Every finding on record at Cayuga Nursing and Rehabilitation Center

Based on record review and interviews during the recertification and abbreviated (NY00341003) surveys conducted 1/16/2025-1/24/2025, the facility failed to ensure the residents' environment remained free of accident hazards for one (1) of three (3) residents (Resident #171) reviewed. Specifically, Resident #171 had a physician order for a regular dysphagia (difficulty swallowing) pureed texture diet and was served and fed ground vegetables, began to cough, and was sent to the hospital. Additionally, staff education was not initiated timely after the incident. This resulted in Immediate Jeopardy past non-compliance to Resident #171 and placed all residents on modified consistency diets at risk for serious injury, serious harm, serious impairment, or death. Findings include: The facility policy, Dysphagia, dated 3/2022 documented the Speech Language Pathologist would identify and convey swallowing recommendations to nursing and dietary staff so the recommendations could reflect on the resident's meal ticket. The care plan, orders, and care card were to be updated. The facility policy Activities of Daily Living Services revised/reviewed 1/19/2024, documented assistance with eating and drinking was provided to residents and included monitoring dietary restrictions. Regular training sessions were conducted to update staff on best practices and address identified areas for improvement. The 2019 [NAME] Diet and Nutrition Care Manual documented vegetables on a pureed diet should be soft, well-cooked, and pureed using appropriate recipes, and free from chunks, lumps, and/or seeds. All pureed foods were the consistency of moist mashed potatoes or puddings. Resident #171 had diagnoses including dementia and oropharyngeal dysphagia (difficulty swallowing). The 3/30/2024 quarterly Minimum Data Set assessment documented the resident had severely impaired cognition, had functional limitation in both arms and legs, was dependent for eating, did not have a swallowing disorder , and received a mechanically altered diet. The 1/29/2022 physician order documented regular pureed diet. The 11/29/2023 Speech Language Pathologist #35 evaluation and plan of treatment documented the resident had swallowing dysfunction and was referred for dysphagia services due to worsening signs/symptoms of dysphagia. The resident was on a pureed diet and aspiration (inhaling food/fluid into the lungs) precautions. The 4/4/2024 Registered Dietitian #34 quarterly nutritional assessment documented the resident had an abnormal weight loss, received a pureed diet with honey thickened liquids, a change in feeding ability was noted, and a mechanically altered diet was required. The Comprehensive Care Plan initiated 7/12/2023 and revised 4/25/2024 documented the resident had nutritional problems related to dysphagia and a mechanically altered diet, with a goal to tolerate consistency served with no episodes of aspiration. Interventions included monitor for signs and symptoms of dysphagia including pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, and appearing concerned during meals; provide and serve regular pureed diet with honey thick liquids. The resident required assistance with activities of daily living. Interventions included extensive assistance of 1 with feeding, pureed solids with honey thick fluids. The 5/1/2024 facility Investigation Summary initiated by the Director of Nursing at 6:00 PM, documented Licensed Practical Nurse #10 reported Resident #171 was fed the wrong consistency diet at 5:30 PM in the 2nd floor dining room. The physician was notified, and the resident was sent to the emergency department. The investigation summary included the following witness statements: - 5/1/2024 Certified Nurse Aide #3 documented they were feeding the resident, noticed the resident was not swallowing, was trying to cough, and nodded their head when asked if they were choking. They sat the resident upright and began to take food out of their mouth. Another certified nurse aide (unidentified) told Certified Nurse Aide #3 the resident had the wrong consistency food, and the nurse was called. The statement did not include what food the certified nurse aide was feeding the resident. - 5/1/2024 Certified Nurse Aide #9 documented they entered the dining room, staff were already with the resident, they looked at the resident's meal tray, noticed it was the wrong consistency, took the tray to Dietary Aide #4 and explained that it was the wrong consistency. - 5/1/2024 Licensed Practical Nurse #10 documented they were called to the unit dining room for a coughing resident. Resident #171 had coughed up some food with a large amount of phlegm. Staff were unable to get the resident's blood oxygen saturation above 87%, the on-call provider was called, and the resident was sent to the emergency room . - 5/1/2024 Dietary Aide #4 was interviewed by the Director of Nursing and stated they did not remember the incident but believed the certified nurse aide must have served the wrong food. - 5/2/2024 Dietary Aide #13 documented they helped Dietary Aide #4 load the food cart to be taken to the 2nd floor unit for supper. Dietary Aide #13 told Dietary Aide #4 what each food item was, what scoop to use, and the tops of the pans were labeled with what each food item was. - on 5/2/2024 the Administrator reviewed video surveillance of the 2nd floor dining room. At 5:12 PM Certified Nurse Aide #3 brought Resident #171 their meal tray and began assisting the resident with feeding. Within minutes the resident began to show signs of choking. Multiple certified nurse aides and a nurse stepped in to confirm the resident's airway was clear and no longer choking. There was no Heimlich Maneuver performed and the resident was able to cough up the food consumed. The video review did not include observations of the resident's food being plated by dietary staff. - 5/3/2024 the Director of Nursing documented significant information related to the incident included Resident#171's meal ticket for 5/1/2024 was accurate, and the meal tray was accurate except for Brussels sprouts that were chopped, mechanical soft and not pureed. - The investigation summary submitted to the New York State Department of Health on 5/7/2024 at 1:16 PM by the Director of Nursing documented the dietary server (unidentified) filled the tray, the certified nurse aide (unidentified) passed out the tray and fed the resident. The dietary and certified nurse aide were suspended for 3 days. All nursing, social work, therapy, and recreation staff were educated and quizzed on safe dining. Certified Nurse Aide #3's educational record documented: - on 10/12/2023 they completed a Food Safety and Diets quiz. The quiz documented they were to never give any resident food or beverage unless they knew the resident's diet order and to report any concerns involving resident's safety and wellbeing. - on 10/19/2023, they completed the skill of feeding a resident which included tray placement/removal, diet types/consistencies, and reading meal ticket/documentation. The 5/2/2024 hospital discharge summary for Resident #171 documented the resident was admitted with breathing issues due to aspiration of Brussels sprouts. The discharge diagnoses were acute hypoxic respiratory failure secondary to acute acquired pneumonia (infection in the lungs) versus aspiration pneumonitis (pneumonia caused by inhaling food or fluid into the lungs). A 5/3/2024 at 4:17 PM Director of Nursing progress note documented the Interdisciplinary Team met to discuss the choking incident, an investigation was underway, dietary and nursing staff involved were to be re-educated, and leadership staff would spend time in the dining room at meals to monitor that meal tickets were being accurately filled. The 5/3/2024-5/14/2024 dietary consistency in-service documented dietary staff were educated on types and examples of appropriate diet consistencies and what foods to avoid for that type of consistency. A 5/14/2024 at 1:17 PM Director of Nursing progress note documented dining safety education went out to employees in departments who helped serve meals and helped residents with eating and was to be completed by 5/23/2024. The 5/7/2024 Dining Safety for Clinical Staff education documented mealtimes could be hectic, which made it even more essential the facility reduced the risk of incidents by making sure the residents received the diet they were supposed to have. The post-test included a question about meal ticket checks. The sign-in sheets documented staff education began on 5/7/2024. During an interview on 1/17/2025 at 2:56 PM, Certified Nurse Aide #3 stated meal trays with plates, meal tickets, and utensils, were brought to the unit on a cart by dietary staff. Food was placed in the unit kitchenette and served by dietary workers. Unit staff put drinks on the trays, the tray was then placed on the kitchenette counter, the dietary server plated the food items and put the plate back on the meal tray on the counter. The meal tray was then delivered by unit staff to the resident. The dietary server was responsible for ensuring the correct consistency food was plated, and unit staff were responsible for checking the meal ticket against the food items before serving to ensure they were correct. The aide stated they did not check the meal ticket, and the food served before feeding Resident #171 their supper on 5/1/2024 and they fed the resident the wrong consistency Brussels sprouts. They stated the unit had a lot going on in the dining room during that meal. They were feeding the resident their food, the resident looked like they were trying to cough something up, was not making vocal noises, and the aide summoned the nurse right away. The resident went to the hospital and returned a few days later on aspiration precautions and comfort measures. During a telephone interview on 1/21/2025 at 1:09 PM, Dietary Aide #4 stated the unit staff gave the dietary server the resident's meal ticket, the server read the ticket, plated the food, and returned the plate to the meal tray and placed it on the counter for delivery to the resident. If there was a discrepancy, unit staff were to bring the food back to the server for correction. Each meal ticket listed the resident's food consistency. Dietary Aide #4 denied plating the wrong food for Resident #171 on 5/1/2024 and stated unit staff must have delivered the resident the wrong meal tray. They stated there should have been multiple steps to ensure the resident did not receive the wrong consistency food. During an interview on 1/21/2025 at 2:00 PM, Licensed Practical Nurse #10 stated unit staff checked the resident's meal ticket prior to putting drinks on the tray, placed the tray on the kitchenette counter, the dietary server plated the food after reading the meal ticket, and the tray was taken to the resident by unit staff. Every staff member who touched the tray, including whoever was feeding the resident, should check the meal ticket and the food to ensure they were correct to prevent the resident from getting the wrong consistency and choking or aspirating the food. On 5/1/2024, Resident #171 received regular Brussels sprouts and should have received pureed. The nurse believed all other foods on the tray were the correct consistency. The resident choked on the Brussels sprouts and cleared their airway by themself. The resident was taken to their room, the on-call provider was called, and the resident was sent to the hospital. They stated the resident's care plan was not followed, and all unit staff were reeducated on diet consistencies and food safety. During an interview on 1/21/2025 at 3:25 PM, Certified Nurse Aide #9 stated during meal service, any unit staff touching a resident's meal tray was to verify the meal ticket matched what was on the tray, including the dietary server. During a meal service observation and interview on 1/22/2025 at 12:07 PM, Dietary Aide #12 stated each pan of food on the steam table was covered with cellophane that was labeled with the date it was cooked and its consistency such as mechanical soft or pureed. Pureed was like pudding consistency and mechanical soft had chunks. They stated they learned the different consistencies when they were trained. During an interview on 1/22/2025 at 2:54 PM, the Director of Nursing stated nursing staff was trained on meal service and consistencies during orientation and yearly. Any staff member touching a meal tray was to verify the meal ticket matched the served food before the resident received the tray. Resident #171 received the wrong consistency food on 5/1/2024, they went to the hospital and was diagnosed with aspiration pneumonia. All nursing staff received post incident education regarding meal ticket verification with the served meal. On 1/23/2025 at 11:21 AM, the Director of Nursing stated 2nd floor unit staff received informal education regarding checking meal tickets and was unsure when the Registered Nurse Educator started the formal education for all nursing staff. During an interview on 1/22/2025 at 2:55 PM, Dietary Manager #26 stated food consistency education was done for dietary staff after the incident on 5/1/2024. Staff education on consistencies and training to check meal tickets versus consistency was provided upon hire and yearly. During an interview on 1/23/2025 at 11:15 AM, Registered Nurse Educator #14 stated nursing staff education on checking meal tickets versus served food and drinks did not begin until 5/7/2024 because they had to generate the education in the education computer system. That was where most of the education was done for staff, including the post test. Those staff members without computer access were provided with education in person. The staff who were directly involved in the incident were educated immediately post incident, but the educator was unsure if they had it documented anywhere. During an interview on 1/23/2025 at 11:22 AM, the Administrator stated the facility knew the cause of the incident the day it occurred. The facility was given, by regulation, 5 days to complete their investigation, and post incident education was provided at the completion of the facility investigation. The video of the incident was not saved, but a detailed summary, to include what was viewed on the video, was provided in the investigation and the summary. During an interview on 1/23/2025 at 3:14 PM, Medical Director #7 stated they expected staff to follow orders which included diet orders. Eating the wrong consistency could cause some residents to cough or choke on the food. 10NYCRR 415.4(b)(1)(i)____________________________________________________________________________ Immediate Jeopardy past non-compliance was identified, and the Administrator notified on 1/23/2025 at 11:30 AM. The facility provided verification the following corrective actions were completed: - On 5/2/2024 Certified Nurse Aide #3 was reeducated on following resident care plans regarding appropriate diet and consistency as ordered. - On 5/3/2024-5/14/2024 all dietary staff were educated on diet consistencies. - On 5/7/2024-5/11/2024 all nursing staff were educated on diet consistencies. - On 1/23/2025 staff education rosters were reviewed, and no discrepancies were identified. - During mealtime observations on 1/22/2025 and 1/23/2025, diet consistencies matched resident requirements.

Based on observation, record review, and interviews during the recertification survey conducted 1/16/2025-1/24/2025, the facility did not ensure residents received treatment and care in accordance with professional standards of practice 1 of 1 resident (Resident #49) reviewed. Specifically, Resident #49 was administered 14 doses of expired levetiracetam (seizure medication) from 1/10/2025 to 1/17/2025. Findings include: The facility policy, Medication Administration, revised 9/2019 documented the individual administering the medication should verify the medication selected for administration was the correct medications based on the medication order and the medication label. The individual administering a medication should be aware of the following information concerning each medication before administration: the route and frequency of administration, appropriate timing of medication administration, normal dosage and maximum dosage, and the expiration date had not been exceeded. Errors in administration of medications would be reported immediately to the attending physician and an incident report would be sent to nursing administration. Resident #49 had diagnoses including convulsions, dementia, and heart failure. The 12/19/2024 Minimum Data Set assessment documented the resident had severe cognitive impairment and a history of a seizure disorder. An 8/8/2023 physician order documented levetiracetam oral tablet 250 milligrams, give 1 tablet two times a day for convulsions. During the Unit 3 medication cart inspection on 1/17/2025 at 12:34 PM with Licensed Practical Nurse #31, there was a medication card (blister pack) for Resident #49 with levetiracetam 250 milligram tablets and an expiration date of 12/30/2024. The medication was dispensed on 8/21/2024 and had 14 tablets missing from the medication card. Licensed Practical Nurse #31 stated they did not realize the medication was expired and administered the levetiracetam to Resident #49 that morning. There were no additional blister packs of levetiracetam 250 milligram tablets in the medication cart. The blister pack had space for 30 tablets. The spot where the second dose of the medication was removed was initialed and dated 1/11/2025. There were 16 tablets remaining in the blister pack. The 1/2025 Medication Administration Record documented levetiracetam oral tablet 250 milligrams, give one tablet by mouth two times a day at 8:00 AM and 8:00 PM for convulsions and was administered as follows for a total of 14 doses; - on 1/10/2025 at 8:00 PM by Licensed Practical Nurse #31 - on 1/11/2025 at 8:00 AM by Registered Nurse #39; at 8:00 PM by Licensed Practical Nurse #30. - on 1/12/2025 at 8:00 AM by Registered Nurse #39; at 8:00 PM by Licensed Practical Nurse #40. - on 1/13/2025 at 8:00 AM and 8:00 PM by Registered Nurse #39. - on 1/14/2025 at 8:00 AM and 8:00 PM by Registered Nurse #39. - on 1/15/2025 at 8:00 by Licensed Practical Nurse #10; at 8:00 PM by Licensed Practical Nurse #2. - on 1/16/2025 at 8:00 by Licensed Practical Nurse #31; at 8:00 PM by Licensed Practical Nurse #30. - on 1/17/2025 at 8:00 AM by Licensed Practical Nurse #31. Nursing progress notes dated 1/10/2025-1/16/2025 did not document seizure activity for Resident #49. During an interview on 1/23/2025 at 4:27 PM, Licensed Practical Nurse #31 stated medication was delivered to the facility twice a day. The medication cards were not checked for expiration as often as they should, and they did not usually check the cards until more medication arrived. If medication was noted as expired, they should replace it. Medications should not be administered past their expiration date because they could lose their potency and were not as effective. During an interview on 1/23/2025 at 4:35 PM, Licensed Practical Nurse Unit Manager #32 stated medications were delivered to the facility twice a day and the expiration dates were checked weekly on all medication cards. If a medication was expired the nurse should have removed it from the medication cart, reordered the medication, and notified the Unit Manager. If an expired medication was given to a resident the physician should have been notified and there was no documented evidence the physician was made aware that Resident #49 was administered expired levetiracetam. They stated expired medications should not have been administered to Resident #49 because the effectiveness of the medication was not accurate, and they were unsure what the medication could do to the resident. During an interview on 1/23/2025 at 9:21 AM, the Director of Nursing stated they were unsure how often the nurses checked medication expiration dates. They were working with the nurses on not over ordering medications and they did not think the nurses were looking at expiration dates. They stated nurses should rotate the older medication cards to the front when new cards arrived at the facility. Resident #49 should not have received expired medications because the efficacy could have changed. During an interview on 1/24/2025 at 10:41 AM, Physician #7 stated they expected nurses to check expiration dates before they administered any medication. They wanted to be notified if a resident received expired medication. 10NYCRR415.12

Based on interviews and record review during the recertification survey conducted 1/16/2025-1/24/2025, the facility did not ensure that views, grievances, or recommendations voiced by residents during Resident Council group meetings were considered or acted upon and responded to with a rationale for 10 of 10 anonymous residents present at the resident group meeting. Specifically, 10 of 10 anonymous residents present at the resident group meeting stated they did not receive responses to topics or concerns addressed in prior meetings. Additionally, there was no documented evidence residents' voiced concerns were investigated, and rationales or responses were provided to the residents. Findings include: The facility policy, Resident Council, revised 3/18/2024, documented the resident council would provide a platform for residents to voice their concerns, provide feedback, and actively participate in decision-making processes that would directly impact their living conditions and experiences within the facility. The resident council would serve as a liaison between residents and facility administration addressing concerns or complaints regarding facility operations, policies, and resident experiences. The council appointed liaison would assist with documentation, relaying concerns to facility managers, ensuring facility follow through and would report back to the council as requested. The facility policy Resident Rights, revised 3/18/2024, documented the facility would establish a formal process for residents to file complaints or grievances. Residents would be provided with information on the procedure for addressing complaints and would have access to a designated individual or department to seek resolution. During a resident group meeting on 1/17/2025 at 9:54 AM, 10 anonymous residents stated the facility did not follow up, address, or resolve their concerns. They stated they did not receive any feedback from the facility about concerns regarding staff not responding timely to call lights, communication with unit staff, noise levels on the units during shift change and at night, and one resident stopped attending because they felt like it was useless. Resident Council meeting minutes documented: - on 8/2/2024, old business noted, calls bells were not being answered timely, residents were not receiving their meds because they were unavailable, noise levels at night were awful especially during 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM shifts. New concerns were raised about staff playing music while performing care and passing meal trays. - on 9/6/2024, old business noted, call bells not being answered timely, medications not available, Unit 2 staff were still noisy on 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM shifts, agency nurses forgot to give medications, and staff played music when performing care and passing meal trays. New concerns were raised about staff using offensive language. - on 10/21/2024, old business noted, call bells not being answered timely, medications were still not in the facility, Unit 2 staff was still noisy, staff played music when performing care and passing meal trays, and staff were still using offensive language. New concerns were raised about residents taking food from other trays, and cell phones being used by aides in resident rooms. The residents felt like they were attending resident council meetings and complaining but nothing was being done about it. - on 11/1/2024, old business noted, call bells not being answered timely, medications were given late, residents and staff were loud, staff were still using offensive language, and music was played on staff cellphones. New concerns were raised about cellphone usage at the nursing station, residents were getting up late for breakfast, items were stolen from resident rooms, and residents were not being assisted to bed timely. - on 12/6/2024, old business noted, residents not woken up for breakfast, items were stolen from resident rooms, personal cellphone usage at the nursing station, and not being assisted to be timely. New concerns were raised about loud staff, staff swearing and using inappropriate language, staff were not being truthful, staff were taking too many breaks at once, music was played on staff cellphones, staff were wearing ear buds while providing care, and residents were assisted to bed too early/late. The residents wanted to see compliance with their concerns and not just on paper. Resident Council staff responses documented: - in 8/2024, the Food Service department noted nursing was responsible for checking all items on resident trays and they would monitor dietary staff to ensure they did not have their phones out during meal service, and they believed it was a Director of Nursing issue. There were no other documented staff responses related to resident's voiced concerns. - in 9/2024, the Nursing Department noted they would start monthly staff meetings and include break education, education to staff on passing medications in the dining room and using basins for hygiene and hiring and training new staff to allow for timely care. The dietary department noted residents would need to notify nursing if they had a missing item on their tray and nursing should check all trays prior to the tray going to the resident. - in 10/2024, the Food Service department noted residents who took food off trays should be reported to the nursing staff who oversaw the meal service. Once meals were delivered to residents it was nursing staff who supervised meal consumption. There were no other documented staff responses to the resident's voiced concerns. - in 11/2024, there were no documented staff responses to the resident's voiced concerns. - in 12/2024, the nursing department noted all issues were addressed in staff meetings. During an interview on 1/24/2025 at 8:41 AM Recreation Leader #37 stated they ran resident council meetings until December 2024. During the Resident Council meetings, they went around the table and asked the residents what their issues were so they could let other departments know. They documented the specific issues and delivered them to each department. A response sheet was filled out and returned with the plans to fix the problems. In the next resident council meeting they would go over old business and how it was addressed before they moved on to new concerns. They were unsure why the old business and new business had a lot of the same concerns with no resolutions. They were not the one who typed up the minutes or held onto the staff response sheets. Residents expressed their concerns were not addressed and they were not seeing changes. They stated it was important to address resident council concerns because the facility was the residents' home, and it was their job to make sure residents were taken care. During an interview on 1/24/2025 at 11:30 AM, Activities Director #36 stated they started at the facility in the middle of November, and they reviewed the old Resident Council minutes. The minutes seemed to be all over the place with no structure. They noticed reoccurring issues that were not resolved. They constructed a new agenda since they took over Resident Council and they thought the resident's concerns were now being addressed. The resident's wanted to see things done and not just on paper. Activities Director #36 stated they reviewed the minutes in their monthly Quality Assurance and Performance Improvement meetings. They thought since bring the issues to the meeting, there was more of a response from other departments. During an interview on 1/24/2025 at 12:01 PM, the Administrator stated they were not involved with Resident Council, but they reviewed the monthly minutes. They tried to follow up with the residents' concerns within a week or by the next meeting. Facility response sheets were kept with the minutes and were brought back to the Resident Council meetings to address concerns. They saw repeated concerns on the monthly minutes, but they had a new Activities Director who made corrections to the resident council. They thought outcomes were being communicated back to the residents. They did not think there was a clear depiction of what the follow up was because it was not documented appropriately so it looked like they were not addressing the resident's concerns. 10NYCRR 415.5(c)(6)

Based on record review and interviews during the recertification and abbreviated (NY00354013) surveys conducted 1/20/2025-1/24/2025, the facility did not ensure all alleged violations involving abuse, neglect, or mistreatment were thoroughly investigated for 1 of 1 resident (Resident #371) reviewed. Specifically, Resident #371 was care planned for 2-person assistance with a mechanical lift for transfers and Certified Nurse Aide #29 transferred the resident alone resulting in the resident nearly falling. The resident was not assessed by a qualified professional following notification of the care plan violation and was subsequently found with skin tears to both legs. Findings included: The facility policy, Resident Incident/Accident Documentation within Electronic Medical Record revised 7/25/2024, documented all incidents that involved resident care would be investigated and documented on the Incident Documentation Tool and enabled the facility to evaluate care given to residents, to assist in the prevention of incidents, and evaluate the intervention given in the event of an incident. An incident was an occurrence not consistent with the routine operation of the facility or routine care of a resident. Reports were completed by licensed practical nurses and registered nurses. The nursing supervisor or designee would immediately notify the Administrator or designee of statements that physical abuse, mistreatment, or neglect has occurred, if a physical condition, like a bruise, was inconsistent with the history or course of treatment of the resident, or there was an observation of an act or condition of abuse, mistreatment, or neglect. Resident #371 had diagnoses including atrial fibrillation (an abnormal heart rhythm), long term use of anticoagulants (blood thinners), and progressive neuropathy (sensory and motor nerve damage). The 8/7/2025 Minimum Data Set assessment documented the resident was cognitively intact but had periods of altered consciousness, had no behavioral symptoms, and required moderate assistance to dependence for most activities of daily living. The 7/31/2024 Comprehensive Care Plan documented the resident had an activities of daily living self-care performance deficit related to musculoskeletal impairment. Interventions included the resident was non-ambulatory, was dependent for transfers with two-person assistance and a mechanical lift, required moderate assistance of two people for lying to sitting at the edge of the bed, and required moderate assistance for rolling left to right. Staff statements completed on 9/7/2024 documented: -Licensed Practical Nurse #30 stated Certified Nurse Aide #29 approached them and stated they were leaving at the end of tray pass as they had attempted to transfer a resident to get them up for dinner, the resident was combative, and the resident was almost dropped to the floor. They attempted to gain help by turning on the call light and then pulling the call light from the wall to trigger the emergency light, but no one came to assist them. The Manager on Duty was notified and Licensed Practical Nurse #30 was asked to obtain statements from the other staff on the floor. Licensed Practical Nurse #30 determined the resident was a mechanical lift with assistance of 2, not a one-person transfer. - Certified Nurse Aide #33 noticed Resident #371 was not up for the dinner meal. Certified Nurse Aide #29 offered to go get the resident for the meal. Certified Nurse Aide #33 stated they thought the resident was a one-person transfer. Certified Nurse Aide #29 declined assistance to get the resident up. Certified Nurse Aide #29 was upset no one came to assist them and stated the resident pulled Certified Nurse Aide #29 down and the resident was almost on the floor. - Certified Nurse Aide #28 stated they were going to go get Resident #371 up for dinner and went to look at the list (for transfer status) and saw Certified Nurse Aide #29 at the desk then go down the hall. They asked Certified Nurse Aide #29 if they needed assistance and was told they did not. Approximately 5 to 10 minutes later, Certified Nurse Aide #29 went into the dining room asking where everyone was, they were calling for help because Resident #371 was sitting on the aide's leg. There was no documented evidence the resident was assessed by a qualified professional following the reported care plan violation with the transfer. The 9/8/2024 at 3:50 PM Licensed Practical Nurse #27 Incident note for a skin impairment documented. A bruise on the right shin and three skin tears on the left shin were found on 9/8/2024 at 10:20 AM while the resident was lying in bed. The origin of the skin tears and bruise were unknown. The skin tears required butterfly bandages and were left open to air. The provider and the resident's family were notified. The 9/8/2024 at 11:21 AM Investigation report prepared by Licensed Practical Nurse #39 documented: - on 9/8/2024 the resident was found in bed with four skin tears measuring 5.0 by 0.7 centimeters, 1.0 by 1.0 centimeters, 0.5 by 0.5 centimeters, and 1.0 by 0.6 centimeters on the left lower extremity, and a bruise measuring 5.0 by 1.5 centimeters on the right leg. - The resident was unable to give a description of what happened and was alert and orientated only to person. - The were no predisposing environmental or situational factors. The resident had impaired memory, impaired vision, poor safety awareness, and had a current acute condition. The 9/8/2024 investigation summary documented: - It was undetermined when the skin tears and bruise occurred, and they were discovered during morning care. - Licensed Practical Nurse #27 and Licensed Practical Nurse #28 were interviewed. They reported the skin tears and bruising were not present on 9/7/2024 in the morning and were present on 9/8/2024, during morning care. Licensed Practical Nurse #27 noted the skin tears were not present when they saw the resident's legs for a treatment on 9/7/2024 at 4:00 PM (before the inappropriate transfer occurred). - The resident was combative at times, they had poor intake of food and water, they were a mechanical lift transfer but there was one known incident of an attempt of a one person transfer 9/7/2024 in the evening with no noted skin tears. The undated Investigation Conclusion signed by the Director of Nursing documented the care plan violation was the first incident and documented Certified Nurse Aide #29 was suspended for three days and was re-educated on checking the Kardex for each resident and making sure to follow it. There were planned and scheduled October in-services for bed mobility, safe transfers, and mechanical lift training. They were unable to determine the cause of the skin tears. The resident was noted to be combative with care and that could have been the cause of the skin tear. The resident had a history of skin tears, poor intake, and was observed wheeling their wheelchair into multiple pieces of furniture throughout their stay. There was no documented evidence the facility addressed the lack of assessment by a qualified professional on 9/7/2024 for possible injury following the transfer by one staff. During a telephone interview on 1/21/2025 at 1:57 PM, Certified Nurse Aide #29 stated they were serving dinner trays in the dining room when they noticed Resident #371 was not in the dining room. They offered to go get the resident and was informed by Certified Nurse Aide #33 the resident was a one-person transfer. They woke Resident #371 up, got them turned to the side of the bed with the wheelchair next to the bed, and attempted to stand the resident with a gait belt. Resident #371 started to be combative, was not bearing weight, and almost slid off the bed due to being mid-transfer. Certified Nurse Aide #29 stated they had to put their leg in-between the resident's legs and scoot the resident back onto the bed. When the aide went to the nursing station, they were informed the resident was a mechanical lift, not a one-person assist. One of the nurses, they were unsure whom went to assist with getting the resident up. The nurse did a full body check and there were no injuries. During an interview on 1/22/2025 at 4:39 PM, Licensed Practical Nurse #30 stated they were not assigned to Resident #371's floor, but they were the Supervisor on duty. They were called down to the unit due to Resident #371 being transferred incorrectly and a skin tear on the resident's leg. They believed the registered nurse did the assessment on the resident as licensed practical nurses were not allowed to do the skin check in that situation. During an interview on 1/23/2025 at 9:33 AM, Registered Nurse #39 stated if a resident was improperly transferred while they were on duty they should be notified. They stated on 9/7/2024, they were not notified of Resident #371 being transferred incorrectly. If it had been reported to them, they would have assessed the resident, documented, and then reported the incident. During an interview on 1/24/2025 at 9:29 AM, the Director of Nursing stated there were two kinds of investigations, one required notification of the Director of Nursing immediately and the other required nursing staff to fill out a risk assessment. The risk assessment was for falls, a bruise, a skin tear, or a resident to resident incident. If a resident or staff had an injury related to an improper transfer, they were usually notified immediately. If a resident was injured due to a care plan violation, they obtained statements from the staff or obtained a verbal statement. Those verbal interviews were summarized on the witness statement section of the incident report. For injuries of unknown origin, they did a 72-hour look back at the resident's care and obtained statements from staff who worked. They expected a full assessment on the resident after the improper transfer. There was no accident and incident report entered for the improper transfer on 9/7/2024 and they were not aware it had occurred until they started the investigation on the injury of unknown origin on 9/8/2024. There was no documentation the registered nurse on duty was notified and they should have been. They stated they were able to rule out abuse and neglect without having a documented assessment or a note about the transfer incident as the resident had a history of being combative and self-inflicted injuries from kicking items. The resident also did not appear fearful when spoken to about the incidents. 10NYCRR 415.4(b)(3)

Based on record review and interviews during the recertification survey conducted 1/16/2025-1/24/2025, the facility did not ensure at the time of admission residents had physician orders for immediate care consistent with the resident's physical status for 1 of 1 resident (Resident #473) reviewed. Specifically, Resident #473's hospital discharge orders and hospital discharge summary had conflicting diet consistency information that was not clarified on admission to the facility. Findings include: The facility policy, Physician Visits & Medical Orders, revised 1/19/2024, documented the attending physician would prescribe the medical regimen of care for the residents they admitted . Before or on admission of a resident, the physician would submit information pertaining to the admitting diagnosis(es), current medical findings, the diet prescribed, medication treatment orders, and the resident's functional status. Medical orders would be written by physicians to meet the needs of the resident. Members of the interdisciplinary team would provide care, services and treatment according to the most recent medical orders and according to laws, regulations and standards of practice. The facility policy, Admission of Resident to Care Facility, revised 1/19/2024, documented the facility would ensure each resident received necessary care and services upon admission. Resident #473 had diagnoses including mild cognitive impairment, hypertension (high blood pressure), and weakness. The Minimum Data Set assessment was not yet completed. The 1/21/2025 hospital discharge summary documented the hospital stay was complicated by new thin liquid dysphagia (difficulty swallowing), for which the resident was given a thickened liquid diet. The resident never had trouble with thin liquids or swallowing at baseline per family. The speech language pathologist evaluation during admission showed evidence of dysphagia with thin liquids. The discharge summary documented diet as below, can be re-evaluated by speech language pathologist. The nursing home transfer documented a regular diet. The 1/21/2025 physician order entered by the Director of Nursing at 11:13 AM documented a regular diet, regular texture, regular thin consistency. The order was signed by Nurse Practitioner #23 on 1/21/2025. During a lunch observation on 1/22/2025 at 12:41 PM, Resident #473 had a mug containing a thin brown liquid and a cup containing a thin, clear amber colored liquid. The resident was actively drinking the amber colored liquid. The resident's visitor questioned the liquids as the resident had thickened liquids the day before. A speech language pathologist arrived and removed the thin fluids and said they were going to check with the other speech language pathologist to see if they did an evaluation on 1/21/2025. The 1/22/2025 at 12:52 PM Physician #7 order documented the resident was to receive a regular diet, regular texture, with nectar consistency liquids. The 1/22/2025 at 2:24 PM Speech Language Pathologist #16 progress note documented a skilled dysphagia evaluation was medically indicated due to discrepancy between diet recommendation on the hospital discharge paperwork and report from the resident's family. Thin liquids were not trialed due to patient preference for nectar. They recommended regular solids, nectar liquids, and skilled dysphagia treatment 3-5 times a week for 4 weeks using restorative and compensatory techniques. During an interview on 1/23/2025 at 1:36 PM, Licensed Practical Nurse Manager #15 stated when admitting a resident, the Director of Admissions brought them a hard copy of the hospital orders. They entered those orders into the electronic medical record. The Director of Nursing and another Nurse Manager checked the orders for accuracy. That was their triple check system. If information in the discharge paperwork was inconsistent, it should be clarified. They were not working the day Resident #473 was admitted so they had not reviewed their orders. The resident was admitted on thin liquids and should have been on nectar thick. The correct consistency was important because the resident could have choked or aspirated which could lead to complications. During an interview on 1/24/2025 at 9:10 AM, the Director of Admissions stated when a resident was admitted they received the discharge summary and orders the day of admission, reviewed them, and uploaded them to the documents tab in the electronic medical record. If the hospital orders and discharge summary had conflicting information, they would clarify. Additionally, they created a portable document format (PDF) file with all preadmission information they had obtained and sent it to the on-call provider, the Director of Nursing and the appropriate Nurse Manager. The on-call provider, once they received the portable document format, printed it, signed it, and returned it and those became the admission orders. On 1/17/2025 a hospital physician, entered a diet change of nectar thick liquids as a message rather than an order. As a result, it did not flow into the orders. Therefore the 1/16/2025 order for a regular diet was the only active hospital diet order the resident had. They became aware of that issue after the resident was already admitted and the question regarding the appropriate liquid consistency was raised. The resident's admission paperwork did not give them an inclination there was a swallowing issue and when they saw the regular diet, it did not cue them to look for dysphagia. They did not think their facility caught the issue but should have as that was why there was a triple check system. During an interview on 1/24/2025 at 10:03 AM, Speech Language Pathologist #16 stated they reviewed Resident #473's records and saw a regular diet but did not see the resident had thin liquid dysphagia. On 1/21/2025, they were told the resident's family wanted the resident to have nectar thick liquids, so they did an evaluation that day. During an interview on 1/24/2025 at 11:21 AM, the Director of Nursing stated they often put the admissions orders in and if not, they performed one of the checks. When they put the orders in the electronic medical record, they looked at the discharge orders but only looked at the discharge summary if there were new medications. Any order that needed clarification was not activated. They entered Resident #473's admission orders but did not review their discharge summary because there was nothing in the orders that made them question anything. They had since reviewed the discharge summary and saw the resident had thin liquid dysphagia while at the hospital. If they had reviewed the discharge summary on admission and saw that, they would have asked speech to evaluate the resident and held the diet order pending that evaluation to make sure they could swallow safely. During an interview on 1/24/2025 at 11:44 AM, Nurse Practitioner #23 stated when there was a new admission, they looked over the discharge orders and discharge summary to make sure everything was appropriate. Once nursing entered the orders, they reviewed and signed off. If there was conflicting information, they would ask the nursing staff to ask for clarification from the discharging facility. They were involved in Resident #473's admission and would have reviewed their orders and summary. They did not know if there was conflicting information about their diet and did not recall asking nursing to clarify their diet. During a follow up interview on 1/24/2025 at 2:49 PM, Nurse Practitioner #23 accessed the resident's medical record and reviewed the discharge instructions and summary. They stated they saw the diet was regular but in the discharge summary, saw documentation on evidence of dysphagia and had to be reevaluated by speech. They stated the information was certainly conflicting and orders should have been clarified to ensure they were given the appropriate fluids to reduce the risk of aspirating. 10 NYCRR 415.11

