Every finding on record at Elizabeth Church Manor Nursing Home

Based on observations, record review, and interviews during the recertification survey conducted 7/28/2025-8/1/2025 the facility did not ensure sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service for 2 of 3 resident units (Units 1 and 3). Specifically, Unit 1's and 3's meal trays were consistently delivered after the posted scheduled mealtimes and concerns were identified with the effectiveness of meal preparation and other food and nutrition services. Deficiencies related to food and nutrition services were identified in F 809 Frequency of Meals/Snacks at Bedtime; F 812 Food Procurement, Store/Prepare/Serve; and F 814 Dispose of Garbage and Refuse Properly.Findings include:The Resident Listing Report, dated 7/28/2025, documented the facility's resident census was 117. The undated facility policy Dietary Staffing, documented the facility should maintain adequate and qualified dietary personnel, including management and support staff, to ensure that all meals and snacks were safely prepared, handled and serviced in a timely and person-centered manner. Staffing levels were determined based on the census, resident acuity, meal service model, and operational hours. The projected schedule for the week of 7/27/2025-8/9/2025 documented the following:- On 7/28/2025 there was one cook, one supervisor and five kitchen staff for the morning shift; one supervisor and three kitchen staff working the dinner shift; and one kitchen staff working 11:00 AM- 7:30 PM. - On 7/29/2025, there was one cook, one supervisor, and 3 kitchen staff for the morning shift. One kitchen staff called off for the morning shift and one kitchen staff did not report to work for the shift. The evening shift had one supervisor and three kitchen staff. - On 7/30/025 there was one cook, one supervisor, and two kitchen staff. Two kitchen staff called off for the morning shift. There were three kitchen staff working the dinner shift; and one kitchen staff working 11:00 AM- 7:30 PM on trays.- On 7/31/2025 there was one cook/supervisor and four kitchen staff working the morning shift; four kitchen staff working the dinner shift; and one kitchen staff working 11:00 AM- 7:30 PM. - On 8/1/2025 there was one cook, one supervisor, and four kitchen staff working the morning shift; four kitchen staff working the dinner shift; and one kitchen staff working 11:00 AM-7:30 PM.During an interview on 7/31/2025 at 11:02 AM, the Director of Social Work stated the current census was 113. They were the grievance officer for the facility, and they received a lot of concerns about mealtimes and dietary issues. There was a lack of staff in the dietary department, they were actively hiring for diet aides and a Food Service Manager. They had all hands helping to put trays together at mealtimes and certified nurse aides were consistently helping with the tray line. They stated during resident council they should have someone from dietary come to talk to the residents and address their concerns but recently there was no one available. During an interview on 7/31/2025 at 1:16 PM, Dietary Aide #15 stated they started their shift at 6:00 AM and start serving breakfast at 7:00 AM. There was one cook on duty for breakfast and lunch and only one cook on at a time. They start serving lunch at 11:00 AM. They were not sure when supper was served because they were finished with their shift usually between 3:00 PM and 4:00 PM. This was based cleaning needs because the kitchen was to be cleaned before they left. There were four dietary aides to serve each meal and included around 115-120 people to serve. The kitchen served two others on-site facilities, Assisted Living and Independent Living. Sometimes when they were short staffed, certified nurse aides came to the kitchen to help serve the food. They stated they needed more dietary staff. The weekend meals were usually one-half hour late due to low weekend staffing. During an interview on 7/31/2025 at 1:34 PM, Lead Dietary Aide #16 stated they used to be a supervisor, but they just signed a new job title and worked 11:00 AM- 7:30 PM. They had on the job training on different aspects of the job. They stated lunch started serving at 11:15 AM and supper at 4:40 PM. The kitchen also cooked and prepared meals for the Assisted Living and Independent Living facilities. They had one cook for all three buildings. They stated it usually took 1.5 hours to serve the facility, and they were usually done by 5:45 PM-6:00 PM. They only had two servers for all three facilities. There was only one person who served the skilled facility and four people to do the tray line. They were short staffed and could not always get the job done adequately.During an interview on 7/31/2025 at 1:50 PM, the Food Service Manager stated they were acting as the Food Service Director. They stated they were the first cook and came in at about 5:00 AM. The morning cook recently left the position. The meal tray line started at 7:00 AM for breakfast and continued until 8:00 AM; lunch was from 11:15 AM-12:30 PM; and supper was 5:40 PM-6:00 PM. They stated they also worked on weekends as a cook. The meals were occasionally late. The latest the meals were served was one hour late and was due to short staffing. The maximum staffing was 6-7 kitchen staff on days, and 5-6 kitchen staff for evenings and did not include the cooks. There was one cook and one supervisor for every meal, every day. There was enough staff scheduled to get the job done if they all come in to work. They stated they serve two buildings (skilled and the assisted/independent living buildings) which was about 200 people between all the buildings. If there were 1-2 staff call outs, which happened daily, it made a significant impact on the dietary service. Certified nurse aides helped on the tray line, and they received on the job training by dietary staff. The training usually took half a shift. They had a regional Registered Dietitian, and they were waiting for a Food Service Director. The kitchen closed about 7:30 PM but staff stayed late if the meals were late. During an interview on 7/31/2025 at 2:33 PM, Food Service Manager/Certified Dietary Manager stated they were in this role for 3 years and was based out of Pennsylvania. They stated they assisted with training staff. This week one cook resigned and now only had one cook, so the supervisor was cooking. They stated it should take an hour to get the first to last carts delivered to the residents. The meal carts were sometimes late due to staffing issues. The ideal staff should be one cook and 7 diet aides. Recently, they had certified nurse aides helping in the kitchen, working the tray line and dish room.During an interview on 8/1/2025 at 1:09 PM, the Assistant Director of Nursing/Graduate Nurse #3 stated they help in the kitchen with meals. They have staffing issues in the kitchen. When staff call in for the kitchen, they had to all come together to ensure the resident needs were met, and if they had to help on tray line, they would. During a telephone interview on 8/01/2025 at 1:29 PM, Regional Corporate Food Service Director stated their role at the facility was Director of Culinary Services and they were at the facility once or twice a week. They were not aware they were listed as the Acting Director of Dining Services but assisted with directing the kitchen. The current Assistant Manager/Supervisor was recently promoted to supervisor. The dietary staffing was an issue, and their focus was hiring. They stated there was not enough staff for extras, but the facility met the minimal standards. The nursing staff were trained to assist with tray line. They stated there were times when the meals were late but was not aware of the irregular mealtimes and was told they had not been over 15 minutes late.10NYCRR 415.14(b)(1)(2)

