complaint #NY 472) during the Standard survey completed on 9/8/17 the facility did not inform the resident's legal representative or interested family member or immediately consult with the resident's Physician when there is a significant change in the resident's physical, mental or psychological status and a need to alter treatment significantly. One (Resident #71) of four residents reviewed for family and Physician notification had issues. Specifically, nursing staff did not immediately notify the Physician of the findings and impression of the resident's left shoulder x-ray report obtained on 1/7/17. The findings are: 1. Resident #71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set - a resident assessment tool) dated 1/9/17 revealed the resident was cognitively intact, understands and is understood. Review of the electronic Interdisciplinary Notes revealed the following: On 1/7/17 at 16:39 (4:39 PM) the Registered Nurse (RN #4) Shift Supervisor documented, 310 PM: Called to resident's room. Resident laying on his back at the foot of his bed, head toward the BR (bathroom) door. Walker nearby. Stated He landed on his left shoulder and couldn't raise his arm. Further review of the note revealed, Call to (physician name). N.O. (new order) X-ray left shoulder, clavicle and scapula (2 view). On 1/7/17 at 19:15 (7:15 PM) the RN # 4 Supervisor documented, 700 PM: All X rays negative. Left shoulder, clavicle and scapula. Son updated. On 1/7/17 at 19:34 (7:34 PM) the RN #4 Supervisor documented, Left should X-ray nondiagnostic study due to shadowing poor positioning and limited field of view. On 1/9/17 at 5:46 AM the Licensed Practical Nurse documented, Awake at the start of the shift anxious, 'my shoulder', 'I can't do anything with it'. On 1/9/17 at 12:21 PM the RN Supervisor (RN #3) documented, Resident complains of pain in the arm, cannot lift it, denies any tingling/numbness. Neurological checks show grip strength is equal in both hands, left arm flaccid, resident unable to hold arm up in the air, states I just can't do it. (Physician name) updated on resident's status and new order to send to (hospital) for eval (evaluation). Review of a shoulder x-ray report, dated 1/7/17, revealed the following finding: Single AP (anterior-posterior) view of the left shoulder is nondiagnostic due to poor positioning and limited field of view. The impression documented is: Relatively nondiagnostic evaluation of the left shoulder. Reassessment is recommended to highlight the shoulder articulation (shoulder joint) including the humeral head (top of upper arm bone) and the glenoid (area of the shoulder). Review of the 24-hour Nurse Report Sheet for 1/7/17 revealed the resident was found on the floor at 3:30 PM, complained of left shoulder pain and decreased range of motion. There is no documentation regarding the physician orders [REDACTED]. Review of a Physician Discharge Summary dated 1/9/17 revealed the physician documented, fell , dislocated left shoulder. Sent to (hospital name) for evaluation and treatment. Review of the facility Corrective Action Form, dated 1/17/17 revealed the RN Nursing Supervisor did not notify the physician of the results of the left shoulder x-ray report completed on 1/7/17 post-fall, as the results indicated as being non-diagnostic. Resident was further evaluated at the hospital on [DATE] at which time the resident was diagnosed with [REDACTED]. Review of statement dated 1/12/17 and signed by the RN Shift Supervisor (RN #4) revealed the MD was not notified because the results were misinterpreted, other 2 x-rays were essentially negative and the decision was based on my assessment skills. Interview with the Administrator on 9/7/17 at 11:19 AM revealed the Administrator was involved with investigation of the incident with the RN Supervisor (RN #3) as the RN Supervisor was acting as the Interim Director of Nursing (DON) at the time of the incident. The Administrator stated that he and the Interim DON reviewed the resident's record and determined that the RN Shift Supervisor (RN #4) did not inform the physician of the inconclusive x-ray result. The Administrator further stated that the RN Shift Supervisor (RN #4) was aware of the need to inform the physician of the results of the x-ray report. Interview with the RN Supervisor (RN #3) on 9/8/17 at 10:26 AM revealed that the off-shift RN Supervisor will address any x-ray results that return after hours and weekend and will place