Based on record review and interviews during the recertification survey conducted 1/16/2025-1/24/2025, the facility did not ensure that residents with newly evident or possible serious mental disorders, intellectual disabilities, or related conditions were referred for a Level II Preadmission Screening and Resident Review (a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities were not inappropriately placed in nursing homes for long term care; a Level II Preadmission Screening and Resident Review identifies the specialized services required by the resident) for 1 of 2 residents (Resident #66) reviewed. Specifically, Resident #66 had a significant mental illness and a change in behavior that required medication intervention and there was no documentation a new Screen Level I was completed, or a Level II referral was initiated. Findings include: The New York State Department of Health Instruction Manual for Department of Health-695 (2/2009) documented if a Residential Health Care Facility resident was newly diagnosed with a mental illness, a new SCREEN and Level II referral must be completed within 14 calendar days. If a Residential Health Care Facility resident, who was previously identified as having mental illness was identified as having experienced a significant change in physical and/or mental condition, a new SCREEN and Level II Evaluation must be completed within 14 calendar days. During an interview on 1/23/2025 at 11:16 AM, the Administrator stated they did not have a facility policy regarding Preadmission Screening and Resident Review. Resident #66 had diagnoses including schizophrenia, hallucinations, and delusional disorder. The 12/26/2024 Minimum Data Set assessment documented the resident was cognitively intact, had a diagnosis of schizophrenia and hallucinations, and was receiving an antipsychotic medication routinely and as needed. The comprehensive care plan initiated on 5/1/2024, and revised 8/7/2024, documented the resident had a psychosocial well-being problem related to the diagnosis of schizophrenia in the resident's teen years that required inpatient mental health services; they continued to have psychosis and delusions, was accusatory toward staff, and refused basic care and prescribed medications; they were verbally and physically violent towards staff and would throw objects including food, fluids, and feces; they had made accusations of rape within the facility, did not trust staff or their family, and continued to confabulate incidents of abuse. Interventions included monitor/document resident feelings and response to internal and external problems, initiate referrals as needed or increase social relationships, allow time to answer questions and to verbalize feelings, remove to a calm safe environment when conflict arises, and paper and plastic products for safety during meals. The comprehensive care plan initiated on 10/18/2021, and revised 1/19/2025, documented the resident had potential for non-compliance related to impaired judgement with incontinence care, showers, medication, and activities of daily living. Interventions included allow time for making decisions about treatment regime to provide sense of control, encourage participation, reapproach if resistant with activities of daily living, and to praise the resident when behavior was appropriate. The 4/9/2021 Screen Form (New York State Department of Health-695 2/2009) documented the resident required skilled services, did not have a significant mental illness, and did not require a Level II evaluation. The resident's face sheet documented the resident's schizophrenia and major depressive disorder diagnosis had an onset date of 4/17/2021 and their hallucinations and delusional disorders diagnosis had an onset date of 11/8/2023. Nursing notes from 10/28/2024-11/4/2024 documented the resident had behavioral symptoms including refusal of medications, using profane language, hallucination, delusional thoughts, yelling and screaming, ripping the call light from the wall, verbally abusing staff, throwing food, and stating staff were mental patients making them watch them sexually assault and murder people. The 10/21/2024 Psychiatric Mental Health Nurse Practitioner #44 progress note documented a chief complaint of irritability and delusions. The resident was being seen after addition of Secuado (a medication used to treat schizophrenia) for management of psychosis, irritable behaviors, and mood stabilization. The resident stated they were a brain surgeon in one of their other lives. The resident was diagnoses with schizophrenia in high school and was previously institutionalized because of mental illness. The plan/recommendations were given that the resident recently recovered form COVID-19 infection which may have influenced their behaviors. The 10/30/2024 Social Worker #38 progress note documented the interdisciplinary team met for the resident's quarterly care meeting. The resident had been exhibiting more aggressive behaviors toward staff and refusing medications over the last two weeks. The resident continued to see the psychiatric nurse practitioner for medication reviews and a psychotherapist a few times. However, the resident had been refusing to see the psychotherapist the last couple of months. The resident was alert, oriented, and able to make their needs known. However, due to the resident's schizophrenia the resident often was non-compliant with care and medications. The 11/4/2024 Psychiatric Mental Health Nurse Practitioner #45 progress note documented they were asked by staff to see the resident who was non-compliant with their Secuado patch, was aggressive, yelling all night about having a baby, cursing staff, calling them [expletive], throwing food and drink at staff, and attempting to rip the call bell out of the wall. They approached the resident in the company of two staff members and the resident yelled Get out!. The resident was at the maximum dose of Risperdal (antipsychotic), but it seemed ineffective in managing the psychosis. The resident's behaviors posed an immediate risk to the resident or others. Nonpharmacological interventions and least restrictive measures had been attempted in the past with minimal improvement. During an interview on 1/23/25 at 12:15 PM Social Worker #18 (from a sister facility) stated if a resident had a significant change with mental illness it needed to be reviewed. Resident #66 did not have a Level II screen, and they had questioned that due to the resident's mental illness diagnoses. The resident was diagnosed with schizophrenia in high school with a history of inpatient stays. They now had escalation of behaviors requiring medication intervention: The resident should have had a new screen. If they did not have a new Level II screen, they would not know what specialized services the resident required and was placed in long term care appropriately. Resident #66 may need alternative services due to their long standing history of schizophrenia. During an interview 1/23/25 01:21 PM the Administrator stated the Director of Social Work was responsible for maintaining Preadmission Screening and Resident Review, referring and updating the state authority. 10NYCRR 415.11(e)

Based on record review and interviews during the recertification survey conducted 1/16/2025-1/24/2025, the facility did not ensure a discharge planning process was in place addressing each resident's discharge goals and needs and involved the resident and the resident representative for 1 of 2 residents (Resident #105) reviewed. Specifically, Resident #105 expressed the goal to be discharged back to their prior living situation and was not assisted with discharge planning or updates on the status of their discharge goal. Findings include: The facility policy Comprehensive Care Plan, revised 1/19/2024, documented to the extent practicable, the resident had the right to participate in planning for care, treatment and services shall include discharge planning to include return to the community or discharge to an appropriate level of care. The facility policy, Discharge Planning, revised 8/23/2023, documented the facility would work collaboratively with the resident to ensure a smooth transition of care; would ensure all residents who expressed a desire to return to the community were provided the opportunity and assistance by the facility to allow the resident to live in the most integrated and least restrictive setting possible; resident education would be a major focus of discharge planning activities; and would permit the resident, their legal representative or health care agent the opportunity to participate in deciding where the resident will live after discharge from the facility; and permit the resident, their legal representative or health care agent the opportunity to participate in deciding where the Resident #105 had diagnoses of metabolic encephalopathy (a chemical imbalance in the brain) and repeated falls. The 11/15/2024 Minimum Data Set admission assessment documented the resident's overall discharge goal was to be discharged to the community and an active discharge plan was already occurring for the resident to return to the community. The 12/27/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition and was independent with most activities of daily living. The Comprehensive Care Plan revised 11/18/2024, documented the resident had a discharge plan to complete short term rehabilitation and return to their apartment if able. Interventions included inform the resident about referrals made to support the discharge and organize discharge meetings as needed. The 11/8/2024 at 1:42 PM former Social Worker #38 's progress note documented Resident #32 presented as alert and oriented, was able to make their own decisions and make their needs known. The resident stated their goal was to attend and participate in therapy to regain strength and independence and go back to their apartment where they lived independently. The resident had a friend who checked on them and assisted with their needs. The resident stated they were able to manage their own activities of daily living and was still driving to get their groceries. The 11/12/2024 at 9:22 AM former Social Worker #38 's progress note documented per the hospital record; the resident's friend was unsure if the resident would be able to return to their apartment. Social Worker #38 would call the friend to schedule a care meeting per the resident's wishes. The 12/27/2024 Occupational Therapy Discharge Summary documented the resident was independent for all functional skills except bathing which required set up assistance. The 12/27/2024 Physical Therapy Discharge Summary documented the resident was independent for all functional skills. There was no documented evidence an Interdisciplinary care plan meeting was held to discuss the resident's discharge potential and goals. During an interview on 1/16/2025 at 11:20 AM, Resident #105 stated they were concerned about not being able to go home. They were supposed to go home in 12/2024. They worked with Veterans Affairs for everything they needed. They had not received therapy for the last two weeks and had to postpone several appointments because of still being at the facility. They had friends that could give them a ride home and had practiced stairs in therapy. They were still paying for their apartment and their landlord lived downstairs. They did not recall attending any care plan or discharge meetings since being admitted . During an interview on 1/22/2025 at 4:43 PM, Certified Nurse Aide #20 stated Resident #32 was very independent, was steady on their feet, and alert and oriented. During an interview on1/22/2025 at 4:47 PM, Licensed Practical Nurse #21 stated Resident #32 was independent, alert and oriented, pleasant, had good safety judgement and was able to make their needs known. They were not sure why they were still in the facility. During an interview on 1/23/2025 at 12:57 PM, Licensed Practical Nurse Manager #15 stated Resident #32 was at the facility for rehabilitation and their plan was to go home. The resident was very independent, quiet, liked to stay in their room, and their cognition was good. They did not recall going to the resident's care plan meeting or any discussion about a discharge plan for them. They were not sure if the resident was still receiving therapy or why they were still at the facility. The facility's goal was to get people home as quickly as possible. During an interview on 01/23/2025 at 2:34 PM, the Occupational Director stated Resident #32 came to them due to a fall at home. The resident was no longer on therapy services and had maxed out about a month ago. They were mostly independent for activities of daily living. The Occupational Director believed the resident was on a wait list at a senior apartment complex downtown and the apartment they lived in prior was a concern due to it being a bedroom in someone else's house. Once the resident was accepted at the senior apartment complex, they would plan for home services to make sure it was set up well for them. The resident would need daily checks and a life alert due to high risk for falls. If someone had been independent for a couple weeks and not a fall risk, they would be a candidate for discharge. During an interview on 1/23/2025 at 3:05 PM, Social Worker #18 stated the Licensed Practical Nurse Director of Quality Management scheduled the discharge planning meetings and resident progress and goals were discussed. Residents should be invited to all care plan meetings without exception and there should be documentation of who attended the care plan meeting. Social work entered the discharge care plan and when they became aware that a resident was going to be cut from therapy they started working on the discharge plan. Resident #32's goal was to return to their apartment, and they did not know if the resident was on a wait list to go to a senior apartment complex. The resident was cut from therapy on 12/27/2024 and should have had things put in motion at that time to get them discharged . There was no documentation of any meetings or communication with the resident about going home. The resident slipped through the cracks. It was important for the mental health of the resident to go home and not lose their functionality while waiting to do so. During an interview on 1/23/2025 at 4:07PM, the Licensed Practical Nurse Director of Quality Management stated they or the Administrator scheduled the discharge planning meetings and let the family and resident know. They called or spoke directly to the families and told the residents directly and the conversations should be documented. They stated they were not involved with Resident #32, had no firsthand knowledge of the resident, was not involved in a discharge care plan meeting. Former Social Worker #38 had been talking with the resident. The resident was cut from therapy on 12/27/2024 which should have triggered a care plan meeting. During an interview on 1/24/2025 at 8:44 AM, the Administrator stated they knew the resident was on a waiting list for a senior apartment complex, was no longer getting therapy, and was independent/supervision for activities of daily living. They thought there was some question regarding the resident's cognitive status and safety. Lack of support in the community was a concern for a safe discharge. 10NYCRR 415.11(d)(3)

Based on observations, record review, and interviews during the recertification survey conducted 1/16/2025-1/24/2025, the facility did not ensure that residents who required dialysis services (filtration of blood when the kidneys do not work) received such services consistent with professional standards of practice for 1 of 1 resident (Resident #65) reviewed. Specifically, Resident #65 received hemodialysis treatments at a community-based dialysis center and there was inconsistent communication and collaboration between the dialysis center and the facility. The facility policy, Care of Hemodialysis Resident, revised 3/30/2024, documented all residents receiving dialysis-hemodialysis would have interventions in place for appropriate care and treatment. The facility would complete the hemodialysis report prior to each dialysis treatment and send it to the dialysis center with the resident. The hemodialysis reports would be reviewed upon the resident's return from dialysis and confirm any new recommendations with the primary physician, if indicated. Resident #65 had diagnoses including of end stage renal disease (kidney disease), diabetes, and hypertension (high blood pressure). The 12/19/2024 Minimum Data Set assessment documented the resident had intact cognition, was independent with most activities of daily living, and received dialysis. The Comprehensive Care Plan, revised 7/22/2024, documented the resident required hemodialysis. Interventions included hemodialysis three times a week and obtain vitals and weights per recommendations. The 8/19/2024 physician orders documented: - hemodialysis every Tuesday, Thursday and Saturday. - vital signs before and after dialysis treatments. Document pre and post weight obtained at dialysis and call dialysis if not listed in the communication book. - the resident's dialysis communication book was to be filled out and sent with the resident to dialysis, reviewed upon return from dialysis, and call the dialysis provider for report if communication book was not present on return from dialysis every Tuesday, Thursday and Saturday. Resident #65's dialysis report sheets for 34 dialysis sessions had 25 sessions with incomplete documentation of vital signs and/or pre and post dialysis weights from the dialysis center staff on 10/29/2024, 10/31/2024, 11/2/2024, 11/7/2024, 11/9/2024, 11/12/2024, 11/14/2024, 11/19/2024, 11/21/2024, 11/27/2024, 11/30/2024, 12/3/2024, 12/5/2024, 12/7/2024, 12/10/2024, 12/12/2024, 12/14/2024, 12/18/2024, 12/21/2024, 12/23/2024, 12/26/2024, 12/28/2024, 12/30/2024, 1/9/2025, 1/18/2025, and 1/21/2025. The interdisciplinary progress notes did not document any communication with the dialysis center regarding any follow up that had been done regarding the 25 incomplete dialysis report sheets. During an interview on 1/16/2025 at 1:09 PM, Resident #65 stated they received dialysis three times a week for about 4 hours each time. They carried the communication book back and forth between the two facilities. During an interview on 1/21/2025 at 3:04 PM, Licensed Practical Nurse #10 stated when a resident returned from dialysis their vital signs and dressing were checked. The nurse that was assigned to the resident's hall was responsible for checking the communication sheet upon the resident's return. If the sheet was blank, they should call the dialysis center to see if there was a concern and document they did so. They stated they did not look at Resident #65's report sheet when the resident returned from dialysis that day or call dialysis to get a report. It was important to get a report from dialysis to see if the resident had a full treatment and to know if their blood pressure dropped. During an interview on 1/23/2025 at 12:13 PM, Licensed Practical Nurse Manager #15 stated Resident #65 had a communication book that went with them to dialysis. Their unit was responsible for completing the upper portion and the dialysis center was responsible for the lower section. There was no phone-to-phone report between the two facilities. They expected when a resident returned from dialysis, the nurses review the sheet to make sure the vital signs were good. If the lower section was not filled out, vital signs would be taken right then, the dialysis center was called to get report, and all communication would be documented in a progress note. That process was important so that anyone could go back and look at those sheets and know what the vital signs were and if dialysis went well. During an interview on 1/24/2025 at 11:10 AM, the Director of Nursing stated prior to going to dialysis Resident #65 received a few medications, had their vital signs taken, and the communication book was sent with them. Dialysis should fill out their section and nursing should look at the report sheet when the resident returned. It was hit and miss if dialysis completed the form. They expected to be notified if there were any issues on the form. If the form was blank or incomplete nursing should be checking the resident's vital signs and notify either them or the Unit Manager so they could see the resident and make sure they were stable. Incomplete report sheets were a normal, ongoing thing. Dialysis was good about calling them if there was an issue. If there were no issues, they might not see anything on the report sheet. If dialysis did not call and the form was blank, they assumed everything was fine. 10NYCRR 415.12(k)

Based on observation, record review, and interviews during the recertification survey conducted 1/16/2025-1/24/2025, the facility did not ensure medication rates were not greater than 5 percent for 2 of 5 residents (Resident #27 and 110) reviewed. Specifically, Resident #27 was administered 5 medications over one hour late; their sliding scale insulin dose was given after breakfast and not before as ordered; and the insulin pen was not primed (removal of air bubbles); and Resident #110 was administered four medications via mouth and not via a gastrostomy tube as ordered and the medications were administered over one hour late. The facility's medication error rate was 37.04%. Findings include: The facility policy, Medication Administration, revised 9/2029, documented the individual administering a medication would be aware of the route, frequency, and appropriate timing of medication administration. Any errors in medication administration would be reported immediately to the attending physician, and an incident report would be sent to nursing administration. Medications would be administered only upon the orders of physicians, dentists, or podiatrists who were members of the medical staff. There was no documented evidence of a facility policy on blood glucose monitoring and insulin administration. 1) Resident #27 was had diagnoses including cerebral infarction (stroke), type 2 diabetes (the body does not use insulin effectively), depression, and hyperlipidemia (high blood fat levels). The 12/2/2024 Minimum Data Set assessment documented the resident had intact cognition and received daily insulin injections. Physician orders documented the following: - on 11/26/2024 Plavix (blood thinner) 75 milligrams once a day by mouth; duloxetine (anti-depressant) 30 milligrams delayed released capsule once a day by mouth; fenofibrate (cholesterol medication) 160 milligrams once a day by mouth; and levetiracetam (anti-seizure medication) 500 milligrams twice a day by mouth. - on 12/7/2024 Novolog (rapid-acting insulin) Injection Solution 100 units/milliliter per sliding scale subcutaneously before meals for hyperglycemia: if blood glucose level is 150 - 200 (milligrams/deciliter) = give 2 Units; 201 - 250 = give 4 Units; 251 - 300 give 6 Units; 301 - 350 = give 8 Units; 351 - 400 = give 10 Units; 401 - 450 = Notify provider if over 400. - on 12/12/2024 insulin glargine (long-acting insulin) 18 units subcutaneously every morning. The January 2025 Medication Administration Record documented the following scheduled medication administration times: - 8:00 AM clopidogrel (generic name for Plavix), duloxetine, fenofibrate, levetiracetam at 8:00 AM and 9:00PM - 9:00 AM insulin glargine at 9:00 AM - aspart insulin at 7:30 AM, 12:00 PM, and 5:00 PM before meals inject as per sliding scale. During an observation on 1/17/2025 at 9:20 AM, Licensed Practical Nurse #24 performed a finger stick blood glucose on Resident #27 with a result of 326 milligrams/deciliter. The resident stated they ate a good breakfast just after 8:00 AM (approximately 90 minutes prior to the blood glucose test). Licensed Practical Nurse #24 prepared the following medications: clopidogrel 75 milligrams, duloxetine 30 milligrams, fenofibrate 160 milligrams, levetiracetam 500 milligrams, aspart insulin 8 units, and glargine insulin 18 units. Licensed Practical Nurse #24 prepared the glargine insulin, dialed the pen to 18 units and did not prime (remove air bubbles) the pen. Once preparation was completed at 9:38 AM, they asked a coworker to get the supervisor. At 9:45 AM Registered Nurse Educator arrived and was asked to check that the 8 units of aspart insulin was drawn up correctly. Registered Nurse Educator approved the insulin dosing and Licensed Practical Nurse #24 entered the resident's room. Licensed Practical Nurse #24 proceeded to administer medications and the aspart and glargine insulins to the resident. The January 2025 medication administration record documented on 1/17/2025 Licensed Practical Nurse #24 signed for the administration of 8 units of aspart insulin for the scheduled 7:30 AM dose with a documented blood glucose of 326 milligrams/deciliter. Clopidogrel, duloxetine, fenofibrate, and levetiracetam were all signed as administered at 8:00 AM by Licensed Practical Nurse #24. The resident's weight and vitals summary documented Licensed Practical Nurse #24 entered a blood sugar of 326 on 1/17/2025 at 9:54 AM. During an interview on 1/17/2025 at 10:00 AM, Licensed Practical Nurse #24 stated the aspart insulin was due at 8:00 AM and the dose was based on the sliding scale and blood glucose results. After referring to the medication administration record, they stated the finger stick blood glucose was scheduled for 7:00 AM and the aspart at 7:30 AM because glucose checks were to be done before meals. Glucose levels should be done before meals to provide compensation for the food the resident would eat and would have enough insulin to continue throughout the day. If they checked the glucose level before they ate the result would have been different and likely lower. A lower result could have affected the amount of insulin that was needed. The next glucose check was due at 12:00 PM before lunch. If insulin doses were too close together it could cause hypoglycemia (low blood glucose). Licensed Practical Nurse #24 stated they were behind on their medication pass and the facility did not tell me what they were supposed to do. They stated insulin pens should be primed before dialing up the dose, but they did not do so with Resident #27. If the pen was not primed, the resident would get less insulin than what was prescribed which could affect their blood sugar. During an interview on 1/23/2025 at 5:06 PM, Registered Nurse Educator stated they did not question Resident #27's insulin being administered at 9:45 AM on 1/17/2025 as there were new insulins that could be given at all times of the day. If a nurse was unable to get a blood glucose reading before the resident ate it should be reported as the sliding scale insulin would not apply. It should be reported to medical who would then direct the nurse what to do. During an interview on 1/23/2025 at 1:22 PM, Licensed Practical Nurse Manager #15 stated medications could be administered as early as an hour before and as late as an hour after the scheduled time. If a nurse was running late with medication administration, they should report, and the doctor should be contacted for further instructions. Blood glucose checks were done before breakfast by the day shift. It was important they were done before breakfast because if the resident ate first, it could skew the results. If the resident already ate before the nurse was able to obtain a blood glucose, they expected the nurse to report to them and not medicate based on that blood glucose result. Insulin should not be given two hours late as it could impact subsequent blood glucose readings. Resident # 27 was an insulin dependent diabetic and on sliding scale insulin before meals. Their morning insulin and blood glucose check were due at 7:30 AM. Checking blood glucose and administering insulin at 9:45 AM was not acceptable. They should have been notified to determine how to proceed but did recall anyone reporting to them on 1/17/2025. 2) Resident #110 had a diagnoses including gastrostomy status (feeding tube) and dysphagia (difficulty swallowing). The 12/26/2024 Minimum Data Set assessment documented the resident had intact cognition, required substantial assistance with most activities of daily living, and had a feeding tube. The 1/10/2025 physician orders documented: - Eliquis 5 milligrams (a blood thinner) via percutaneous endoscopic gastrostomy tube (a feeding tube) twice a day - lacosamide oral solution 20 milliliters (an anti-seizure medication) via percutaneous endoscopic gastrostomy tube twice a day - metoprolol 25 milligrams (cardiac medication) via percutaneous endoscopic gastrostomy tube every 6 hours - famotidine 20 milligrams (an antacid) via percutaneous endoscopic gastrostomy tube twice a day The January 2025 medication administration record documented the following scheduled medication administration times: - Eliquis at 9:00 AM give via percutaneous endoscopic gastrostomy. - lacosamine at 9:00 AM via percutaneous endoscopic gastrostomy. - famotidine at 9:00 AM via percutaneous endoscopic gastrostomy. The January 2025 medication administration record documented Licensed Practical Nurse #10 signed for the following medications on 1/21/2025 at the 9:00 AM scheduled time: - Eliquis 5mg via percutaneous endoscopic gastrostomy - lacosamide 20 milliliters via percutaneous endoscopic gastrostomy. - metoprolol 25 milligrams via percutaneous endoscopic gastrostomy. - famotidine 20 milligrams via percutaneous endoscopic gastrostomy. During an observation on 1/21/2025 at 1:42 PM, Licensed Practical Nurse #10 entered Resident #110's room and told the resident they were going to try and take their pills by mouth. The resident was given a medicine cup with three whole pills, a 30 milliliter medicine cup half full of a clear liquid, and a plastic drinking cup of clear liquid. The resident took the three pills and the fluid in the medicine cup by mouth and drank clear fluid from the drinking cup. Licensed Practical Nurse #10 then exited the room. There was no documented evidence in nursing progress notes regarding late administration of medications or administering the medications by mouth and not via percutaneous endoscopic gastrostomy as ordered. During an interview on 1/21/2025 at 2:44 PM, Licensed Practical Nurse #10 stated medications could be administered as early as an hour before and as late as an hour after the scheduled time. If they were running late and it was going to be an additional two hours before they administered the medications, they should call the on-call provider to get permission to give the medications late. If someone took their medications via a tube it should be documented at the top of the medication administration record and in the body of the order itself. They stated it was not within the scope of a nurse to change the route of medication administration without a physician order. They gave Resident #110 their pills by mouth to see if they could swallow them versus having to give them via the tube. They were unsure if there was an order to give by mouth, but the Registered Nurse Educator told them to do it. Today was the first time they gave the pills like that. They spoke to the speech language pathologist earlier and thought they were going to watch the resident take their pills, so they waited to administer the medications. They just wanted to give the resident their medications, so they administered them on their own. Some of the medications were scheduled for 9:00 AM and were given outside the hour window. They did not call to get approval from the physician to give them late but should have. It was important to give medications as ordered as the resident could have choked. During an interview on 1/23/2025 at 4:55 PM, the Registered Nurse Educator stated they told Licensed Practical Nurse #10 that Resident #110 had a diet change and speech pathology needed to see the resident to see if it was safe to take their pills by mouth. Registered Nurse Educator stated Licensed Practical Nurse #10 told them they gave the pills by mouth even though the order said via tube. Licensed Practical Nurse #10 was supposed to wait for speech pathology. Licensed Practical Nurse #10 did not mention they gave the medications late or if they spoke to the speech therapist. During an interview on 1/23/2025 at 1:32 PM, Licensed Practical Nurse Manager #15 stated the route medication was given was determined by the physician and was part of the physician order. A nurse could not make that determination. If the order read to give via tube, then meds should only be given that way. Resident #110 had a percutaneous endoscopic gastrostomy tube and dysphagia. Their medications should not have been administered by mouth on 1/17/2025 as they could have choked and aspirated. They expected nurses to follow the physician order. 10NYCRR 415.12(m)(1)

Based on observations, record review, and interviews during the recertification survey conducted 1/16/2025-1/24/2025, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen. Specifically, there were unclean areas in the kitchen; and potentially hazardous foods in the main kitchen were prepared and left out of temperature too long. Findings include: The facility policy, Cooling of Food Items, effective 8/5/2021, documented foods should be cooled 135 degrees Fahrenheit to 70 degrees Fahrenheit in 2 hours and from 70 degrees Fahrenheit to 41 degrees Fahrenheit in 4 hours (not to exceed 6 hours). If food is not cooled to 41 degrees Fahrenheit within 6 hours, reheat to 165 degrees Fahrenheit for at least 15 seconds (within 2 hours) and discard if not served immediately. Place pans in an ice bath and stir foods as they cool, then refrigerate. Place cooling items on the top shelf of the refrigerator or freezer uncovered or loosely covered in 2-inch shallow pans. The facility policy, Food Storage, last revised 7/6/2023, documented all perishable foods would be stored at proper temperatures, and refrigerated at 35-41 degrees Fahrenheit. During an observation on 1/16/25 at 10:55 AM the drain behind the oven was full and backing up with a strong, foul odor present. There was food debris under and around the equipment. During an observation on 1/16/25 at 10:59 AM a deep hotel pan of crab cake mix in the continental 2 door cooler was labeled as made 1/15. The crab cake mix was measured at 48 degrees Fahrenheit in the presence of the Director of Dietary. They stated food could be out of temperature for 2 hours and the mix was made the previous day by the night cook. They stated the drain had been a problem on and off. The Crab Cake production recipe documented once the crab cakes were portioned after mixing, chill the crab cakes for 2-3 hours. Cover product and marinate at or below 40 degrees Fahrenheit. During an interview on 1/16/25 at 11:05 AM the Facility Services Director stated they had a problem with the drain in the kitchen about 3 or 4 months ago and had the contractor come and snake it. During an interview on 1/17/25 at 2:22 PM the Director of Dietary stated cooling of food should not be done in quantity. They documented cooling temperatures of items like roasts. They prepared a lot of food the day before it was served, and they made sure it was completely chilled before service. They stated when using warm ingredients, such as the crab cake mix, it should have been put into shallow pans and chilled faster. During an interview on 1/16/25 at 2:30 PM [NAME] #43 stated they prepared the crab mix the previous evening mix using cold crab, eggs, heavy cream, and mayonnaise and breadcrumbs at room temperature. They placed it in the hotel pan and into the cooler. They stated they should have split the crab mix into shallower pans. Food could be out of temperature for 4 hours. During an interview on 1/17/25 at 2:51 PM Registered Dietitian #34 stated it was important to ensure foods were properly prepared, cooled, and stored to reduce the risk of any bacterial pathogenic growth and reduce the risk of food borne illness. 10NYCRR 415.14(h)

Based on record review and interview during the abbreviated survey (NY00289457 and NY00288549), the facility did not ensure residents were provided a therapeutic diet prescribed by a physician for 1 of 3 (Resident #1) residents reviewed. Specifically, Resident # 1 was admitted to the facility with a recommendation for an altered consistency diet due to a history of food obstruction. The resident did not have a physician ordered diet until after an episode of coughing and vomiting during a meal. The resident subsequently required hospitalization for removal of an esophageal food obstruction. Findings include: The facility policy Therapeutic Diets revised 7/6/2023 documented therapeutic diets will be ordered by the attending physician and shall be reviewed at least quarterly during the multidisciplinary care conference. Resident #1 was admitted to the facility with diagnoses including vertebral compression fracture, congestive heart failure (CHF), and esophageal obstruction. The 10/27/2021 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment, required extensive assistance for most activities of daily living (ADL), was edentulous (absence of teeth), and received a mechanically altered diet. The 10/18/2021 swallowing evaluation performed at the hospital prior to admission to the facility documented the resident had been treated for a food obstruction and a large bolus (ball-like mixture of food) of meat was removed from the esophagus. The resident had reduced mastication (chewing) due to edentulousness, and esophageal phase dysphagia (difficulty swallowing). An altered diet texture was needed including Level 6, soft and bite sized (soft, fork tender foods that are in small pieces), with Level 5 ground meats (minced and moist). A physician order dated 10/19/2021 documented mechanical soft diet with thin liquids. The order included a discontinued date of 10/19/2021. The physician's orders implemented on admission on 10/20/2021 did not document a diet order. The 11/8/2021 dietetic technician #9's progress note documented the absence of a diet order. They discussed with nursing and added a diet order for no added salt (NAS), mechanical soft per resident preference with thin liquids. The comprehensive care plan (CCP), initiated 11/9/2021, documented the resident had difficulty chewing/swallowing related to poor dentition requiring a pureed diet and history of esophageal dilatation (widening of the esophagus). Interventions included puree diet, low lactose, and thin liquids. There was no documented evidence of a diet order following the dietetic technician's note or the 11/9/2021 CCP update. A 12/22/2021 nursing progress note by registered nurse (RN) #3 documented the resident vomited on a pork chop this day. The resident stated it was slimy and they could not eat it. The resident vomited several times including a small amount of undigested food and copious amounts of phlegm. The facility was unable to provide a copy of the resident's meal ticket from 12/22/2021 documenting the diet order that was in place at that time and what food was provided to the resident that date. A 12/22/2021 licensed practical nurse (LPN) #9's progress note documented the resident continued to have dysphagia since lunch with emesis (vomiting) of fluids and phlegm. The evening Supervisor was notified. A 12/22/2021 statement by RN #3 documented during the medication pass, they had entered the resident's room and observed them retching and vomiting up pieces of meat. The resident stated they tried to chew the pork chop but it was slimy and they could not chew and swallow it. Observation of the meal tray included pureed vegetables and stuffing, and a pork chop that was not mechanically ground thoroughly. A 12/23/2021 progress note by speech language pathologist (SLP) #7 documented a swallow evaluation was requested due to the events at the noon meal on 12/22/2021. The resident reportedly consumed a whole pork chop cut up into small pieces. The resident was currently ordered to receive mechanical soft solids with ground meats due to history of oropharyngeal and esophageal phase dysphagia. The resident was edentulous and did not not have dentures. Yesterday the resident had an episode of emesis of undigested pieces of pork chop. The resident's family member reported a history of lower esophageal obstruction in 10/2021 which required endoscopy with removal of a piece of pork chop to resolve. The daughter reported another episodes of suspected esophageal obstruction that occurred when the resident was living at home which resolved on its own after a couple of days. The resident had a suspected esophageal blockage with incomplete clearance of food and liquids. SLP #7 recommended to consider emergency room transfer with gastroenterology evaluation with upper endoscopy to evaluate and treat a suspected esophageal obstruction. Additionally, downgrade to pureed solids and thin liquids pending assessment and treatment. A 12/23/2021 progress note by nurse practitioner (NP) #6 documented they completed a visit for coughing and vomiting. The resident complained of not being able to keep anything down. The resident's family expressed concern of a possible food bolus as the resident had a history of them. They requested the resident be sent out for evaluation. The resident was transferred and admitted to the hospital for bolus removal. The plan included to monitor tolerance of the diet and provide a mechanical soft diet with ground meats. On 12/23/2021, the physician's order documented NAS (no added salt), pureed texture, regular/thin consistency, low lactose. The facility investigation dated 12/24/2021 documented the resident had a diet order for mechanical soft, but the pork chop they received may not have been ground properly on 12/21/2021. At the time of the incident, physician's orders in the EHR did not document any diet order. After the incident occurred, the resident had a physician order written for pureed diet with thin liquids. The hospital discharge summary dated 12/27/2021 documented the resident was treated for an esophageal foreign body and esophageal distal stricture. The resident was also found to have a small hiatal hernia. Due to the dental problems, the resident should be on a pureed diet, as long as the resident does not have dentures they should not advance beyond ground consistency. During an interview on 10/5/2023 at 11:00 AM, physician #1 stated admission orders should include a diet order. The registered dietitian (RD) or nursing would review the discharge paperwork from the hospital to determine the diet that was needed. The information would be entered into the medical record for a signature. A correct diet order would be important to the resident to provide care. Lack of an accurate diet order could put the resident at risk for aspiration or choking. During an interview on 10/5/2023 at 12:00 PM, LPN #5 stated they transcribed admission orders from the physician to the electronic health record (EHR). The Admission Coordinator obtained discharge instructions, then the provider reviewed them. The nurses put the orders in the EHR, the provider reviewed and signed them as well as signing a paper copy and emailing. Diet orders were not always on discharge orders and sometimes were received during verbal report. If there was no diet order entered the dietary department should notice. They stated the first 2 things they usually checked admission orders for were the diet and code status. They did not remember if they entered Resident #1's admission orders. During an interview on 10/5/2023 at 10:47 AM, SLP #7 stated an SLP screen typically happened on admission if a resident had an altered diet ordered. That would be determined by hospital discharge documents or a verbal report. If there was no diet order, usually SLP or nursing would be asked to evaluate. All residents required a diet order to provide the correct texture/consistency to prevent aspiration or choking. SLP #7 had not been asked to see Resident #1 prior to the incident on 12/22/2021. They were not aware that there was not a physician diet order, or that the resident had a history of food obstruction prior to 12/22/2021. During an interview 10/18/2023 at 9:53 AM, diet technician #9 stated that while they were employed at the facility, they were provided oversight by an RD. There were gaps when the facility did not have an RD employed. A new admission required a review of primary medical history, weight, and nutritionally relevant information. This was obtained by the Admission Coordinator and placed in the chart for review. A diet order must be physician ordered and there could be input from the RD or SLP. A resident should not be fed without a diet order. Dietetic technician #9 did not remember the specific resident or incident. They stated they would have notified medical, nursing, therapy, and Administration if they had noted a missing diet order. They were not able to write diet orders, just make recommendation based on evaluation. They did remember during the time of the resident's admission, orders were missed. They stated a correct diet order was important for resident safety, to prevent choking or aspiration. 10NYCRR 415.14(e)