Based on observations, record review, and interviews during the recertification and abbreviated (NY00385403) surveys conducted 7/28/2025-8/1/2025, the facility did not ensure residents had the right to a dignified existence for 2 of 3 units (First and Third Floors) reviewed. Specifically, the First floor meals were served more than 30 minutes late; the Third floor meals were served more than 30 minutes late, and dining table residents were not served together. Additionally, deficiencies were identified in sufficient dietary support personnel to safely and effectively carry out the functions of the food and nutrition service (F802) that led to an undignified dining experience.Findings include:The undated facility policy, Dining Experience Policy, documented meals would be served at consistent, scheduled times, with flexibility for alternate meal schedules. Communal dining was encouraged for socialization. The undated facility policy, Dignity, documented meals would be served in a manner that maintained dignity and avoid treating residents as a task and resident would be encouraged and supported to make choices about their daily schedule, meals, activities, and care. The undated facility document, Cart Delivery Times, posted on the window of the third-floor kitchenette documented breakfast carts came at 8:00 AM and 8:10 AM, lunch carts came at 12:20 PM and 12:30 PM, and dinner carts came at 6:00 PM and 6:10 PM. The first-floor breakfast carts came at 7:40 AM and 7:50 AM, lunch carts came at 12:00 PM and 12:10 PM, and dinner carts came at 5:40 PM and 5:50 PM. During an interview on 07/28/2025 at 11:17 AM, Resident #97's family stated the meals were coming later. During an interview on 7/28/2025 at 12:05 PM, Resident #13's family stated food service was very delayed. On 7/27/2025, the family was present with Resident #13 and dinner was not served until 8:00 PM. There were times lunch was not served until 3:00 PM when shift change was occurring. The family stated they come to have lunch with the resident but may have to do this less frequently due to the timeliness of meals. They sat around for hours waiting for the meal to be served. During a resident group meeting on 7/28/2025 at 2:38 PM, seven anonymous residents stated the meals were served late. They were served dinner at 7:20 PM and 6:30 PM. The kitchen did not have enough staff for the 120 meals they had to prepare. The facility asked certified nurse aides to assist in the kitchen and that took staff away from the residents that needed assistance on the units. During a lunch meal observation on 07/28/2025, the lunch meal was served on first floor at 1:10 PM. The following observations were made during a Third floor lunch meal observation on 7/28/2025:- at 11:42 AM, staff started bringing residents to the dining room for lunch.- at 12:39 PM, Resident #97 was talking to their family and asking if lunch was coming and hoping it would be there soon. The resident was sitting outside the dining room with an empty tray table in front of them.- at 12:44 PM, there were no meal carts on the third floor. - at 12:51 PM, no beverages or snacks were served.- at 1:00 PM, the first meal cart was delivered to the unit.- at 1:02 PM, the first meal tray came off the cart and staff obtained beverages for the tray which was taken out of the dining room.- at 1:05 PM, the first meal tray was served in the dining room to table 5. Staff at the tray cart were looking for another tray to serve the same table. The staff was overheard stating the cart was not stocked per table. - at 1:06 PM, all members of table 5 were served. The meal cart was closed. Certified Nurse Aide #7 stated the cart did not have trays for complete tables, and they would have to wait for the second cart to serve the tables together. - at 1:11 PM, there were 7 staff members standing in the front of the dining room, no trays were served. 3 residents were eating, and 33 were not yet served.- at 1:13 PM, the second meal cart was delivered to the unit. - at 1:14 PM, Resident #87 was served their meal, staff removed the entree and told the resident they needed to get a replacement entree for them.- at 1:17 PM, Resident #87's meal ticket was returned to their tray.- at 1:23 PM, Director of Nursing #2 observed the staff pass trays, and verbally noted the last tray on the cart being served.- at 1:29 PM, Resident #87 was served their entree. During a dinner meal observation on 7/28/2025, the dinner meal was served on the First floor at 6:20 PM. The following observation were made during the Third floor dinner meal on 7/28/2025:- at 5:24 PM, Licensed Practical Nurse Assistant Director of Nursing #3 was on the third floor and asked staff to go to the dining room. No staff were present in the dining room with 25 residents waiting for their dinner.- at 6:09 PM, the first meal cart was delivered to the unit. Director of Nursing #2 and Licensed Practical Nurse Assistant Director of Nursing #3 were on the unit to help with passing trays.- at 6:12 PM, Director of Nursing #2 stated the carts were not organized as they should be. They stated they knew residents should be served together, but the carts were not set up to do that. They were going to serve the meal trays as they were loaded into the meal cart. They stated they knew this would mean that some residents at one table would not be served at the same time as their tablemates. The remaining residents at the table would have to wait for their meal cart to arrive before they were served.- at 6:17 PM, the first cart was served. Resident #44 was waving for staff and repeating their name while pointing to the meal cart. The other three residents at the table were served their meal, but not Resident #44. Staff told Resident #44 more food was coming.- at 6:19 PM, Licensed Practical Nurse Assistance Director of Nursing #3 removed the seating chart from the wall and stated tables 7, 8, 9, and 10 could come on the second cart as they needed more assistance. - at 6:23 PM, the second meal cart was delivered to the unit. - at 6:24 PM, Resident #44 was served their meal.- at 6:30 PM, all meal trays were served. During an observation on 7/30/2025, the first breakfast tray was delivered to the Third floor at 8:38 AM. During a lunch meal observation on 7/30/2025, the lunch meal service started at 12:28 PM, and all trays were served by 1:00 PM. The following observations were made during the Third floor lunch meal on 7/30/2025:- at 12:51 PM, Resident #87 was served their meal and began eating while Residents #72 and #62 at the table were not yet served. Resident #72 tapped on the table and said, right here, can you get mine right here. - at 12:52 PM, One resident at table 6 was served their meal, the two other residents at the table were not yet served. - at 12:52 PM, Resident #72 was served their meal. Resident #87 had completed about 75% of their meal.- at 12:54 PM, Resident #62 was served their meal. Resident #106, from the neighboring table completed their meal and was saying good-bye as they exited the dining room.- at 12:57 PM, Resident #106 ate 100% of their meal before exiting the dining room. During an interview on 7/31/2025 at 10:42 AM, Certified Nurse Aide #19 stated the tray service was difficult. They had to pour beverages in paper cups because they were coming in prepackaged containers, like milk cartons and small plastic containers with tin foil lids. Beverage used to come in hard plastic dining cups. They stated the kitchen did not have enough staff to do the dishes, so they used the paper cups. The meal carts did not match the seating chart. Trays on the carts could be for the residents who ate in the hallway or the dining room. It was not dignified to serve some of the residents and not the whole table at once. They tried to gauge whether to serve the cart as it came or wait for the second cart and serve the whole table together. They sometimes had to move the residents around from table to table so they could serve the residents together if only one cart was on the unit. They had to think about the benefit of the resident, serve cold food or serve what was available regardless of the seating chart. There was a day lunch did not come until the second shift was coming in, about 3:00 PM. During an observation and interview on 8/1/2025 at 8:39 PM, Certified Nurse Aide #7 stated since the former dietary manager left the facility a few months ago there were meal service issues. They spoke with members in Administration and Corporate team, but no changes or education was done. The meals were always late, at least 30 minutes daily, and weekend meals were more than an hour late. The two meal carts came to the unit about 15 minutes apart. Breakfast was supposed to be served at 8:00 AM. At 8:44 AM, a meal cart was observed entering the dining room. Certified Nurse Aide #7 stated that cart was the second meal cart for the unit and should have been on the unit at 8:10 AM. They helped by bringing the tray carts back to the kitchen after meal service as the dietary department did not have anyone to come get them. During an interview on 8/1/2025 at 8:55 AM, Licensed Practical Nurse #12 stated the meals were always late. Breakfast usually came to the unit about 9:00 AM. The carts usually came about 10-15 minutes apart, and sometime longer than 15 minutes. The dietary department was short staffed. The tables should be served together, but sometimes they served the residents when each cart came regardless of the tray order, or they would wait for both carts because they did not always know when the second cart would come to the unit. The resident could have behaviors in the dining room with the delays. On the weekends, there were a couple times when the meal was about 2 hours late. During an interview on 8/1/2025 at 12:08 PM, Director of Nursing #2 stated they expected meals to be served on time. There were complaints from residents, family, and staff about food service. The biggest complaint was meals were not delivered to the floors timely. Nursing staff was helping the dietary staff in the kitchen. During an interview on 7/31/2025 at 1:16 PM, Dietary Aide #15 stated meals were usually 30 minutes late on weekends due to staffing problems. During an interview on 7/31/2025 at 1:34 PM, Lead Dietary Aide #16 stated there were times meals were an hour late due to short staffing. During an interview on 7/31/2025 at 1:50 PM, Food Service Manager #13 stated the meals were occasionally late when served to the residents. They did not want to serve undercooked food to the residents and low staffing was the cause for meals being late. They determined the loading of the meal trays based on how the tickets printed out by seat. They loaded the tables and then the room trays. The dietitian and nursing set up the table seating charts. They received the seating chart just before survey started this week. They were not sure why residents at the same table were not served together. It was not a dignified meal experience when tablemates were not served at the same time. 10 NYCRR 415.5(b)(1-3)