the report in the physician's folder for the doctor's review. The RN Supervisor (RN #3) stated she was told that the x-ray was negative in morning report. The RN Supervisor further stated the CNA (certified nurse aide) spoke to her about the resident's status on 1/9/17 and that she (RN #3) assessed the resident for a possible stroke, called the physician and received orders to send the resident to the hospital. The RN Supervisor (RN #3) stated, I did not see the x-ray report and recommendations until later that morning. Review of the policy entitled, Radiology Services revised 12/12/16 revealed, Any abnormal result will be reported immediately to the physician, nurse practitioner, physicians assist or clinical nurse specialist. 415.3 (e)(2)(ii)(b)

Based on observation, interview, and record review during the Standard survey completed on 9/8/17, the facility did not maintain an effective pest control program so that the facility was free of pests. Issues included live and dead cockroaches observed in the dish wash area of the Main Kitchen. The finding is: 1. Observation in the Main Kitchen on 9/5/17 at approximately 9:55 AM revealed eight live cockroaches and three dead cockroaches were located in the dish wash area. A second observation on 9/6/17 at approximately 10:00 AM revealed nine dead cockroaches were located in the dish wash area. Interview with the Food and Beverage Director on 9/5/17 at approximately 10:20 AM and 9/6/17 at approximately 10:20 AM revealed he had not previously seen cockroaches in the kitchen and was unaware of any issue with cockroaches. Interview with a Dishwashing Attendant on 9/6/17 at approximately 10:00 AM revealed he observed approximately four live cockroaches in this location during his shift last night and he has worked at this facility for one month and first observed cockroaches approximately two weeks ago. Interview with two Dietary Aides on 9/8/17 at approximately 10:20 AM revealed they have both worked at this facility for longer than one year and there has been an intermittent cockroach problem in the Main Kitchen since a new automatic dishwasher was installed and wall repair performed last summer. Interview with a Dishwashing Attendant on 9/8/17 at approximately 11:25 AM revealed he has worked in this facility for approximately two years and he has been seeing cockroaches in the Main Kitchen for just over one year. Interview with the Facilities Director on 9/5/17 at approximately 12:50 PM revealed the facility has a contract with an exterminator for weekly service. Additional interview with the Facilities Director on 9/7/17 at approximately 11:20 AM revealed he was first made aware of the cockroaches in the kitchen on 9/1/17 when a dietary employee brought it to the attention of the Assistant Facilities Director so he could inform the exterminator. Further interview revealed the Facilities Director created a computerized maintenance work order on 9/1/17, printed it, and placed it in the communications binder for the exterminator. He further stated he did not discuss the topic of cockroaches with Food and Beverage Director at that time. Interview with the Chief Operating Officer on 9/7/17 at approximately 11:20 AM revealed she was unaware of any issues with cockroaches until it was brought to her attention on 9/5/17. Review of a computerized maintenance work order dated 7/24/17 revealed the description, (NAME OF FOOD AND BEVERAGE DIRECTOR) reported cockroaches seen in the serving line where they store cups and in the bakery area. Interview with the Food and Beverage Director on 9/8/17 at approximately 8:35 AM revealed there must have been a miscommunication because he told a secretary that he saw one eight-legged bug on 7/24/17 and asked the secretary to create a computerized maintenance work order for him. Review of exterminator reports dated 6/20/17 through 9/5/17 revealed the following written observation by the exterminator, All drains are caked with slime and grease, grease on walls and floor of main kitchen, dish tank needs cleaning - roach and fruit flies are getting out of control due to this. Further review revealed this observation was dated 7/26/16 and was listed as resolved on 7/11/17. Interview with the Food and Beverage Director on 9/8/17 at approximately 1:30 PM revealed he does not review extermination reports and he was unaware of the exterminator's comment regarding kitchen cleanliness. 483.70(h)(4), 415.14(h), 415.29(j)(5) 14-1.160