Based on record review and interview during the recertification survey conducted 6/1/23-6/8/23, the facility did not ensure each resident was offered influenza and/or pneumococcal immunizations and received education regarding the benefits and potential side effects of the immunizations for 3 of 5 residents (Residents #79, 102, and 416) and 6 of 11 staff (licensed practical nurse [LPN]#10, recreation aide #20, nurse practitioner [NP] #25, resident helper #26, certified nurse aide [CNA] #28, and dietary aide #30) reviewed. Specifically, there was no documented evidence Residents #79 and #146 were offered, declined, or educated on the pneumococcal immunization; no documented evidence Resident #102 was offered, declined, or educated on the influenza and pneumococcal immunization; and no documented evidence LPN #10, recreation aide #20, NP #25, resident helper #26, CNA #28, and dietary aide #30 were offered or educated on the influenza immunization. Findings include: The facility policy Pneumococcal Polysaccharide Vaccination revised 3/2016 documented the facility would provide vaccination against pneumococcal disease to prevent the spread of this type of infection. The vaccine would be offered to the resident population. All persons, upon admission, would be reviewed for receiving the pneumococcal vaccine. Each resident would be offered the recommended immunization unless contraindicated or already immunized. Documentation in the resident's medical record would include whether the resident did or did not receive the vaccine. The facility policy Influenza Vaccine revised 3/2019 documented all residents and employees who had no contraindications to the vaccine would be offered the influenza vaccine between October 1st and March 31st of each year. Education on benefits and side effects would be provided. Those receiving the vaccine would have documentation entered in their record. A resident's refusal would be documented on the Informed Consent for Influenza Vaccine and placed in the resident's record. An employee refusal would be documented on the Employee Informed Consent for Influenza Vaccine. The Infection Preventionist (IP) would maintain surveillance data. If the vaccine was administered from an outside agency, documentation would be provided to the facility. On 6/5/23 at 3:15 PM, the facility staff and resident immunization matrix for influenza and pneumonia vaccines documented LPN #10, recreation aide #20, NP #25, resident helper #26, CNA#28, and dietary aide #30, did not have a record of influenza vaccination being received or a declination of the vaccine including benefits and potential side effects of the vaccine. Residents #79 and 416 did not have a record for the pneumonia vaccine being received or a declination of the vaccine including benefits and potential side effects of the vaccine. Resident #102 did not have a record for either the influenza or pneumonia vaccine being received or a declination of the vaccine including benefits and potential side effects of the vaccine. During an interview on 6/7/23 at 12:57 PM, agency LPN #10 stated they refused the flu vaccine offered by their primary physician on 10/12/22 and had a copy of their declination on their mobile phone. The LPN stated no one at the facility asked about the flu immunization or a declination. During an interview on 6/7/23 at 1:08 PM, resident helper #26 stated they received the flu vaccine from an outside source and the facility did not inquire about their flu vaccines status. Resident helper #26 stated their flu vaccine documentation was at home. During an interview on 6/7/23 at 1:17 PM, activities leader #20 stated they started working at the facility in 3/2023 and was not offered the flu vaccine. The leader did not receive the vaccine from an outside source. Activities leader #20 stated the registered nurse (RN) Infection Preventionist (IP) asked about their immunization status on 6/6/23 and told them they would not receive the flu vaccine as it was too late in the season. During an interview on 6/7/23 at 2:23 PM, NP #25 stated they declined the flu vaccine and signed a declination. The NP stated they were unsure if the facility's Human Resource department had the declination on file. During an interview on 6/7/23 at 2:38 PM, the Director of Nursing (DON) provided the surveyor with a copy of agency LPN #27 flu declination that was provided by the nursing agency on this date. The DON stated the facility had no other declinations or vaccination records for the employees in question. During an interview on 6/8/23 at 9:41 AM, CNA #28 stated they were offered the flu vaccine by the facility and refused. The CNA could not remember if they were required to sign a declination. During an interview on 6/8/23 at 10:22 AM, the RN IP #29 stated they were responsible for tracking all resident and staff vaccinations, obtaining a refusal declination if needed, and educating staff during the flu season. Refusals were tracked via a declination form. The RN IP stated they offered and reminded staff needing either the vaccine or declination when they passed them in the facility hallways. The forms were on hand at the times the facility offered a formal vaccine clinic. The RN IP was aware the documents were a state requirement. New orientee's were provided the form with their orientation packet. If a staff member received the flu vaccine, a specific sticker was placed on their identification badge. The RN IP stated they came in on off-shift hours to vaccinate the staff working those hours. Agency staff personnel records were obtained from each agency. Staff who received the vaccine from an outside source were to submit the documents to the RN IP as proof. Residents receiving the vaccines had the administration date entered into their medical records. If a resident declined a vaccine, a declination form was obtained and entered into the resident's record. Unit Managers were to assist in obtaining the vaccination record or declination forms from families or outside physician offices for residents in the facility. They stated they did not know why declination forms were available. During an interview on 6/8/23 at 11:48 AM, the Director of Nursing (DON) stated employee and resident vaccinations were offered and tracked by the RN IP. If a staff member or resident refused, the RN IP was to obtain a signed declination, educate them on mask wear during flu season, and re-offer the vaccine later. The admissions department was to obtain the resident's immunization record upon admission. 10NYCRR 415.19 (a)(1-3)

Based on observation, record review, and interview during the recertification survey conducted 6/1/23-6/8/23, the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 2 of 3 resident units (Unit 2 including resident rooms 203, 214, 217, the second floor lounge area near the elevator, dining room, nursing station, tub room near room [ROOM NUMBER], soiled utility room across from the nursing station, the central shower room, the hallway to the ramp lounge; Unit 3 including resident room [ROOM NUMBER], and the hallway near emergency exit stairwell #2). Specifically, there were unclean and damaged floors, damaged walls, and unclean ceilings. Findings include: The following observations were made on Unit 2: - on 6/1/23 at 10:40 AM, the lounge area near the elevator had 1 stained ceiling tile. - on 6/1/23 at 10:48 AM, the dining room had two stained ceiling tiles and a 1 inch x 1 foot section of peeling wallpaper. - on 6/1/23 at 10:52 AM, the nursing station floor had a 3 inch circular divot depression in the floor, the flooring material was broken creating a potential tripping hazard. - on 6/1/23 at 11:00 AM, the tub room near room [ROOM NUMBER] had discolored hard water stains on the floor. - on 6/1/23 at 11:05 AM, resident room [ROOM NUMBER] had three circular divot depressions in the floor and the wall over the window had peeling paint. - on 6/1/23 at 11:55 AM and on 6/7/23 at 10:17 AM, resident room [ROOM NUMBER] had a 2 inch x 6 inch section of scraped wall near a window, and the cushions and the arm rests of the resident's wheelchair were unclean. - on 6/1/23 at 12:00 PM, the soiled utility room across from the nursing station had a 2 foot x 4 foot stained ceiling tile. - on 6/1/23 at 12:26 PM and on 6/2/23 at 9:37 AM, resident room [ROOM NUMBER] had an 8 inch section of scraped wall. - on 6/1/23 at 12:40 PM, the central shower room had a stained ceiling tile. - on 6/1/23 at 1:08 PM, the hallway to the ramp lounge had 5 windows with missing and damaged hardware. The windows opened fully to approximately 30 inches. The following observations were made Unit 3: - on 6/1/23 at 11:35 AM, the hallway near emergency exit stairwell #2 had four stained ceiling tiles. - on 6/1/23 at 12:00 PM, resident room [ROOM NUMBER] had four circular divot depressions in the floor, and a section of the floor was peeling. There was no documented evidence of submitted work orders for the environmental observations. During an interview on 6/7/23 at 9:30 AM, the Director of Housekeeping stated they were involved in the last monthly environmental tour of the facility. They stated they were aware of how to use the work order system and they had accessed it utilizing the computers at the resident unit nursing stations. The staff on the resident units were also aware of how to use the nursing station computer for work orders. The Director of Housekeeping stated the housekeeping supervisor usually covered the second floor. They stated four housekeepers had left the facility within the last three weeks. They stated they expected the housekeepers to check the resident units from floor to ceiling, including damaged floors, walls, and ceilings. The Director of Housekeeping stated they were not aware of the specific items identified and the maintenance department was responsible for checking the hardware on the windows. They stated that it was important to ensure that the environment was maintained within the facility as the residents were living there, and if areas were not homelike or in good repair the residents would not be happy and could be exposed to unsafe conditions. During an interview on 6/7/23 at 2:01 PM, the Director of Facilities stated they were aware of a few of the stained ceiling tiles but did not know the specific locations. They stated they did a daily walk-through of the facility which included checking random resident rooms. They also conducted annual facility inspections. The Director of Facilities stated they took notes on a pad during facility inspections, and if a serious issue was identified it should be entered into the work order system. They stated the housekeeping staff would report any issues they identified, and a housekeeping checklist was utilized by the housekeeping staff. The Director of Facilities stated that resident wheelchair washing was scheduled so that each wheelchair was washed at least once a month but could be placed on a routine schedule to be cleaned more frequently. They stated window hardware was checked annually, and any issues identified would be documented on a notepad. Window hardware was checked by housekeeping staff while in resident rooms. The Director of Facilities stated that it was important for the facility to have a clean, safe, homelike environment so that residents and staff were happy and safe. 10 NYCRR 415.29(j)(1) 43754

Based on record review and interview during the recertification survey conducted 6/1/23-6/8/23, the facility did not ensure residents and/or resident representatives the right to participate in the development and implementation of the person-centered plan of care for 1 of 1 resident (Resident #45) reviewed. Specifically, Resident #45 and/or the resident's representative were not invited to attend the resident's interdisciplinary care plan meeting and were not included in the care planning process. Findings include: The facility policy Interdisciplinary Care Plan Meetings revised 7/19/18 documented the resident and/or designated representative would understand their right to attend their interdisciplinary care plan meeting and to be an active participant in their plan of care. Upon admission, the resident and/or representative was provided with a letter inviting them to the admission care plan meeting at a time and date to be specified. Individuals were encouraged to attend all care plan meetings. Invitations were sent by the social worker. Resident #45 was admitted to the facility with diagnoses including panic disorder, anxiety, and depression. The 11/7/22 admission Minimum Data Set (MDS) assessment documented the resident was cognitively intact, self-choice and family involvement in care discussions were very important, and the resident participated in the assessment. The 11/4/22 admission assessment documented the resident had a diagnosis of dementia, wore glasses, was oriented to self/time/situation, and was verbally appropriate. The comprehensive care plan (CCP) initiated 11/9/22 documented the resident was independent for meeting emotional, intellectual, physical, and social needs. Interventions included encourage ongoing family involvement, invite the resident's family to attend special events, activities, and meals, and establish and record the resident's prior level of interests by talking with the resident and family on admission and as necessary. The was no documented evidence the resident or their representative were invited to or attended the initial admission care plan meeting. The 2/23/23 at 1:35 PM psychosocial progress note by the Director of Social Services documented the interdisciplinary team met for the resident's quarterly care plan meeting. The care plans were reviewed and updated. The resident was alert, oriented and able to make needs known; was nervous/anxious daily; and spoke with their family daily. There was no documented evidence the resident or the resident's family were invited to or attended the care plan meeting. During an interview on 6/1/23 at 10:41 AM, the resident's representative stated they had never been invited to a resident care plan meeting since the resident had been admitted and they would like to attend. During an interview on 6/6/23 at 1:14 PM, the Director of Social Services stated invitations for new admission and annual care plan meetings, unless the resident requested more frequent attendance, were sent to each resident and/or their family. The Director stated they were the only staff in their department, and they usually documented the invitation in a progress note. The Director of Social Work stated the resident had told them in the past they did not want to attend a meeting and wanted their family to attend instead. They stated the facility had conducted admission and quarterly care plan meetings for the resident and there was no documentation the family attended or was invited. When re-interviewed on 6/8/23 at 10:15 AM, the Director of Social Services stated the facility had a discussion initially with the resident's family regarding long term care placement, therapy completion, and advance directives. The Director stated the facility used to send invitations to care plan meetings prior to COVID-19 and was not sure why that practice ended. Invitations were based on the MDS schedule and sent a week or two prior to the scheduled care plan meeting. The Director did not know why the invitations for this resident were not sent or why a progress note was not written. During an interview on 6/8/23 at 11:23 AM, licensed practical nurse (LPN) Unit Manager #5 stated care plan meetings were based on the MDS schedule and resident/family invitations were sent by the social services department. The LPN Manager stated the resident's family was very involved in their care and the resident was cognizant enough to attend a care plan meeting if they desired. The LPN Unit Manager was not sure if the resident or family were ever invited to the meetings. During an interview on 6/8/23 at 11:35 AM, the Administrator stated they expected that an invitation to at least the initial/annual/significant change care plan meetings was sent to the resident and/or their family. Invitations were provided by the social services department in the in-person, by telephone, or by mail. The Administrator expected the invitation to be documented in the care plan meeting notes or in a progress note. The Administrator was not aware that the family or the resident had not been invited to a meeting. 10NYCRR 415.3(e)(v)

Based on observation, record review, and interview during the recertification survey conducted 6/1/23-6/8/23, the facility did not ensure that prompt efforts were made to resolve grievances that residents may have for 1 of 1 resident (Resident #42) reviewed. Specifically, Resident # 42 had a pair of gray pants misplaced in the laundry that were not replaced. The facility policy, Resident Complaint and Grievance Process dated 2/2012 documented as part of the facility's commitment to safe, respectful, and high-quality care, all concerns brought to the organization's attention by residents/legal representatives shall be reviewed in a timely manner. This organization shall respond to such concerns in a timely, reasonable, and consistent manner. Resident #42 was admitted with diagnoses including Parkinson's disease (a progressive neurological disorder), depression, and anxiety. The 4/5/23 quarterly Minimum Data Set (MDS) assessment documented the resident was cognitively intact and required limited assistance with most ADLs. During an interview on 6/1/23 at 11:34 AM the resident and their spouse were in the resident's room and the spouse stated the resident had been missing pants for about 3 months. The spouse described the pants as gray colored scrub pants with an elastic waist and had been bought at the recommendation of staff due to ease of putting them on and taking them off the resident. They stated the purchase price had been about $48.00. The resident's spouse stated they had notified all unit certified nurse aides (CNAs) when the pants were noticed missing. The pants were labelled by the laundry department with the resident's name when they were brought into the facility. The resident and their spouse stated neither one of them had been updated about the missing pants in at least 2 months and the pants had not been replaced. There was no documented evidence a missing item report or grievance form had been completed for the resident's missing pants. During an interview on 6/7/23 at 11:15 AM, certified nurse aide (CNA) #34 stated most resident laundry was done in the facility, unless resident families did it. Resident #42's family did not do their laundry. Resident clothing was dropped off at reception for labeling so when it went to laundry it could be returned to the right resident. The CNA stated they had a few residents who complained of missing laundry. Resident #42's spouse had reported a pair of gray scrub pants that were missing. The CNA stated they either go in person to laundry or call laundry to report missing items. They were not sure if Resident #42's pants were found. During an interview on 6/7/23 at1:16 PM, licensed practical nurse (LPN), Unit Manager # 35 stated all resident clothing went to the front desk, then to laundry for labeling with the resident's name. The LPN Unit Manager stated If a resident complained of missing clothing, they called laundry to report it, and attempted to find the item. Resident #42's spouse let them know the gray scrub pants were missing. The LPN Unit Manager stated they followed up with laundry and heard nothing more, so they assumed it was resolved. During an interview on 6/7/23 at 2:26 PM, the Director of Social Work (SW) stated they were the grievance officer for the facility. Grievance forms were available on the units and should be filled out for missing clothing. Staff should assist a resident with looking for missing items, but if not found a grievance should be filled out. A grievance form for missing items would be the only way for the facility to know to investigate. The Director of SW stated they would receive the grievance then review it with the Administrator and the Director of Nursing. Staff were told in orientation to notify SW of missing clothing. The SW was not aware resident #42 was missing clothing and did not have a grievance form on file. During an interview on 6/8/23 at 9:26 AM, Laundry Supervisor #36 stated resident clothing was turned in at reception on admission to be washed, dried, labelled, and inventoried. Any new clothing should follow the same process. If an article of clothing came through with no name, it was kept for at least 90 days while trying to find the owner. A resident should let CNAs, or the nurse know about missing items and nursing staff should notify laundry. They were aware Resident #42 was missing one sock, and a pair of gray scrub pants. The Laundry Supervisor stated they had searched everywhere and did not find the resident's items. They stated they remembered labeling the gray scrub pants themself. They kept looking for the pants and there had not been any resolution. The facility should have a way to help the resident with missing items, but they were not sure what it was. During an interview on 6/8/23 at 10:48 AM, the Administrator stated the grievance officer was the Director of SW. They stated if staff was notified of a missing item, they should look for the item and if not found they should help the resident fill out a grievance form. Staff were educated on the grievance process during orientation. The employee handbook also included the grievance process. Staff should make sure the Director of SW was aware of the grievance otherwise the concern would not be followed up on. 10NYCRR 415.3(c)(1)(i)

Based on observations, record review, and interviews during the recertification survey conducted 6/1/23-6/8/23 the facility did not ensure the development and implementation of a comprehensive person-centered care plan for each resident that included services to attain or maintain the highest practicable well-being for 2 of 3 residents (Residents #101 and 102) reviewed. Specifically, Resident #102 received Lovenox (blood thinner) injections and did not have a care plan that included precautionary and monitoring measures for possible adverse effects; and Resident #101 did not have an individualized care plan that included the resident's customary routines, interests, preferences, and choices to enhance their well-being and to guide staff in managing the resident's dementia care. Findings include: The facility policy Baseline Care Plan revised 3/24/22 documented baseline care plans would be developed and implemented for each resident and include instructions needed to provide effective and person-centered care for the resident. Care plans should contain a list of current medications and services and treatments to be administered by the facility. The facility's April 2023 Dementia Care and Management training documented residents with dementia had a progressive brain disorder that made it more difficult for them to remember things, think clearly and communicate with others, or take care of themselves. In addition, dementia could cause mood swings and even change a person's personality and behavior. The training objectives included tips for communicating with residents with dementia, behaviors, and non-pharmacological considerations for behaviors, and a review of differences of dementia, delirium, and depression. 1)Resident #102 was admitted to the facility with diagnoses including left femur (thigh bone) fracture, and history of falls. The 4/11/23 Minimum Data Set (MDS) assessment documented the resident was cognitively intact, required extensive assistance of 2 for bed mobility and transfers, limited assistance of 1 for locomotion on the unit, did not ambulate, had a history of falls, and received daily injections. A physician order dated 4/7/23 documented Lovenox injection solution, prefilled syringe 40 milligrams (mg)/0.4 milliliters (ml), inject subcutaneously every 24 hours for DVT (deep vein thrombosis, blood clot) prevention, with an end date of 6/9/23. The 4/7/23 unsigned admission/readmission screening documented the resident had bruising on the left thigh/pelvis/groin status post left total hip replacement. The screening did not document the use of Lovenox. The comprehensive care plan (CCP) active through 6/8/23 did not include a focus of anticoagulant therapy to include monitoring for potential adverse effects related to bleeding. The 6/7/23 Kardex (care instructions) did not include recognition of and monitoring for adverse effects of anticoagulant therapy. During an interview on 6/7/23 at 11:09 AM certified nurse aide (CNA) #34 stated resident care needs were found on the Kardex. They stated they had never seen a Kardex that included the need to monitor residents that were on blood thinners. CNA #34 stated at a previous employment CNAs were not allowed to cut a resident's fingernails if they were on blood thinners, but they had not been educated on any restrictions at this facility. During an interview on 6/7/23 at 11:59 AM licensed practical nurse (LPN) Unit Manager #35 stated potential risks of anticoagulant use could include impaired skin integrity such as bruising, bleeding, gastrointestinal (GI) bleeding, and abnormal laboratory values. Fall prevention was important if a resident received anticoagulants. Staff should notify the nurse for any abnormal bleeding. The LPN Unit Manager stated there should be a care plan in place for anticoagulants. Registered nurses (RNs) were responsible for initiating care plans. During an interview on 6/7/23 at 1:27 PM nurse practitioner #25 stated high risk medications included anticoagulants, antipsychotics, and antiseizures. They required extra monitoring on a day to day basis. If a resident received anticoagulants they should be monitored for bruising, bleeding of the gums, fall risk, and dark tarry stools. High risk meds should be care planned and included on the Kardex to make staff aware of possible side effects. Resident #102 was on Lovenox and should have been monitored for adverse effects. During an interview on 6/8/23 at 9:46 AM RN Nurse Educator #48 stated high risk medications included anticoagulants. Residents receiving these medications should be monitored for possible adverse effects including bleeding. Staff should monitor for bruising, dark tarry stools, bleeding during oral care, nose bleeds, and blood in vomit, and notify the nurse if they were present. They stated the Kardex should be resident specific and should crosswalk with the CCP. During an interview on 6/8/23 at 10:14 AM the Director of Nursing (DON) stated the admission care plans were initiated by RNs, including the DON, the night RN Supervisor, the MDS nurse, and the Nurse Educator. Care plans were resident specific. The hospital discharge summary, admission assessments, and medication orders should be reviewed to include in the CCP. Anticoagulants were considered a high risk medication and should be care planned. Staff should monitor the resident for prolonged bleeding, bruising, bleeding gums, and signs of a GI bleed. They stated this should be communicated to the CNAs by the Kardex, so they were aware. 2)Resident #101 was admitted to the facility with diagnoses including dementia, recurrent major depressive disorder with psychotic symptoms, and anxiety. The 4/3/23 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition, it was very important for the resident to do things with groups of people, go outside when the weather was good, participate in their favorite activities, and participate in religious services and/ or practices. The resident required extensive assistance of 2 for transfers and dressing, limited assistance of 1 with locomotion on and off the unit, received an antipsychotic for 3 of 7 days, and received an antidepressant for 7 of 7 days. The March 2023 physician orders documented the resident received 20 milligrams (mg) escitalopram (Lexapro, antidepressant) once daily, 300 mg bupropion XL (Wellbutrin, antidepressant) once daily, and 2 mg aripiprazole (Abilify, antipsychotic medication) every other day at bedtime for hallucinations. The comprehensive care plan (CCP) initiated 3/10/23 did not include person-centered plans that supported the resident's dementia, depression, or activities care needs. On 4/28/23 the CCP was updated to include the resident as an elopement risk/wanderer related to impaired safety awareness. Interventions included certified nurse aides (CNAs) were to check for presence of [wander detection device] bracelet during care and report to charge nurse immediately if missing, keep picture of resident at reception desk, monitor location every 2 hours, and check wander guard bracelet functionality. There was no documented evidence of an individualized care plan with interventions that included the resident's customary routines, interests, preferences, and choices to enhance their well-being and to guide staff in managing the resident's care. On 5/1/23 the licensed clinical social worker (LCSW) #33 from an outside behavioral health services documented the resident was referred for inability to adjust to illness, increased anxiety, and cognitive difficulties. The resident's mood appeared depressed, and they had trouble concentrating. The resident was interested in utilizing therapy. Non-pharmacological interventions that could be used by the treatment team and resident included empathic listening and statements to facilitate adjustments and sense of support, encourage participation in pleasant activities, and provide positive reinforcement. A stamp on the progress note documented Nursing Review dated 5/22/23. The undated care instructions documented staff would monitor interactions between the resident and others for safety, they would intervene and separate the residents if interactions became verbal or physical. Additionally, check presence of wander guard bracelet during care and report to charge nurse immediately if missing and monitor location every 2 hours. There was no documented individualized resident centered interventions. During an observation and interview on 6/1/23 at 4:41 PM, the resident was in their room in their wheelchair, reading a book, and their television was on. During the interview the resident began to cry as they talked about the loss of their family members. The resident stated they liked to read fiction books and there were no activities, and they went to therapy. During an interview on 6/7/23 at 2:00 PM licensed practical nurse (LPN) Unit Manager #5 stated a registered nurse (RN) needed to initiate the CCP. Residents should have care plans for dementia and depression diagnoses. The CCP should be resident centered as that was how staff know what care to provide the residents. They stated Resident #101 did have a diagnoses of dementia and depression and was also followed by behavioral health services. They stated they were in charge to ensure the CCP was complete and accurate. They were unaware the resident's CCP did not included dementia or depression. They reviewed the behavioral health services recommendations but did not add the interventions to the CCP. The recommended interventions could help the resident feel more comfortable. During an interview on 6/8/23 at 8:40 AM, the Director of Recreation stated it was their job to ensure the resident's activity care plan was in place within 5 days of admission. It was important to have care plans in place, so staff knew how to care for and engage the resident. Activities were important for residents with dementia and depression as they could boost their moods. They were unaware the resident did not have an activity care plan and did not recall any of the behavioral health services recommendations being discussed during the interdisciplinary team (IDT) morning meetings. During an interview on 6/8/23 at 11:07 AM, the Director of Social Services stated they created some topic areas on the CCP but there was no discipline who was assigned to create the depression or dementia topics on the CCP. It was important for the CCP to be resident specific as it showed staff how to care for the resident. They were aware Resident #101 had diagnoses of depression and dementia and they did not know the resident was not care planned for depression or dementia. During an interview on 6/8/23 at 12:06 PM, the Director of Nursing (DON) stated a RN needed to initiate care areas on the CCP because LPNs could not. LPNs could update the CCP once it had been started. It was important for residents to be care planned for dementia and depression as it impacted how staff cared for them. It was also important for the residents to have activity care plans as activities could help with depression. They stated staff received annual dementia care training. 10NYCRR 415.11(c)(1)

Based on observation, record review, and interview during the recertification and abbreviated (NY00316633) surveys conducted 6/1/23-6/8/23, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 4 residents (Residents #6 and 50) reviewed. Specifically, Resident #6 was not assisted with toileting as planned; and Resident #50 was not assisted with getting out of bed and was not dressed. Findings include: The facility policy, Increasing Resident Independence revised 1/2021 documented direct health care providers should assist, support, and encourage the resident to maintain good standards of personal hygiene and grooming which included: bathing, teeth care (oral care), hair care, assistance with dressing (as needed), nail care, proper toileting, and elimination/reduction of body odors. The facility policy, Incontinent Care revised 11/2022 documented every incontinent resident would be washed and clothing changed as soon as possible after occurrence to prevent odors, irritation, and skin breakdown and to maintain cleanliness, comfort, and dignity. 1) Resident #6 was admitted with diagnoses including major depressive disorder, abnormalities of gait/mobility, and history of a healed fracture. The 4/29/23 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, required extensive assistance of 2 for toileting, was totally dependent on 2 for transfers with a mechanical lift, did not reject care, and was always incontinent of urine and bowel. The comprehensive care plan (CCP) initiated 9/27/19 and revised 10/31/22 documented the resident had frequent bladder incontinence related to impaired mobility. Interventions included disposable briefs and clean peri-area with each incontinence episode. The resident had a self-care performance deficit or limited physical mobility related to impaired mobility. Interventions included extensive assistance of 1 for toilet use, and assistance of 2 using a mechanical lift for transfers. The resident care instructions as of 6/2023 documented the resident required extensive assistance of 1 for toileting, total dependence on 2 for transfers by a mechanical lift, used white incontinence briefs, and was to be checked and changed every 2 hours. During a continuous observation on 6/1/23 from 8:17 AM-12:06 PM, Resident #6 was observed: - at 8:17 AM sitting in their wheelchair in the dining room eating breakfast; - at 9:48 AM sitting at the dining room table with 2 other residents; - at 10:14 AM eating ice cream in the dining room. - at 10:43 AM, being brought to their room by certified nursing assistant (CNA) #7. The CNA turned the resident's TV on and did not check or change the resident. - at 11:20 AM sitting in their room in front of the television. - at 12:06 PM, being transported by CNA #7 to the dining room for lunch. The resident was not checked or changed from 8:17 AM-12:06 PM. The 6/1/23 activity of daily living (ADL) documentation survey report documented the resident was toileted at 2:09 PM. During a continuous observation on 6/5/23 from 9:17 AM-1:46 PM, Resident #6 was observed: - at 9:17 AM sitting in their wheelchair in the dining room with a mechanical lift pad underneath them. - at 10:25 AM sitting at the dining room table with two other residents. - at 10:41 AM being brought to their room by registered nurse (RN) Unit Manager #13 who turned the television turned on. - at 11:54 AM, in their room in front of the television. -at 12:20 PM, being brought to the dining room by CNA #7 for lunch. -at 1:33 PM sitting at the dining room table after lunch. No staff interactions were observed. -at 1:45 PM sitting at the dining room table after lunch. No toileting, checking, or changing occurred from 9:17 AM-1:46 PM. The activity of daily living (ADL) documentation survey report did not document toileting from 6/5/23-6/8/23 from 7:00 AM to 3:00 PM. During an interview on 6/5/23 at 1:50 PM CNA #7 stated they were familiar with Resident #6. They stated they typically did morning care at 6 AM for all their assigned residents and then after lunch they put residents back to bed and changed them. CNA #7 stated that residents did not get changed every 2 hours today because there were only 2 CNAs to do care. They stated if there were 3 or 4 CNAs then residents would get checked more often. During a follow up interview on 6/6/23 at 11:04 AM CNA #7 stated Resident #6 was not checked or changed at all during the day shift on 6/5/23 because there were 2 CNAs on the unit all shift and the resident was a mechanical lift and required 2 people to use. During an interview on 6/7/23 at 12:40 PM licensed practical nurse (LPN) #10 stated Resident #6 required a mechanical lift and total care for all their activities of daily living. The resident was care planned to be checked and changed every 2 hours and this should be followed. LPN # 10 stated the resident was at risk for skin breakdown and irritation if they were not checked and changed and not provided incontinence care. During an interview on 6/7/23 at 2:01 PM with RN Unit Manager #13 stated Resident #6 required total care and used a mechanical lift. The RN Unit Manager expected staff to check and change the resident every 2 hours starting at the beginning of their shift when staffing was available. They stated there were 2 CNAs working on the unit on 6/5/23. They stated if there were 3 CNAs on the unit, they would expect the resident to be checked and changed every 2 hours. 2) Resident #50 had diagnoses including stroke with hemiplegia (paralysis), lower leg contractures, and adjustment disorder. The 5/13/23 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, sometimes understood others or made self understood, had inattention and disorganized thinking, felt it was somewhat important to choose their own clothes, required extensive assistance of 2 with dressing, toilet use, and hygiene, had functional limitation in both legs, and was always incontinent of bowel and bladder. The Kardex (care instructions) active 6/2023 documented the resident was scheduled for a shower on Tuesday evenings with 2 person assistance. The resident was totally dependent for dressing, toileting, and personal hygiene, required extensive assistance of 2 for bed mobility. The 5/31/23 comprehensive care plan (CCP) documented the resident had an ADL self performance deficit and limited physical ability related to stroke, weakness, and contractures. Interventions included total dependence of 1 for dressing, hygiene, and toileting; explain care prior to providing; reapproach 5-10 minutes later and reattempt; ask yes/no questions; cue and reorient; and allow choice and reapproach if refusing. During an observation on 6/5/23 at 10:47 AM, Resident #50 was lying on their back in bed wearing a hospital gown. There was a body wedge under their right shoulder. There were multiple clean shirts and pants in the resident's closet and dresser. At 12:46 PM and 2:13 PM, the resident remained lying on their back in bed wearing a hospital gown. The 6/5/23 resident ADL documentation survey report documented certified nurse aide (CNA) #21 signed at 2:18 PM the resident was dressed using extensive assistance of 1. During an observation on 6/6/23 from 8:28 AM-12:30 PM, Resident #50 was lying on their back in bed wearing a hospital gown. From 1:00 PM until 2:33 PM, the resident was lying on their back in bed wearing a hospital gown. The 6/6/23 resident ADL documentation survey report documented CNA #21 signed at 11:32 AM the resident was dressed and was totally dependent on 1. There were no progress notes documenting the resident refused to be dressed on 6/5/23 or 6/6/23. During an interview on 6/6/23 at 1:51 PM, CNA #21 stated they were assigned to Resident #50. Staff had to do everything for the resident. They stated the resident was able to voice their needs occasionally and preferred to lie on their back in bed. They stated the evening shift got the resident out of bed on occasion. The CNA stated they did not offer to get the resident out of bed on 6/5/23 or 6/6/23 and they did not know why the resident was not dressed in their own clothes. The CNA stated morning care was provided by day shift staff. During an interview on 6/6/23 at 2:49 PM, licensed practical nurse (LPN) #16 stated resident specific care was documented in the resident's care plan. Staff were to document all care refusals and the nurse was to make a progress note. Staff were to offer to dress Resident #50 daily. CNAs should inform the nurse if a resident refused care. The LPN did not know why the resident was not dressed for 2 days. During an interview on 6/8/23 at 11:06 AM, LPN Unit Manager #5 stated they expected residents to be dressed daily by 2:00 PM unless they refused. The CNA was to tell the Unit Manager of refusals, and refusals should be documented in the resident's electronic record. The resident required total care and could be resistive with care. The LPN Manager stated they expected staff to dress the resident in at least a shirt every day. The medication nurses were responsible for ensuring that each resident was dressed daily, prior to lunch. The LPN Manager did not know why the resident was not dressed on 6/5/23 and 6/6/23 as the resident had clothes in their room. During an interview on 6/8/23 at 11:54 AM, the Director of Nursing (DON) stated each resident should be dressed and out of bed before noon unless they refused. CNAs should notify the unit nurse know of any refusals and the refusal should be documented in the resident's record. 10NYCRR 415.12(a)(3)

46276 Based on observation, record review, and interviews during the recertification survey conducted 6/1/23-6/8/23, the facility did not ensure they provided residents with an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 2 of 4 residents (Residents #83 and 86) reviewed. Specifically, Residents #83 and 86 were not offered meaningful activities of their choosing as care planned. Findings include: The facility policy, Activities dated 2/7/22 documented upon admission there was a set procedure to provide continuity of car. The Activities Director gathered information from Social Services and Director of Nursing (DON), resident was greeted by staff and provided an activities calendar, an activities assessment was done within 14 days, and the resident's likes and preferences were communicated to the activity staff by the Activity Director. The facility Activities Calendar documented the following scheduled activities for June 2023: - 6/1/23- 8:00 AM Daily chronicle, 10:30 AM crossword [NAME] 1st floor dining room, 10:30 AM mobile nail cart, 2:00 PM Words in Words game 1st floor dining room, 2:00 PM sensory room, and 4:00 PM Games recreation room - 6/2/23- 8:00 AM Daily chronicle, 10:30 AM Gospel sing-along recreation room, Food committee 1st floor dining room, Chair Tai Chi 3rd floor, 2:00 PM Bingo 2nd floor, 2:00 PM origami surprise box recreation room, and 4:00 PM trivia recreation room. - 6/5/23- 8:00 AM Daily chronicle, 10:00 AM Resident council meeting recreation room, 10:30 AM ART-[NAME] 3rd floor and 2:00 PM Movies recreation room. - 6/6/23- 8:00 AM Daily chronicle, 10:30 AM Kaffeeklatch (coffee & news) recreation room, 10:30 AM Art on 2nd floor, starfish [NAME], Cooking together recreation room, 2:00 PM Balloon volleyball 3rd floor, 4:00 PM Monopoly recreation room - 6/7/23- 8:00 AM Daily chronicle, 10:30 AM Crossword [NAME] 1st floor dining room, 10:30 AM mobile nail cart, 2:00 PM workout Wednesday's 3rd floor-arms, and 4:00 PM Card Sharks recreation room. 1) Resident #83 was admitted to the facility with diagnoses including cerebral vascular disease and dementia. The 4/1/23 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment, had behavioral symptoms not directed toward others 1-3 of 7 days, required supervision with most activities of daily living (ADLs), felt that reading, music, pets, going outside, and doing favorite activities was very important, and doing things with groups was somewhat important. The comprehensive care plan (CCP) revised 3/27/23 documented the resident was a high risk for falls related to vascular dementia and impaired decision making. Interventions included to encourage the resident to participate in activities that promoted exercise, physical activity for strengthening, and improved mobility as tolerated. There was no individualized person-centered care plan for activities. An unsigned 3/27/23 activity assessment documented the resident graduated from an Ivy League college, used to play baseball, liked historic building preservation, loved dancing, 60s and 70s music, Indian food, pets, and nature. Activities should be modified to accommodate their cognitive deficit. The resident's CCP did not include an individualized person-centered care plan for activities based on their assessed interests and background. The resident care instructions active for 6/2023 documented the resident was independent with mobility and required limited assistance of 1 for transfers and dressing. The resident was to be monitored for location every 2 hours, participate in activities that promoted exercise, physical activity for strengthening, and help improve mobility. Resident #83 was observed: - on 6/1/23 at 11:28 AM pacing in the hallway of the 3rd floor. At 11:41 AM returning to their room and lying down in bed. - on 6/2/23 at 10:19 AM sleeping in bed. At 11:09 AM, 11:13 AM, and 11:29 AM walking up and down the unit hallway. There was no activity calendar posted on unit and no activities were taking place on the unit. At 11:56 AM the resident was lying down in their bed. - on 6/5/23 at 9:12 AM in the dining room; at 9:57 AM and 10:05 AM walking in the hallway; at 10:12 AM and 11:33 AM sitting in an orange chair by the elevator; at 12:44 PM walking to their room; and at 12:57 PM pacing in the hallway. The resident was not observed engaged in any group or individual activities. - on 6/6/23 at 9:44 AM lying in bed in their room. The resident was not observed engaged in any group or individual activities. The activity task record completed by activities leader #19 documented the resident attended the following activities: - on 6/5/23 at 11:55 AM Music therapy/program exercises (did not correspond to the scheduled activities on the June 2023 calendar). - on 6/6/23 at 9:07 AM Music therapy/program exercises (did not correspond to the scheduled activities on the June 2023 calendar). 2) Resident #86 was admitted to the facility with diagnoses including major depressive disorder and dementia. The 3/19/23 Minimum Data Set (MDS) assessment did not include the resident's cognitive status, the resident required supervision with walking in their room and the corridor. The 9/17/22 MDS documented the resident had severe cognitive impairment, did not exhibit behavioral symptoms, and felt it was somewhat important to listen to music, and very important to be around animals, keeping up with the news, doing things with groups of people, doing favorite activities, going outside, and participating in religious services or practices. The comprehensive care plan (CCP) revised 6/14/22 documented Resident #86 spent most of their time wandering and sleeping. Interventions included to provide a program of activities that was of interest and empowered the resident by encouraging/allowing choice, self-expression and responsibility, introduce the resident to other residents with similar backgrounds and interests, the resident needed bedside/in-room [ROOM NUMBER]:1 visits if unable to attend out of room activities, the resident preferred piano, socializing with staff and peers, and preferred activities included knitting, yoga, piano, pets, travel, church, and cooking. An unsigned 3/17/23 Activities-Participation Review documented the resident would wander in and out of some structured activities on the unit. The resident had confusion and had a hard time focusing for long periods of time. The resident had no perception of personal space at times and tended to upset other residents when this occurred. The resident enjoyed listening to music, 1:1 interactions with staff, some a la carts, watching TV, visiting with family and some special events. The resident care instructions as of 6/2023 documented encourage resident to participate in activities that promote exercise; invite to additional intakes, provide with activities calendar, and notify of changes. Resident #86 likes piano music, socializing with staff and peers. knitting, games, pets, travel, music, church, cooking, playing piano and likes 1:1 visits for social and sensory. Resident #86 was observed: - on 6/1/23 at 12:58 PM, 1:16 PM, and 1:28 PM in the TV room sleeping on the couch; at 2:25 PM sitting up on the couch; at 2:48 PM walking around the unit; and at 4:39 PM walking around the unit. No activities were observed being conducted on the unit during these times. - on 6/2/23 at 8:55 AM and 9:01 AM walking around the unit; at 10:27 AM sitting in orange chairs by the nursing station; at 10:55 AM attempting to socialize with a physical therapist walking by; at 11:53 AM sitting in orange chairs by the nursing station; and at 12:43 PM walking in the hall on the unit - on 6/5/23 at 9:11AM walking on the unit; at 9:30 AM spitting on their hands and touching tables in the TV room; at 10:00 AM spitting on their hands and touching chairs by the elevator; at 10:25 AM walking out of their room saying I don't know what to do to keep ourselves going; and at 10:30 AM asking staff if they could follow them and staff did not interact with Resident #86. The resident was not observed participating in activities of interest as planned. The activity task record completed by activities leader #19 documented the resident attended the following activities from 6/5/23-6/6/23: - on 6/5/23 at 8:41 AM Music therapy/program exercises (did not correspond to the scheduled activities on the June 2023 calendar). - on 6/6/23 at 9:07 AM TV/Movies and at 2:59 PM family/friend/activity/staff visits (did not correspond to the scheduled activities on the June 2023 calendar). - on 6/7/23 at 2:59 PM family/friend/activity/staff visits (did not correspond to the scheduled activities on the June 2023 calendar). During an interview on 6/6/23 at 11:32 AM activities leader #19 stated the 3rd floor was a dementia unit, it was not treated any differently than other floors, and they did not have an overall dementia program or specialized activities. They stated that recreation aide #20 usually conducted cognitive programs such as crafts and they usually passed out the Daily Chronicle at 8:00 AM. They stated if the resident was in the area when the radio was on that is what they documented. They stated they received dementia training yearly and was also a certified nurse aide (CNA). During an interview on 6/7/23 at 12:27 PM CNA # 21 stated the 3rd floor had no activities for a while since the previous activity person retired. They stated there was TV for activities and occasionally they had Bingo. They stated there were no 1:1 activities. CNA #21 stated if there was an outdoor activity, they took residents downstairs but struggled because the residents had dementia and could have behaviors, so it was hard to take them outside. They stated they tried to engage with the residents on the unit during their shift. They thought the residents could be bored if they did not have activities and a lack of activities could affect the residents' quality of life. They stated Resident #86 liked music and Resident #83 was more of an observer. During an interview on 6/7/23 at 12:47 PM, licensed practical nurse (LPN) #16 stated there were no daily activities on the unit. Sometimes the residents went to another floor for activities but there were no 1:1 activities provided on the unit. LPN # 16 stated Resident #83 could sometimes engage in activities, and usually walked about the unit, had audio books, and speech therapy worked with them to learn how to use them. Resident #86 wandered and did attend music activities. During an interview on 6/7/23 at 1:07 PM recreation leader #20, stated they had no educational background in recreation, all the units had the same activities, and they conducted activities based on the calendar on the 2nd and 3rd floor. They stated they did not provide chair tai chi for the 3rd floor on 6/2/23. During a second interview on 6/7/23 at 1:17 PM, recreation leader #19 stated the [NAME] activity did not happen on the 3rd floor because they were pulled to work as a CNA on the 2nd floor. They stated if they charted music therapy it meant the residents were sitting in the dining room listening to music. If they charted exercise, it would be physical, but many items were lumped together in the same category. Resident #83 did not do structured activities and refused 1:1 when they talked to them. The recreation leader stated staff also passed out the Daily Chronicle (an informational sheet with trivia and facts) to residents. They stated Resident #83 liked music, would attend music activities, but would not attend most structured activities. During an interview on 6/7/23 at 1:30 PM Recreation Director #18 stated the 3rd floor had residents with memory care issues. They stated they offered residents with dementia the same programs as those without. They also offered each resident activities based on their abilities. They oversaw the activities on the calendar. If an activity was on the calendar, then it should take place. They stated they were not aware that chair tai chi and [NAME] did not happen. Activity Director #18 stated if music was turned on in the dining room that would not be considered music therapy. Group activities should occur on the 3rd floor, and they wanted to be made aware if an activity did not occur. Lack of activities could affect residents' quality of life. They stated neither Resident #86 nor Resident #83 attended structured activities. During an interview on 6/8/23 at 9:10 AM occupational therapist (OT) #23 stated Resident #86 would stay up for days and sleep for days. Their significant other visited almost daily, and they enjoyed the visits. Resident #83 would mostly observe activities on the unit. The 3rd floor did not have a lot of activities. They brought in a projector screen and keyboard that played music, and the residents who did not usually verbalize would say thank you afterward. They stated they played cards and provided modified assistance to the residents. Therapy would also take the residents outside at times. The therapy department collaborated with a local college and created different type of activities they used for therapy, such as playing catch. They also included other residents that were in the vicinity to those activities to engage them as well. . 10NYCRR 415.5(f)(1)