Based on observations, record review, and interviews during the recertification survey conducted 7/28/2025-8/1/2025, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards in one (1) out of one (1) main kitchen. Specifically, the main kitchen was unclean, had damaged freezer storage equipment, improperly stored utensils, and improper storage of food products.Findings include: The undated facility policy Kitchen Cleaning and Sanitation, documented all surfaces in the kitchen and food preparation areas were to be cleaned and sanitized regularly to maintain a safe environment for food storage and preparation, and to ensure the prevention of foodborne illness and cross-contamination. The undated facility policy Refrigerator and Freezer Cleaning and Temperature Monitoring, documented the facility performed routine cleaning of all cold storage equipment and made sure it functioned properly. The food should be stored six inches off the floor.The undated facility policy Food Storage, documented the facility stored all food and food-related items in a sanitary and organized manner to protect food from contamination and spoilage per regulations. All items in the refrigerator should be covered, labeled, and dated.The following observations were made in the main kitchen on 7/28/2025 at 10:31 AM;-there was water on the floor under the steamer. -a heavy, black, greasy substance was on the floor under the cookline equipment. -there were multiple food products and residue on the floor and under the shelving in the walk-in cooler.-the walk-in freezer door was not closed properly, and several cases of food were stored on the floor. - an ice scoop was lying on top of the ice in the ice machine.The following observations were made in the main kitchen on 7/29/2025 at 11:45 AM:-the floor by the cookline was soiled with a black greasy substance under and around equipment.-the middle reach-in refrigerator was soiled with dried on food debris and liquid.-the floor and under shelving in the walk-in cooler were littered with packaging, food spills, and food debris. Some food products were uncovered, including a large, eight-inch hotel pan of mixed diced fruit with a serving utensil in the product.-the floor in the walk-in freezer had built up black greasy substance and food debris. The door was not able to close properly due to icing in the frame. - The floor in the dry storage areas had black grimy substance on it. Some food packaging and dropped food product were noted on the floor under shelving.During the tray line lunch observation, the first cart was not clean and had a white liquid inside the cart on the bottom. Staff were loading lunch trays into the cart. Food Service Manger #13 wiped up the white substance with a dry cloth, set the cloth down on the counter surface and used the same cloth to wipe out the second cart.During an interview on 7/29/2025 at 12:00 PM, Food Service Manager #13 stated that the cloth used to clean the white liquid from cart one was not put in any sanitizer or cleaning agent prior to wiping out cart two and should have been.During an interview on 7/30/2025 at 12:23 PM, Food Service Manager #13 stated the kitchen was usually cleaned at the end of the night, including the floors under the cookline. The walk-in cooler and walk-in freezer were swept and mopped weekly. They stated the ice scoop should not have been stored in the ice. They stated there should not have been spilled food or food debris under shelving or equipment, in equipment, or inside carts. They stated food product could not be stored on the floor. A food service equipment vendor came in and fixed the freezer door seal, but the door still iced at the bottom and was not closing properly. They knew this affected the freezer's ability to maintain temperatures.During a follow-up interview on 8/1/2025 at 9:50 AM, Food Service Manager #13 stated potentially hazardous foods should be dated, labeled, and stored in the walk-in cooler. They were supposed to use test strips to make sure the sanitizer levels were in range in the three-bay sink.During an observation on 8/1/2025 at 10:04 AM, Dietary Aide #18 was using the three-bay sink. They stated they were not taught how to test the sanitizer levels in the three-bay sink.During an interview on 8/1/2025 at 1:29 PM, Regional Director of Food Service #14 stated they assisted Food Service Manager #13 with kitchen oversight. Cleaning should be done routinely, including the floors under the cookline, the walk-in cooler and freezer, and under shelves. They stated education was provided this past week after the walk-in freezer door was left open. If the door was not closed properly the freezer temperatures and food product inside the freezer would be affected. They stated ice scoops should not be stored in the ice and food products should not be stored on the floor. They stated staff should be testing sanitizer for the three-bay sink, to ensure the sanitizer was effective, but they did not have enough staff for the extras right now.10NYCRR 415.14(h)

Based on observations, record review, and interviews during the recertification survey conducted 7/28/2025-8/1/2025, the facility did not ensure garbage and refuse was disposed of properly in one (1) of one (1) main kitchen. Specifically, the main kitchen garbage and refuse areas were not maintained to prevent attraction and harborage of pests.Findings include: The undated facility policy Garbage Disposal and Waste Management, documented all garbage, refuse, and waste was collected, stored, and disposed of in a manner that minimized health risk and prevented pest infestation. Kitchen waste was to be emptied multiple times a day. The exterior waste storage should be covered and secured to prevent pest access and kept free of overflowing waste. During an observation on 7/28/2025 at 10:40 AM, there were piles of trash and debris scattered on the ground around the dumpsters outside the main kitchen.During an interview on 7/30/2025 at 12:23 PM, Food Service Manager #13 stated the kitchen garbage was taken down the hall and put out the side door and into the dumpsters at the end of the night. They stated garbage should not be all over the ground near the dumpsters. If garbage was not disposed of properly and spilled on the ground, it could attract pests. During an interview on 8/1/2025 at 1:29 PM, Regional Director of Food Service #14 stated that kitchen dumpsters should be closed with no debris on the ground around them. They stated garbage should be emptied more often than it was, generally after each meal.10 NYCRR 415.14(h)

Based on record review and interviews during the recertification survey conducted 7/28/2025-8/1/2025, the facility did not ensure as needed orders for psychotropic drugs were limited to 14 days for one (1) of five (5) residents (Resident #14) reviewed. Specifically, Resident #14 had a physician order for as needed Ativan (anti-anxiety medication) that was not reevaluated for appropriateness or discontinuation after 14 days. Findings include: The undated facility policy PRN [as needed] Medication Administration Policy, documented special precautions were taken with psychotropic [as needed] medications, which required time-limited orders and clinical justification. Psychotropic medications were any drug that affected brain activities related to mental processes and behavior. All [as needed] orders must include the duration of the order (especially for psychotropics). [As needed] orders for psychotropic medications must be limited to 14 days, unless the attending physician documented and justified the need for continuation. The medications could not be renewed automatically and must be reassessed and re-ordered with the included rationale.Resident #14 had diagnoses including vascular dementia, paranoid personality and bipolar disorders. The 7/23/2025 Minimum Data Set assessment documented the resident had severe cognitive impairment and received antipsychotics, antianxiety, and antidepressant medications.The Comprehensive Care Plan initiated 6/10/2025 documented the resident had impaired cognitive function/dementia or impaired thought processes related to dementia. Interventions included the administration of medications and monitor for side effects and effectiveness.The physician order, created by Director of Nursing #2, and signed by Nurse Practitioner #9 documented Ativan 0.5 milligram with a start date of 6/20/2025 with the follow instructions:- give 0.5 tablet daily for agitation and anxiety disorder - give 0.5 tablet every 12 hours as needed for agitation and anxiety disorder - give 1 tablet daily for agitation and anxietyThe order did not include an end date. There were no documented revisions or renewals.The 6/17/2025 Licensed Pharmacist #11 Note to Attending Physician/Prescriber documented as needed psychotropics had a 14-day limitation on all as needed orders. Order may be extended beyond 14 days if the attending physician or prescribing practitioner believed it was appropriate to extend, documented clinical rationale, and provided specific duration of use. Please address Ativan use. Handwritten notes on the review form highlighted Physician #10 and under the area, Physician/Prescriber Response documented, stop after 14 days for PRN order, with a signature.The 6/2025 Medication Administration Record documented Ativan 0.5 milligrams every 12 hours as needed for agitation and anxiety disorder with a start date of 6/20/2025 and no end date. The resident did not receive an as needed dose of Ativan from 6/20/2025-6/30/2025. There were no medical provider progress notes documenting the resident was evaluated for use of as needed Ativan. The 7/15/2025 Licensed Pharmacist #11 Note to Attending Physician/Prescriber documented as needed psychotropics had a 14-day limitation on all as needed orders. Order may be extended beyond 14 days if the attending physician or prescribing practitioner believed it was appropriate to extend, documented clinical rationale, and provided specific duration of use. Please address Ativan use. There was no documented response from the physician or prescriber.The 7/2025 Medication Administration Record documented Ativan 0.5 milligrams every 12 hours as needed for agitation and anxiety disorder with a start date of 6/20/2025 and no end date. The resident did not receive an as needed dose of Ativan during 7/2025. During an interview on 8/1/2025 at 8:55 AM, Licensed Practical Nurse #12 stated Director of Nursing #2 was the former Unit Manager. The antipsychotic medications were reviewed every few months. Resident #14 had an order for routine and as needed Ativan. If the provider re-ordered the medication the start date would be the date of the re-order. The Ativan order was active since 6/20/2025. They were not sure if the as needed Ativan needed an end date, or who was responsible for adding that information to the order.During a telephone interview on 8/1/2025, Licensed Pharmacist #11 stated they completed the pharmacy medication reviews monthly. The pharmacy reviews were sent to the Director of Nursing. As needed medications were part of the monthly review, and as needed psychotropics should be limited to 14 days at most. If the resident had an as needed order for Ativan without an end date, that would be included on the recommendation given to the Director of Nursing. Once the recommendation was sent, it was the responsibility of the facility to follow through with the providers. During a follow up telephone interview at 11:54 AM, Licensed Pharmacist #11 stated the monthly reviews were sent to Licensed Practical Nurse Assistant Director of Nursing #3 who was the acting Director of Nursing for the facility.During an interview on 8/1/2025 at 12:08 PM, Director of Nursing #2 stated they were the Director of Nursing on record, but Licensed Practical Nurse Assistant Director of Nursing #3 was the acting Director of Nursing. Monthly medication reviews were done by the licensed pharmacy consultant every 3 months. The pharmacy recommendation papers went from the consultant pharmacist to the provider who signed off as agree or disagree with a note. The Unit Manager made any needed changes. Resident #14 had an as needed order for Ativan dated 6/20/2025, it was still an active order and was past the 14 day and should be reviewed. There was a note from the provider for the resident but was not a date to stop the Ativan after 14 days. The pharmacy review was scanned into the resident's record on 6/25/2025. The order was still active and was not stopped and should have been reassessed by the provider. During an interview on 8/1/2025 at 1:09 PM, Licensed Practical Nurse Assistant Director of Nursing #3 stated they helped the Unit Managers and worked with Director of Nursing #2 to train to be a Director of Nursing. The pharmacy consultant sent the reviews to the Director of Nursing. The provider made notes, the Unit Managers made the changes, and the unit clerk scanned the documents into the resident's record. Ativan had a 14-day reassessment requirement. There would be no potential for negative outcome from the resident as the nurses should be following the order and using appropriate nursing judgment.During a telephone interview on 8/1/2025 at 1:59 PM, Nurse Practitioner #9 stated the medication review papers came from the pharmacy and the Unit Managers distributed them to the providers. They often discussed these with the Unit Managers and checked agree or disagree on the form. The medications were reviewed quarterly. As needed Ativan re-order need depended on the indication for use. If the pharmacist made a recommendation and the provider agreed, they expected the change to be made.During a telephone interview on 8/1/2025 at 3:08 PM, Physician #10 stated the pharmacy consultant made recommendations and the Unit Managers gave the recommendations to the nurse practitioners to review. If they had questions, they contacted them to review. As needed Ativan should be reviewed and reordered every 14 days. If the pharmacist recommended a change and they documented they agreed to it, they expected the documented change to be completed. If the medication was reviewed for reorder, there should be a note with the reviewed information. It was important to review as needed orders as they may need to make changes if the medication was being used regularly, or to discontinue the medication if it was not being used. 10 NYCRR 415.4(a) (2-7)

Based on record review and interviews during the recertification survey conducted 7/28/2025-8/1/2025, the facility did not conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently both during day-to-day operations and emergencies. The facility did not review and update the facility assessment as necessary. Specifically, the facility assessment did not accurately reflect the clinical nutrition staff and department heads.Findings include:The 2024-2025 Facility Assessment documented the incorrect name of the Director of Nursing. The assessment documented the facility resources needed to provide competent support and care for the resident population every day and during emergencies. The assessment listed one Director of Nurses with a New York State license; 1 Director of Food and Nutrition which included Food service Director/ Diet technician/Registered Dietitian, Certified Dietary Manager, 3 cooks, and 6 food service aides. The registered dietitian listed was not full time or a department head, and the facility did not have a Dietary Director. During an interview on 7/31/2025 at 1:50 PM, Food Service Manager #13 stated they were full-time and not the department head. They also worked as a cook. They stated a regional staff person performed the Food Service Director job duties. During an interview on 7/31/2025 at 2:57 PM, Registered Dietitian #4 stated they work part-time at the facility and was hired for clinical duties only. They were not aware of any other responsibilities within the department. During an interview on 8/1/2025 at 12:08 PM, Director of Nursing #2 stated they were in the Infection Control (preventionist) position for about 3 weeks and was acting as the Director of Nursing while Assistant Director of Nursing #3 was training for the Director of Nursing role.During an interview on 8/1/2025 at 1:09 PM, Assistant Director of Nursing #3 stated their official title was Assistant Director of Nurse Trainee. Their badge documented GN/DON (Graduate nurse/Director of Nursing) trainee. They stated the official Director of Nursing on record was Director of Nursing #2. During an interview on 8/1/2025 at 1:29 PM, the Regional Director of Food Service stated they worked 2 days a week at the facility and was not aware they were listed as the Food Service Director. They stated they were under the impression they were assisting with directing the kitchen.During an interview on 8/1/2025 at 2:03 PM, the Administrator stated the Director of Nursing was also the Infection Preventionist and training the Assistant Director of Nursing. The previous Assistant Director of Nursing/Infection Preventionist left employment at the facility the week prior to survey. They were working with staffing agencies to hire qualified cooks. 10NYCRR 415.26