conducted 6/1/23-6/8/23, the facility did not ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #99) reviewed. Specifically, Resident #99 had a history of multiple falls and did not have their locked wheelchair placed next to them while in bed as planned. Findings include: The facility policy Fall Prevention revised 3/24/22 documented findings from the resident fall risk evaluation should be incorporated to reduce the number of falls. The facility policy Baseline Care Plan revised 3/24/22 documented implementation of the baseline care plan was to increase resident safety and safeguard against adverse events. Resident #99 was admitted to the facility with diagnoses including dementia, unsteadiness, and a history of repeated falls. The 4/10/23 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, required assistance of 1 for walking, extensive assistance of 2 for bed mobility and toilet use, limited assistance of 1 for transfers, had functional limitation of 1 leg and 1 arm, used a walker or wheelchair, had 2 falls with no injury and 2 falls with minor injury since admission, and received physical therapy (PT) and occupational therapy (OT). The 3/30/23, 5/2/23, and 5/10/23 Fall Risk Assessments documented the resident had fallen in the past, did not use ambulatory aids, had difficulty rising from a chair, could not walk unassisted, had an impaired gait, and was a high fall risk. The 4/13/23 revised comprehensive care plan (CCP) documented the resident had limited physical abilities and was a high fall risk. Interventions included walking 50 feet with standby assistance of staff following with a wheelchair, limited assistance of 1 with bed mobility, extensive assistance of 1 with toileting, staff standby assistance with transfers, non-skid socks, and place locked wheelchair next to bed when the resident was in bed. The 5/11/23 at 12:38 PM nurse practitioner (NP) #25 progress note documented the resident had falls on 4/28/23 and 5/1/23. The resident was confused, was unsteady on their feet, was unable to ask staff for assistance due to dementia, and had no safety awareness. The 5/28/23 at 2:43 PM licensed practical nurse (LPN) #16 progress note documented the resident was found lying on the floor in front of their wheelchair on the left side of their bed. The resident self-transferred. The 5/29/23 at 4:32 AM registered nurse (RN) #37 progress note documented the resident was found lying on their back next to the right side of their bed at 3:38 AM. The resident sustained 2 lacerations to the left of their eye. The 5/30/23 at 3:31 PM licensed practical nurse (LPN) #16 progress note documented the resident was found lying on their back on the floor in their room between the bed and their wheelchair. The 6/6/23 at 1:57 PM Director of Nursing (DON) progress note documented the interdisciplinary team met to discuss the resident's fall on 5/30/23. The care plan was reviewed, and the resident continued to self-transfer. The undated care instructions documented non-skid footwear/socks while in bed, while ambulating, or when mobilizing in their wheelchair, and place the locked wheelchair next to the bed when the resident was in bed. During an observation on 6/6/23 at 9:36 AM, Resident #99 was in the unit dining room sitting in their wheelchair. The resident wheeled themself out of the dining room at 9:45 AM. At 10:29 AM, certified nurse aide (CNA) #22 brought the resident to their room. At 11:09 AM, Resident #99 was lying in bed with their wheelchair in the bathroom. The resident's call bell was on the floor next to the bed. At 11:45 AM, the resident remained in bed with the wheelchair in the bathroom. During an interview on 6/6/23 at 11:47 AM, CNA #22 stated resident specific care was documented on each resident's care instructions. CNAs were to check the care instructions daily at the beginning of each shift. It was important to do so, as the resident's status may have changed. Resident #99 had frequent falls and was unsteady.The CNA stated they had put the resident to bed that morning and had left their wheelchair in the bathroom. The CNA stated the resident's wheelchair was supposed to be next to the bed when they were in bed. It was important to follow to care instructions for safety purposes. During an interview 6/6/23 at 1:46 PM, LPN #16 stated staff should check the care plan and care instructions daily to ensure there were no changes from the previous day. It was important to follow the plan for safety reasons. The resident's care instructions documented the bed was to be at knee level and the resident's wheelchair was to have the brakes locked and next to the bed when the resident was in bed. The resident had an increased risk of falling if the interventions were not implemented. The LPN was not aware the wheelchair was in the bathroom and not at bedside as planned. The LPN stated the resident had other falls recently and they would want to be made aware if the care plan was not followed. During an interview on 6/7/23 at 2:00 PM, LPN Unit Manager #5 stated the resident was at high risk for falls due to impulsiveness and impaired safety awareness. The resident had multiple falls with no major injuries and should have their wheelchair at the bedside as planned. During an interview on 6/8/23 at 9:10 AM, occupational therapist (OT) #23 stated fall risk interventions were discussed in morning report. The resident should have a locked wheelchair at the bedside when in bed as the resident was very impulsive and if the plan was not followed it could increase the risk for falling. During an interview on 6/8/23 at 12:06 PM, the DON stated they expected staff to follow resident care instructions. 10 NYCRR 415.12(h)(1)

Based on observation, interview, and record review during the recertification and abbreviated (NY00316633) surveys conducted 6/1/23-6/8/23, the facility failed to ensure that residents maintained acceptable parameters of nutritional status for 1 of 8 residents (Resident #101) reviewed. Specifically, Resident #101 had a significant weight loss that was not reviewed with the medical provider or reassessed by clinical nutrition staff. Findings include: The facility policy Weights-Obtaining and Monitoring revised 9/5/22, documented: - All residents would be weighed upon admission/readmission; weekly for four weeks then monthly thereafter, unless otherwise ordered by the [physician] or indicated by the registered dietitian (RD)/diet technician (diet tech). - Any residents with a noted increase/decrease of 5 pounds (lbs.) or greater from the previous documented entry would be re-weighed with a 2 person check system. - Weights would be assessed monthly by the RD/diet tech for significant change: specifically, weight increase or decrease of 5% in one month, or 7.5% over 3 months, or 10% in 6 months. - Residents with significant change in weight, including an increase or decrease, would have weekly weights implemented for four weeks for closer monitoring. Resident #101 was admitted to the facility with diagnoses including major depression, dementia, and diabetes. The 4/3/23 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition; required extensive assistance for most activities of daily living and supervision for eating; weighed 134 pounds, had a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months, and was not on a physician prescribed weight-loss regimen. The 3/14/23 comprehensive care plan (CCP) documented the resident had a potential for nutritional deficiencies. Interventions included: invite the resident to activities that promote nutritional intake; monitor/document/report any signs or symptoms of dysphagia; monitor/record/report any signs or symptoms of malnutrition to the physician (which included significant weight loss of 3 pounds in a week, >5% in a month, >7.5% in 3 months, or >10% in 6 months); obtain and monitor labs; provide and serve diet and supplements as ordered; RD to evaluate and make diet change recommendations as needed; occupational and speech therapy as necessary; review medication changes; and weight the resident at the same time every day and record monthly. The CCP did not document any resident-specific interventions, supplements, or fortified foods, or that the resident had a history of significant weight loss prior to admission. The care instructions, active on 6/7/23, documented the resident was to be supervised with eating and weighed monthly using the wheelchair scale. The 3/10/23 RD #14 Admission Nutrition Assessment documented the resident received a regular diet and was able to feed themselves with limited assistance or supervision. The resident's previous facility reported the resident had a 17 pound or 11% weight loss in the previous 6 months related to intentional portion control by the resident. The RD estimated the resident's nutrient needs to be 1600-1950 calories (25-30 calories per kilogram) and 65-80 grams of protein (1-1.2 grams per kilogram protein). The resident was consuming less than 26-50% of their meals; their baseline at the previous facility was 50% at meals and was provided with a Health Shake (oral nutritional supplement) twice a day. The resident was at risk for malnutrition and dehydration. The 2023 Weight Record documented on 3/11/23, the resident weighed 142.2 pounds. The 3/14/23 RD #14 nutrition progress note documented the admission assessment was completed and the care plan was updated. The resident's previous facility reported the resident had a 11% weight loss in 6 months due to the resident intentionally restricting portion sizes. The resident's intakes provided less than 25% of the resident's estimated needs. The resident reported an ok appetite related to the adjustment of moving facilities. The RD recommended updating the resident's preferences as needed, Health Shake twice a day, and encourage the resident's intakes with the resident eating in the dining room for all meals. The 2023 Weight record documented: - On 3/15/23, the resident weighed 145.6 pounds - On 3/29/23, the resident weighed 134.2 pounds (5.6% in 2.5 weeks, 9% loss in 2 weeks, significant) The 3/29/23 RD #14 nutrition progress note documented the resident was readmitted after a hospitalization for a fall with surgery to their left shoulder. The resident's intake following readmission continued to be less than 25% of meals and their fluid intake was low. Staff were to continue to encourage intakes. Prune juice was added for regular bowel movements and Health Shakes were increased to three times a day with fortified foods for wound healing and weight maintenance. The 3/30/23 physician #15 progress note did not document they were aware the resident had a significant weight loss. The 2023 Weight Record documented on 4/3/23, the resident was reweighed and weighed 134.2 pounds, which confirmed the 3/29/23 weight of 5.6% significant weight loss in 2.5 weeks and 9% significant weight loss in 2 weeks. The 4/6/23 RD #14 Nutrition Assessment documented the resident had a 6% weight loss in 1 month related to poor appetite. The resident's nutrition needs were reassessed to be 1500 to 1800 calories per day (25-30 calories per kilogram) and 60-70 grams of protein per day (1-1.2 grams per kilogram). The resident's significant weight loss was noted. The family reported it was the resident's baseline. Intakes since admission had been less than 25% of meals and fluid intake was inadequate. The RD recommended continuing daily prune juice, Health Shakes three times a day, and fortified foods for optimal intakes and weight maintenance. The 4/11/23 RD #14 nutrition progress note documented the resident's intakes remained inadequate and their supplement intake was less than 50% per the electronic record. The resident was at risk for malnutrition due to poor intakes and recent significant weight loss. Med Pass 2.0 (oral nutritional supplement) 4 ounces twice a day was added, and the reduced sugar Health Shake was discontinued due to refusals. The 4/11/23 physician order documented Med Pass 2.0 twice a day for risk of malnutrition. The 2023 Weight Record documented on 4/12/23, the resident weighed 132.4 pounds The 4/13/23 nurse practitioner (NP) #25 progress note documented the resident weighed 145.6 pounds. There was no documentation the resident had a significant weight loss. The 4/16/23 physician #24 progress note did not document the resident had a significant weight loss. The 2023 Weight Record documented the following: - On 4/19/23, the resident weighed 125.2 pounds (6.7% loss in 1 week, significant) - On 5/3/23, the resident weighed 121.4 pounds (14.6% loss in 2 months and 9.5% loss in 1 month, significant) The 5/5/23 physician #15 progress note documented the resident had a 10% weight loss over a month; there was no documentation the physician addressed the resident's significant weight loss. The 5/9/23 NP #25 progress note documented the resident had a significant weight loss of 17% in a month. There was no documentation the resident's significant weight loss was addressed. The 5/10/23 NP #25 progress note documented the resident was being seen after testing positive for COVID-19. The resident had no noted edema, the resident's current weight was 121.4 lbs., their weight 1 month ago was 145.6 lbs., and they had 17% weight loss at one month. There were no medical interventions recommended to address the weight loss. The 5/11/23 RD #14 progress note documented they noted a significant weight loss of 10% in 1 month related to poor appetite. The resident was tolerating their diet; they continued with inadequate intakes of 0-25% of their meals. The resident was accepting of Med Pass 2.0 twice a day; the RD increased supplementation to three times a day and added fortified foods to all meals (the RD did not document which fortified foods were being added). There was no documentation the resident's nutrient needs were re-assessed after a significant weight loss. The 5/11/23 physician order documented Med Pass 2.0 three times a day for risk of malnutrition. There was no documentation the resident's care plan was updated for the resident's significant weight loss. The 5/16/23 Physician #24 documented the resident was being seen after testing positive for COVID -19. The resident had no noted edema, the resident's current weight was 121.4 lbs., their weight 1 month ago was 145.6 lbs., and they had 17% weight loss at one month. There were no medical interventions recommended to address the weight loss. On 6/4/23, the resident weighed 120.3 pounds (15.7% loss in 3 months, significant) During an interview on 6/7/23 at 12:27 PM, certified nurse aide (CNA) #21 stated the resident ate independently after setup. They ate pretty good, and their weight had been stable. Weights were obtained at the beginning of the month. The resident was weighed on the wheelchair scale and there were no issues with the scale. A reweight list was provided by the Unit Manager and staff would then obtain the weight and the Unit Manager entered the weights in the computer. During an interview on 6/7/23 at 2:00 PM, licensed practical nurse (LPN) Unit Manager #5 stated weights were obtained by CNAs the first week of the month. The LPN then entered the weights into the computer, and if a 4 pound plus or minus difference was noted, nursing staff was to reweigh the resident. When a difference was noted, the RD asked for reweights to be completed as soon as possible. The RD communicated via email what reweights were needed. The LPN stated Resident #101 had lost weight and they were not aware of exact amount of weight as it had been gradual. Resident #101 should have had reweights taken on 4/19/23 and 5/3/23. The RD and the Unit Manager both looked at the weights. They stated they were not sure if the RD asked for a reweight for the resident. Resident #101 had been eating 50-100% of their meals, had a history of an eating disorder. The eating disorder was not on their diagnosis list, and they were unsure why. Medical should be notified of significant weight changes by the RD. They stated there were weight meetings to discuss significant weight changes, and they did not recall Resident #101 being discussed. During an interview on 6/8/23 at 10:00 AM, RD #14 stated resident weights were to be obtained the during the 1st week of the month and reweights should be completed if there was a 5 pound difference. Nursing was supposed to initiate the reweights, and at times they were missed. The RD stated they would send an electronic communication to Unit Managers on any needed reweights or missing weights. The RD monitored for the residents for significant changes in weight and a significant weight change was a 5 % change in one month, 7.5% change in 3 months, or 10% change in 6 months. The interdisciplinary team discussed weights. They stated they documented in a progress notes if there were significant changes and any weight trends and included if the resident was at risk for malnutrition. If there were any significant weight changes, they would then review nursing progress notes, therapy notes, request a consult for therapy if needed, and would add any additional interventions as recommended. The RD stated if a resident triggered for a significant change they should complete a full nutritional assessment, which included adjusting the resident's estimated daily nutritional needs. The RD stated on 3/29/23, Resident #101's intakes were documented at less than 25%, they increased their nutritional supplements to three times daily, and added a fortified cookie between meals. They stated on 4/6/23 they wrote a note the resident had a significant loss of 6% at 1 month. They continued to provide supplements as ordered. On 4/11/23, they documented the resident's intakes were low, and they started tracking the resident's acceptance to their ordered supplements. The RD stated an email was sent to NP #25 on 4/11/23 regarding the resident's weight loss. They stated the resident had a significant weight loss since 4/11/23 and they should have notified the NP about the weight loss. The resident was started on a med pass supplement twice daily, continued to receive fortified foods, and their Health Shake was discontinued due to poor acceptance. They stated a reweight was not obtained and the resident's estimated needs were not reassessed. On 5/3/23, they documented the resident had another significant weight loss and the med pass supplement was increased to 3 times daily. They stated they did not complete a reassessment of the resident's nutritional needs. During an interview on 6/8/23 at 11:11 AM, NP #25 stated they worked closely with the RD. The RD would email them weight concerns. The NP stated when reviewing the chart, the RD notes were visible to the physicians and the NP. Resident #101 had lost 20 pounds in the past 3 months. Their last visit with them was about a month ago in May. It appeared the resident's weight was trending down, but they were not made aware there had been a significant weight change. They stated they would want to be made aware of significant weight changes and there was an ongoing effort to improve communication with the RD regarding weight changes. If they were made aware they would have reviewed the resident's medications and looked at other medical issues that might have led to the resident's weight loss. 10NYCRR415.12(i)(1) 46276

Based on observation, interview, and record review during the abbreviated survey (NY 019), the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure ulcers for 1 of 3 residents (Resident #1) reviewed. Specifically, Resident #1 developed a pressure ulcer on the posterior (back) right thigh caused by a cast. The pressure ulcer was not assessed timely after being identified, a treatment was not ordered or implemented timely, and when the pressure ulcer worsened, the orthopedic surgeon and wound specialist were not notified for intervention timely. The resident was subsequently admitted to the hospital for incision and drainage (a surgical procedure used to release pus or pressure under the skin), wound V.A.C. (vacuum assisted closure) placement and intravenous (IV) antibiotics for wound infection. This resulted in harm to Resident #1 that was not immediate jeopardy. Findings include: The facility's 8/26/2019 Skin Care Protocol documents it is the responsibility of all caregivers to prevent, care for, and provide appropriate prevention and treatment to maintain skin integrity. Upon admission, readmission, significant change, quarterly, annually, and as needed, a Skin Risk Assessment will be completed. The risk level initiated immediate care and preventive measures as noted on the plan of care. Residents' skin will be checked during care delivered by certified nurse aides (CNA) daily and CNAs will notify the unit nurse of any new findings and document in the electronic medical record (EMR). Any new open areas will be reported immediately to the Nurse Manager or Supervisor for assessment. The registered nurse (RN) will be notified to perform an assessment on any new pressure ulcers and will document findings, initiate treatment, and will ensure the order is entered into the Treatment Administration Record (TAR). Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/2/21 Minimum Data Set (MDS) assessment documented the resident had intact cognition, scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS), required extensive assistance from 2 staff for bed mobility, was at risk for pressure ulcer development, and had no pressure ulcers. The undated Kardex (care instructions) documented the resident was non-ambulatory; required a Hoyer (mechanical) lift for transfers; was to be turned and positioned every 2 hours as needed, and staff were to use a draw sheet or lifting device to move the resident. The 1/27/21 orthopedic consult documented the resident's right knee was openly reduced (surgical repositioning of bone) on 10/8/20, they had recurrent dislocation of the knee and the resident had been in a long leg cast since the surgery to avoid re-dislocation. The cast was removed during the visit and the resident's skin was intact except a small area of [CONDITION(S)] (redness) over the anterior patella (front of knee). The resident declined placement of another cast and was placed in a well-padded dressing with a knee immobilizer over the top. The resident was to follow-up in 3 months. The 1/29/21 orthopedic consult documented there was continued instability of the resident's internal right knee prosthesis and a long leg cast was applied that date. The 1/29/21 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/21 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/21 Documentation Survey Report (CNA care provided) documented: - on 2/8/21 at 10:59 PM, by CNA #4, skin with open areas; and - on 2/9/21 at 12:42 AM, by CNA #2, skin with open areas. There was no documentation the resident's skin was assessed after CNAs #2 and 4 documented the resident had open areas on 2/8 and 2/9/21. The nursing progress notes for 2/8 did not address the skin with open areas as documented by the CNA and there were no nursing progress notes for 2/9/21. The 2/21 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2/10/21 at 3:28 PM, RN Supervisor (RNS) #1's progress note documented the CNAs called her to check an open pressure ulcer at the upper edge of the resident's cast on the right leg. The old ABD pad was removed and there was a moderate amount of yellowish green drainage on the pad. The pressure ulcer measured 11 centimeters (cm) x 1.5 cm x 2 millimeters (mm). The pressure ulcer was cleansed with normal saline, antibiotic ointment was applied, and a new ABD dressing was applied. There was no documentation a medical provider was notified of the pressure ulcer, no documentation a treatment was ordered, and no documentation a plan was implemented to prevent the pressure ulcer from worsening. On the 2/12/21, the Documentation Survey Report, by CNA #2 noted at 2:33 AM, skin with open areas. The 2/12/21 nurse practitioner (NP) #3's progress note documented she was asked to see the resident due to a worsening skin issue on the right posterior thigh. The resident stated the pressure ulcer was tender to touch and they recently had a cast placed due to non-adherence with a brace. The resident was found to have pressure induced deep tissue damage, the wound was unstageable, and measured 8 cm x 3 cm with 100% slough (non-viable tissue). The plan was to cleanse the wound with normal saline, apply nickel thick Santyl (wound treatment that removes dead tissue), cover with an ABD pad, and put part of the ABD pad under the cast. The note documented to notify orthopedics, refer the resident to the consulting wound care provider, and continue [MEDICATION(S)] (opioid narcotic) for pain. There was no documented evidence that orthopedics was notified and no documentation a referral to the consulting wound care provider was made. The 2/13/21 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The treatment was documented as completed on the TAR on 2/13 through 2/15/21. The 2/16/21 at 12:04 PM, NP #3's progress note documented the resident was seen for a worsening skin issue and staff reported the wound had a foul odor. The RN and unit clerk were instructed to set up an appointment with orthopedics. The 2/16/21 at 11:11 AM, nursing progress note documented orthopedics was contacted and a consult was requested for as soon as possible due to the wound on right posterior leg caused by the cast. The medical record documented the resident went to the orthopedics appointment on 2/17/21 and was sent from the appointment to the hospital. The 2/26/21 hospital discharge summary documented the resident was admitted to the hospital on 2/17/21 after they presented to their orthopedic appointment with a full thickness right posterior pressure ulcer behind the casted leg. The resident was admitted to the hospital with orthopedic recommendations for incision and drainage (I&D) and wound V.A.C. placement. The wound V.A.C. continued for 3 days and the resident was taken back to the operating room on 2/23/21 where an I&D was repeated, and the wound was closed. On 3/3/21 at 10:00 AM, Resident #1 stated in an interview, they were recently readmitted from the hospital after developing a wound on the back of the right thigh that occurred from a cast. They had to have an operation and currently had sutures in place. The resident stated CNAs #2 and 4 found the wound and notified nursing and nursing did not respond timely. On 3/3/21 at 11:40 AM, the resident's dressing change was observed completed by licensed practical nurse (LPN) #5. The resident's leg was immobilized in a brace that extended above the knee. The brace was removed. An ACE bandage was removed from the upper thigh followed by removal of Kerlix (rolled dressing). An ABD pad and 4 x 4 dressing was removed. The old Xeroform (a petroleum wound dressing) was removed. The wound was cleansed with normal saline. Multiple sutures were intact with edges of the wound well approximated (held together). There was an open area to the inner aspect of the thigh wound at the end of the suture line that was shallow and approximately 2 cm x 1 cm x 0.2 cm. New Xeroform was applied, followed by 4 x 4 dressing and ABD pad, and the wound was wrapped with Kerlix and ACE wrap. On 3/3/21 at 11:40 AM, licensed practical nurse (LPN) #5 stated in an interview, the resident initially had a leg brace and was not compliant and was taking it off so orthopedics put the resident in a cast and she knew the resident's skin would eventually breakdown. A week or so before the wound opened, the resident's skin around the upper part of the cast was getting red and irritated, and an ABD was put between the cast and skin to reduce pressure. On 3/3/21 at 3 PM, RNS #1 stated in an interview, she was notified on 2/10/21 by CNAs #2 and 4 the resident had a pressure ulcer. At the time she assessed the resident, there was an open area behind the cast and an ABD pad was already in place. There was yellow green drainage on the ABD pad, no redness, and it did not appear infected, although she stated yellow green drainage was not typical drainage from a wound. She applied [MEDICATION(S)] and a new ABD pad. She did not review the resident's medical record to determine if the pressure ulcer was new or existing and she did not obtain a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/3/21 at 3:21 PM, CNA #2 stated in a telephone interview, she and CNA #4 worked together on the night shift and gave the resident a bed bath. She stated when they turned the resident on their side, they saw the back of the cast and the resident's skin. CNA #2 stated there was no way to position the resident's leg to relieve the pressure from the cast and the cast continued to rub and made indentations on the resident's leg. The skin behind the cast started with a red area that eventually broke down and became nasty looking and yellow. She stated she thought she documented the open area in her CNA documentation. She stated before the resident went to the hospital, every time she was on duty, she notified nursing the resident had a wound behind the cast that was getting worse. The nurses told her they were aware, and a treatment was already ordered. She stated the only treatment the resident had was an ABD pad tucked into the back of the cast. She observed the pad with the same dried crusty material drainage on it for days in a row. She stated the resident never refused care from her and CNA #4. On 3/4/21 at 11:01 AM, NP #3 stated in a telephone interview, she should be notified immediately when a resident developed a new pressure ulcer to ensure the resident had the appropriate treatment ordered. She first became aware Residnet #1 had a wound on 2/12/21 and was not aware RN #1 first observed the wound on 2/10/21. She stated she should have been notified on 2/10/21 so she could have assessed the resident's wound and ordered an appropriate treatment. The yellow green drainage RN #1 documented on 2/10/21 could have been related to an infection and she would not expect [MEDICATION(S)] to be a treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . When she saw the resident's wound on 2/12/21, it was unstageable with 100% slough. She wanted orthopedics notified that day to determine if they wanted the cast removed. She was not sure who she asked to notify orthopedics and that was the responsibility of nursing to complete. On 2/12/21, she also asked nursing to set up a consult with the facility's wound specialist. The resident should have been seen by the wound specialist on 2/15/21 which was their normal day at the facility and that appointment was not made timely. On 2/16/21, she was asked to evaluate the resident's wound again. There was no dressing in place when she saw the resident that day. The wound had an unpleasant odor. She could not accurately measure the wound because of how it extended under the cast and she started antibiotics that day because the wound was infected. She was not aware the CNAs documented the resident's skin was open starting on 2/8/21. On 3/4/21 at 12:54 PM, CNA #4 stated in a telephone interview, she notified nursing on multiple occasions the resident's ABD pad did not appear to be changed as ordered and the wound had gotten worse and smelled bad. When orthopedics put the cast on, an area on the resident's leg opened and initially it was just superficial. She notified nursing and they said there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Sometimes she would go in to change the resident and there would be no ABD pad in place. She recalled telling RN #6 and she did not think RN #6 did anything about the wound. She also believed CNA #2 mentioned it to LPN #8 (Assistant Manager) who was also the wound nurse. CNA #4 stated she finally mentioned the area to a different RN and the resident was sent to the hospital. On 3/17/21 at 1:52 PM, RN #6 stated in a telephone interview, she was a charge nurse on the night shift. The process when a resident developed a new skin area was for the area to be assessed, the on-call provider notified if necessary, and they were to document findings and what was done in the progress notes. She would also put a note in the NP book to notify them of the area. She stated Resident #1 was not on her unit and RNS #7 was on that unit. She stated she did not recall any CNAs notifying her of the resident's skin issues. On 3/18/21 at 10:02 AM, LPN #8 stated in a telephone interview, she was the former Assistant Manager of the resident's unit and the wound nurse for the facility. She stated she first became aware the resident had a pressure ulcer behind the cast after the resident was sent to the hospital. She was never notified of the skin issue prior to that. When the resident was noted by the CNAs to have open areas, the area was not assessed timely by the RN. When the RN assessed the wound, the physician should have been notified for a treatment and the NP should have been notified to follow-up and that was not done timely. On 2/12/21, when NP #3 wanted the resident to see the wound consultant, the NP would have notified her to schedule the appointment and she was not notified. When NP #3 wanted orthopedics notified of the resident's wound, either RN Manager #9 or unit clerk #10 would have been responsible to notify orthopedics. LPN #8 stated orthopedics was not notified timely as they were not notified until 2/16/21 after the NP had requested notification on 2/12/21. On 3/18/21 at 10:31 AM, unit clerk #10 stated in an interview, when the NP saw residents and wanted an appointment scheduled, the NP either verbally told her, sent her an email, or left her a note to schedule the appointment. She stated she was not at the facility on 2/11 through 2/22/21 and another unit clerk would have picked up her duties those days. 10NYCRR 415.12(c)(1)