Based on observations, record review, and interviews during the recertification survey conducted 7/28/2025-8/1/2025, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of six (6) residents (Resident #4) reviewed. Specifically, during Resident #4's wound dressing treatment Licensed Practical Nurse #8 did not perform hand hygiene when changing from contaminated to clean gloves. Findings include:The undated facility Wound Care Dressing Change, documented hand hygiene was required before starting the dressing change, after removing soiled dressings, and at the end of the procedure. Resident #4 had diagnoses including Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) left heel pressure ulcer. The 6/16/2025 Minimum Data Set assessment documented the resident had severe cognitive impairment, an unhealed pressure ulcer, infection of the foot, received pressure injury care and application of dressings to the feet. Wound culture results obtained on 7/22/25 documented mixed flora and pseudomonas (bacteria) species.A 7/23/2025 at 12:41 PM Licensed Practical Nurse #20 progress note documented the wound culture was reviewed by Nurse Practitioner #9. A new order was provided to begin Cipro (antibiotic) 500 milligrams for 7 days. A 7/30/2025 at 7:55 AM Licensed Practical Nurse #21 progress note documented the resident continued on antibiotics for foot infection. The 7/2025 Treatment Administration Record documented Stage 4 left heel wound cleanse with wound wash, pat dry, apply zinc to peri-wound edges, apply Opticel AG (antimicrobial dressing with silver), cover with dry 4 x 4 gauze, secure with tape, apply heel cup every day shift. During a wound treatment observation on 7/30/2025 at 10:45 AM, Licensed Practical Nurse #8 performed a dressing change on Resident #4's left heel. Licensed Practical Nurse #8 removed the soiled dressing, removed their soiled gloves, did not perform hand hygiene, put clean gloves on, and applied the clean dressing.During an interview on 07/31/2025 at 10:38 AM, Licensed Practical Nurse #8 stated they should perform hand hygiene before and after the dressing change. They stated they changed gloves after the soiled dressing was removed. Hand hygiene was not necessary at that time because their hands had been in gloves and were clean. They stated that they should have hand sanitizer in the room to use between glove changes.During an interview on 08/01/2025 at 12:08 PM, Registered Nurse/Infection Preventionist #2 stated that per the facility procedure, hand hygiene was required after removing old dressings and removing the soiled gloves and before putting clean gloves on. They stated hand hygiene was critical before starting the dressing change, after removing the soiled gloves, and at the end of the dressing change as hands could be contaminated with organisms from the wound and could cross contaminated the clean dressing.10 NYCRR 415.19(a)(b)

Based on observations and interviews during the recertification survey conducted 7/28/2025 - 8/1/2025, the facility did not ensure one qualified individual, who was not the Director of Nursing, was responsible for the facility's Infection Prevention Control Program. Specifically, the Assistant Director of Nursing was not qualified based on education, training, experience or certification to assume the role of Infection Preventionist and the Director of Nursing assumed those duties.Findings include: The undated facility policy Infection Surveillance, documented the Infection Preventionist served as the leader of surveillance activities, maintained documentation of incidents, findings, and any corrective actions regarding infection control. They were responsible to report findings to the Quality Assurance Committee and public health authorities.The undated facility Emergency Phone Numbers form documented Director of Nursing #2 was also the Infection Preventionist. Assistant Director of Nursing #3 was the Director of Nursing in Training and the Assistant Director of Nursing.The 2024-2025 Facility Assessment documented the Infection Preventionist should be a New York State Licensed Registered Nurse.The 7/3/2025 Infection Preventionist certificate documented Director of Nursing #2 successfully completed the Centers for Disease Control and Prevention training course.During an interview on 8/1/2025 at 12:08 PM, Director of Nursing #2 stated they were in the Infection Preventionist position for about three weeks. Assistant Director of Nursing #3 was being trained for the role. If anyone requested to speak with the Director of Nursing, Assistant Director of Nursing #3 would talk with them and bring Director of Nursing #2 in as needed. The previous Director of Nursing terminated their employment on 7/3/2025. The previous Infection Preventionist terminated their employment about three weeks ago.During an interview on 8/1/2025 at 1:09 PM, Assistant Director of Nursing #3 stated they were training for the Director of Nursing role. They assisted Director of Nursing #2 with tasks but within their scope of practice. Director of Nursing #2 was the current Infection Preventionist, as they were not certified to maintain that position. They stated they had not yet passed their New York State Registered Nurse test, and the position required the holder to be a registered nurse in New York State.During an interview on 8/01/2025 at 2:03 PM, the Administrator stated Director of Nursing #2 was also acting as the facility's Infection Preventionist while training Assistant Director of Nursing #3, who was uncertified for the role. The regional office and management consulting team were responsible for verifying the credentials for staff holding those roles. The Administrator stated they were aware the Director of Nursing should not have any other responsibilities, and this was the reason they were training the Assistant Director of Nursing in the Infection Preventionist role. The previous Assistant Director of Nursing, who was the Infection Preventionist, terminated their employment with the facility on 7/29/2025. 10NYCRR 415.14(d)(1)(2)

Based on observation, record review, and interviews, during the abbreviated survey (NY00354300) the facility failed to ensure residents remained as free of accident hazards as possible for 7 of 55 residents (Residents #1, #4, #5, #6, #7, #8 and #9) reviewed. Specifically, Resident #1 who had severely impaired cognition, had a contour mattress and right side bed rail (assist rail) and was not assessed for appropriate alternatives to the bed rail, was not assessed for entrapment risk, did not have the risks and benefits of a bed rail reviewed, and there was no informed consent from the resident's representative before installation of the bed rail. Subsequently, the resident was found with their body out of the bed and their head wedged between the bed rail and the mattress and was pronounced deceased . Additionally, Residents #4, #5, #6, #8, and #9 had multiple risk factors identified on their bed rail assessments and were recommended to have bed rails applied; Residents #4, #5, #6, #7, and #8 did not have risks and benefits of bed rails reviewed with them or their representatives and did not have informed consent prior to the use of bed rails. This resulted in Immediate Jeopardy to Resident #1 and placed all residents with bed rails at risk for the likelihood of serious harm, serious impairment, serious injury, or death (Refer to F 700). See heading titled Bed Rail Assessments. Based on record review and interviews during the abbreviated survey (NY00354147) the facility failed to ensure each resident received adequate supervision to prevent accidents for 2 of 3 residents (Residents #16 and #17) reviewed. Specifically, Resident #17, who had severely impaired cognition and known wandering behaviors, exited the building undetected by staff, crossed the road to a gas station, and remained away from the facility for over 40 minutes before their whereabouts was reported to the facility. Additionally, Resident #16 who had severely impaired cognition and a history of wandering behavior, was observed by staff who were walking through the lobby, exiting the front lobby door in their wheelchair. This resulted in Immediate Jeopardy to Resident #17 and placed all residents with exit-seeking behaviors at risk for serious harm, serious injury, serious impairment, or death. See heading titled Elopement. Findings include: Bed Rail Assessments The job description for Registered Nurse Assessment Nurse signed by Assessment Registered Nurse #9 on [DATE], documented essential functions and requirements included completing the nursing assessment, pressure ulcer risk assessment, fall risk assessment, pain assessment, physical restraint determination and the elopement risk assessment at intervals; assist in the care plan process in conjunction with the Interdisciplinary Team to ensure appropriate treatments and/or interventions were implemented according to resident need and physician orders; perform assessments in relationship to change in resident status; communicate effectively with residents and families; current knowledge and practice of accepted standards of professional nursing practice; and, awareness of environmental safety. On [DATE] the facility provided a list of 54 residents in the facility who currently had bed rails on their beds. 1) Resident #1 had diagnoses including Alzheimer's disease, epilepsy (a seizure disorder), and unsteadiness on their feet. The [DATE] Minimum Data Set Assessment documented the resident had severely impaired cognition, required partial to moderate assistance for rolling left to right and sitting on the side of the bed, required supervision, or touching assistance to stand and for chair/bed to chair transfer, and did not use bed rails. A [DATE] Bed Rail Assessment (using the facility's former Bed Rail Assessment tool) completed by Assessment Registered Nurse #39 documented the risks and benefits of bed rails were discussed with the resident representative and verbal