Based on record review, observation, and interview conducted during the extended recertification survey, it was determined the facility: - failed to develop a system to ensure trained staff were available in the facility to perform CPR (cardiopulmonary resuscitation) 24 hours a day, if needed, as evidenced that the facility could not verify current CPR certification for 23 of 32 nursing staff; - failed to have a system in place to determine whether 4 of 30 sampled residents (Residents #8, 9, 10 and 26) lacked capacity for decision making; and - failed to have a system in place to determine the most appropriate person was specified to determine Residents #8, 9, 10 and 26's advance directive wishes. Specifically, Residents' #8, 9, 10 and 26 MOLST (Medical Orders for Life Sustaining Treatment) were signed by a surrogate/health care proxy (HCP), without documented evidence these residents lacked capacity. Additionally, the facility failed to ensure 1 of 30 residents (Resident #14) reviewed for advanced directives had the right to formulate advance directives in accordance with New York State law; and failed to ensure Resident #14's wishes were followed. Specifically, when Resident #14 changed his wishes from wanting a full code performed (CPR) for cardiopulmonary arrest, to wanting DNR (Do Not Resuscitate, allow natural death), the facility failed to clarify the resident's DNR wishes in a timely manner, and proceeded to initiate CPR. Additionally, the facility failed to ensure the necessary care and services were provided for 5 of 24 sampled residents (Residents #2, 9, 10, 11 and 14) and 5 additional residents (Residents #26, 27, 28, 29, and 30) reviewed for code status (level of medical interventions to perform if cardiopulmonary arrest occurs). Specifically, after the facility became aware of Resident #14's inadvertent resuscitation efforts, the facility failed to recognize and correct the multiple errors and inconsistent code identifiers on Residents' #2, 9, 10, 11, 14, 26, 27, 28, 29, and 30 care guides, medical records, wristbands, face sheet and the facility code status list (kept in resident gathering areas and last updated in 2015). This resulted in the potential for serious harm that is Immediate Jeopardy for Residents #2, 9, 10, 11, 14, 26, 27, 28, 29, and 30. The Immediate Jeopardy situation was removed on [DATE] based on the following corrective actions taken by the facility: - development of a new policy and procedure for identification of residents' code status; - consistent implementation of the facility's revised system for communicating residents' code status; - training of all staff on the revised policy and procedure for properly identifying residents' code status and advanced directives and implementing those wishes. Surveyors conducted staff interviews to determine their knowledge of this policy. Findings include: CPR CERTIFICATION: A policy dated [DATE] titled Cardiopulmonary Resuscitation (CPR) and Basic Life Support, provided on [DATE] as a current policy, documented CPR certification expiration dates would be monitored by the In-Service Director or Designee, who would schedule recertification classes and notify specific nurses when they were due for the renewal class. During an interview with MDS (Minimum Data Set) Coordinator on [DATE] at 12:30 PM, she stated they did not currently have anyone in the facility doing inservice training. She stated she would provide the surveyor with the current list of staff who were CPR trained. She said the Director of Nursing (DON) was responsible for checking staffing to be sure someone was CPR trained on each shift. On [DATE], the DON provided a list that included 32 nursing staff. Nine of the staff were documented as overdue for retraining. There was no date of required recertification for 14 of the staff. On [DATE] at 1:30 PM, the Acting DON stated she was still waiting to receive all the information regarding staff that were currently CPR certified. During an interview with the MDS Coordinator on [DATE] at 2:30 PM, she stated the facility has not had a nurse educator since ,[DATE]. She stated the facility previously kept CPR certification cards in the employee files, and the nurse educator used to keep a list of who had the training and when it was due. The facility was unable to provide documentation that a list of current CPR trained staff had been maintained. They were unable to provide documentation that all nursing staff listed had current CPR training at the time of the recertification and extended survey. DETERMINATION OF CAPACITY: The facility policy for Advance Directives, Family Health Care Decisions Act, provided on [DATE] and dated [DATE] documented the use of 9 forms for identifying resuscitation, do not resuscitate (DNR, allow natural death), and treatment decision determinations for the facility (Forms #0016, 0017, 0018, 0019, 0020, 0021, 0022, 0023, and 0024). The policy documented a determination that an adult resident lacked capacity was made by the attending physician to a reasonable degree of medical certainty, with a concurring physician's determination for the same information. During an interview with the Director of Social Services on [DATE] at 8:40 AM, he stated the Admissions Coordinator requested information on advance directives from the applicant, including the Medical Orders for Life Sustaining Treatment (MOLST) and Health Care Proxy (HCP). On the day of admission or the next week day (if a weekend admission), the social worker would discuss advance directives again with the resident. If the resident was unsure of his/her wishes, social services would readdress it with the resident either within a few days, or at the first quarterly review. If there were no directives and the resident had cognitive issues, social work was to check for the resident's contact person. If there was a HCP and the HCP agent requested a DNR, the social worker facilitated a MOLST. Once it was signed and witnessed, it was left for the physician to complete. The Director of Social Services stated he did not get involved with the determination of capacity and did not know how that was completed or documented, or how a surrogate was determined if there was no HCP. He stated the Medical Director knew what to do. The Director of Social Services was not aware of any forms used for determination of capacity. When the Medical Director was interviewed on [DATE] at 10:30 AM, he stated most of the residents were admitted from the hospital and came with advance directives in place. He stated he did not routinely write specific advance directives for the residents, as these were determined pre-admission. He stated the facility currently did not have a form for determining capacity and he was not aware of a policy specifically addressing the issue. He said the social worker was involved based on the physician's opinion of capacity. The Medical Director stated he believed he wrote a progress note pertaining to a resident's lack of capacity and requested the social worker initiate the MOLST with the HCP. If the resident did not have capacity and did not have a HCP, the Medical Director did not think there was a process to determine the information, and did not think the facility had a formal process to activate a HCP. During an interview with social worker #32 on [DATE] at 2:25 PM, he stated he looked for a MOLST or hospital discharge orders when a resident was admitted . If there were no advance directives on admission, he would test the resident's cognitive status (BIMS, Brief Interview for Mental Status) to be sure his/her memory was intact, and if so, discuss advance directives with the resident. If it was not intact and the resident did not understand, the HCP was contacted. If there was no HCP, the family was contacted and was asked who in the family would know the resident's wishes, if anyone. The social worker did not utilize the surrogate list as determined by the New York State Family Health Care Decisions Act. Social worker #32 stated if the MOLST was completed by a family member, it was witnessed by two persons and given to the physician, usually physician #33. During an interview with physician #33 on [DATE] at 11:48 AM, he stated he never acted as a concurring physician at this facility to determine residents' capacity for DNR decision making. He did not think the facility had a system in place for this process. 1) Resident #10 was admitted on [DATE] and had [DIAGNOSES REDACTED]. A Non-hospital DNR was signed on [DATE] and was in the resident's current record. A social work admission evaluation dated [DATE] documented the resident was admitted on [DATE]. The resident was a full code and had a HCP. Advance directives were reviewed, and education was provided to the resident and/or health care agent. There was no documentation on the evaluation if the resident or the health care agent was involved in the discussion(s) on [DATE]. A MOLST form documented DNR status for the resident. The form was signed on [DATE] by what was documented as a health care agent, and by the physician on [DATE]. The form documented guidelines including limited medical interventions, do not intubate (DNI), no feeding tube, and use antibiotics. There was no documentation in the resident's record a determination of incapacity to make medical decisions was completed by qualified medical staff, that would include diagnoses/condition and probable duration, prior to implementing the MOLST form with the resident's health care agent. The comprehensive care plan (CCP) was updated on [DATE] and documented the resident had a HCP and MOLST, with DNR and DNI instructions in place. Nursing and social services were to ensure documentation of implemented advance directives were in place. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was severely cognitively impaired and required limited to extensive assistance with most activities of daily living. The face sheet (resident demographics) dated [DATE] included a section labeled, Advance Directives. This portion of the face sheet was blank. During an interview with licensed master social worker (LMSW) #43 on [DATE] at 2:30 PM, she stated she completed a brief interview on mental status with a resident to determine if they were able to complete advance directives. She stated if a resident was not able to complete the interview, she would contact family and discuss directives. She stated there used to be a form that included signatures by two physicians, and the process of completing advance directives changed approximately one year prior. She stated it was not clear who was responsible for making a determination of capacity at this time. 2) Resident #8 had [DIAGNOSES REDACTED]. A MOLST form signed and dated [DATE] documented the resident had do not resuscitate (DNR, allow natural death) instructions with limited medical interventions: do not intubate (DNI, do not place a breathing tube), comfort measures only, send to hospital if necessary, no feeding tubes, and a trial period of intravenous (IV) fluids and antibiotic use. The MOLST was signed by the resident's HCP and a physician. A social services progress note dated [DATE] documented the resident was somewhat alert and oriented to surroundings and was able to make basic needs known. The resident did not have a MOLST and had a non-hospital DNR order that was completed on [DATE]. The resident was on comfort measures and the resident had a HCP. The comprehensive care plan (CCP) dated [DATE] documented the resident had alterations in thought process related to dementia, as evidenced by short term memory loss and moderately impaired daily decision making. A nursing progress note dated [DATE] documented the resident was alert, made themselves understood, and was able to understand others. The MOLST was reviewed and signed by the physician on [DATE], [DATE], and [DATE]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had moderate cognitive impairment and required extensive to total assistance with most activities of daily living. Physician orders [REDACTED]. There was no documented evidence the physician made an initial determination the resident lacked decision making capacity, including assessment of the cause and extent of the incapacity and the likelihood the resident would regain decision making capacity. There was no documentation another health care practitioner concurred on the resident's lack of decision making capacity, and the HCP could make decisions regarding health care needs and wishes. Attending physician #33 was interviewed on [DATE] at 8:55 AM. He stated when he admitted a new resident, he would ask questions about their mentation. If the resident had a HCP, they would let him know what the code status should be. If a family requested not to perform CPR, he would not. He stated when he sees the resident, he would get an initial feeling of incompetency and would inconsistently document in the medical record about decision making ability. He stated he did not realize the facility required two professionals to concur on the determination of capacity and document on a regular basis. ADVANCE DIRECTIVES: Prior to survey, the facility's policy Advanced Directives: Identifying Residents Who Are Full Code, revised on [DATE], documented when a resident specified their advance directive for CPR (cardiopulmonary resuscitation when needed), the following would have the resident's code status documented: - Appropriate color identification bracelet was on the resident (or as indicated by the care plan i.e. wheelchair or walker); - Update the Advance Directive Face Sheet; - Add name from full code list; - Distribute full code list to all departments; and - Add to care plan/care guide. 3) Resident #14 had [DIAGNOSES REDACTED]. A hospital history and physical dated [DATE] documented the resident wished to be a full code. The resident was educated regarding his poor prognosis and he reported he would think about a possible DNR status, but this is something that we should again inform the patient of. A nursing progress note dated [DATE] documented the resident was admitted to the facility from the hospital. Admission physician orders [REDACTED]. A social service admission evaluation dated [DATE] documented the resident was able make his needs known and was capable of making his own decisions. The resident was a full code. A social service progress note dated [DATE] documented the resident was alert, oriented and able to make his needs known. The resident was given a copy of the Medical Orders for Life-Sustaining Treatment (MOLST) form and advanced directive info provided. The resident requested to review the form with his wife. There was no documented follow up regarding the resident's advance directive wishes and if any further information or guidance was needed regarding the MOLST form. The comprehensive care plan (CCP) dated [DATE] documented the resident's cognition was intact and to provide reminders and reassurance as needed. The CCP did not contain any documentation regarding the resident's code status. The CCPs updated [DATE] and [DATE] documented staff were to provide reminders and reassurance as needed. The CCP documented the resident's advance directives were for Full Code. A nursing progress note dated [DATE] documented the resident was sent to the hospital. The resident signed a MOLST form dated [DATE] and documented the resident was DNR and wanted to allow natural death. A hospital discharge summary dated [DATE] documented the resident was hospitalized from [DATE] - [DATE] [MEDICAL CONDITION] related to [MEDICAL CONDITION] of his bilateral lower extremity wounds. A nursing progress note dated [DATE] documented the resident was readmitted to the facility. Physician orders [REDACTED].>There was no documented evidence social work reviewed the resident's MOLST form with him upon his return from the hospital and addressed the resident's change in code status. A hospital discharge summary dated [DATE] documented the resident was hospitalized from [DATE] to [DATE] for bloody bowel movement related to an upper GI (gastrointestinal) bleed from a [DIAGNOSES REDACTED] ulcer. The resident required treatment in the intensive care unit and received 7 units of packed cells and 2 units of fresh frozen plasma. A nursing progress note dated [DATE] documented the resident was readmitted to the facility. Physician orders [REDACTED].>The last nursing note documented in the resident's record was dated [DATE] at 2:15 PM and specified the resident was able to make his needs known, was out of the bed to a chair, and denied pain. An accident/incident form, dated [DATE], documented the resident was found unresponsive, without respirations or pulse at 9:30 AM by a certified nurse aide (CNA). The report documented the resident was without pulse, respirations or blood pressure. The report documented the nurse was alerted by the CNA to come to the resident's room. When she arrived, the resident was lying on his back and another nurse was in the room checking the resident's pulse. The resident did not have a pulse. The CNA care guide in the room was checked, which documented the resident was a full code. CPR was initiated by the two nurses present, while a code blue was called. The Director of Nursing (DON) and other staff arrived. The DON asked for the MOLST and then determined the resident was a DNR. CPR was stopped at that time and the attending physician pronounced the resident. The incident report documented the care guide was not accurate based on record review, care plan and interviews and that the CCP was followed. The resident's most recent CCP ([DATE]) specified the resident was a Full Code. The CCP did not accurately reflect the resident's MOLST form, signed [DATE] and the physician's orders [REDACTED]. Attached to the investigation and dated [DATE], Resident Helper #66's witness statement documented that at 9:45 AM that morning, she went into the resident's room to see if he was done with breakfast, but he didn't say anything so, she reported it to RN #30. The Resident Helper wrote that the nurse (RN #30) came in, checked the resident and said he was just sleeping. The Resident Helper documented this was unusual for the resident as he wasn't responding to anyone talking to him. The accident/incident report documented to prevent reoccurrence: 1st floor arm band placement was reviewed and new bands placed and facility wide audit by social work. The investigation report was signed by the Director of Nursing on [DATE] and as completed on [DATE]. The report documented the incident was not reportable to the New York State Department of Health as the resident died in bed, no neglect, abuse or mistreatment occurred. CNA #29's statement was attached to the incident report and dated [DATE] after the investigation closed on [DATE]. This statement documented that at 9:30 AM on [DATE], she and another CNA went into Resident #14's room to wash him up, but they could not wake him. CNA #29 documented she noticed the resident was not breathing and went and got registered nurse (RN) #30. The CNA then checked the care card on the back of the resident's door that stated the resident was a full code. There was no documented rationale why CNA #29's statement was written after the Administrator reviewed and signed the completion of the investigation. There was no documentation that determined the reasons for the inconsistent timeline of events between the Resident Helper #66's witness statement and CNA #29's statement, and how long CPR was performed before the DON determined the resident was a DNR. During an interview with registered nurse (RN) Manager #27 on [DATE] at 9:20 AM, he stated a resident's code status was determined by looking at their bracelets. A red bracelet was worn for DNR and a blue bracelet for full code. He stated resident's were frequently non-compliant with wearing the bracelets. Other indicators to determine code status included a red sticker on the chart indicating DNR, the MOLST, and a physician order. During an interview with CNA #28 on [DATE] at 12:18 PM, she stated she would determine a resident's code status by looking at the care guide on the back of the resident's door. During an interview with CNA #29 on [DATE] at 12:26 PM, she stated she would look at the care guide on the back of the bedroom door to determine a resident's code status. She stated there was an incident last week, she walked into the resident's room he was not breathing, and she called the nurses in to the room. She stated one nurse looked at the resident's care guide and called out he was a full code and the other nurse started chest compressions. She stated someone called a code blue. The DON showed up, opened the resident's chart and realized he was a DNR and the CPR was stopped. During an interview with RN #30 on [DATE] at 12:45 PM, she stated if she found a resident with no pulse she would look at the back of door at the care guide to determine if they wanted a DNR or a full code. She stated she was the first nurse to arrive in the resident's room when he was found not breathing by the CNA. She stated she checked his pulse and checked the resident care guide, it documented full code and the other nurse started chest compressions. She stated the resident was not wearing a bracelet at the time. She stated the DON arrived after a code blue was called and when she opened his chart she noticed he was a DNR. She stated the resident's care guide had not been updated when he returned from the hospital. On [DATE] at 1:00 PM in the Unit 1 clean utility room, above the cart holding the suction machine and other emergency supplies, was a sign that was titled Residents Wanting CPR. The list contained names of resident's from each unit and the list was dated [DATE]. RN #30 removed the list from the wall and stated she would be getting rid of the list as it was too old and was no longer accurate. During an interview with RN #31 on [DATE] at 8:50 AM, she stated if she found a resident with no pulse she would check their care guide on the bedroom door and if the resident was off the unit she would look at their bracelet. She stated if the resident was not wearing a bracelet and the care guide was not available she would initiate CPR until the resident's code status was determined. RN Manager #27 was interviewed a second time on [DATE] at 9:05 AM and stated he would expect the nursing staff to perform CPR until the resident's code status was determined. During an interview with an activity leader on [DATE] at 9:20 AM, she stated residents from all 3 floors attended activities in the cafe and if she found a resident unresponsive she would get a nurse from the 1st floor. She stated there was a sign on the wall the nurse could refer to indicating what residents were full code. The activities leader showed the surveyor the sign titled Residents Wanting CPR. The list contained names of residents from each unit and was dated [DATE]. She stated the list was outdated as it contained residents that were deceased . When the Medical Director was interviewed on [DATE] at 10:30 AM, he stated he was not aware of the incident with Resident #14. He stated staff knowledge of a resident's code status was from reviewing the MOLST and the binder of the chart. He did not think the facility kept a list of residents with their code status, and was not aware of any other identifiers for code status. During an interview with Licensed Master Social Worker (LMSW) #43 on [DATE] at 2:30 PM, she stated it was social services responsibility to meet with the resident/representative on admission to discuss directives and to complete a MOLST. She stated when a MOLST was filled out, she was to notify nursing of the decision for CPR or DNR. She stated nursing would then complete an order and notify the physician. She stated if a resident had a change in status, nursing was to make a social service referral and they would discuss directives. She stated if there was a change in directives following the completion of a MOLST, the MOLST would be flagged and she would notify the unit secretary to update the resident's binder. She stated social service was responsible for updating the advance directives portion of the care plan and updating the MOLST. She stated nursing would be responsible for updating the CNA care guide. She stated if a resident would not wear an ID bracelet, there were other measures they could take to document code status, and staff should be notifying nursing management when a resident did not have an ID bracelet. During a combined interview with the Administrator and the DON on [DATE] at 2:32 PM, the Administrator stated when Resident #14 received CPR and he was DNR, they determined there were multiple identifiers indicating code status. They were looking at revising the Advance Directive Policy and after the incident social services had completed a house wide audit to ensure care guides, bracelets, face sheets, stickers on spines of chart and the MOLST all matched the resident's wishes regarding code status. He stated if a resident was found without a pulse, and they were not wearing a bracelet, staff were to perform CPR, until the resident's code status was determined. He stated he was not aware of any lists in the facility indicating residents who were full code. He stated nurses were responsible, in conjunction with social services, to ensure the residents were able to be identified regarding their code status. The Minimum Data Set (MDS) Coordinator was interviewed on [DATE] at 2:35 PM and stated she had previously been the Staff Educator. She stated the steps to follow when a resident was found unresponsive included to check the resident's name bracelet, red for DNR and blue for CPR, check for code status in the resident's chart, and check code status on the care guide (care instructions) on the back of the bedroom door. If a resident was a CPR, Code Blue would be paged, 911 would be called, and CPR would be started while waiting for help. If the resident did not have a wristband, she would check code status in the medical record. During an interview with the DON on [DATE] at 4:30 PM, she provided the surveyor with the resident's care guide that was in place at the time of the incident. On top of the document under code status was the word FULL, which had been crossed out with a single line and DNR was written next to it and dated [DATE]. The DON stated the resident's code status was changed on the care guide after he died . 4) Resident #28 had [DIAGNOSES REDACTED]. A [DATE] nursing progress note documented the interdisciplinary team met and the resident had do not resuscitate (DNR, allow natural death) in place. A [DATE] nursing assessment documented the resident had a DNR in place. A [DATE] social service evaluation documented the resident had a DNR in place and did not have a MOLST form. A [DATE] physician progress notes [REDACTED]. He would recommend following up with social services to help complete a MOLST form due to his overall non-compliance and advancement of his dementia. A [DATE] nursing progress note documented social services was to complete MOLST form. A [DATE] physician orders [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had moderate cognitive impairment, could usually make himself understood and understand others, and required minimal assistance with activities of daily living. The comprehensive care plan (CCP) dated [DATE] documented the resident had a HCP and advanced directives. Staff were to provide CPR and the directives documented to not implement a feeding tube. A [DATE] social service evaluation did not document code status and documented the resident had a MOLST in place. The resident's record had no documentation a MOLST form was in place at the time of this evaluation. A [DATE] social service progress note documented in response to a referral to social work, the social worker would follow-up with the resident and provide counseling if needed. There was no documentation regarding advance directives. A [DATE] nursing assessment documented the resident had a Full Code (cardiopulmonary resuscitation) status in place. A MOLST form documented the resident was to receive CPR, limited medical interventions including a trial period of non-invasive ventilation and IV fluids, he was not to receive a feeding tube, use antibiotics and hospitalize if needed. A health care agent of the resident consented to the terms of the MOLST on [DATE]. The resident's primary physician signed the MOLST on [DATE]. There was no further documentation in the resident's record regarding decision for code status documented on the MOLST on [DATE]. The face sheet (demographics) dated [DATE] included a section to document advance directives, including code status. This area of the face sheet was left blank. A physician's orders [REDACTED]. The resident's chart binder had a red sticker indicating DNR status. The resident was observed on [DATE] at 11:45 AM and the resident did not have an identification bracelet on. The resident's room was observed simultaneously with registered nurse (RN) Supervisor #42 and a certified nurse aide (CNA) care guide (care instructions) was not located in the resident's room and the RN Supervisor stated the resident took his care card down. The undated CNA care guide copy, kept at the nursing station, documented the resident was a full code. Resident assistant (RA) #18 was interviewed on [DATE] at 12:20 PM. She stated residents with DNR orders would have a purple wristband. During an interview with RN Supervisor #42 on [DATE] at 12:28 PM, she stated the residents on Unit 3A often took down their care guides and took off their ID bracelets. She stated in the event a resident was found unresponsive she would check for an ID bracelet first and then refer to the resident's MOLST form for code status. During an interview with the acting unit secretary on [DATE] at 12:10 PM, she stated she had worked at the facility in the past and had been responsible for updating ID bracelets with directives and chart indicators. She stated she returned for employment to the facility recently and was no longer responsible for updating the bracelets, or chart indicators. Certified nurse aide (CNA) #21 was interviewed on [DATE] at 12:37 PM. She stated she would check for a resident's code status in the care plan in the chart. If a resident was found unresponsive, she would check their wristband, and green would mean DNR and blue would mean CPR. During an interview with registered nurse (RN) Manager #3 on [DATE] at 3:55 PM, she stated she had not been working the day the resident's MOLST was implemented with a full code status. She stated another nurse recently informed her the resident's daughter had made the decision for full code status; she had not been notified prior to this and did not update the resident's record. She stated if a resident did not have a care guide in

Based on observation, interview, and record review conducted during the extended recertification survey, it was determined the facility failed to consistently provide a safe environment and adequate supervision for the facility's 136 residents as it related to an immediate risk to their health and safety from fire. Specifically, for all the facility's residents, the facility failed to communicate proper fire procedures to all facility staff during the loss of the fire alarm system; facility staff failed to demonstrate appropriate response to fire safety procedures; and facility staff failed to ensure fire safety procedures were consistently implemented and followed. This resulted in no actual harm with potential for serious harm that is Immediate Jeopardy and Substandard Quality of Care. The Immediate Jeopardy situation for the protection of residents from fire was removed on 8/17/2016 based on the following corrective actions taken by the facility: - Development of a policy and procedure to respond to fires during the total loss of the fire alarm system; - Development and implementation of a 24 hour fire watch procedure; and - Training of all duty staff in the alternative response procedures to fire during the total loss of the fire alarm system including code phrase, response to fire, and alternative notification of emergency services. Additionally, based on observation, interview and record review conducted during recertification and abbreviated surveys (NY 700 and NY 848), the facility did not provide supervision and assistance to prevent accidents for 2 of 24 residents reviewed for accidents (Residents #6 and 15). Specifically, Resident #6 left the premises without staff knowledge and no plan was in place to assess the resident's ability to leave unsupervised. Resident #15 was care planned to not use bathroom facilities off of the unit and was observed independently entering the bathroom on a different floor. Findings include: FIRE SAFETY CONCERNS: 1) On 8/10/2016 between 2:16 PM and 2:35 PM, during environmental rounds on Unit 3A (secured unit) with the Administrator and a surveyor, a strobe light for the fire alarm system was observed flashing. The Director of Maintenance attending to the strobe light stated the system was being tested at the time of the observation. On 8/10/2016 between 4:00 PM and 4:30 PM, the Administrator stated to a surveyor the fire alarm was out of service due to storm damage from the previous night. During an interview with the Administrator on 8/10/2016 at 6:13 PM and a surveyor, a fire watch and training of staff was discussed with the Administrator. He stated it would be started immediately and information on the fire watch was to be prominently posted. (A fire watch is conducted by a person or persons assigned to an area for the purpose of protecting the occupants from fire or similar emergencies. Fire watch at minimum involves special action beyond normal staffing, including assigned staff dedicated to walking the areas affected. Individuals are to be specially trained in fire prevention and in occupant and fire department notification techniques, and are to understand the particular fire safety situation for public education purposes.) On 8/11/2016 at 9:40 AM, the main entrance was observed by a surveyor. Fire watch information was not observed to alert occupants the facility was on a fire watch, and the status of the alarm system was not able to be readily determined as the surveyor entered the building. On 8/11/2016 at 10:20 AM, the Administrator and the Director of Maintenance were interviewed with 2 surveyors. The Administrator stated the fire watch continued from overnight. He stated he received a proposal from a fire alarm contractor and he granted them permission to start the job. The Director of Maintenance stated the fire system was completely non-functional, the pull stations would not work, the fire doors would not automatically close, no parts were available to repair the old system, and the new installation would be complete in 1 to 2 weeks. During review on 8/11/2016 at 11:15 AM of the fire plan for employees, revised 8/1/2014 and 8/12/2015, the following documentation in the plan was noted: - The facility's code word for fire was Doctor Red; - Internal phone (red phone) used for emergencies was extension 211; - Staff must know the fire plan, location of fire pull boxes and fire equipment, and where a complete copy of the fire plan was located; - In the event of a fire, do not use elevators, close all doors, follow the fire plan RACE (Rescue, Alarm, Confine, Extinguish); - Alarm displays were at the main entrance, 3A nursing station, copier/mail room, and the first floor mechanical room; and - The receptionist (Monday-Friday 8:00 AM to 8:00 PM), or at all other times, a staff member at the 3A desk, would do announcements and paging. During interviews with staff on 8/11/2016 between 12:15 PM and 1:00 PM, the following information was obtained regarding staff knowledge of the facility's fire safety procedures and response to the total loss of the fire alarm system: - At 12:15 PM, certified nurse aide (CNA) #8 on Unit 3B stated if the fire alarm was going off, the red phone would ring and it would be the fire department. If she saw a fire, she would use the white phone, dial 69 and page Doctor Red and the location. - At 12:20 PM, licensed practical nurse (LPN) #2 on Unit 3B stated he would call Code Red if there was a fire, although he was not certain and said we have so many codes. If he heard a staff member yell the code word on the unit, he would call higher ups first. He stated he usually had the phone on the medication cart (it was not present during the interview). He stated the best course of action was to evacuate the floor by using the elevator or the stairs. He stated he thought the residents could all be brought together to the elevators in 10 minutes and he was not sure how long they would then need to wait for an elevator to evacuate the unit. He stated there were two phones on Unit 3B; the red phone called the police (it actually connected to the front desk). The panel by the phones lit up and gave general information, but it was a hodgepodge the way the panel was laid out. He stated he was not sure if there was a panel anywhere else in the building. - At 12:30 PM, CNA #6 on Unit 3A stated if there was a fire, she thought she could pull the fire alarm, although she was not sure as the fire alarm pulls had covers over them. - At 1:15 PM, registered nurse (RN) Manager #27 stated if he saw a fire he would call the fire line or dial the operator. He stated the operator would activate the fire alarm, he would page 79, and announce the location of the fire. Corporate Food Service Director #23 was interviewed on 8/11/2016 at 1:10 PM. He stated that in the event of a fire, he would pull the alarm, call 911, call the nursing supervisor, and locate fire extinguishers if needed. The policy included RACE (Remove, Activate, Contain, and Extinguish). The fire and location would be announced over the loud speaker. He would make sure the kitchen lights were turned off, turn off the gas and any equipment in the kitchen, and report to the designated area and await further instructions. Food service worker #24 was interviewed on 8/11/2016 at 1:15 PM. He stated if he discovered a fire he would pull the alarm on the wall, call maintenance or the receptionist so they could alert the proper authority. He would turn off the lights, stoves and gas in the kitchen, and make sure all the fire doors were closed. He would make sure all employees in the area were accounted for, secure all residents, and wait for directions. Food service worker #25 was interviewed on 8/11/2016 at 1:25 PM and stated if he discovered a fire he would alert the manager, find a fire extinguisher, and see if he was allowed to put it out. Food service worker #26 was interviewed on 8/11/2016 at 1:30 PM. She stated if she discovered a fire, she would use the fire pull station and call down to the front desk so it could be announced. All of the equipment in the kitchen would be shut off. The kitchen staff would wait for direction on what to do next. When the specific staff member assigned to conducting the fire watch was interviewed on 8/11/2016 at 1:50 PM, housekeeping staff #52 stated if he saw a fire, he would dial 911, then dial 211 from the phone on the wall. He stated he then would page 79 and say fire in the building and to evacuate and give location of the fire. On 8/11/2016 at 7:50 PM, in a discussion with the Administrator, Director of Maintenance, and 2 surveyors on removing the immediacy of the fire safety issues, the following was discussed regarding the development of an inservice plan to address: - Immediate training for all building staff on alternative fire safety procedures during the total loss of the fire alarm system; - Training all staff on the code phrase to alert building staff in the event of fire and how to notify building staff of fire; - Procedure to notify the fire department in the event of a fire (calling 911); - Proper training of staff in manually closing all fire doors when alerted to fire; and - Development of plan to train staff during shift changes to ensure all staff in the building can respond to fires appropriately. During review on 8/11/2016 of the fire watch inservice plan for employees received at 10:30 PM, the following documentation in the plan was noted: - Fire watch was required and the fire alarm system was not functional, including strobe lights, audible alarms, smoke detectors, and delay egress/automatic fire doors; - Staff notification of fire watch using signs placed at entrance doors; - All employees are to be on heightened alert during the fire watch because the fire alarm system will not activate in the case of fire; - Examples that may indicate fire include having visible smoke or fire, or the smell of fire; - Any employee suspecting fire should call 911, and then dial 79 and page Doctor Red 4 times with the location; - The Supervisor is responsible to call 911; - General fire procedures are followed; - Additional responsibilities in the event of fire during fire watch include shutting smoke doors and the need for the door code to release the magnetic locks; and - RACE (see acronym that follows) Fire Plan information provided. RACE is an acronym for: R = Rescue - Remove residents from danger and simultaneously; A = Alarm - Call out Doctor Red to other staff who are to pull the fire alarm (New York State Department of Health requested plan revision at 10:50 PM as fire alarm did not work) and Dial 79 to page Doctor Red 4 times and state the exact location; C = Contain - Fire doors should be closed. Close all doors and windows on the unit, including adjoining bathroom doors. Turn off fans in resident rooms and on the unit. Put residents in rooms (does not need to be in their own room). Clear hallways of chairs, carts, and any other possible obstructions. E = Extinguish - If time and conditions warrant, prior to the arrival of the fire department, attempt to extinguish the fire. Do not go into a smoke-filled room or attempt to extinguish a fire out of control. Evacuate residents only on the order of the Administrator or Nurse Manager in charge. Between 1:00 AM and 2:00 AM on 8/12/2016, fire training was conducted for building staff. At 2:00 AM on 8/12/2016, the Administrator informed the surveyors the training was complete. A fire drill was discussed with the Administrator and the surveyors. A fire drill was conducted on 8/12/2016 and observed by surveyors and facility staff. The following was observed on Unit 3A: - At 2:09 AM, an LPN was given the scenario of a trash can fire in resident room 354 by the Director of Maintenance. (Resident room 354 was not searched.) - At 2:12 AM, the LPN walked to the nurse station, obtained a cordless phone, and called 911; (no page was made) - The LPN stated to the Director of Maintenance when he stated he did not hear a page, Didn't know you actually wanted me to page.; at 2:14 AM, the LPN paged Code Red 3A 3 times; and - Between 2:14 AM and 2:18 AM, an LPN and an aide were clearing the corridors. No additional staff were present on the unit. Following the fire drill on 8/12/2016 at 2:20 PM, the Administrator stated facility staff required a lot of cueing, and would be retrained immediately. Following staff fire training on 8/12/2016, a fire drill was observed by a surveyor. The following was observed on unit 2: - At 3:35 AM, a CNA was given the scenario of smoke coming from resident room 213 by the Director of Maintenance; - At 3:36 AM, the CNA closed the resident room door (the room was not searched); - At 3:38 AM, staff were unsure how to page, a call was made to 76 and page for Doctor Red 2nd floor; - At 3:40 AM, the staff were not sure if the nurse supervisor was aware, and made a call; - A resident remained out of his room and was found by the responding nurse supervisor in the service corridor near the kitchen; and - Additional units were not aware of this drill during this time as the page was not heard on all units. A second drill was conducted at 3:50 AM using the proper procedure. On 8/12/2016, additional fire drills were conducted, and the following was observed by surveyors: - At 11:30 AM, a resident aide was given a fire scenario on unit 3B. The staff member stated she did not know how to page and was unsure of RACE; - Between 11:30 AM and 11:32 AM, the resident aide stated to a staff member: There is a fire and I need help. Activities staff #68 walked by and stated, What do you need help with? I can't read minds. - at 11:35 AM, a page for Doctor Red was made was made by CNA #1; - between 11:35 AM and 11:37 AM, significant commotion was observed by the surveyor, staff were not sure of fire procedures and were responding slowly to the drill; - at 11:36 AM, RN #30 arrived on unit 3B and was unaware a fire drill was in progress or that there was a fire on the unit. She stated she did not hear the page; - at 11:37 AM, a page for Doctor Red re-announced; - at 11:38 AM, CNA #1 attempted to call the nursing Supervisor. The Supervisor did not answer the phone for 2 attempts, and when she did finally connect, it was the scheduler who had the phone; - at 11:45 AM in an interview with the scheduler, she stated she usually has the house phone during the day; - at 11:40 AM, a surveyor observing unit 3A did not hear any pages; and - at 2:44 PM, an additional page was not heard announced by a surveyor standing under the speaker near room 115. Additional surveyors observed lack of response as staff were not aware a drill was being conducted because they did not hear an announcement. During an interview at 3:00 PM on 8/12/2016, the Director of Maintenance stated he was aware of intermittent issues with the paging system. He stated sometimes humidity can cause problems. During the interview, the Director of Therapy stated during the last drill she did not hear the first 2 pages, and had heard the third and fourth page. She stated she was directly under a speaker. On 8/16/2016 at 2:22 PM, dietary staff #68 stated he worked in the facility for approximately 7 months, and had not had any recent fire safety training. He stated if he saw a fire, he would run outside. On 8/16/2016 at 2:25 PM, dietary staff #61 stated she had worked in the facility for approximately 3 weeks. She stated if she saw a fire, she would get everyone and call for help, go into the office, and was still kind of new and did not know how to call the nursing supervisor. She stated if there was a fire elsewhere in the facility, she was not sure if the supervisor would call to let the kitchen know. During this interview, a surveyor heard an inaudible page in the kitchen. The page very muffled and no words were clear. On 8/16/2016 at 2:30 PM, the main dietary phone was observed by a surveyor. No emergency contact information for the building nursing Supervisor was present. In an interview on 8/16/2016 between 2:30 PM and 2:40 PM with linen aide #37 regarding response to fire, she stated if there was a fire she would pull the fire alarm. At 3:15 PM on 8/16/2016, the Acting Director Of Nursing #22 stated to a surveyor all staff were in the process of being re-trained on fire safety procedures. LACK OF SUPERVISION OF THE UNIT AND OUT OF THE BUILDING 2) Resident #6 had [DIAGNOSES REDACTED]. A 2/5/2016 admission wander risk assessment documented the resident was at low risk to wander. The resident was not an elopement risk and no care planning was needed. A 2/23/2016 interdisciplinary note documented the resident was not able to return to his previous living arrangement and his discharge plan at that time was uncertain. A 5/9/2016 nursing progress note documented the resident was alert, oriented, required 1 assist with transferring, and ambulated with a walker. A 5/10/2016 comprehensive care plan (CCP) documented the resident was admitted to the facility and was unable to return to his previous living arrangement. A referral had been made to an independent agency in the community to assist with discharge planning. The resident was not a good candidate for out on pass privilege related to his recent CVA. The 5/11/2016 Minimum Data Set (MDS) assessment documented the resident was moderately cognitively impaired. The resident did not wander, and he required limited to extensive assistance with most activities of daily living (ADLs). The MDS documented the resident participated in the assessment and had an active discharge plan in place. The CCP was updated on 5/12/2016 and documented the resident preferred to spend the majority of time in his room. He was to be offered or encouraged time out of room for socialization. A 6/16/2016 social service progress note documented supportive counseling was offered and the resident would contact a friend regarding discharge. A 7/5/2016 nursing progress note documented the resident was alert and oriented, was able to make needs known, required 1 assist for transfers, and used a wheelchair for mobility. A 7/12/2016 social service progress note documented the resident would have a friend call to discuss discharge to home and social services had not heard from that friend. The resident notified social services he would like to be discharged if his friend was willing to help. There was no further information regarding discharge by social services following this note. A 7/29/2016 physician progress notes [REDACTED]. He had returned to independent status and appeared to have capacity for his own health care decisions. The physician would try to speak with nursing tomorrow or Monday to review whether the resident could really return to the community given his huge improvement. The resident was potentially ready to live at a lower level of care. A nursing progress note dated 7/30/2016 at 5:00 AM documented the nurse saw the resident at 11:00 PM sitting outside in his wheelchair wearing a hospital gown with sweat pants. The nurse spoke with him for several minutes and did not notice anything out of the ordinary. He stated to the nurse he was getting fresh air. The nurse checked on the resident at 12:00 AM and he was sitting in the same spot. At 12:30 AM, the nurse received a phone call from a certified nurse aide (CNA) reporting she could not locate the resident. The nurse searched outside and within 10 minutes called the code for a missing resident. At 1:12 AM, the nurse left a message for 1 family member, and spoke to a second family member. At 1:30 AM, police were notified. At 2:46 AM, police contacted the nursing Supervisor and documented the resident was found at his personal residence. The resident stated to police he would not return to the facility. There were no further notes in the resident's record regarding the incident. A 7/30/2016 CNA statement, attached to the facility's investigation of the incident, documented she had arrived to work at 10:55 PM and the resident was sitting outside near the front entrance. The CNA proceeded to clock in and around 12:25 PM she went outside to bring the resident back in and he was no longer outside. A 7/31/2016 hospital history and physical note documented the hospital nurse practitioner (NP) spoke with the facility's physician. The resident was successful in therapy, could have been discharged , however, there was not a safe discharge plan for the resident, and the resident was working with social work to create a safe plan. The note documented 2 days prior the resident was sitting outside of the facility, which he normally did and when the patient did not come back, the staff became concerned and they called the police. The police found the resident at his personal address with a family member. The police tried to get the resident to go back to the facility and he refused. The facility tried to contact the resident the next day and tried to get him to come back and he refused. The resident was signed out against medical advice (AMA). The hospital note documented the resident returned to the hospital after a fall and they were attempting to transfer the resident back to the facility. A nursing progress note dated 8/2/2016 at 4:00 PM documented the resident was readmitted to the facility at 3:00 PM from the hospital and the nurse noted to refer to the admitting nursing assessment for details. A 8/2/2016 (not timed) admission wander risk assessment documented the resident was at low risk to wander and was not an elopement risk. The portion documenting if the resident was an elopement risk documented no and was crossed off and re-written as yes by another nurse. There was no date when the change was made. There was no documentation the CCP was updated to reflect the incident, re-admission, change in Unit, or the resident's preference to sit outside. There was no documentation in social services notes regarding the incident or re-admission. A nursing progress note dated 8/2/2016 at 11:00 PM documented the resident was adjusting well and had moved to Unit 2. The surveyor and Director of Nursing (DON) reviewed the resident's record on 8/3/2016 at 2:35 PM. The resident was assessed for wandering upon admission on 2/5/2016. There was no documented evidence a quarterly wander assessment was completed until 8/2/2016, when the resident was readmitted to Unit 2 and a re-admission nursing assessment was completed. The facility's elopement/unsafe wandering list was not updated until 8/4/2016 to reflect the resident's placement on Unit 2 and implementation of the WanderGuard device. During an interview with the primary physician on 8/4/2016 at 12:50 PM, he stated he saw the resident for an appointment on 7/29/2016 and the resident had verbalized he wanted to leave at that time. The physician contacted nursing and social work that evening to address this, and the nurse Manager had already left for the day. He stated he was able to discuss the resident with the social worker. He stated he contacted the facility the morning of 7/30/2016 and asked nursing to monitor the resident closely and he was informed at that time the resident had already eloped. The physician stated he spoke with the hospital 3 times, after the elopement, about the resident's cognitive deficits and stated the resident should not be allowed to leave independently. During an interview with the Director of Social Services on 8/4/2016 at 1:15 PM, he stated he did not recall speaking to the physician on 7/29/2016. He never considered the resident an elopement risk and he was working on setting up arrangements for the resident to return to the community. He did not know until the following Monday the resident had eloped that weekend. He attempted to speak with the resident regarding the incident, and the resident said a friend picked him up and brought him home and he did not want to discuss it. During an interview with CNA #36 on 8/16/2016 at 1:30 PM, she stated the resident was able to roam the building himself and he was on the elopement list. She stated the resident now had a WanderGuard, as he had left the building prior to his re-admission without notifying staff. She stated he received the WanderGuard when he returned to the facility. She stated the resident would take himself outside. She would normally ask him during the shift if he planned on going outside, and he would sit out front of the reception entrance and did not make any attempts to leave. She stated there was nothing in place to document if a resident left the floor, only if a resident planned to leave facility grounds. During an interview with RN Manager #27 on 8/16/2016 at 9:02 AM, he stated he was not working when the resident had left the building. He stated the resident had went out at 10:00 PM to sit as that was not atypical for him. He stated the resident's community living arrangements changed while he was at the facility and he was to remain at the facility until alternative arrangements could be made. The RN stated the social worker was setting up discharge and did not involve nursing in the discharge planning. The facility tried to get the resident to come back to sign discharge paperwork and he did not want to return. He stated the resident had never talked about leaving prior to the incident. He stated when the resident was readmitted , he tried to speak with the resident to determine who picked him up and how he was able to leave the facility grounds, and the resident did not tell him. The RN stated there was not a plan in place for residents who wished to sit outside independently. 3) Resident #18 had [DIAGNOSES REDACTED]. The current certified nurse aide (CNA) care guide (care instructions) dated 11/25/2015 documented the resident was independent in transfers and ambulation and had a wheelchair. She was alert and weepy at times, and did crafts and exercises. The resident was to be encouraged to participate in social activities, as she often chose to stay in her room. She was to be transported to socials, parties, entertainers, and outdoors. A nursing progress note dated 1/18/2016, recorded as a late entry from 1/6/2016, documented the resident took a taxi to the supermarket and was observed with alcohol in her cart. The licensed practical nurse (LPN) documented the social worker, Assistant Director of Nursing (ADON), and the Director of Nursing (DON) were aware of the incident. It was not clear if the resident purchased the alcohol. There was no documented evidence in the resident record if the resident was counseled/educated at the time of the incident. A physician progress notes [REDACTED]. The physician was going to write an order to not allow the resident out alone. A nursing progress note dated 2/4/2016 documented the nurse observed an empty alcoholic beverage can in the resident's room. The resident had a physician order [REDACTED]. A social service progress note dated 2/5/2016 documented the social worker and the physician met with the resident regarding the alcohol found in her room. The resident was informed she was not to drink alcohol due to her history. She was to have supervised visits with family, and was to be examined when re-entering the facility. Supportive counseling was to be continued to be provided to the resident. A physician progress notes [REDACTED]. Given the resident's history, the resident was informed she was in danger of a real tragedy. A nursing progress note dated 3/4/2016 documented the resident was alert and oriented with forgetfulness at times. The resident was documented as independent with transfers, used a wheelchair, but can walk. Nursing progress notes dated 3/4, 3/5, 3/6, 3/7 and 3/9/2016 documented the resident was alert and oriented with forgetfulness. Social service progress notes dated 5/11, 5/17, and 6/2/2016 documented the resident was unwilling to let the social worker help her look in her room for a personal item that was missing. The resident claims she already looked in her room and it was not there. Nursing progress notes dated 5/27, 5/28, 5/29, 5/30 and 5/31/2016 documented the resident was alert and oriented with periods of forgetfulness. On 5/31/2016, social work documented in the comprehensive care plan (CCP) that the resident was able to make independent decisions. Social work was to provide supportive counseling as needed, assist with coping strategies, and encourage social support. A quarterly nursing assessment dated [DATE] documented the resident was low risk for wandering and not at risk for elopement. The comprehensive care plan (CCP) dated 6/14/2016 documented the resident was at risk for an accident/incident related to physical performance limitations at times. The resident was to be encouraged to ask for assistance as needed and was to be monitored for risk factors. The CCP did not address the resident leaving the facility unsupervised or a plan related to the use of alcohol. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact, exhibited verbal behaviors directed toward others, and required supervision with all activities of daily living (ADLs). Nursing progress notes dated 6/24, 6/26, 6/27, 6/28, 6/29 and 6/30/2016 documented the resident was alert and oriented with occasional forgetfulness. The current physician orders [REDACTED].! This means that she cannot go out alone or must have purchases examined on return to the facility. The orders included a statement the resident may leave the facility independently. During an interview with the physician on 8/17/2016 at 12:15 PM, he stated he thought the order was for supervised visits out of the building and said he would have to check the order. He did not intend for her to leave the building independently without supervision, as a result of her history of complications with alcohol use. During an interview with the receptionist on 8/8/2016 at 12:20 PM, she stated she was not aware of any method for residents signing out when they sat in the front of the building. She said she checked on the residents to be sure they did not go far away from the building. She said she had pictures of residents with WanderGuards, last updated on 8/4/2016. The resident was observed on 8/9/2016 sitting outside the facility at 2:30 AM. The resident stated she enjoyed sitting and watching (thunder) storms. During an interview with LPN #16 at 4:00 AM on 8/12/2016, she stated the facility started a system for residents to sign out when leaving the building to sit outside. She stated this was to help know the whereabouts of all residents during a fire drill. During an interview on 8/12/2016 at 2:15 PM, the Acting DON (Director Of Nursing) stated the plan for residents to sign out was never implemented as the residents did not want to do it. On 8/12/2016, the resident was observed between 3:00 PM and 4:00 PM entering the facility. The resident was ambulating and was pushing her wheelchair in front of her, with a large plant on the seat of the chair. The resident stated she went shopping and bought the plant for herself. During an interview with the Administrator on 8/17/2016 at 9:10 AM, he stated he was unable to find anything related to a policy for signing out when leaving the building. He stated he would check again with the Acting DON. At 12:25 PM on 8/17/2016, the sign out book was requested from the nursing staff on Re