consent was given by the resident representative for the use of bilateral bed rails. Alternatives to bed rail use and restraint determination areas on the assessment tool were not documented. The Comprehensive Care Plan, initiated [DATE], documented the resident had activities of daily living self-care performance deficits related to confusion, dementia, and chronic pain. Interventions included the resident required extensive assistance to turn and reposition in bed, and limited assistance for transfers. The resident was at moderate risk for falls related to confusion and lack of safety awareness. Interventions included keep bed at knee height when the resident was in bed, and frequent safety checks while in bed. There was no documentation the resident had a right side bed rail, contoured mattress, or that the left side of the bed was against the wall. A [DATE] Physical Therapist #44 progress note documented the resident performed bed mobility sit to supine and supine to sit using a right side bed rail requiring stand by assistance. The resident benefited from verbal/tactile cues for sequencing and technique. An [DATE] Bed Rail Assessment documented the resident's level of consciousness fluctuated, they had an alteration in safety awareness due to cognitive decline, had a history of falls, displayed poor bed mobility, and had difficulty with balance or poor trunk control. Interventions included to provide frequent staff monitoring at night and provide assisted toileting at night. Bed rail recommendations were for a right side bed rail to serve as an enabler to promote independence. The resident/responsible party signature and date block documented verbal [DATE] and was signed off by Assessment Registered Nurse #9. There was no documentation the risks and benefits of a right side bed rail were discussed, or that informed consent was given for the use of a right side bed rail by the resident's representative. A [DATE] facility incident report documented the resident was last observed at 4:30 AM during incontinence care. At 5:45 AM when Licensed Practical Nurse #4 came into the resident's room to administer medications, they observed the resident with their head and neck wedged between the right side bed rail and mattress. After assessment by Registered Nurse #3 the resident was pronounced dead. Resident #1's death certificate documented the resident expired on [DATE] at 5:45 AM and the immediate cause of death was listed as probable positional asphyxia (a body position that prevented normal breathing). The resident care instructions as of [DATE] documented the resident's bed was kept at knee height, they required frequent safety checks while in bed, required limited assistance for transfers, and used a rolling walker to maximize independence with transferring. There was documentation of the use of a right side bed rail. During an observation on [DATE] at 10:14 AM Resident #1's left side of the bed was against the wall and a bed rail was attached to the right side of the bed. During an interview on [DATE] at 10:00 AM the Director of Therapy stated bed rail use required a nursing assessment for the ability to use the bed rail correctly and safely. They thought maintenance was responsible for the installation of bed rails at the request of nursing and was unsure if therapy ever requested bed rails. Bed rails caused a risk for entrapment and were not used to prevent falling from bed. They stated Resident #1 received therapy to improve transfer safety, but therapy had taken place in the gym, not in the resident's room, so they had not assessed Resident #1 for bed rail use. During an interview on [DATE] at 1:18 PM, the Administrator stated bed rail use was determined by an assessment, generally at the request of the resident or family member. (Refer to F700) During an interview on [DATE] at 9:48 AM Registered Nurse Unit Manager #10 stated the resident had been using the right side bed rail to stand, pivot, and transfer from their bed into their wheelchair. During a telephone interview on [DATE] at 3:16 PM Resident #1's Representative stated they did not know the resident had a bed rail and they did not recall facility staff ever calling them to discuss the risks and benefits of a bed rail. They would remember something like that. When they went to the facility to pick up some items from Resident #1's room on [DATE] they were surprised to see a bed rail on the bed. 2) Resident #4 had diagnoses including Alzheimer's disease and Parkinson's disease (a progressive neurological disorder). The [DATE] Minimum Data Set Assessment documented the resident had intact cognition, impaired vision, and required partial to moderate assistance for rolling left to right, lying to sitting on side of bed, sitting to standing and chair/bed to chair transfers, and did not use bed rails. The Comprehensive Care Plan, initiated on [DATE], documented the resident had activities of daily living decline. Interventions included extensive assistance of one to turn and reposition in bed, and right and left bed rails to facilitate independent position changes. The [DATE] Bed Rail Assessment documented the resident's level of consciousness fluctuated, they had an alteration in safety awareness due to cognitive decline, had a history of falls, displayed poor bed mobility, had difficulty with balance or poor trunk control and was visually challenged. Interventions included provide assisted toileting for the resident at night and visual and verbal reminders to use the call bell. Bed rail recommendations were for bilateral rails to serve as an enabler to promote independence. The resident/responsible party signature and date block documented verbal and was signed off by Assessment Registered Nurse #9. There was no documentation the risks and benefits of bed rails were discussed, or that informed consent was given for the bed rails. During an observation on [DATE] the resident's bed had bilateral bed rails with the right side of the bed against the wall. Resident care instructions as of [DATE] documented the resident had right and left bed rails as assistive devices to facilitate independent position changes. During an interview on [DATE] at 2:18 PM Resident #4's Representative stated the resident had the bed rails for a long time. They did not recall if the risks or benefits of bed rails were discussed with them prior to installation or when they may have given informed consent. The [DATE] updated Bed Rail Assessment by Registered Nurse Unit Manager #19 documented bed rail use was not indicated, and the bed rails were removed. There was no physical restraint assessment documented for the right side of the bed against the wall with a contoured mattress until [DATE] by the Assistant Director of Nursing. 3) Resident #5 had diagnoses including Alzheimer's disease. The [DATE] Minimum Data Set Assessment documented the resident had severely impaired cognition, required partial to moderate assistance for rolling left to right, lying to sitting on side of the bed, sitting to standing and chair/bed-to-chair transfers, and did not use bed rails. The Comprehensive Care Plan, initiated on [DATE], documented the resident had an activities of daily living self-care performance deficit related to limited mobility. Interventions included extensive assistance of one to turn and reposition in bed, the left side of the bed was against the wall per resident preference, and they had a contoured mattress. There was no documentation the resident had a right side bed rail. The [DATE] Bed Rail Assessment documented the resident's level of consciousness fluctuated, they had an alteration in safety awareness due to cognitive decline, displayed poor bed mobility and had difficulty with balance or poor trunk control. Interventions included provide assisted toileting for the resident at night and visual and verbal reminders to use the call bell. Bed rail recommendations were for a right side bed rail to serve as an enabler to promote independence. The resident/responsible party signature and date block documented verbal [DATE] and was signed off by Assessment Registered Nurse #9. There was no documentation the risks and benefits of bed rails were discussed, or that informed consent was given for the bed rail. During an observation on [DATE] the resident's bed had a right side bed rail, and the left side of the bed was against the wall. The resident care instructions on [DATE] did not document the use of a right side bed rail. The [DATE] at 4:55 PM updated Bed Rail Assessment by the Assistant Director of Nursing documented bed rails were not indicated, and the right side bed rail was removed. There was no physical restraint assessment documented for the left side of the bed against the wall with a contoured mattress until [DATE] by Registered Nurse Unit Manager #26. During an interview on [DATE] at 10:07 AM Assessment Registered Nurse #9 stated if a new admission entered the facility and the bed, they were in already had bed rails attached, they would do a bed rail assessment at that moment to see if the resident could use them appropriately. They were not aware of any other interventions trialed first on Resident #1 before the right side bed rail was recommended, and they were not aware of the resident's family or representative requesting a bed rail. When they did bed rail assessments, they went into the resident rooms to observe the bed rails. Sometimes residents were in their beds and sometimes they were not when they did the bed rail assessments. During a follow-up interview on [DATE] at 10:09 AM Assessment Registered Nurse #9 stated they had been in that role since ,d+[DATE]. They did not have any specific training on completing bed rail assessments and was told they were to do the bed rail assessments and to answer the questions (on the assessment tool). Regarding making the decision as to whether a resident should have bed rails based on answering the questions on the Bed Rail Assessment tool, they stated they did not have a clear understanding of the risks involved in bed rail use. They did not realize that assist bars were considered bed rails. Not every resident received a bed rail assessment. If a resident wanted to try a bed rail they would do an assessment. When they did quarterly bed rail assessments, they would go with what the resident already had on the assessment tool, either bilateral rails or just a left or right bed rail. On admission they discussed the risks and benefits of bed rails with the resident or resident representative. Some risks of bed rails were entrapment or skin tears. They did not document the risks and benefits of bed rails because there was no place to free text on the assessment tool, and they did not write a nursing progress note. They never consulted therapy regarding bed rail assessments. They had never had an actual conversation with Resident #1's family or representative regarding their bed rail. They observed Resident #1 sleeping in their bed when the bed rail was attached, and another time observed the resident using the bed rail to get back into bed after a fall. Since they had been in their role as Assessment Registered Nurse, they had never discontinued a bed rail and they had never had a family say no to a bed rail. During an interview on [DATE] at 10:33 AM the Director of Nursing stated bed rail assessments were usually done by Assessment Registered Nurse #9 but sometimes they were done by Registered Nurse Unit Managers if Assessment Registered Nurse #9 was not working, or if it was off-hours. If residents had multiple risk factors during the bed rail assessment, they still might get bed rails because it would be resident-specific. They would reach out to therapy with any bed rail questions or get input from certified nurse aides about what they might think of a particular resident using bed rails. Bed rail discussions did not come up during Interdisciplinary Team meetings. There was no training plan Assessment Registered Nurse #9 received before performing bed rail assessments. Assessment Registered Nurse #9 would typically go over assessments with the Minimum Data Set Coordinator if they had any questions. When quarterly bed rail assessments were done on residents, Assessment Registered Nurse #9 should observe bed rails in person, and if there were a lot of risk factors during the assessment they should discuss these with staff on the unit. Before installation of bed rails, the risks and benefits should be discussed with the resident or resident representative and be documented. Informed consent should also be documented. Bed rails should be discussed during care plan meetings as that was a part of the topics that would be reviewed. In the past when a resident was discharged from the facility and they had bed rails, the bed rails were left on the bed. They did not consider assist rails as bed rails, but rather, as mobility devices, because the rails did not extend from the headboard to the footboard. Risks of bed rails included entrapment or injury. They observed Resident #1 using their bed rail in the past for mobility and had never heard of any issues from staff about the resident using it inappropriately. They also had never heard any concerns from therapy about Resident #1's bed rail use. During an interview on [DATE] at 11:07 AM the Medical Director stated they had not been included in resident bed rail assessments or discussions. Each residents' situation and risk factors should be reviewed in detail very carefully before bed rails were recommended. Resident #1 had been their patient and if they had been included in the bed rail assessment for them, they would have been very reluctant for the resident to have bed rails due to the risks involved, which included entrapment. In the case of Resident #1, bed rails led to their death. 10NYCRR 415.12(h)(2) *************************************************************************************** Immediate Jeopardy was identified, and the Administrator was notified on [DATE] at 4:44 PM. Prior to survey exit the Administrator was notified on [DATE] at 3:55 PM that Immediate Jeopardy was lifted retroactively to [DATE] based on the following corrective actions taken: -All residents with bed rails received updated bed rail assessments and physical restraint/safety assessments if their beds were placed against the wall, care plans were updated and orders for bed rails were obtained. -A revised bed rail assessment tool was created to address interventions attempted prior to bed rail installation taking into consideration medical conditions; an area on the assessment form addressed risks and benefits of bed rail use with an area for documentation; and informed consent, whether verbal or in person, by the resident or resident representative, with their name and date. -Education of staff was done for the new bed rail assessment tool, bed rail policy and procedure and safety of the residents' environment. -Plan to educate any staff that has not received training (due to illness, vacation, or leave of absence) will be completed before going on the floor to work. **************************************************************************************************** Elopement The undated facility policy, Door Test, documented to test alarmed doors, they would go to the panel and ensure doors were alarmed, announce that the facility would conduct a test, and doors 1A, 1B, 1C, 2A, 2B, 2C, 3A, 3B and 3C were the doors that needed to be tested . They would go to the door, push the crash bar, and hold pressure against the magnet, note how long the magnet would hold the door for 15 to 20 seconds, then repeat door procedure at each of the 9 doors between the three floors in the building. They would check with the nurse to ensure the pager went off, announce the test was complete, and log into the book with the date and concerns found. The facility policy, Wandering and Elopement Risk Identification and Management, dated ,d+[DATE], documented unsafe wandering was defined as random or repetitive locomotion without regard to physical safety which placed the wandering resident or other residents at risk of harm. Comprehensive assessment of each resident for wandering behaviors and elopement risk with new onset wandering and/or elopement risk was the responsibility of the Interdisciplinary Care Planning Team. Plant Operations were responsible for ensuring the stairwell doors and exit doors were connected to the wandering management system. All staff were responsible for prompt response to all facility alerts and alarms, and immediately reporting potential issues identified with any component of the electronic wandering managements system to a licensed nurse. If alarms, systems or locking devices were temporarily disengaged or malfunctioning, ensure a backup plan was in place to safeguard the residents and consider completing a census count to ensure all residents were accounted for. 1) Resident #17 had diagnoses including Alzheimer's dementia. The [DATE] Minimum Data Set assessment documented the resident had severely impaired cognition, did not wander or reject care, had no upper or lower extremity impairments, used a walker, and used a wander/elopement alarm daily. The [DATE] comprehensive care plan documented the resident was at risk for elopement. Interventions included wander monitoring system transmitter applied to the left ankle and investigate reason for elopement attempts and document findings. The [DATE] Elopement Evaluation documented the resident had a score of 5 (a score of 1 or more was considered at risk for elopement), a history of elopement or attempted leaving the facility without informing staff, verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door, wandered, wandering behavior was a pattern, and their wandering was goal directed. The facility document Door Alarm Checks reviewed from [DATE]-[DATE] documented there were 9 doors checked with no problems. The following dates did not have documented evidence of door alarm checks: [DATE], [DATE]-[DATE], [DATE]-[DATE], [DATE], [DATE], [DATE], and [DATE]. The door checks on [DATE]-[DATE] by Maintenance Assistant #29 documented no problems. The [DATE] at 4:25 PM Social Worker #14 progress note documented they observed the resident attempting to leave the unit via the elevator. They re-directed the resident away from the elevator. The [DATE] facility investigation documented: - At 4:22 PM the