Based on observation, record review, and interview conducted during the extended recertification and abbreviated surveys, it was determined Administration failed to ensure the facility's resources were effectively and efficiently used to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each of the facility's 136 residents. Specifically, Administration failed to ensure adequate supervision and a safe environment was provided to ensure proper fire safety procedures were communicated, understood, and consistently followed during the total loss of the electrical fire alarm system for the 136 residents in the building. Additionally, Administration failed to ensure policies and procedures for residents' advance directives were properly identified, communicated, and consistently implemented, including the determination of residents' decision-making capacity, and the availability for CPR (cardiopulmonary resuscitation)-trained staff. Administration's failures to ensure fire safety procedures and the proper implementation of residents' advance directives resulted in the potential for serious harm to the residents' health and safety that is Immediate Jeopardy. The Immediate Jeopardy and Substandard Quality of Care in fire safety procedures and the Immediate Jeopardy in proper implementation of residents' advance directives was removed prior to survey exit on [DATE] based on staff interviews, review of new and revised policies and Administration's corrective actions, including: - The fire watch implementation, with properly trained fire watch staff, to adequately track and monitor the fire watch on a timely basis; - Revised fire safety procedures and trained staff on the use of alternative procedures, including the use of backup 2-way radios, while the fire alarm system was nonfunctional; - Initiation of a fire alarm system replacement in a timely manner. - The development and consistent implementation of a new policy and procedure for identifying and communicating residents' advance directive code status; - The training of all staff on the revised policy and procedure. Refer to F155, F323 and K155 Findings include: 1) F155 Re: CPR CERTIFICATION; DETERMINATION OF CAPACITY; ADVANCE DIRECTIVES: Administration failed to ensure 1 of 30 residents (Resident #14) reviewed for advanced directives had the right to formulate advance directives in accordance with New York State law and failed to follow Resident #14's wishes in a timely manner for DNR (Do Not Resuscitate, allow natural death), and initiated CPR (cardiopulmonary resuscitation). After the facility became aware of Resident #14's inadvertent resuscitation efforts, the facility failed to recognize and correct the multiple errors and inconsistent advance directive code status identifiers on Residents' #2, 9, 10, 11, 14, 26, 27, 28, 29, and 30 care guides, medical records, wristbands, face sheet and the facility code status list (kept in resident gathering areas and last updated in 2015). CPR CERTIFICATION: Administration also failed to ensure CPR-trained staff were available in the facility 24 hours a day, if needed, as evidenced the facility could not verify current CPR certification for 23 of 32 nursing staff. A policy dated [DATE] titled Cardiopulmonary Resuscitation (CPR) and Basic Life Support, provided on [DATE] as a current policy, documented CPR certification expiration dates would be monitored by the In-Service Director or Designee, who would schedule recertification classes and notify specific nurses when they were due for the renewal class. During an interview with MDS (Minimum Data Set) Coordinator on [DATE] at 12:30 PM, she stated they did not currently have anyone in the facility doing inservice training. When the MDS Coordinator was re-interviewed on [DATE] at 2:30 PM, she stated the facility has not had a nurse educator since ,[DATE]. She stated the facility previously kept CPR certification cards in the employee files, and the nurse educator used to keep a list of who had the training and when it was due. DETERMINATION OF CAPACITY: The Administrator failed to have a system in place to determine the most appropriate person was specified to determine 4 of 30 residents' (Residents #8, 9, 10 and 26) advance directive wishes for their MOLST (Medical Orders for Life Sustaining Treatment) and failed to ensure these residents lacked capacity to make their own decisions. The facility policy for Advance Directives, Family Health Care Decisions Act, provided on [DATE] and dated [DATE] documented the use of 9 forms for identifying resuscitation, do not resuscitate (DNR, allow natural death), and treatment decision determinations for the facility. The policy documented a determination that an adult resident lacked capacity was made by the attending physician to a reasonable degree of medical certainty, with a concurring physician's determination for the same information. When the Director of Social Services was interviewed on [DATE] at 8:40 AM, he stated he did not get involved with the determination of capacity; did not know how that was completed or documented; did not know how a surrogate was determined if there was no Health Care Proxy; and stated he was not aware of any forms used for determination of capacity. During an interview with physician #33 on [DATE] at 11:48 AM, he stated he never acted as a concurring physician at this facility to determine residents' capacity for DNR decision making. He did not think the facility had a system in place for this process. ADVANCE DIRECTIVES: Prior to survey, the facility's policy Advanced Directives: Identifying Residents Who Are Full Code, revised on [DATE], documented when a resident specified their advance directive for CPR (cardiopulmonary resuscitation when needed), the following would have the resident's code status documented: - Appropriate color identification bracelet was on the resident (or as indicated by the care plan, i.e. wheelchair or walker); - Update the Advance Directive Face Sheet; - Add name from full code list; - Distribute full code list to all departments; and - Add to care plan/care guide. During a combined interview with the Administrator and the DON on [DATE] at 2:32 PM, the Administrator stated that Resident #14 received CPR when he was DNR. He stated they were looking at revising the Advance Directive Policy. After Resident #14's incident, he stated a house wide audit was conducted to ensure all care guides, bracelets, face sheets, stickers on spines of chart and the MOLST all matched the resident's wishes regarding code status. He stated he was not aware of any lists in the facility indicating residents who were full code. During an interview with the DON on [DATE] at 4:30 PM, she provided the surveyor with the resident's care guide that was in place at the time of the incident. On top of the document under code status was the word FULL, which had been crossed out with a single line and DNR was written next to it and dated [DATE]. The DON stated the resident's code status was changed on the care guide after he died . 2) F323: ACCIDENT SUPERVISION AND FIRE SAFETY PROCEDURES: Administration failed to ensure proper fire procedures were communicated to all facility staff during the loss of the fire alarm system; failed to ensure facility staff were able to demonstrate appropriate response to fire safety procedures; and failed to ensure fire safety procedures were consistently implemented and followed. This resulted in the potential for serious harm that is Immediate Jeopardy and Substandard Quality of Care. 3) K155: FIRE WATCH IMPLEMENTATION: Administration failed to properly institute a fire watch when the entire electrical fire alarm system became non-functional for more than 4 hours; failed to ensure the assigned fire watch staff were properly trained on the revised fire safety procedures during the non-functioning of their fire alarm system; failed to communicate to all facility staff that a fire watch was implemented; and failed to ensure all staff were trained on the alternative fire safety procedures while their electrical fire alarm system was inoperable. This resulted in Immediate Jeopardy for all 136 residents residing in the building. The Administrator did not convey to the surveyors there were any problems with the facility's fire alarm system during the fourth day of survey ([DATE]) until he was interviewed between 4:00 PM and 4:30 PM on [DATE]. He told a surveyor the fire alarm was out of service due to storm damage from the previous night. When the Director of Maintenance was interviewed on [DATE] at 5:35 PM, he stated he became aware the electrical fire alarm system was not functioning when he saw a trouble light on at approximately 8:00 AM on [DATE]. He stated he immediately tried to reset the system with no success and then called the fire alarm vendor at 7:51 AM. In an interview with the Administrator at 10:20 AM on [DATE], he stated fire alarm contractor #1 diagnosed the issue, and fire alarm contractor #2 was consulted regarding the issue. He stated the facility received a proposal from fire alarm contractor #2 on [DATE], and he had given approval for the new contractor to complete the installation of the new system. With the Administrator present, the Director of Maintenance stated the installation would occur within 1 to 2 weeks. He stated department heads had a memo regarding the system and assumed they knew to communicate to all staff. In an interview with the Director of Maintenance on [DATE] at 5:35 PM, he stated he became aware the system was not functioning when he saw a trouble light on at approximately 8:00 AM on [DATE]. He stated he immediately tried to reset the system with no success and then called the fire alarm vendor at 7:51 AM. He stated fire alarm contractor #1 arrived between 10:00 AM - 11:00 AM and billed the facility for 1 hour of service. He stated fire alarm contractor #1 informed him the system was dead and not repairable. He stated fire alarm contractor #1 made a recommendation to replace the system, and that they had previously submitted a bid to replace it. He stated fire alarm contractor #2 was called as he thought it was a good idea to get a second opinion. He stated fire alarm contractor #2 arrived in approximately ,[DATE] hours and agreed the system was not repairable, and stated storm damage may have caused the issues. He stated the fire watch became a discussion at that point as it was kind of going on prior, but was not recorded. He stated he had never done a fire watch except for an hour or 2 prior to this time. He stated the fire alarm monitoring company did not receive trouble notifications and was not aware there was a problem with the alarm. 10NYCRR 415.26(a)

Based on record review, observation, and interview conducted during the recertification and abbreviated (NY 848) surveys, it was determined for 4 of 4 residents (Residents #8, 9, 12, and 20) reviewed for pressure ulcers and 1 additional resident (Resident #46), the facility did not ensure care was provided that prevented residents from developing pressure ulcers and/or did not ensure residents with pressure ulcers received the treatment and services needed to promote healing and prevent infection. Specifically: - Resident #8's skin breakdown was not assessed timely by a qualified person; care interventions were not implemented timely; the care plan was not reviewed to determine if current interventions were effective; the physician order [REDACTED]. - When Resident #46 developed 2 pressure ulcers in the facility, his plan of care was not evaluated to determine its effectiveness. Additionally, the resident's pressure ulcer was not monitored as planned and treatments were not completed as ordered. - Resident #20 developed a pressure ulcer that was not consistently monitored as planned; and was not provided with pressure relief while out of bed. - Resident #9, with a history of skin impairment, was observed in a Geri-chair and a wheelchair without preventative measures in place to prevent pressure ulcers from developing. - Resident #12 had a history of [REDACTED]. This resulted in actual harm that is not immediate jeopardy for Residents #8 and 46. Findings include: 1) Resident #8 had [DIAGNOSES REDACTED]. A weekly skin assessment dated [DATE] documented the resident's pressure ulcer to the left buttock was healed. The area was fragile and the plan was to continue with Allevyn (protective dressing). Physician orders [REDACTED]. A nursing progress note by licensed practical nurse (LPN) #67 dated 4/26/2016 at 6:45 AM documented the resident had 2 small areas on her bottom that were unopened and appeared to be on the verge of opening. The nursing supervisor was aware and they would continue to monitor. There was no documented evidence in the medical record the areas were assessed by a qualified person until 5/9/2016. A weekly skin assessment sheet dated 5/9/2016 stated the resident had an Unstageable pressure ulcer to the left coccyx that measured 1.6 centimeters (cm) x 1.0 cm. The wound bed contained 100% slough (moist dead tissue) and the surrounding skin was red. A nursing progress note dated 5/9/2016 documented the resident had an Unstageable pressure ulcer to the left coccyx area measuring 1.6 cm x 1.0 cm, the wound base contained 100% slough, the peri-wound was red, there was no drainage, and a note was left in the physician book. A physician order [REDACTED]. The comprehensive care plan (CCP) was updated on 5/9/2016 and documented the resident had an Unstageable pressure ulcer on the the left coccyx. Interventions included to turn and reposition every 2-3 hours while in bed and reposition every 1-2 hours in her wheelchair and monitor for signs and symptoms of infection. A weekly skin assessment sheet dated 5/12/2016 documented the pressure ulcer was Unstageable, measuring 1.5 cm x 1.5 cm with 100% slough and the wound status was unchanged. A nurse practitioner (NP) progress note dated 5/19/2016 documented the resident had a few issues with her buttocks, measuring 1.4 cm x 1.8 cm with 75% slough, slightly worse from last week, surrounding skin is macerated. Will continue with Santyl and border gauze. The area located on left buttocks with a slight amount of drainage noted no particular odor. Area is avoidable with proper nutrition and repositioning. A weekly skin assessment sheet dated 6/2/2016 documented the pressure ulcer was Unstageable, measured 1.2 cm x 1.2 cm with 100% slough and had improved. Preventative measures included an air mattress and turning and repositioning. A NP progress note dated 6/9/2016 documented the pressure ulcer on the buttocks measured 1.2 cm x 1.4 cm with 50% slough and was slightly improved from last week. The pressure ulcer was avoidable with proper nutrition and repositioning. A NP progress note dated 6/16/2016 documented the buttocks pressure ulcer measured 1 cm x 1.5 cm and was slightly improved from the previous week. The pressure ulcer was avoidable with proper nutrition and repositioning. The weekly skin assessment sheets documented: -On 6/16/2016 the pressure ulcer was Unstageable, measured 1.0 cm x 0.8 cm, the wound bed contained 80% slough and was improving; -On 6/23/2016 the pressure ulcer was Unstageable, measured 1.0 cm x 0.5 cm, the wound bed contained 80% slough and was improving; and -On 6/28/2016 the pressure ulcer was not staged, measured 0.8 cm x 1.0 cm, the wound bed contained 100% slough and was improving. A NP progress note dated 7/5/2016 documented the buttock pressure ulcer measured 1 cm x 1.8 cm and slightly worsened from the previous week with 90% slough. A weekly skin assessment dated [DATE] documented the left coccyx pressure ulcer measured 2 cm x 2 cm x 0.1 cm and the wound bed contained 90% eschar (black, dry dead tissue) and 10% slough. The assessment did not document a Stage of the pressure ulcer and the treatment was Hydrogel (a product that adds moisture to the wound) and then cover with a Coversite dressing. The pressure ulcer had worsened. There was no documented evidence the resident's plan of care was reviewed to determine effectiveness of current interventions to promote healing. A NP progress note dated 7/20/2016 documented the resident's pressure ulcer on her bottom measured 2 cm x 2 cm. The treatment was to cleanse the pressure ulcer and apply border gauze and continue to reposition. There was no documented evidence in the medical record the resident was turned and repositioned as planned or that she was resistive to the turning and repositioning. A NP order dated 7/20/2016 documented to discontinue previous treatment to the pressure ulcer on the resident's buttock. The new order documented to cleanse the buttocks with wound cleaner, apply Hydrogel and cover with [MEDICATION NAME] every day and the resident should be in and out of bed for meals only and be reposition from side to side. There was no documented evidence the resident was to get out of bed for meals only and that the resident was to be repositioned from side to side was added to her plan of care. A nursing progress note dated 7/28/2016 at 10:15 AM documented the buttocks pressure ulcer measured 5 cm x 3 cm, was Unstageable and the wound bed contained 100% slough. Treatment orders were changed to Silver Alginate (antibacterial wound product) then cover with [MEDICATION NAME]. The nurse documented he would attempt to get alternating pressure mattress for the resident. A weekly skin assessment sheet dated 7/28/2016 documented the left coccyx pressure ulcer measured 5 cm x 3 cm, the wound bed contained 100% slough and the treatment was changed to Silver Alginate. The assessment did not document a Stage and the pressure ulcer had worsened; the assessment had not been documented since 7/12/2016. A NP order dated 7/28/2016 documented to discontinue the Hydrogel treatment and change to cleanse the pressure ulcer with wound cleaner, apply Silver Alginate to wound bed and cover with [MEDICATION NAME] every 2 days. The resident was to have an alternating pressure relief mattress and to call out to find one. A nursing progress note dated 7/28/2016 at 11:30 AM documented a call was placed to a health care agency to order an alternating pressure relief mattress for the resident, and the agency would review the payor source options. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had moderate cognitive impairment, required extensive assistance for bed mobility and transfers, was totally dependent for hygiene and required limited assistance for eating. A physician progress notes [REDACTED]. The pressure ulcer contained large areas of yellow slough and his proposal is Santyl with Allevyn. A physician order [REDACTED]. The order was not transcribed by a nurse and was not added to the treatment administration record (TAR). A nutrition progress note dated 8/5/2016 documented the resident had progressive decline and weight loss due to decreased intake and fall with [MEDICAL CONDITION]. The resident disliked and was not consuming available nutritional supplements (snacks, nutritional juice drink, magic cup and Boost Breeze) and frequently refused assistance with eating. Her pressure ulcer was worsening. With fortified foods provided she accepts at present meeting nutritional requirements. Monthly physician renewal orders dated 8/5/2016 documented to cleanse the buttocks pressure ulcer with wound cleanser, apply Silver Alginate to the wound bed and cover with [MEDICATION NAME] every 2 days and prn. A nutrition progress note dated 8/8/2016 documented the pressure ulcer was worsening, the resident had significant weight loss due to poor intake and refusal of supplements. A treatment and wound observation was made on 8/10/2016 at 9:30 AM with LPN #19. The resident was on an alternating air mattress and was no administered pain medication prior to the LPN removing the pressure ulcer dressing. The dressing was heavily saturated with greenish drainage and there was a foul odor. The pressure ulcer measured approximately 5 cm x 3 cm and the wound bed contained 95% necrotic tissue and 5% slough. The LPN cleansed the pressure ulcer and placed Silver Alginate on the wound bed and then covered it with an Allevyn dressing. She stated the pressure ulcer looked worse than yesterday when she changed the dressing. She stated she would document on the pressure ulcer in the nursing progress notes and let the supervisor know. She stated wound rounds were usually done on Thursdays and the wound team consisted of the NP, the MDS nurse and the nurse Manager, and the Unit did not currently have a Nurse Manager. Nursing documentation on the 24 hour report dated 8/10/2016 for the 7:00 AM- 3:00 PM shift stated the butt wound had a large amount of green/yellow drainage, was foul smelling, painful and necrotic and the dressing was intact. Nursing documentation for both the 3:00 PM- 11:00 PM and the 11:00 PM- 7:00 AM shift stated dressing intact. There was no documented evidence the physician was notified and consulted regarding the pressure ulcer worsening and developing signs of infection. The physician was interviewed on 8/12/2016 at 8:55 AM. He stated he needed to know about any resident with a pressure ulcer and the rounds were done by the skin team. The skin team would update him on the status of the wound. He would expect the skin team to assess the wound weekly and he would review the notes. He would take the recommendations made by the skin team and base his orders on those recommendations or the NP would write orders if she had seen the wound and write a progress note as well. He stated the resident had broken her hip some time ago and now spent a great deal of time in bed. He stated he had last seen the pressure ulcer with the nutritionist and she had suggested we go back to Santyl because the pressure ulcer was covered with yellow. He stated he may not have flagged the order and that was why it probably was not carried through. He stated he had not seen the wound in some time, but he should be informed if the area had worsened. An alternating air mattress was ordered due to her non compliance with turning and repositioning. He stated if the resident was in pain every time she was moved he would recommend giving her pain medications but if the pain only lasted a short time she may be able to tolerate it rather than putting her on a narcotic pain reliever. A nursing progress note dated 8/13/2016 at 7:55 PM documented a call was placed to the attending physician with concerns over the sacral decubitus. New orders were received earlier today and would be implemented by staff this date. Will notify doctor of any changes in VS (vital signs), fever as well. A registered nurse (RN) progress note, recorded as a late entry for 8/13/2016 on 8/14/2016, documented new orders were received from attending physician to discontinue previous treatment to coccyx, spray wound wash to open area and pat dry, apply Santyl to open area, cut silver alginate to fit wound, cover with Allevyn dressing every day and notify physician of any changes. The writer documented she assisted the physician in assessing the wound. A foul odor and slough were noted. A nursing progress note, dated 8/15/2016, documented on that day, the NP ordered Keflex (an antibiotic) 500 milligrams (mg) three times daily for 7 days; to discontinue wound wash and use normal saline to cleanse wound. Then, apply Santyl to eschar and cover with silver alginate and dry sterile dressing every day and prn. A physician progress notes [REDACTED]. The sacrum looked worse than when he saw it last week and part of reason may be that an order for [REDACTED]. I am not sure any Rx (treatment) will help. The physician ordered the resident be given [MEDICATION NAME] (narcotic pain reliever) to assist with the pain. A nursing progress note dated 8/16/2016 at 7:00 AM documented the resident was calling out in pain during care. [MEDICATION NAME] 5 mg was given orally stat, with effectiveness. The NP was interviewed on 8/16/2016 at 10:00 AM. She stated she was in the facility one day per week on Tuesdays. She stated skin rounds used to be on Tuesdays and they changed the skin round day to Thursday so she had not been able to see the resident's wound. The Unit RN Manager had left several weeks ago and she had been part of the skin team. She stated the skin team would document in the chart on the wound. She would expect documentation of an assessment of the pressure ulcer at least weekly. If the wound status changed, she would expect the treatment nurse to document and inform an RN who should assess the change as soon as possible. She stated the resident was very frail and had a significant deterioration in her condition. RN #27 was interviewed on 8/16/2016 at 11:55 AM. He stated he had done a full house skin check on every resident on 7/28/2016 and had seen the resident's pressure ulcer then. The Nurse Manager on the unit had left a few weeks ago. He stated the wound looked terrible, was black and sloughy. The treatment was silver alginate and that was the best treatment. The resident was non-compliant with turning and repositioning so he ordered an alternating air mattress at that time. RN #27 stated there was improvement with the silver alginate, and wound rounds were planned for the following day. A second NP was interviewed on 8/16/2016 at 12:45 PM. He stated he had been asked to see the wound. He stated the wound had a foul odor and slough and he believed Santyl would help with the debridement of the necrotic tissue and he ordered an antibiotic. He stated he had not seen the wound prior to that but given all of the resident's health concerns he did not foresee it improving. The Medical Director was interviewed by telephone on 8/16/2016 at 12:56 AM. He stated he had not seen the wound until 6 weeks ago when skin rounds were completed every week by the NPs. The Acting Director of Nursing (DON) was interviewed on 8/17/2016 at 10:20 AM. She stated all pressure ulcers were assessed every week by one of the NPs and the Unit Manager. The Unit Manager from a different unit had been trying to make the rounds on the resident's unit but they were not being done weekly. She stated when the LPN had documented the status of the pressure ulcer on the 24 hour report she would expect the supervisor to follow up at that time and assess the status of the wound. She stated they did measure the wound when it was assessed on 8/13/2016 and did not know why there was no documentation of the assessment. She stated if a physician wrote an order and did not flag the order, it would be the responsibility of the floor nurse to review all charts to ensure all orders were noted. 2) Resident #46 had [DIAGNOSES REDACTED]. An admission assessment dated [DATE] documented the resident was admitted on [DATE]. His skin was intact, and he had slightly limited sensory perception and very limited mobility. A nursing progress note dated 6/24/2016 documented the resident required 1-2 assist for bed mobility. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was intact; he required extensive assist for bed mobility and was totally dependent for personal hygiene. The resident had an indwelling urinary catheter and a [MEDICAL CONDITION]. The MDS documented the resident did not have any pressure ulcers, was at risk of developing them, and had a pressure reducing device on his mattress and wheelchair. The comprehensive care plan (CCP) dated 7/1/2016 documented the resident had potential for skin breakdown related to [MEDICAL CONDITION] and impaired bed mobility. Interventions included to toilet the resident every 2-4 hours and as needed (prn), conduct weekly skin rounds, and assess for and provide appropriate pressure relieving devices. Turning and repositioning was not identified on the CCP. The weekly skin check flow sheet documented: - On 7/7/2016, the resident refused a shower and was provided with a bed bath. There was no documented evidence the resident's skin was checked by a licensed staff. - On 7/15/2016, the resident was given a bed bath and his skin was checked by licensed staff. A registered nurse (RN) progress note dated 7/15/2016 documented the resident had an open area, on his coccyx that measured 1.0 centimeters (cm) x 0.5 cm. There was no documented evidence the resident's CCP was updated to reflect his current status or reviewed to determine effectiveness of current interventions to promote healing. A physician order [REDACTED]. A licensed practical nurse (LPN) progress note dated 7/19/2016 documented to discontinue the Allevyn dressing as the resident had no open area and to use skin repair cream every shift. There was no documented evidence a RN assessed the area and made the determination the open area was resolved. The resident's treatment administration record (TAR) documented the Allevyn dressing was applied on 7/15/2016. There was no further documentation on the TAR that specified the Allevyn dressing was changed on 7/19/2016 as ordered. The TAR documented skin repair cream was initiated on 7/21/2016 on the 7:00 AM - 11:00 PM shift. A physician order [REDACTED]. A RN progress note dated 7/22/2016 at 11:45 PM, recorded as a late entry for 7/21/2016, documented skin rounds were completed on the resident and no open area was noted. A Dermal Lesion Tracker sheet dated 7/28/2016 documented the resident had a Stage II pressure ulcer on the right buttock that measured 1 cm x 1 cm x <0.1 cm and the status of the pressure ulcer was the same (although skin was documented as intact on 7/22/2016). A LPN progress note dated 7/28/2016 documented the resident was seen on skin rounds and he had a Stage II pressure ulcer on the coccyx and [MEDICATION NAME] was applied to the area and was to be changed every 3 days. The TAR documented to to apply [MEDICATION NAME] dressing to open area on coccyx; change every 3 days; and check placement of dressing every shift. There was no documented evidence on the TAR the [MEDICATION NAME] was changed on the 7/31/2016 as ordered. During an skin observation on 8/16/2016 at 10:32 AM with RN #27, the resident was assisted over on to his right side with the assistance of 2 certified nurse aides (CNAs). There was no dressing in place when he was rolled to his side. The RN stated maybe it had fallen off during the night. RN #27 said staff were to notify nursing if the dressing had fallen off. He stated he had not been notified. On the right buttock, the resident was observed with a Stage II pressure ulcer, measuring 1.5 cm x 1.5 cm, with a pink and moist wound bed. On the left buttock, the resident had another pressure ulcer. When the surveyor asked RN #27 about that site, RN #27 stated that was a new area. The RN measured the area; stated it was a Stage II pressure ulcer and measured 1.5 cm x 0.7 cm, with a pink moist wound bed. The TAR documented the [MEDICATION NAME] treatment was due to be changed on 8/15/2016. When the TAR was reviewed on 8/16/2016, the most recent [MEDICATION NAME] dressing change was performed on 8/12/2016. There was no documented evidence the treatment was completed as ordered on [DATE]. During an interview with RN #31 on 8/16/2016 at 11:00 AM, she stated she was the only nurse on the 7:00 AM - 3:00 PM shift on 8/15/2016 for passing medications and doing treatments. She stated she only completed some of the treatments. She stated she did not change the [MEDICATION NAME] treatment to the resident's buttocks yesterday nor, did she observe the dressing. She stated the CNAs would come and let her know if the dressing had fallen off. The CNA care guide (care instructions) was observed on 8/16/2016 at 11:10 AM and turning and repositioning was not identified on the care guide. CNA #34 stated the resident did not get turned and repositioned as he got up into his wheelchair. She stated the resident got out of bed around 11:00 AM daily. During an interview with the RN Manager #27 on 8/17/2016 at 9:30 AM, he stated the resident was supposed to be turned and repositioned every 2 hours, and he heard from other staff the resident was non-compliant with that. He stated the resident was always compliant when he went in there. He stated the resident had come in to the facility with an air mattress that he brought it from home. RN #27 said he did not think it provided much pressure relief. He stated pressure ulcers were monitored weekly to ensure healing and pressure ulcers were resolved by RNs or physician. He stated he did not know why this resident's pressure ulcer was not monitored weekly, nor why the resident's care plan was not evaluated to ensure appropriate interventions were in place. The surveyor attempted to interview LPN #16 by telephone on 8/17/2016 at 10:20 AM and a message was left. No return call was received before the survey exit. During an interview with the resident's physician on 8/17/2016 at 3:50 PM, he stated pressure relief interventions were based on an RN's assessment and would include turning and repositioning, cushion in wheelchairs and a pressure reducing mattresses. He stated if a resident developed a pressure ulcer, he would expect the care plan be reviewed to ensure appropriate pressure relief interventions were in place. He stated he would expect treatments to be completed as ordered to maximize healing. 3) Resident #20 had [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) dated 1/26/2016 documented the resident had the potential for skin breakdown related to impaired bed mobility and incontinence. Interventions included to keep skin clean and dry and toilet the resident every 2-4 hours. A nursing progress note dated 2/12/2016 documented the resident had a broken blister to her left heel. A nursing progress note dated 2/13/2016 documented the resident's left heel had a brownish area measuring 2 centimeters (cm) x 0.5 cm and appeared to be an absorbed blister. The resident's heels were placed on a pillow and the resident's name was written on the physician list. A physician progress notes [REDACTED]. A nursing progress note dated 2/13/2016 documented the resident was seen by the physician and there was a new order for booties to both heels as the resident had a pressure lesion on her left heel. There was no documented evidence the resident's CCP was reviewed or revised to ensure appropriate skin interventions were in place or that it was updated to reflect the addition of booties to her feet. A physician progress notes [REDACTED]. The area was surrounded by loose skin and was a deflated blister, there was no drainage and there was minimal spotting on sheet. A nurse practitioner (NP) progress note dated 3/23/2016 documented the resident had a pressure ulcer that measured 1.3 x .7, continue with the wound gel and review weekly. There was no documented evidence in the progress note regarding the location of the pressure ulcer, Stage or wound description. There was no documented evidence the resident's pressure ulcer on her heel was monitored weekly. Nursing progress notes documented: - On 4/23/2016 at 4:40 PM and 11:00 PM, the resident had a scabbed area on the left heel; - On 4/24/2016, the resident had a scabbed area on the left heel; and - On 4/26/2016, the resident has heel booties in place to relieve pressure and scabbed areas continue on heels. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was severely impaired; the resident required extensive assistance with most activities of daily living (ADLs) including bed mobility; and she did not have any pressure ulcers, venous or arterial ulcers. The MDS documented she had an open lesion that required application of a dressing. The resident was observed on 8/7/2016 at 10:10 AM in bed with her heels resting directly on the mattress. The resident had green booties sitting on the chair in her room next to her bed. The resident was observed on 8/10/2016 at 5:15 PM sitting in a wheelchair in her room. The resident did not have any socks or shoes on and her feet were resting directly on the floor. The resident's feet were observed and she had a small pink area to the bottom of her right heel with peeling skin around it. On the outer area of the left heel she had a small pink area with peeling skin around it. At 6:30 PM, the resident was observed in the unit dining room eating dinner. The resident did not have any socks or shoes on. CNA #41 stated she had wheeled the resident into the dining room from her room and did not notice she was not wearing any socks or shoes. The resident was observed on 8/11/2016 at 8:05 AM in bed on her back with the head of her bed elevated and she was feeding herself breakfast. At 9:30 AM, 9:45 AM, 10:00 AM and 10:17 AM she remained in bed in the same position. At 10:17 AM certified nurse aide (CNA) #34 stated the resident remained in bed as they were still getting residents up for the day. She stated there was only 2 CNAs on the floor and an orientee and they still had 6 residents to get out of bed. The resident was observed on 8/12/2016 at 11:30 AM sitting in a wheelchair in the hallway with thin black socks on her feet and her feet resting on the floor. On 8/16/2016 at 9:30 AM the resident was observed eating her breakfast in bed. At 10:00 AM, the resident was in the hallway in her wheelchair with thin dark socks on her feet, which were resting on the floor. During an interview with registered nurse (RN) Manager #27 on 8/17/2016 at 12:45 PM, he stated weekly skin rounds were completed for any resident with pressure ulcers, surgical incisions or any other area a resident might have that was questionable. He stated the resident had a spot on her heel and he was not sure if the area was caused by pressure or trauma as she would frequently bump the back of her foot on the wheelchair foot pedals causing the heel to bleed. RN Manager #27 stated he was sure the resident's heels were monitored on weekly skin rounds and he was unable to provide the weekly monitoring sheets as he could not find them. He stated the area on the resident heel had since healed and she was at increased risk for further skin breakdown. He stated booties were initiated for the resident to wear while she was in bed and he did not know what the resident wore on her feet during the day for protection. He stated the resident should not be going around in her bare feet and she should have something more on her feet other than socks. He stated if the TAR was blank, it indicated the treatment was not completed. 10NYCRR 415.12(c)(1)

Based on record review, observations and interviews conducted during the recertification survey, it was determined the facility did not provide the care and services to 1 of 24 residents (Resident #12) reviewed for quality of care. Specifically, when Resident #12 was identified to be at risk for skin breakdown, the facility did not provide protective and preventative measures to prevent the development of skin impairment that required debridement from the presence of necrotic tissue. Findings include: Resident #12 had [DIAGNOSES REDACTED]. Nursing admission note dated 7/2/2015 at 5 PM documented the resident was alert and oriented; had positive pedal pulses with 2+ [MEDICAL CONDITION] of the resident's bilateral lower extremities; a 0.3 cm x 1.0 cm scabbed area on top of right great toe; a 0.5 cm x 0.5 cm scabbed area on the right third toe; the left elbow with a 1.0 cm x 1.5 cm scabbed area on left elbow; and bilateral reddened thighs and reddened mid-lower abdomen. The resident's Minimum Data Set (MDS) assessment, dated 7/10/2015, documented his cognition was intact, he had little energy, he required extensive assistance with bed mobility, transferring between surfaces, dressing, use of the toilet, hygiene, and bathing. The MDS documented the resident was at risk for skin breakdown and had no current ulcers, wounds, and/or skin problems. The MDS documented he required a pressure reducing device for the bed and chair, nutrition/hydration interventions, and ointments/medications. The comprehensive care plan (CCP), dated 7/6/2015, documented the resident was at risk for skin breakdown related to impaired mobility and diabetes. The goal was to maintain skin integrity without breakdown over the next 90 days. There were no documented skin protective/preventative interventions on this CCP. The monthly physician order [REDACTED]. The resident's laboratory values dated 8/12/2015 documented his hemoglobin = 13.2 g/dl (norm = 14.0 - 18.8 g/dl); hematacrit = 41% (norm = 42 - 52%); [MEDICATION NAME] = 3.0 g/dl (norm = 3.2 - 5.2 g/dl) and his glucose = 186 mg/dl (norm = 70 - 100 mg/dl). Licensed practical nurse (LPN) #25's progress note, dated 8/20/2015 for the 3 PM - 11 PM shift, documented the resident had blister on his left heel that was draining blood tinged fluid, and a dry dressing was applied. LPN #25's progress note, dated 8/21/2015 for the 3 PM - 11 PM shift, documented the resident had a blister on his left heel which had blood tinged drainage. The nursing progress note, dated 8/23/2015 at 2:45 PM, documented the resident had blister on his left heel that measured 3 x 5 centimeters (cm), a dry dressing was applied, and the resident was added to the list for the physician to see the following day. The physician progress notes [REDACTED]. The physician order, dated 8/24/2015, documented an ultrasound was to be taken of the resident's left leg. The Ultrasound Report, dated 8/25/2015, documented the resident had an extensive [MEDICAL CONDITION] of the lower extremity. The nursing progress note, dated 8/25/2015 on the 3 PM - 11 PM shift, documented the resident's left heel had blood tinged drainage, skin prep (a barrier film), and a dry dressing was applied. The nursing progress note, dated 8/26/2015 at 10 PM, documented the resident's left heel had a darkened area around it. The physician order, dated 8/28/2015, documented to apply skin prep to the left heel and leave open to air. The physician progress notes [REDACTED]. The physician referred the resident to the wound clinic. The Wound Clinic discharge instructions, dated 9/4/2015, documented the resident's left heel bone had a wound with the primary etiology: diabetic wound and a secondary etiology: pressure ulcer acquired in the facility on 8/10/2015. The wound measured 1.7 cm x 3 cm x 0.1 cm, with the wound bed unable to be visualized fully covered with eschar (dead tissue). The wound was debrided at the time with forceps , a blade and scissors and was not well tolerated. The Wound Clinic recommended a collagen (a protein based dressing that promotes healing) dressing, changed every other day, and to provide a Roho (a pressure relieving device) cushion for the wheel chair. Physician orders, dated 9/4/2015, documented to start the resident on [MEDICATION NAME] (antibiotic used to treat bacterial infections) for 10 days per wound clinic recommendations. The treatment administration record (TAR) documented to change the dressing to the left heel every other day with collagen to the wound bed, cover with dry dressing, and wrap with Kling (gauze). The Wound Clinic discharge instructions, dated 9/11/2015, documented the resident's his left heel measured 1.7 cm x 2.7 cm x 0.1 cm, the wound bed was fully covered with eschar. A Roho cushion for the wheel chair and a plan to turn and position the resident every 2 hours was recommended. The physician order, dated 9/14/2015, documented the resident requested an air mattress for skin care. Nutrition note, dated 9/14/2015, documented the resident's food preferences were updated and additional changes were made to the meal plan to continue to increase the protein content of diet. The surveyor interviewed the resident on 9/15/2015 at 8:40 AM. The resident stated he had the wound on his heel for weeks before the facility had an idea of what direction of care to take. The resident stated he insisted on another opinion and an air mattress so it would start to heel. LPN #24 was observed providing wound care to the resident's left heel on 9/15/2015 at 2 PM. LPN #24 entered the resident's room and set her Kling, gauze, saline, and collagen on the resident's overhead table. The table top was not cleaned prior to the supplies being set on it and had crackers, crumbs, a cup of water, books, a television remote, and a cell phone on it. LPN #24 then applied her gloves, removed the old gauze, picked the collagen out of the wound bed with her fingers, cleaned the wound, and applied a clean dressing. When interviewed following the wound care, LPN #24 stated she should have washed the table top or utilized a clean barrier prior to setting the wound care supplies on it. She stated after removing the old dressing, she should have put on clean gloves before applying the new dressing. LPN #25 was interviewed on 9/15/2015 at 2 PM and stated when she first noted the blister on the resident's left heel on 8/20/2015, she thought the wound was being followed by the facility's skin team, so she did not fill out a skin referral form, but only documented the blister on the facility's 24 hour report sheet. When registered nurse (RN) Manager #26 was interviewed on 9/16/2015 at 8:55 AM, he stated when the resident was admitted , he was identified at risk for skin breakdown. He stated the resident was there for short term rehabilitation and was mobile, so no interventions were put into place to prevent skin breakdown. He stated the 3 - 11 PM nurse told him (RN #26 unsure of the date) the resident had a wet area and he then told the physician. He stated the physician asked if the area was open, and when he told the physician no, he was advised to monitor the area. He stated once it opened, the physician ordered Skin Prep to the heel wound. RN Manager #26 stated he did not incorporate any interventions to prevent skin breakdown into the resident's care plan and thought he needed a physician order [REDACTED]. The resident's physician was interviewed on 9/17/2015 at 9 AM, and stated he expected residents at risk for skin breakdown to have interventions put into place to prevent skin breakdown including a pressure relieving mattress, heel protectors, and close monitoring. He would expect to be notified as soon as an area of breakdown was identified and said he was notified of the resident's left heel wound on 8/24/2015. He stated he assessed the wound when he was made aware, monitored until it started to worsen, and then referred the resident to the wound care clinic. He stated the wound care clinic initiated an antibiotic and wound care orders. He stated the resident was provided with the air mattress at the resident's request. When interviewed on 9/17/2015 at 12:25 PM the Assistant Director of Nursing, in charge of the facility's infection control program, stated staff were expected to change their gloves between soiled and clean dressing changes during wound care. 10 NYCRR 415.12

Based on record review, observation, and interview conducted during the standard survey, it was determined for 2 of 5 residents (Residents #5 and 17) reviewed for pressure ulcers, the facility did not ensure appropriate treatment and services were provided to promote healing and prevent pressure ulcers. Specifically, Resident #5 experienced harm when she developed a Stage II pressure ulcer in the facility on the right heel that increased in length, width and depth; progressed to a Stage III with pain on palpation; developed an infection; began to show improvement until another infection and new maceration of the periwound developed in the pressure ulcer. The resident was not consistently provided with a pressure-relieving device in bed as planned and proper infection control procedures were not followed during wound treatment observations. For Resident #17, identified at risk for skin impairment, the facility did not provide pressure relieving device as planned, and the resident developed two Stage II pressure ulcers. Findings include: 1) Resident #5 had [DIAGNOSES REDACTED]. The Pressure Ulcer Assessment Record dated 6/23/2015 documented the resident developed a Stage II pressure ulcer on the right medial heel that measured 1 cm x 1 cm x 0.2 cm, with a pink wound base. Interventions included heel lifts in bed, an air mattress, and boots. On 6/26/2015, the Pressure Ulcer Assessment Record documented the resident's right heel pressure ulcer now measured 1.5 cm x 1.2 cm x 0.2 cm with 25% yellow slough, 5% necrotic area, and bloody purulent exudate. The Pressure Ulcer Assessment Record documented the resident's right heel pressure ulcer was assessed weekly from 7/1/2015 when it remained a Stage II until 7/8/2015 when the pressure ulcer became a Stage III that measured 2 cm x 2.2 cm x 0.2 cm that was 90% slough, purulent exudate, with an odor, and had pain upon palpation. The physician ordered an antibiotic (Keflex) for 7 days and a treatment change to Santyl and Skin Prep. On 7/15/2015, Pressure Ulcer Assessment Record documented the resident's antibiotic was changed (to [MEDICATION NAME]); and the periwound was now 4 cm x 3.5 cm scant [DIAGNOSES REDACTED] and was wet/white. The Pressure Ulcer Assessment Record documented the resident's right heel pressure ulcer was assessed weekly from 7/24/2015 to 7/31/2015 when the treatment was changed to [MEDICATION NAME]; the pressure ulcer was now unstageable; measured 2.2 cm x/ 2.4 cm x 0.2 cm with 85% slough and 15% red, with moderate bloody purulent exudate. The periwound was assessed as a Stage II and was 4 cm x 4 cm. The resident continued to be assessed to have pain when the pressure ulcer was touched. On 8/5/2015, the Pressure Ulcer Assessment Record documented the resident's right heel pressure ulcer's treatment was changed by the physician to Isosorb gel (a debridement agent) with Allevyn heel (wound dressing. The right heel was assessed to be unstageable and measured 2.2 cm x 2.4 cm x 0.2 cm. A referral was made to rehabilitation therapy and other interventions were to remain in place (float heels, air mattress, and boots). The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was severely impaired. The resident required extensive assistance with transferring and was dependent on staff for bed mobility, locomotion, dressing, toilet use, hygiene, and bathing. The occupational therapy (OT) referral, dated 8/6/2015, documented the resident was noted during recent dressing change to have increasing worsening of pressure ulcer to the right heel. The OT documented the resident was noted when in bed to roll self onto (her) left side which increases pressure despite pressure relieving boots to the pressure ulcer on the right medial heel. The recommendation was that an abductor wedge be utilized to assist in keeping resident's legs separated while in bed. The resident care card (care instructions), dated 9/2/2015, documented to use an abductor wedge while in bed. The Pressure Ulcer Assessment Record documented the resident's right heel pressure ulcer continued to be assessed weekly, including on 9/9/2015. On that date, the resident's pressure ulcer was assessed to be a Stage III that measured 1.9 cm x .9 cm x 0.4 cm with only 10% slough and no pain present. On 9/11/2015, the physician notes documented the resident's heel shows more depth. Physician's orders, dated 9/11/2015, documented not to change the resident's right heel dressing until 9/15/2015 so he could visualize it with skin team RN. The resident was observed in bed on 9/14/2015 at 2:18 PM and 3:02 PM. She was lying on her left side and did not have the abductor wedge in place to separate her legs. The abductor wedge was on a chair in her room. At 4 PM, certified nurse aides (CNAs) #4 and 5 entered the resident's room and transferred the resident to her wheelchair. During pressure ulcer care observations on 9/15/2015 from 10 AM to 10:30 AM with the skin team including the physician, registered nurse (RN) #3, Assistant Director of Nursing (ADON), and nutritionist. The resident was observed sitting in her wheelchair with her feet hanging approximately 6 inches from the floor. An undated Allevyn dressing and gauze wrap were observed on the resident's right inner heel. After removing the gauze wrap, RN #3 placed a pillow under the resident's right leg/foot; and wiped the pressure ulcer with normal saline from the normal saline bottle sitting directly on the floor. RN #3 then placed the treatment and dressing supplies on the over bed table, without a barrier. RN #3 measured the resident's right heel to be 1.6 cm x 0.8 cm x 0.2 cm, and all present observed the pressure ulcer had a foul odor. The ADON stated the periwound (skin around the wound) was macerated (white soggy skin, caused by too much moisture). The physician stated he would order an antibiotic. The resident's 9/2015 Medication Administration Record [REDACTED]. The physician and RN #3 were both interviewed 9/15/2015 from 10 AM to 10:30 AM during the dressing change, and noted the foul odor and macerated periwound skin were noted. When interviewed on 9/15/2015 at 1:50 PM, RN #3 stated he had not used Iodosorb gel in the past and did not know what the manufacture's recommendations were for the product. He stated the resident had been getting the treatment for [REDACTED]. He stated a lot of dressings were changed every 3 days and he had no reason to question the order to leave the dressing on for a 4th day. He stated the dressing change was done in the wheelchair as the physician was here and it would have taken too much coordination to put the resident in bed. The resident was observed on 9/15/2015 at 2:10 PM lying in bed on her left side, the abductor cushion was not in place. When interviewed on 9/15/2015 at 2:25 PM, CNA #5 stated she did not put the resident's abductor cushion in place when she put her to bed on 9/14/2015. She stated there were only 2 CNAs working, and she could not get everything done. 2) Resident #17 had [DIAGNOSES REDACTED]. The interdisciplinary progress note (written by unknown discipline), dated 5/18/2015 at 2:05 PM, documented the resident had a contracture of the left hand, wore a palm guard, and received passive range of motion (ROM) during care. The licensed practical nursing (LPN) progress note, dated 7/28/2015 at 2 PM, documented the resident required assistance with dressing and grooming as she had bilateral hand and arm contractures that limited her ability to participate in her activities of daily living (ADL's). The July 29, 2015 physician orders documented the resident was to have a weekly skin audit, Skin Prep to her bilateral heels everyday, an air mattress, and a splint to her left elbow to decrease her contracture. There was no physician's order for a palm guard. The resident's Minimum Data Set (MDS) assessment, dated 7/30/2015, documented the resident's cognitive status was moderately impaired (BIMS score of 10 of 15); required total assistance with ADL's; had arm impairments, and was at risk for skin breakdown. The Braden Scale (used to determine risk for pressure ulcers) dated 8/15/2015 documented the resident was at risk for skin breakdown. The extended care guide (care instructions), updated 8/17/2015, documented the resident was to have a palm guard in the left hand at all times. The comprehensive care plan (CCP), dated 8/28/2015, documented the resident required extensive assistance with ADL's, had right and left hand contractures, and was at risk for alteration in skin integrity. The goal was to maintain skin integrity through the next quarter. Interventions included to assess for changes in the skin every shift, assess and provide appropriate pressure relieving devices, provide ROM, and to wear a palm guard in the left hand related to contractures. There was no documented evidence of the times the palm guard should be applied. The resident was observed during the resident group meeting on 9/15/2015 from 10:10 AM - 11:20 AM, with her left hand contracted without a pressure relieving device. The care guide, dated 9/16/2015, documented the resident was to wear a left palm guard at night. Staff were to encourage the resident to open her fingers on both hands and to clean both palms/hands after each meal. The care card did not document to monitor skin. During the following observations, the resident was without her palm guard or other pressure relieving device in place. Her middle and ring fingers of her left hand had long, dirty, jagged nails that pressed on the palm of her left hand. - on 9/15/2015 at 9:30 AM, 9:40 AM, and 12:50 PM; - on 9/16/2015 at 7:55 AM prior to morning care being provided; and - on 9/17/2015 at 7:30 AM and 8:20 AM prior to morning care being provided. When interviewed on 9/17/2015 at 8:20 AM, the resident stated she had not worn the left palm guard in a long time and did not know when it was last provided. She stated she thought people had just given up on her left hand. The resident told the surveyor she wanted to have physical therapy. When interviewed on 9/16/2015 at 12:50 PM, (certified nurse aide) CNA #20 stated she provided care for the resident on both the 11 PM - 7 AM and the 7 AM - 3 PM shift for the last 2 days. She stated she did not recall when she last completed ROM exercises or applied the resident's palm guard. She stated she thought it had been applied in the past week. When the surveyor asked if she knew where the palm guard was located, the CNA stated she had not seen it since then and had not report it missing to other staff. When the CNA and surveyor observed the resident's hands at that time, the resident's fingernails were long, jagged and dirty. The CNA stated she trimmed the resident's fingernails on her assigned shower days. When interviewed on 9/17/2015 at 10:10 AM, registered nurse (RN) Manager #22 stated she was not aware the resident had hand contractures. After she reviewed the resident's care guide, physician orders, and the CCP, she stated the resident was to wear a left palm guard. She stated she did not know when the resident was supposed to wear it, as there was no documentation when it was to be worn. RN Manager #22 stated if the resident's palm guard was missing, she would expect the staff to notify her to obtain a replacement. She stated no one alerted her the palm guard was missing. RN Manager #22 observed the resident's left hand during the interview and told the surveyor, the resident now had a new Stage II pressure ulcer on the inside of her left thumb, and a new Stage II pressure ulcer on base of the left thumb. 10NYCRR 415.12 (c)(2)

Based on observation, record review, and interview conducted during the extended and abbreviated (NY 659 and NY 218) surveys, it was determined for 44 of 103 resident rooms with windows (Rooms # 102, 111, 112, 116, 118, 119, 128, 130, 131, 132, 134, 136, 137, 140, 141, 201 lounge, 203, 208, 209, 213, 222, 224, 225, 228, 230, 231, 235, 236, 239, 241, 244, 245, 302, 303, 308, 309, 310, 312, 345, 347, 351, 352, 354, 356), and for 19 of 21 resident rooms with electric radiators (Rooms 136, 201, 203, 222, 226, 232, 236, 242, 244, 304, 306, 307, 308, 309, 329, 338, 350, 352, 356), the facility failed to ensure the resident environment was maintained as free of accident hazards as possible. Additionally for 1 of 14 residents (Residents #22), reviewed for accidents, the facility did not ensure necessary supervision was provided to prevent accidents, and for 4 of 11 exit doors observed (doors Unit 3C cross corridor, Unit 3 stairwell, Floor 2 near garden, Unit 3 near medical records) the facility did not ensure alarms functioned as planned. Specifically: - For the 44 of 103 sampled rooms window restrictors limiting how far windows opened were missing or non-functioning. Additionally windows were in disrepair, had loose screen, sharp protruding nails, loose panes, and could not be fully closed and latched. - For the 19 of 21 resident rooms, with electric radiators, surface temperatures were excessively high exceeding 162 degrees Fahrenheit (F). - Resident #22 attempted to exit the building from her bedroom window, was currently residing in a room with an unsecured window, and was not monitored for exit seeking behavior as planned. - For 4 of 11 exit doors did not contain functioning alarms, had alarms that could be by-passed, and a wanderguard receiver in the basement was inoperable on an unlocked exit door. This resulted in no actual harm with potential for serious harm that is Immediate Jeopardy to the health and safety of the facility's 146 residents. THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY OF 12/12/2013. Findings include: Accident Free Environment 1) Resident #22's room (312) window was observed on 11/13/2014 at 1:20 PM and 7:30 PM, the secure, limiting, chain was not attached and the window was able to be opened fully. Observations on 11/13/2014 between 12:30 PM and 1:10 PM, showed the windows in rooms 310, 302, 303, 309, and 347 lacked a secure, limiting chain, device and were was able to be opened fully. On 11/13/2014 between 11:10 AM and 1:30 PM, resident room windows were observed: - The windows in rooms 136, 209, 222, 224, 309, 351, and 356 did not have limiting chains and were able to be opened fully. - The window in room 236 had a disabled limiting chain, was able to be opened fully, and the window trim frame contained several protruding nails. - The windows in rooms 352, 354 had disabled limiting chains and were able to be opened fully. Observations made during the tour of Unit 1, on 11/13/2014 at 12:45 PM, showed there were unsecured windows, with out limiting chains, which could be opened fully, in resident rooms #102, 111, 116, 119, 128, 130, 131, 134, 136, 137, and 140. When interviewed on 11/13/2014 at 1:15 PM, housekeeper #18 stated the windows sometimes got stuck open in the summer, and she remembered when a resident tried to go out a window During an interview on 11/13/2014 at 2:50 PM, the Administrator stated she was not aware of any problems with the facility's windows. She stated there were chains on windows to prevent them from fully opening, and to prevent residents from falling. She stated all resident room windows had chains and maintenance checked the operation and safety of windows during their quality assurance rounds. She stated rounds were conducted in all resident rooms, once a week, and the information obtained during the rounds became work orders for maintenance. She stated just one room was found missing a chain, and she was unsure how long ago that was. She stated she was unaware limiting chains were missing from windows. 2) During observations on 11/13/2014 at 11:10 AM, there was a visible scorch mark, on the lower portion of the window curtain, just above the radiator cover, approximately 1/2 inch x 1 inch, in resident room 226. An upholstered chair was positioned close to the radiator, and felt hot to touch. The top of the radiator was extremely hot to touch, and the temperature at the top of the radiator was 243 degrees Fahrenheit (F). Observations of the facility's three resident units, on 11/13/2014 between 11:10 AM and 1:30 PM, showed: - the temperature at the top of the radiators ranged from 162 - 197 degrees F, in resident rooms 201, 222, 232 (lounge) 236, 242, 304, 338, and 350. There were melted, deformed, plastic window blind slats, and an air conditioner cord directly against the hot area of the radiator in room 304; and beds were directly against radiators in rooms 242, 304, 338, and 350. - The temperature at the top of the radiators ranged from 205 - 273 degrees F, in resident rooms 136, 203, 244, 306, 307, 308, 309, 329, 352, and 356. There were melted, deformed, plastic window blind slats in rooms 244, 306, 329, 352, and 356; there was blistered paint on the surface of the radiator in rooms 203 and 356; beds were against radiators in rooms 306, 308, and 352; and curtains were close to the radiator in room 308. - The top of resident room radiators were very hot to touch in rooms 202, 204, 303, 310, 347, and 353. There was a blanket over the radiator in room 310; a large wicker trunk was within 1 inch of the radiator in room 303; the window shades were warped along the bottom in rooms 347 and 353; and there was a visible reddened area on the surveyors hand after touching the radiator in room 310. During an interview with housekeeper #25 on 11/13/2014 at 1:15 PM, he stated the radiators "definitely" got to hot. He stated there was an occasion, less that a year ago, when a radiator reached 700 degrees F. There was a bird cage near the radiator, and the bird food started to smoke. He said one of the nurses pulled the fire alarm. Housekeeper #25 stated the heat had been "messed up" for some time, and the temperatures seemed hot enough to cause items to burn or melt. He said it had been going on for a long time, and he did not tell anyone. When interviewed on 11/13/2014 at 1:15 PM, housekeeper #18 stated that sometimes the radiators got hot, and she remembered a plastic cup once melted on one. When interviewed on 11/13/2014 at 1:20 PM, licensed practical nurse (LPN) #19 stated a resident once accidentally poured shampoo into the radiator, and the radiator smoked, and smelled bad. When interviewed on 11/13/2014 at 1:25 PM, certified nurse aide (CNA) #20 stated the radiators got hot, and "we used to have a thing about not putting the resident's bed against the radiators." When interviewed on 11/13/2014 at 1:30 PM, physical therapist (PT) #21 stated many times she had been concerned that the radiators were too hot. On 11/13/2014 at 2:50 PM in an interview with the Administrator, she stated she was unable to contact the Maintenance Director, she found his keys and cell phone at the facility and he had not returned her phone calls. She stated there were two incidents where radiators got warm and were not fires. She stated in April 2014 the second floor day room radiator was 600 degrees F, the fire department was notified, and the Maintenance Director then changed out the parts, probably the thermostat. She stated the second incident occurred in October 2014 when a black comb melted in a radiator causing it to smell, and the fire department came. She stated the fire department did not find anything, and the Maintenance Director changed out the thermostat. The Administrator said they discussed moving the thermostats to the outside of the radiators to help better control the temperature setting. She stated she thought there were safety devices installed on the heaters. She stated she touched radiators during rounds, and did not think the surfaces got hot enough to burn someone. The Administrator stated she did not know what rooms had been checked during rounds. 3) Observations on 11/14/2014 between 11:20 AM and 11:45 AM, showed the Unit 3C emergency exit door had a switch to bypass the door alarm, which was in the bypass position. The door was tested and an alarm did not sound. The emergency exit had a delayed egress feature, with an alarm that was inoperable. The device did not sound/alarm when the lock was demagnetizing. Observations on 11/17/2014 between 11:27 AM and 11:40 AM, with Staff #36, showed the second floor stairwell, exit S5, door had an alarm. The door was opened, and no alarm sounded. Staff #36 stated, to the surveyor, the alarm sounded off in the corridor on Unit 3B and was reset there. He stated when staff hear the alarm, they responded to the door to check it. After several minutes, no staff responded to the sounding alarm. Further observations showed the alarm was sounding on Unit 3B, and no staff were visible in the corridor. Observations on 11/17/2014 between 11:40 AM and 11:56 AM, with Staff #36 showed second floor stairwell door #1 had a local alarm that sounded if the door was opened. The alarm consisted of a device next to the door that alarmed when the door was opened which was turned off with a key. There was a set of keys in the alarm which was positioned off. Staff #36 positioned the alarm to on and removed the keys. During an interview on 11/17/2014 at 11:56 AM, the Assistant Director of Nursing stated they performed a facility wide resident head count each time a door alarm sounded. She stated staff were required to respond to the door alarms. She stated she was unaware staff did not respond when exit S5 door alarm was activated earlier that day. Observations on 11/17/2014 at 12:00 PM, showed when staff exited the second floor stairwell door #1, and the alarm sounded. Staff looked for the key in the alarm unit, and staff #36 reset the alarm with the key. Observations on 11/17/2014 between 12:05 PM and 1:05 PM, showed the second floor activities room had two exits. Each exit had a switch that bypassed the local alarm on the door. The switch was in bypass, and the door alarms did not activate when the door was opened. Staff #36 stated, to the surveyor, door alarms were checked monthly. He stated when the local door alarms sounded staff responded. He stated door alarm checks were completed approximately 2 - 3 weeks ago. During an interview on 11/17/2014 between 1:15 PM and 1:30 PM, with staff #36, he stated the Wanderguard system was checked bi-weekly. He stated the Maintenance Director tested the alarm, when a resident set the alarm off, and either nursing or recreation documented those tests. He stated residents were not taken to the basement to test that door, and at times a resident on floor 1 set off the basement alarm. Observations on 11/17/2014 at 1:30, showed stairwell 6, near the garden exit, did not have an alarm on the doors in the basement, first, and second floor levels. At the time of the observation, staff #36, a maintenance helper, and a surveyor followed the stairwell into the basement. Staff #36 stated, to the surveyor, the basement was a restricted area to residents. There were several areas open and accessible including a darkened storage room; an infectious waste room; a maintenance shop; an electrical room; and the wheelchair wash room. Basement exit E1 was a staff entrance and a sign documented the door was alarmed from 9 PM - 6 AM. The door was not locked, and contained a wanderguard sensor. The Wanderguard control unit on the wall adjacent to the door was not illuminated. When tested with a functioning Wanderguard bracelet transmitter, as worn by a resident, the alarm did not sound. Staff #36 stated alarm checks were done, maintenance was to be notified if an alarm was not working. Staff #36 stated he did not know how long the Wanderguard system was not functioning on exit E1. When interviewed on 11/17/2014 at 3 PM, the Administrator stated she did not know which doors in the facility had locks and/or alarms for elopement control. She stated she was not aware of any locked and/or alarmed doors that were not working properly; and she was just informed that residents from Unit 2 were able to exit to Unit 1 and then to the basement undetected. No documentation of the alarm testing was provided. Supervision to Prevent Accidents 4) Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician progress notes [REDACTED]. A 7/24/2014 elopement risk assessment documented the resident was at high risk for elopement and was to be wear a Wanderguard bracelet (a device that detects wandering) to reduce the risk of elopement. A nursing progress note dated 7/24/2014 at 1 PM, documented the resident arrived at the facility, was very upset with her family, placement was related to her family not feeling safe, and the family stated she had poor memory recall. The note recorded the resident was at risk for elopement and was to be monitored. The Minimum Data set (MDS) assessment dated [DATE] documented the resident was severely cognitively impaired. The resident had little interest or pleasure in doing things, felt down, depressed, or hopeless, felt tired or had little energy, and felt bad about herself. The MDS documented the resident required supervision with most activities of daily living (ADL), including ambulation. The comprehensive care plan (CCP) dated 8/7/2014 documented the resident had concerns with adjustment to placement, and alteration in lifestyle, related to admission. Interventions included offering socialization and empathy, observe for changes, evaluate environmental changes, look at past social patterns. The Director of Social Work progress note dated 8/22/2014 documented the resident was to move from the secure unit, to an unsecured unit, related to continued concerns with the resident's roommate. The room change log documented the resident moved from the secure unit to an unsecured unit on 8/26/2014. Nursing progress note dated 8/26/2014 - 8/28/2014 documented the resident wanted to leave, packed her belongings, walked up and down the halls with her suitcases, and removed the Wanderguard bracelet. The physician's progress note dated 8/28/2014 documented the resident was at high risk for psychiatric management difficulties and spoke to the nursing staff about strategies to minimize risks to herself and others. The 24 hour nursing reports and nursing progress notes dated 9/1/2014 - 9/6/2014 documented the resident removed the Wanderguard bracelet, packed her suit cases, asked when the bus was picking her up, wanted to leave, and paced the halls. The resident was placed on 15 minute checks on 9/6/2014. The Director of Social Work progress note dated 9/8/2014 documented the resident wanted to switch rooms due to concerns with her roommate. The note recorded the resident was moved to a room directly across the hall. A nursing progress note, dated 9/13/2014 at 11 PM - 7 AM, documented the resident's roommate requested staff come to their room. Resident #22 was found with the window screen removed, and her leg outside of the window. The resident's belongings were outside on the ground below. The Accident/Incident Report dated 9/13/2014 documented the resident had removed the screen from the window and the screws from the "safety catch", and pushed the window open. The resident had thrown a blanket, a purse, and the Wanderguard bracelet out of the window and her leg was out the window. The report documented the resident did not remember doing that and stated she heard kids outside. The resident was sent to the hospital for evaluation, and returned with a [DIAGNOSES REDACTED]. The report documented the resident was to be on 15 minute checks until 9/18/2014. The resident's 15 minute monitoring check sheets did not document checks: - on 9/14/2014 at 12 AM, 12:15 AM, and 9:45 AM - 2:45 PM; - on 9/15/2014 from 7:15 AM - 2:45 PM; - on 9/16/2014 from 7:15 AM - 2:45 PM; - on 9/17/2014 from 7:15 AM - 2:45 PM; and - on 9/18/2014 after 7 AM. Nursing progress notes dated 9/20/2014 - 9/23/2014 documented the resident made comments of wanting to leave and get out of the facility. The resident was walking to the elevator and hitting the button, wandering the hall, pacing at an activity, and packing her suitcases. The physician telephone order dated 9/23/2014 directed to "document" the resident's behaviors, positive or negative, every shift. Nursing progress notes dated 9/24/2014 - 9/25/2014 documented the resident made comments she wanted to leave. The psychological services initial evaluation dated 10/2/2014 documented the resident was a poor historian, had a limited extended network, was disoriented, and experienced a severe change in environment. Nursing progress notes dated 10/3/2014 - 10/5/2014 documented the resident was seen exiting the stairwell door and was assisted back to the unit. The notes recorded the resident wandered toward the exit door, was agitated, paced the hall, packed her bags, was in and out of other residents rooms, and made statements of wanting to leave. The CCP dated 10/5/2014 documented the resident was at high risk for elopement, was to be monitored, and wandering tendencies and behaviors were to be documented. The resident was to wear a Wanderguard bracelet, be redirected from unsafe situations, and encouraged to attend meaningful activities. The physician orders [REDACTED]. Nursing notes dated 10/12/2014 - 10/13/2014 documented the resident packed her bags, was anxious, and wanted/tried to leave. On 10/13/2014, the nurse practitioner note documented the resident was not appropriate for the locked dementia unit. The note documented over the past weekend the resident had episodes of pacing the hallways, and was beginning to have a manic episode. On 10/16/2014 at 4:10 AM, a nursing progress note documented the resident exited the unit with her suitcases, and walked out an exterior exit door, to the back of the facility's grounds. The resident was assisted back to the unit following the alert alarms sounding. The note documented the resident was hallucinating, saw her brother outside, and was upset when approached by staff. The note documented earlier in the shift the fire alarm sounded and "most likely" upset her. The Director of Social Work documented on 10/16/2014, the resident was moved to a secure unit following the previous evenings event. Nursing progress notes on 10/16/2014 documented the resident wanted to leave, was leaving to meet her husband, was asking about family, and displayed delusions. The CCP dated 10/17/2014 documented the resident displayed socially inappropriate/disruptive behavior related to delusions, and dementia and was frequently packing bags. The CCP recorded the resident was to be praised when demonstrating desired behavior, and be removed from public areas when disruptive. The resident was allowed to ambulate on unit. Nursing progress notes dated 10/18/2014 - 11/7/2014 documented the resident went into other residents rooms, packed her bags, was agitated, wandered the halls, and had occasional behaviors. The resident was observed on 11/13/2014 at 1:20 PM, in her room with the door shut. The resident's window secure limiting chain was unattached, and the window was able to be opened fully. The resident stated, in an interview at that time, she was able to open the window if she wanted to; she did not need to at that time; and the window was not working correctly. During an interview with the Director of Social work on 11/18/2014 at 9:35 AM, she stated: - the resident was admitted to a secure unit, and was transferred to another unit following roommate concerns; - after the resident transferred she learned the resident had been exhibiting exit seeking/wandering behaviors while on the secure unit; - the resident's behaviors included, packing her bags and removing the Wanderguard. - she did not know how long the resident was on 15 minute checks; - she did not know why the resident was not moved to a secure unit after being found with her leg out the window; and - the resident's behaviors "never stopped" when she was on the unsecured unit, and continued until she was transferred back to the secure unit on 10/16/2014. During an interview with LPN #11 on 11/18/2014 at 11:05 AM, she stated it was "normal behavior" for the resident to make statements about going out of state. She stated the resident wandered down the hall with her bag, stating she was going with her family. LPN #11 stated the resident was to be monitored, and behaviors recorded because the resident was up and down the halls with her bags packed. During an interview with CNA #23 on 11/18/2014 at 11:15 AM, she stated the resident packed her suitcases daily, when she was on the secure unit, stating she had an appointment or family was coming. During an interview with CNA #17 on 11/18/2014 at 11:30 AM, stated the resident exhibited the same "behaviors" prior to moving from the secure unit. She stated the "staff" had determined her not to be "at risk" and moved her. During an interview with LPN #46 on 11/18/2014 at 12:25 PM, she stated the resident stood by the elevator, and did not attempt to enter the elevator. She stated the resident "did not wander", had her suit cases packed, and stood by the elevator stating her family was coming. 10NYCRR 415.12(h)

Based on observation and interview conducted during the extended survey, it was determined that the facility failed to ensure food was stored, prepared, and served under sanitary conditions in the main kitchen and on 4 of 4 resident units (Units 1, 2, 3A, and 3B). Specifically, the dishwasher in the main kitchen did not operate in a manner that adequately sanitized dishes; there was multiple unclean dishware, stored for use, in a clean area in the main kitchen; there were multiple unclean surfaces in the kitchen, the food storage room, and the dish room; there were unlabeled, undated food items stored in unit refrigerators. This resulted in no actual harm with potential for serious harm that is immediate jeopardy to the health and safety of its 146 residents. The Immediate Jeopardy for tag F371 was removed prior to survey exit on 11/18/2014. Findings include Concerns in the Main Kitchen 1) Observations on 11/12/2014 between 9:50 AM and 11:15 AM, showed in the main kitchen there was a large puddle of waste water, approximately 10 feet in diameter, on the floor in the dishwasher area. The dishwasher was leaking a significant amount of water onto the floor, and there was a significant amount of food debris visible on the floor. The dishwasher thermometer displayed the final rinse temperature as 170 degrees Fahrenheit (F). The Food Service Director stated at the time of the observation the thermometers were not working and the dishwasher had to have the final rinse tested manually. Record review of the dishwasher log for 11/12/2014 did not include any recorded wash or rinse temperatures. Observations made on 11/12/2014 at 10:08 AM, showed the Food Service Director determined the final rinse temperature of the dishwasher was 146 degrees F, and the surveyor determined the final rinse was 142 degrees F. At that time the Food Service Director stated, to the surveyor, they usually took the temperature when they first filled the dishwasher with hot water, and what they recorded would have been higher, than regular runs when the water cools. Observations on 11/12/2014 calibration of the facility thermometer was verified, with ice water bath method, between 12:12 PM and 12:40 PM. The facility thermometer read 38 degrees F in ice water (32 degrees F). The surveyor verified the temperature of the ice water bath was 32 degrees F. Observations on 11/12/2014 between 10:08 AM and 10:20 AM, showed multiple dishes that had run though the dishwasher contained visible food particles. A dietary staff member disassembled the dish washer spray pipes and most of the spray nozzles were plugged with pieces of plastic and food debris that caused the nozzle to function improperly and spray water out of the dishwasher rather than onto dish surfaces. A dietary staff member was cleaning the dishwasher parts, with the hand held spray wand attached to the wall in the pre-cleaning area, the spray wand sprayed water at a 90 degree angle onto the staff member and only cold water was piped to the pre-clean hand held spray wand. When the surveyor tested the spray wand, only cold water came out of it. During an interview on 11/12/2014 between 10:08 AM and 10:20 AM, dietary staff #51 stated there were usually a lot of dishes that had to be re-run through the dishwasher to get them clean. She stated that happened less often in the afternoon and evening because they presoaked them. She stated she was not sure why they were not presoaking the morning dishes. Observations at that time showed, 3 of 20 bowls; 1 of 5 lids; and numerous plates and pieces of metal silverware were unclean and stored on shelves as clean. An observation on 11/12/2014 at 11:05 AM, showed pre-prepared food on dishware in the trayline cooler, that adequate sanitation of the dishware could not be ensured, dated 11/9, 11/11, and 11/12/2014. During an interview on 11/12/2014 at 11:05 AM, the Food Service Director stated she was unsure how long the dishwasher was not properly sanitizing dishware. The Dish Machine/Pot Washing Log was reviewed with the Food Service Director at that time. Final rinse temperatures were not recorded: - on 11/7/2014, for dinner (midday meal) and supper (evening meal); - on 11/8/2014, for breakfast, dinner, and supper; - on 11/9/2014, for breakfast, dinner, and supper; - on 11/10/2014, for supper; - on 11/11/2014, for dinner and supper; and - on 11/12/2014, for breakfast. Upon completing the review the Food Service Director stated, to the surveyor, there was no way to ensure dishes that were previously run through the dishwasher were properly sanitized. Observations on 11/12/2014 between 11:05 AM and 11:55 AM, showed: - the floor under the range and the prep area contained significant filth buildup, and the Food Service Director stated, to the surveyor, the floor had not been mopped under the equipment for several days; - two 4 foot hood lights under the range hood were not shielded; - the rear screen door was observed propped open and the exterior door was not fully closed; - the floor in the pot wash sink area was not smooth and cleanable; - the ceiling in the pot wash sink area contained significant splash stains and food buildup; - the walls behind the pot wash sink contained significant grease buildup and a mold like substance; - the food storage room had significant buildup on the floor, there were 4 containers of ice cream behind a chest freezer on the floor, 2 light bulbs not shielded, and 2 snap mouse traps under food storage racks; - the mop closet was unclean, and the walls were in disrepair; - Food processor parts were air drying on an absorbent cloth in the prep area; - wiping clothes were stored outside of sanitizing solution in the prep area, cook area, and the dishwasher area; - the floor under the 2 door cooler in the juice area had debris, cups, and significant filth buildup; and - the cooler contained a pan of dripping condensate water above food, and a tube leading from the top of the cooler to a second pan located below the unit. Both pans contained unclean, grimy water. At the time of the observation, the Food Service Director stated, to the surveyor, the cooler was not functioning properly and the pans were usually drained daily. On 11/12/2014 at 11:55 AM, the Food Service Director stated they audited the kitchen in November 2014. She stated she started working at the facility about 6 weeks ago, and the kitchen was much cleaner than when she started. She stated she wanted to start auditing the kitchen 3 times per week. A sanitation checklist dated 11/8/2014 was reviewed with the surveyor. The checklist documented concerns with: - overhead pipes that might leak into food or equipment; - lights that were not clean; - hood and vents that were not clean; - fire extinguishers and hood fire protection systems (fire protection over the stove) that lacked proper inspections or tags; - drawers not organized or clean; - unclean ovens, food trucks, can openers; - china that was not clean or free of stains; - floor and walls not clean and free of debris; - procedure not posted for proper pot and pan washing; and - sanitizing solution not being tested and recorded daily. No corrective actions were recorded on the checklist. The Food Service Director stated, to the surveyor, she was unsure what concerns had been addressed by the facility. On 11/12/2014 at 12:12 PM, the dish washer area was observed. A large pool of standing water remained present. The Food Service Director stated, in an interview at that time, the drain often backed up and she had been telling maintenance about it. She stated a drain company was out and cleaned it previously, but it was still backing up. Observations on 11/12/2014 at 12:40 PM, showed the dishwasher hand washing sink remained inoperable, was unclean, with food particles visible and no paper towels were readily available. Five drain flies were observed in the cart wash area. When interviewed on 11/12/2014 at 1:45 PM, the Administrator stated she did rounds regularly in the kitchen, and had last been in the kitchen the night before. She stated the Director of Food Service did rounds regularly in the kitchen and the rounds included checking the kitchen for sanitary conditions, and that equipment was working properly. During an observation of the kitchen, with the Administrator, on 11/12/2014 between 1:55 PM and 3:00 PM, she stated in an interview, the dark mold like substance on the wall behind the dishwasher was not mold. She stated Occupational Safety and Health Administration (OSHA) had previously tested it, and it was not mold. No documentation of the OSHA test results was provided by the facility prior to survey exit. On 11/12/2014 at 3:40 PM, in an interview with the Food Service Director, she stated maintenance was not timely in the facility. She stated she had been short staffed and just recently received permission to hire a full time supervisor, and was in the process of hiring an additional full time employee. She stated some new staff had not gone through an orientation. The Environmental Log for maintenance documented several issues, dated as submitted on 10/30/2014, were not addressed including: cleaning and dusting the hood; fixing light lenses; repairing a "nasty" leaking ceiling; repairing a broken pipe in the dishroom; and cleaning light lenses. Observations on 11/12/2014 at 3:40 PM, showed a pitcher of cranberry juice in the refrigerator of Unit 3A, dated 11/7/2014, that had not been discarded after the problem with the dishwasher was identified, as stated by the Food Service Director, on 11/12/14 at 11:05 AM. When interviewed on 11/12/2014 at 3:45 PM, certified nurse aide (CNA) #17 stated that sometimes the dishware that came from the kitchen was dirty. On 11/12/2014 at 3:50 PM, the Director of Maintenance was interviewed. He stated a mock survey was conducted the previous week and some issues were identified. He stated they had plans to pressure wash and paint the kitchen floor. He stated there was a collapsed pipe, and the drain contractor had been in 5 times within the last 4 weeks. He stated there were new lenses for the lights, and he had not had time to install them. He stated maintenance was not responsible for the day to day cleaning of the kitchen. When interviewed on 11/12/2014 at 3:40 PM, dietary staff #16 stated utensils that fell on the floor, or in the pool of water on the kitchen floor, were put through the dishwasher before they were used. He stated for the past 2 to 3 weeks they were trying to squeegee the pooling water into another drain; maintenance was notified at least twice of the kitchen drain which had been blocked for at least 2 months now. He stated the container that collected silverware should not have been on the floor. Observations were made of different parts of the kitchen on 11/12/2014 between 4:50 PM and 5:35 PM. Observations of the main area showed: - two food service workers were not wearing hair restraints; - chipped tile by the dishwasher, unsealed sheet metal, and peeling paint exposing concrete; - tile was not smooth and cleanable; - the baseboard was chipped; - peeling paint, rusty metal and mold; - missing ceiling tiles; - splash debris on the ceiling; - rusty lights with missing lenses; - peeling aluminum wall protector; - missing or cracked wall tiles; - a mold like substance on the plastic wall panel by the dishwasher; - missing absorbent ceiling tiles and holes; - the dishwasher was covered with scaled hard water; - trays had scaled hard water on them; - chipped paint and a rusty face on the clean side of the dishwasher; - torn ceiling tiles with holes and dust accumulation; - peeling paint and no baseboard on the base of the wall by the handwash sink; - chipped wall paint by clean dishes and splash debris on the ceiling; and - an unclean and inoperable dishwasher hand wash sink. Observations in the center kitchen trayline area showed: - the main kitchen heat/ventilating/airconditioning ceiling unit was rusty with peeling paint; - the main kitchen floor had paint peeling and chipped tile; - the tray line had unsealed metal and spills; - coolers had drip marks and stains; - the wall receptacle opening was not covered; - the tray line table was unclean with splashes; - unit carts were observed unclean, with food particles and stains, and dark mold like substance was observed on a metal cart along the bottom lip; and - the floor under the freezer was unclean. Observations of cold storage showed: - the walk-in cooler was not clean, and had cardboard pieces, foam cups and 3 single serve butter packets on the floor; - the walk-in freezer had missing outside tiles, exposed drywall, food on the floor, a bus pan of frozen liquid on the floor, and an exposed unpainted, cement wall block; - the wall outside the cooler/freezer was not smooth and cleanable and contained bare cement block and a large gap near the cooler and post; and - There were two, temporary ceiling drain panels in disrepair measuring 2 feet x 4 feet. Observations of the cook prep area showed: - the prep area handwash sink floor had broken tile and was unclean; - a cleaning substance was above the sink in the prep area; - the Floor under the prep area was unclean; - there was no indirect drain present on the food prep sink; - ceiling tiles were cracked/missing; - the food cart had rusty metal with unknown black substance on it; - the floor in the prep area was peeling; - the hood contained grease buildup and was missing a filter, there was grease in the duct, the inspection tag was dated 11/18/2013 and the next service was due on 5/1/2014, and no other hood inspection tags were visible on the hood; and - there were seven, 4 inch x 4 inch tiles missing/cracked behind the range. Observations in the pot wash/service area showed: - the pot sink area had a rusted closet door jamb, peeling floor paint, a wall block with peeling paint and a black/greasy substance, the ceiling was dirty, and a brick in disrepair with orange spray foam on it; - the soda can closet had significant filth build-up, the base tile was chipped/missing, ceiling absorbent tiles were stained, and the wall fan was unclean; - the surveyor was not able to enter the room fully due to the numerous bags of empty soda cans; - the chemical closet was unclean and had rusty shelves; - the dry storage area had wall paint peeling, floor tile missing/in disrepair, cracked tiles, walls that were stained, a 1/4 inch x 10 inch crack up the wall, and 4 cups of ice cream behind the chest freezer remained on the floor; and - the staff corridor had rusty door jambs, peeling paint, and stained absorbent ceiling tiles stained. Concerns on Resident Units: 2) On 11/12/2014 at 1:15 PM, a surveyor observed a cabinet in Unit 2, it contained a container of open, undated cookies, and the cabinet contained black spec resembling mouse droppings. On 11/12/2014 at 3:40 PM, a surveyor observed 3 opened, undated, containers of coffee ice cream, 1 opened container of regular ice cream, and a container of open, undated cookies in Unit 3A refrigerator. On 11/14/2014 at 12:25 PM, the Unit 1 refrigerator contained a plate with a cheeseburger covered in plastic wrap, and a peanut butter sandwich in plastic wrap that were not dated. The Unit 1 refrigerator also had a bowl of applesauce and a pudding that were not in disposable plate ware. On 11/17/2014 between 11:00 AM and 11:20 AM, a personal refrigerator on Unit 3B was observed in room 341. The refrigerator contained an orange that was in an inedible state and rotten, 2 bologna sandwiches with the number resembling a 15 on them, and a container of an undated beef like substance. In an interview with staff #36 at the time of the observation, he stated housekeeping usually checked the personal refrigerators, cleaned them as needed, and discarded food after 72 hours. --------------------------------------------------------------------------------------------- The Immediate Jeopardy situation was removed prior to survey exit on 11/18/2014 based on the following corrective actions taken by the facility: - Implemented a staff training program in food safety. - Developed a system to adequately maintain and monitor dishwasher temperatures. - Initiated the start of a kitchen-wide deep cleaning program. - Educated facility maintenance staff on proper preventative maintenance and cleaning procedures in the kitchen. - Educated the majority of facility staff on roles and responsibility regarding food safety in the kitchen. - Revised policies and procedures to address kitchen issues. - Quality assurance monitoring was initiated, by administrative staff, to ensure compliance with the new/revised policy and procedure. 10NYCRR 415.14 (b)(2)(h)

Based on observation, interview and record review conducted during the standard survey, it was determined that for the facility kitchen, radiators, and windows, the facility failed to ensure Administrative staff administered the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain or maintain the highest practicable physical well-being of each resident. Specifically, the Administrative staff failed to maintain the kitchen in a safe and sanitary manner, and failed to maintain the facility radiators and windows to provide a safe and secure environment. This resulted in no actual harm that was Immediate Jeopardy to the health and safety of all (148) residents. Refer to tags F323, and F371 The Immediate Jeopardy for tag F371 was removed on 11/18/2014, prior to the survey exit. Findings include: When interviewed on 11/18/2014 at 12:35 PM, a facility owner stated he was not involved on a day to day basis at the facility; he was not involved in the development of facility policies; and the facility had a [AGE] year history of things not going correctly. During an interview with the facility Administrator on 11/18/2014 at 12:40 PM, she stated she was aware of on going issues related to sanitary conditions in the facility's kitchen, but had not established or implemented any corrective actions to address the problems. She stated she was unaware that the radiator fires, and the windows that were in disrepair should have been addressed. She stated the Director of Maintenance was supposed to have been tracking those issues. 10NYCRR 415.26(a)

Based on observation, record review and interview conducted during the extended survey, it was determined the governing body failed to ensure the facility was managed in a manner that protected the health and safety of its 148 residents. The facility did not ensure the environment was as free of accident hazards as possible. The facility did not implement fire prevention measures and corrective action following heating unit malfunctions that lead to fire department onsite response; did not ensure facility windows were secured following an attempt of a resident to exit via a window; and did not ensure adequate sanitary conditions were maintained in the kitchen. Specifically, the governing body failed to ensure their preventative maintenance policies were developed and properly implemented to reduce the fire risk from the heating units; to ensure resident safety by securing windows, and for ensuring sanitary conditions were maintained in the kitchen. This resulted in no actual harm with potential for serious harm that is Immediate Jeopardy to the health and safety of the facility's 148 residents. Findings include: Refer to tags F371, F323, F490 The Immediate Jeopardy for tag F371 was removed prior to the survey exit on 11/18/2014. 1) Sanitary Conditions Refer to tag (F371) When interviewed on 11/12/2014 at 11:05 AM, the Food Service Director stated she was unsure how long the dishwasher had not been properly sanitizing dishware. At 11:55 AM, she stated the kitchen had been audited in November 2014 and a checklist of concerns were identified. The Food Service Director stated she was unsure what concerns identified had been addressed by the facility. At 12:12 PM, she stated the drain often backed up and she had been telling maintenance about it. She stated a drain company cleaned it previously, but it was still backing up. When interviewed on 11/12/2014 at 1:45 PM, the Administrator stated she did rounds regularly in the kitchen, and had last been in the kitchen the night before. She stated the Director of Food Service did rounds regularly in the kitchen and the rounds included checking the kitchen for sanitary conditions, and that equipment was working properly. When interviewed on 11/12/2014 at 3:40 PM, the Food Service Director stated maintenance issues were not addressed timely in the facility. When interviewed on 11/12/2014 at 3:50 PM, the Director of Maintenance stated concerns in the kitchen were identified during a mock survey. He stated the drain contractor had been in 5 times within the last 4 weeks, and there were new lenses for the lights and he had not had time to install them. He stated maintenance was not responsible for the day to day cleaning of the kitchen. 2) Accident Hazards/Supervision/Devices Refer to tag (F323) During an interview on 11/13/2014 at 2:50 PM, the Administrator stated she was not aware of any problems with the facility's windows. She stated there were chains on windows to prevent them from fully opening, and to prevent residents from falling. She stated all resident room windows had chains and maintenance checked the operation and safety of windows during their quality assurance rounds. She stated rounds were conducted in all resident rooms, once a week, and the information obtained during the rounds became work orders for maintenance. She stated just one room was found missing a chain, and she was unsure how long ago that was. She stated she was unaware limiting chains were missing from windows. On 11/13/2014 at 2:50 PM, in an interview with the Administrator, she stated she was unable to contact the Maintenance Director. She stated there were two incidents where radiators got warm and were not fires. She stated in April 2014 the second floor day room radiator was 600 degrees F, and stated the second incident occurred in October 2014 when a black comb melted in a radiator causing it to smell. The Maintenance Director changed out the thermostats. She stated she thought there were safety devices installed on the heaters. The Administrator stated she did not know what rooms had been checked during rounds. 3) Administration/Quality Assurance Committee Refer to (F490 and F520) During an interview with the facility Administrator on 11/18/2014 at 12:40 PM, she stated she was aware of on going issues related to sanitary conditions in the facility's kitchen. She stated the QA committee had not addressed the concerns. She stated she did not know the radiator fires, and unsecured the windows should have been addressed by the QA committee. She stated the maintenance department was responsible for tracking those issues, and she had not asked maintenance for their audits. The audits were not discussed in QA meetings, and she did not feel the facility's QA program was effective. When interviewed on 11/18/2014 at 12:35 PM, one of the facility's owner stated he was not involved on a day to day basis at the facility; he was not involved in the development of facility policies; and the facility had a [AGE] year history of things not going correctly. 10NYCRR 415.26(b)(2)(3

Based on record review and staff interview conducted during the extended survey, it was determined the facility's quality assessment and assurance (QA) committee failed to readily and effectively identify issues that had the potential to cause serious harm to the health and safety of residents for the 148 residents, staff and visitors in the facility. Specifically, after the fire department responded 4 times related to heaters, between April and October 2014, the facility's QA committee failed to develop and implement an appropriate plan of action to address the lack of effective preventative maintenance for their heating units to reduce the immediate risk of fire injury; and after one resident attempted to exit the facility via a 2nd floor window the facility's QA committee failed to develop and implement an appropriate plan of action to address the lack of effective preventative maintenance for their windows. This resulted in no actual harm with potential for serious harm that is immediate jeopardy to the health and safety of all its residents. Refer to F371, F323 The Immediate Jeopardy for tag F371 was removed prior to survey exit on 11/18/2014. Findings include: During an interview with the facility Administrator on 11/18/2014 at 12:40 PM, she stated she was aware of on going issues related to sanitary conditions in the facility's kitchen. She stated the QA committee had not addressed the concerns. She stated she did not know the radiator fires, and unsecured the windows should have been addressed by the QA committee. She stated the maintenance department was supposed to have been tracking those issues. The Administrator stated she had not asked maintenance for their audits, and if they were done, they had not been discussed in QA meetings. The Administrator stated she did not feel the QA program at the facility was effective. 10NYCRR 415.27(a-c)

Based on staff interview and record review conducted during the standard survey, it was determined the facility did not provide the necessary care and services to maintain the highest practicable physical well-being for 1 (Resident #2) of 5 residents reviewed for hydration concerns. Specifically, the facility did not ensure Resident #2's attending physician was notified in a timely manner regarding the resident's change in status; and did not ensure Resident #2's urinary output, abnormal lab values, vital signs, and poor intake since admission were assessed in a timely manner. This resulted in actual harm, when the resident required hospitalization for a change in status, that is not immediate jeopardy. Findings include: Resident #2 was admitted on [DATE], with [DIAGNOSES REDACTED]. The resident was also assessed to have severely impaired cognition, according to his "Brief Interview for Mental Status" (BIMS), dated February 8, 2011. The resident's comprehensive care plan (CCP), dated "February 2011" documented the resident had urinary incontinence. Interventions included: staff were to monitor intake and output every shift and do a 3 day voiding diary. The February 1, 2011, "Nutrition Initial Screening", documented the resident's laboratory (lab) results, dated February 1, 2011 prior to admission, included his BUN (blood urea nitrogen, an indicator of hydration status and renal status) level = 40 mg/dl (norm = 6 - 24 mg/dl); and creatinine (an indicator of renal status) level was normal at 1.1 mg/dl (norm = 0.5 - 1.5 mg/dl). On February 2, 2011, the lab report documented the resident's BUN level was high at 40 mg/dl, with a normal creatinine level of 1.02 mg/dl, and a high BUN/Creatinine ratio of 39.2 (norm = 8-20; elevated ratio can be an indicator of dehydration.) Nursing notes, dated February 2, 2011 at 3 PM documented the resident's intake at breakfast and lunch was "poor"; and he "refused liquids". There was no documentation in these nursing notes regarding the resident's urinary output. On February 5 and 6, 2011, nursing notes documented the resident's intake at supper was "poor" with an intake of 120 ml of fluid. There was no documentation in these nursing notes regarding the resident's urinary output. On February 8, 2011, the 11 PM to 7 AM nursing notes documented the resident's respirations were increased at 28-30 per minute; oxygen was applied and the nursing supervisor, day shift nurse and nurse manager were made aware. Nursing specified that at 6 AM, the resident had removed the oxygen and his oxygen saturation level was 96%. There were no documented notes in the medical record, dated February 8, 2011, that documented the resident's physician or nurse practitioner (NP) were notified of this change in the resident's status. On February 8, 2011 at 9:10 AM, the speech language pathologist (SLP) documented the resident's "appetite is very diminished, with many refusals." Review of the 24 hour report, dated February 8, 2011, revealed the resident's name was not documented to be a "Hydration Alert" and there was no documentation on this report regarding the resident's poor intake, or urinary output. An SLP progress note dated February 9, 2011 at 9:10 AM, documented the resident's appetite was "very poor"; he was short of breath; and "had many instances of saying 'I cant eat'." The note documented the resident's pulse was "100+". The SLP documented the registered nurse (RN) on the unit was consulted. A nursing progress note dated February 9, 2011 on the 7 AM - 3 PM shift, documented the resident was at "moderate risk for dehydration"; "fluids offered, but resident keeps refusing." This information was also documented on the 24 hour report for the 7 AM to 3 PM shift. On the 11 PM to 7 AM shift, nursing documented the resident was "spitting fluid out", except at meal time. There was no documented evidence of an assessment by qualified professional staff that included the resident's urinary output, his vital signs and his respirations. A lab report, dated February 9, 2011, documented the resident had abnormal values. the resident's BUN/Creatinine ratio was above normal at 33; his BUN was 66 mg/dl; and his creatinine level was 2.0 mg/dl. There were no documented evidence in the resident's medical record, dated February 9, 2011, that the attending physician was notified of the resident's abnormal lab values and poor intake. A Nutrition Care Plan, initiated February 9, 2011, documented the resident was at risk for dehydration, with a goal for the resident to have no signs/symptoms of dehydration. Interventions included for staff to monitor lab levels and monitor intake and output. The dietitian's progress note, dated February 9, 2011, documented the resident's lab values were "worsening". On February 10, 2011 at 8:30 AM, the SLP documented the resident was seen in the dining room and refused to eat or drink. The SLP brought the resident to his room and attempted to get the resident to drink. The resident was given 1 sip of cranberry juice and "evidenced very strong coughing"; all trials were stopped. The SLP documented the resident developed rapid breathing, and was noted with "increased confusion, anxiety, and decreased interest in foods and liquids. The SLP specified she spoke with nursing about [MEDICATION NAME] (antidepressant) to decrease the resident's anxiety and increase his interest in eating. There were no documented nursing notes, or 24 hour report documentation, dated February 10, 2011, regarding the SLP's recommendation; and no documentation this information was communicated to the attending physician. There was no documented evidence qualified professional staff assessed and monitored the resident's urinary output, his vital signs and his respiration status. A nursing note dated February 11, 2011, documented the NP was in and ordered a Resource 2.0 (a liquid nutritional supplement) to be give 4 times daily with the medication pass. There was no nursing note dated February 11, 2011 and no note from the NP regarding the SLP's recommendation for [MEDICATION NAME] for the resident. There was no documentation on the 24 hour report, dated February 2011, that specified the need to assess and monitor the resident's urinary output, his vital signs and his intake. On February 12, 2011 at 4:30 PM, nursing notes documented the resident's wife stated the resident was "warm to touch". The resident's temperature was documented to be 100.1 degrees F.; and specified the resident "refused solids at supper and took some fluids." The resident's temperature at 9 PM was 98.5 degrees F. There was no documentation in these nursing notes regarding the resident's urinary output, his blood pressure, or his respirations. The 24 hour report, dated February 12, 2011, documented the resident's temperature at 4:30 PM; and specified Tylenol was given. The report documented the resident had an "unproductive cough", and his temperature was to 98.5 degrees at 9 PM. There was no documented assessment of the resident that included his urinary output, his blood pressure or his respirations. A registered nurse (RN) progress note, dated February 13, 2011 on the 7 AM - 3 PM shift, documented the resident's wife believed "he may be running a fever." Nursing documented the resident's temperature was 97.5 degrees F. She was concerned because the resident had "been lethargic" for the past 2 days. The note documented a note was left for the nurse practitioner (NP) and physician to see the resident "on Monday". There was no documented assessment in nursing notes that included the resident's his intake, urinary output, blood pressure, and his respirations. A nursing note dated February 13, 2011 at 12:30 PM documented the resident's son consulted a physician, and then called an ambulance, as the consultant physician believed the resident "should be evaluated at the emergency room ." The NP was contacted for an order. The 24 hour report, dated February 13, 2011 for the 3 PM to 11 PM shift, documented the resident was admitted to the hospital with [REDACTED]." On February 14, 2011, the attending physician documented the resident was sent to the hospital on February 13, 2010, with the admission [DIAGNOSES REDACTED]." The physician documented he was "not aware of what was going on." The RN Unit Manager was interviewed on March 3, 2011 at 11:00 AM and asked if she informed medical staff of the resident's February 9, 2011 abnormal lab results. She stated she could only say she did not document that she reported them to the physician. The surveyor interviewed the NP on March 3, 2011 at 12:05 PM. She stated she was not sure if she was previously aware of the resident's abnormal lab values on the February 9, 2011 lab report. On February 14, 2011, the physician wrote comments on the resident's February 9, 2011 lab report. The resident's BUN, creatinine, and BUN/creatinine ratio were circled, and the physician wrote "? dehy" (question dehydration) on this lab report. The resident's attending physician was interviewed on March 3, 2011 at 12:25 PM. He stated there was a breakdown in the communication system between the facility, staff, and himself, related to the resident's abnormal lab results. The resident's hospital discharge summary, dated February 25, 2011, documented the resident "was found profoundly dehydrated with an elevated BUN and creatinine, and right lower lobe pneumonia" in the emergency roiagnom on [DATE]. The resident was discharged back to the facility on [DATE], with the [DIAGNOSES REDACTED]. A lab report, dated February 28, 2011, documented the resident's BUN, Creatinine and BUN/Creatinine ratio were all within normal limits. In summary, the resident experienced harm and required hospitalization , as the facility: - did not ensure the resident's attending physician was notified in a timely manner regarding the resident's abnormal lab values, poor intake, the SLP's recommendation, and the resident's elevated temperatures. - did not ensure the resident's urinary output, abnormal lab values, vital signs, and poor intake were assessed and monitored in a timely manner. 10NYCRR 415.12

Based on observation, record review, and interviews with staff and residents conducted during the standard survey, it was determined the facility did not provide adequate supervision and assistance to prevent accidents for 1 (Resident #18) of 6 residents reviewed for falls/fractures, and for 1 (Resident #7) of 8 residents reviewed with altered consistency diets. Specifically, Resident #18's level of assistance for safe transferring was changed from assistance of 1 to "independent with assistance of 1 as needed", without an assessment by physical therapy. For Resident #7, the facility did not ensure the diet was consistently implemented as ordered; and did not ensure the resident was consistently supervised during meals. This resulted in actual harm that is not immediate jeopardy for Resident #18, and no actual harm with potential for more than minimal harm that is not immediate jeopardy for Resident #7. Findings include: 1) Resident #18 had [DIAGNOSES REDACTED]. The resident's comprehensive care plan (CCP) updated November 30, 2010, documented the resident fell out of bed that day. The CCP specified the resident was independent with transferring. On December 7, 2010, the resident's CCP was updated and documented the resident required the assistance of 1 person with transferring. On December 10, 2010, nursing documented on a communication form sent to physical therapy, that the resident fell and now was "1 assist." The physical therapist (PT) responded on the same form, "Yes, this is a good idea"; the resident was "marginal" before, which is why she had a "special lock mechanism" on her chair. The PT response included documentation that the resident lacked insight into her need for assistance. The resident's Fall Risk Assessments, dated January 7 and January 30, 2011, documented the resident was at risk for falls. A January 11, 2011 nursing progress note documented the resident was confused, needed assistance with activities of daily living (ADLs), had a decrease in mobility, and fell in November 2010. Nursing sent a request (communication form) to physical therapy for an evaluation, as a result of the resident's decreased mobility. The PT evaluation, dated January 12, 2011, documented the resident required moderate assistance for transferring and walking on level surfaces and was on a restorative physical therapy program. PT documented staff could assist the resident walking to and from the bathroom. The resident was certified to receive restorative therapy from January 12, 2011 to February 12, 2011. The resident's January 19, 2011 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition, required the assistance of 1 person for transferring. On January 30, 2011, the CCP was updated and documented the resident "now" was independent with transfers. On January 30, 2011, the registered nurse (RN) documented the resident was independent with transfer, and was to be assisted "PRN" (as needed). There were no documented instruction that specified when staff were to provide the "as needed" limited assistance with transfer. There was no documentation PT was involved in revising the resident's change in transfer status. Nursing progress notes, dated February 1, 2011, documented the resident fell while transferring herself to the commode. The resident had a large hematoma to the left eye; the eye was "swollen shut"; and the resident asked staff to "get me up or let me die." The resident was transferred to the emergency room . The "Event Report" form, initiated on February 1, 2011, documented the resident had an unwitnessed fall with serious injury of a laceration (cut), contusion (bruise), and hematoma. The report documented prior to the fall, the resident required the assistance of 1 for ambulation and "PRN" assistance for transferring. The resident fell when transferring herself to the commode. The report documented the resident's CCP was immediately updated. No possible contributing factors to the fall were specified. There was no documented evidence the resident's Fall Risk Assessment was updated following the fall on February 1, 2011. The February 2, 2011 hospital discharge summary documented the resident was admitted to the intensive care unit for frequent neurological checks on February 1, 2011, as she sustained injuries from a fall. The resident's injuries included a laceration (with sutures given) and ecchymosis (bruising) to the area surrounding the left eye, a subdural hematoma (bleeding in the brain) on the left side, a large hematoma on the scalp of the left side, and a small hemorrhage (bleed) in the left side of the brain. The report documented a small fracture of the left eye orbit could not be ruled out. Treatment included monitoring in ICU "until the Coumadin (blood thinner) was reversed (Vitamin K given and 4 units of fresh frozen plasma), with no need for surgical repair. On February 2, 2011, the resident's CCP was updated and documented the resident required the assistance of 1 person for transferring. On February 19, 2011, the physician progress notes [REDACTED]. The note documented the resident was more subdued since the fall, not conversational at all, and "no longer carrying the sparks that she had before." The resident showed further impaired cognitive function after the recent fall. The plan included providing total care. On February 19, 2011, a nursing progress note documented the resident's bed mobility decreased following the fall. On February 22, 2011, a nursing progress note documented a significant change assessment was completed, due to a significant change in the resident's status. The resident was now assisted with all ADLs including eating, transferring, and toileting, had a fall with injury, was at risk for further falls, and was turned and positioned in bed. On March 3, 2011 at 10:40 AM, the registered nurse (RN) Manager told the surveyor that nursing decreased the amount of assistance provided to the resident with transferring at the end of January 2011. The RN stated this was done as the resident had "not fallen for a while." She stated normally she would obtain a physical therapy referral before making changes in the level of assistance provided, and she did not see that one was obtained in this case. On March 3, 2011 at 12:40 PM, the PT was interviewed and stated the amount of assistance provided to the resident was decreased by nursing, prior to the resident's fall on February 1, 2011. She stated nursing should not have decreased the amount of assistance provided to a resident without consulting physical therapy. According to nursing practice standards, per New York State Department of Education, an RN can "increase the level of assistance" a resident requires to transfer; an RN can not decrease the amount of assistance provided to a resident, without an assessment from qualified rehabilitation therapists. In summary, Resident #18 experienced actual harm when she sustained a fall, required hospital treatment, and had a significant change in status after the fall, as the facility: - did not ensure the facility provided the resident with 1 person assistance when transferring, as planned by restorative therapy; - changed the resident's transfer status from needing the assistance of 1, to "independent with assistance of 1 "as needed", without an assessment by physical therapy and without instructions to clarify when to implement the "as needed" assistance; - did not ensure nursing staff communicated timely with PT, when nursing made changes in the resident's transfer status. 2) Resident #7 had [DIAGNOSES REDACTED]. The January 27, 2011 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition, required set-up assistance at meals, did not have swallowing difficulty, and was not on a mechanically altered diet. The February 10, 2011 registered dietitian's (RD) assessment documented the resident received mechanical soft consistency food per his request, due to a chewing problem. He required set-up/assistance for eating. On February 11, 2011, a nursing progress note documented the nurse practitioner ordered a mechanical soft diet for the resident. A February 16, 2011 nursing progress note documented at 12:30 PM, the resident was found choking at lunch, was able to clear it himself, and a request was made for a swallowing evaluation. The February 16, 2011 verbal physician order [REDACTED]. The February 21, 2011 RD's progress note documented the resident's diet was changed to mechanical soft on February 7, 2011 at his request and a swallowing evaluation was pending. The swallowing evaluation dated February 24, 2011 documented the resident's diet was changed to mechanical soft on February 11, 2011, the resident choked on food at lunch on February 16, 2011, and the resident's diet was downgraded to puree, pending the evaluation. The evaluation documented the resident had problems with poor or excessive chewing, and was edentulous (did not have any teeth). The resident did not want a dental consult and pharyngeal swallowing difficulty was suspected. Recommendations included a mechanical soft diet, pureed fruits and vegetables, small bites/sips at meals, and for the resident to be positioned upright during meals and for a minimum of 30 minutes after eating. On February 24, 2011, the speech language pathologist (SLP) sent a Therapy-Nursing Communication form that documented the resident required observation by nursing at meals to ensure his safety. The resident's comprehensive care plan (CCP), updated on February 24, 2011, documented the resident had a swallowing evaluation, the diet order was mechanical soft (ground) with pureed fruits and vegetables, the resident required set-up assistance at meals, and the resident spent his time in his room in bed. There was no documented plan for observation (supervision) at meals. The undated CNA Care Card did not specify the resident needed supervision during meals. On February 25, 2011 a verbal physician order [REDACTED]. On March 2, 2011 at 8:40 AM, the resident was observed eating his breakfast meal while lying in bed. The resident was seated upright and received hot cereal, nutritional juice, milk, and an English muffin. The resident's meal ticket documented he was to receive a banana. The resident stated there was a banana on his tray and he refused it. The surveyor did not observe a banana. On March 3, 2011 at 8 AM, the resident was observed lying in bed with his meal tray positioned on an overbed table in front of him. The head of the resident's bed was positioned at a 45 degree angle. The resident received toast, hot cereal, milk, nutritional juices, and a whole banana. The resident stated to the surveyor he did not like hot cereal, and he asked someone to order pancakes for him. At 8:07 AM, the resident received pancakes with whole blueberries on top of them. There was no staff present in the room at 8 AM or 8:07 AM. At 8:21 AM, the surveyor returned to the resident's room. The resident was in his room alone and had eaten between 25 and 50% of the pancakes with blueberries. The surveyor asked the resident if he was going to eat the banana and he stated he could not eat it, as he "almost choked." When the surveyor returned to the resident's room at 8:40 AM, the head of the resident's bed remained at a 45 degree angle and the resident was finished eating. During the 2 breakfast meal observations on March 2 and 3, 2011, the resident was not consistently positioned upright and not consistently supervised. On March 3, 2011 at 10:30 AM, the facility's full-time dietitian stated she did not cover the resident's unit and referred the surveyor to the registered dietitian (RD). She provided a copy of the resident's meal plan which documented the diet order was mechanical soft with pureed fruits and vegetables. The meal plan specified the resident preferred a banana at breakfast. On March 3, 2011 at 11 AM, the RD and registered nurse (RN) Manager were interviewed. The RN stated she did not work the day the resident choked. She stated at present, the resident ate meals in his room, in his bed. She said he was monitored by the staff member assigned to the hallway and staff were in an out of the room during meals. The RD stated the resident was to receive pureed fruits and vegetable per the swallowing evaluation recommendations. She stated she did not think the facility pureed bananas, as the quality would not be good, and she would look into the plan for the blueberries. At 11:40 AM on March 3, 2011, the RD returned and told the surveyor the facility's menu extensions did not specify whether bananas were to be pureed. She stated if residents were alert and oriented, she did not think they would accept a brown, pureed banana. She stated the banana was a special request of the resident, and she should have addressed the plan for the banana when his diet was changed. She stated the blueberries should have been pureed; whole blueberries were provided due to an oversight in the kitchen that morning. In summary, for Resident #7, the facility: - did not provide adequate assistance with positioning and supervision at meals as recommended by the SLP; - did not consistently provide the physician ordered food consistency, in order for the resident to remain free of accidents. 10NYCRR 415.12 (h)(1) & (2)