resident attempted to get on the elevator. - At 7:00 PM Registered Nurse Supervisor #19 observed the resident ambulating on the unit with their walker. - At 8:20 PM Secretary #12 received a phone call from the local gas station the resident was there. - Video surveillance of the [DATE] incident showed the resident near the end of the hall stairwell door on Unit 1 while staff members were obtaining linen and moving another resident from the shower room. Resident #17 exited the stairwell door while a staff member entered a room on the right side of the hallway. Video surveillance showed the resident exited the building with their walker at 7:37 PM, walked across the lawn and down the driveway towards the 4-lane highway in front of the facility. The resident turned left and walked down the side of the highway. Video surveillance from the front lobby at 8:24 PM showed the resident being brought back from the gas station across the street in a wheelchair, with staff carrying the resident's walker. The resident came back into the front lobby doors at 8:25 PM. - A [DATE] incident note by Registered Nurse Supervisor #32 documented Resident #17 had eloped to the gas station next door. The front lobby receptionist had received a phone call from Emergency Medical Services alerting them the resident was at the gas station. The resident was returned to the nursing home in a transport chair and placed in their bed. The resident was then moved to room [ROOM NUMBER] with all their belongings. A wander alert system was in place on their left ankle and wheelchair, and both were functioning properly. - An undated Voluntary/Witness Statement completed by Certified Nurse Aide #15 documented Resident #17 was near the door at the end of the hall on [DATE] when they went into a room to answer a call bell. They stated they did not hear any alarms and if they had, they would have responded. During an interview on [DATE] at 10:00 AM Social Worker #14 stated Resident #17 wandered because they wanted to be outside. On [DATE] the resident was attempting to get on the elevator, and they re-directed the resident. They told the certified nurse aides and Unit Manger #17. During an interview on [DATE] at 11:28 AM Assessment Registered Nurse #9 stated they completed the admission, quarterly, and annual elopement evaluations on residents. If a resident had a change in wandering or exit-seeking behavior, they would not be notified as the Unit Managers would complete the evaluations. The nurses on the units were responsible for checking placement of the wander alert devices every shift. They were told about Resident #17's elopement the next day ([DATE]) during morning report. During an interview on [DATE] at 10:12 AM, Maintenance Assistant #27 stated the on-call maintenance staff for the week was responsible for daily door checks. The procedure was to hold the door, monitor the alarm, and observe to see if staff responded or noticed the alarm. They were unable to identify an issue with the interior door of 1C. The outer door from 1C would normally alarm to a speaker near the nurses' station, but the speaker was blown. If the delayed egress door was held for 15 seconds and the magnet opened, it would remain open until the button on the outside of the door was pushed to reset the magnet. During a telephone interview on [DATE] at 12:43 PM Resident #17's Representative stated the resident had wandering and exit-seeking behaviors since admission. The resident would ask to go home, leave with family, and attempt to use the doors. The Administrator had reported to them about the [DATE] elopement incident. During an interview on [DATE] at 2:14 PM Maintenance Assistant #29 stated they were informed of the potential problem with 1C door on [DATE] at 6:00 AM. They had been on-call the night before but nobody had called them. They had been the on-call staff person for the week and completed the daily and weekly door checklists on [DATE]. On [DATE] they had not checked the exterior doors. The Maintenance Department checked all interior doors daily, but not the exterior doors. There was no documentation for exterior doors. During an interview on [DATE] at 2:28 PM the Director of Plant Operations #7 stated the daily checklist for doors 1A and 1C were for both doors. The checklist documented 9 doors but there were 11 doors checked. The checklist documented 9 doors without issues. However, on [DATE] it should have been documented the exterior door to 1C was not in working order. There was no daily or weekly documentation done on exterior door checks. The wander alert device checklist did not include exterior doors. During an interview on [DATE] at 5:55 PM Secretary #12 stated they received a telephone call on [DATE] that Resident #17 was at the gas station across the street. They assisted with bringing the resident back to the facility. After the resident was returned to the facility, they went to the doors the resident had exited from. The interior door (1C) opened when pushed with no alarm, and the exterior door did the same. Both doors were supposed to alarm, and the interior door was supposed to be locked with a delayed egress unless a badge was used. During an interview on [DATE] at 2:09 PM the Administrator stated the facility no longer used pagers. Instead, the nurse call board system was used. They did not know the date the facility stopped using the pagers, but it was a very long time ago. The doors in the facility were being checked on the weekly door checklist. Both doors (interior and exterior) were included with Stairwell 1C. The daily checklist was only on the interior doors. It was the responsibility of the Director of Plant Operations to ensure all the doors were checked and report back to the Administrator. They should have noticed the current door check policy was not appropriate. 2) Resident #16 had diagnoses including dementia. The [DATE] Minimum Data Set assessment documented the resident had severely impaired cognition, did not wander or reject care, used a walker, was independent with walking 150 feet, and used a wander/elopement alarm daily. The [DATE] Elopement Evaluation documented the resident had a score of 5 (a score of 1 or more was considered at risk for elopement), a history of elopement or attempted leaving the facility without informing staff, verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door, wandered, wandering behavior was a pattern and wandering was goal-directed. The [DATE] comprehensive care plan documented the resident was at risk for elopement. Interventions included identify certain time of day wandering /elopement attempts occurred. The [DATE] at 4:35 PM Registered Nurse #35 progress note documented the resident was found on the 1 North Unit wandering at 4:20 PM. The resident stated they were looking for family who had just left the building. The resident was brought back to the 2 North Unit and was not noted to be exit seeking. A call was placed to the Director of Nursing and Unit Manager. A wander alert device was placed on the resident's left ankle. On [DATE] the comprehensive care plan was updated, and interventions included wander alert device #8 placed on left ankle. A [DATE] Elopement Evaluation completed by Assessment Nurse #9 documented the resident's elopement score was 4 (at risk for elopement). The [DATE] at 11:06 AM Registered Nurse Unit Manager #19 progress note documented they met with the interdisciplinary team, and it appeared the resident had some behaviors of packing their belongings and thought they were going to leave the building. The care plan was updated to include these behaviors and monitor them closely when exit seeking. The [DATE] at 8:25 AM Registered Nurse Unit Manager #19 progress note documented the resident's wander alert device was discontinued. Social work and secretaries were all updated. The [DATE] at 4:04 PM Registered Nurse Supervisor #17 progress note documented Receptionist #21 returned from the restroom in the lobby and looked outside the front doors and saw a resident sitting in a wheelchair with no staff or visitors in sight. They approached the resident and asked what they were doing, and the resident stated they were waiting for the bus. Receptionist #21 brought the resident back into the lobby and notified the supervisor. The [DATE] elopement investigation completed by Registered Nurse Supervisor #17 at 4:05 PM documented: -Receptionist #21 returned from the bathroom in the lobby and looked outside the front doors and saw a resident sitting in a wheelchair with no staff or visitors in sight. They approached the resident and asked what they were doing, and the resident stated they were waiting for the bus. Receptionist #21 brought the resident into lobby and notified the supervisor. -The resident had no injuries observed at the time of the incident, was ambulatory with assistance, orientated to person, they had confusion, recent changes in their medications, and impaired memory. Medical and family were notified of the event. -Receptionist #21's [DATE] at 4:05 PM written statement documented they were returning from the bathroom and looked outside and saw the resident seated in their wheelchair outside the front doors. They did not see anyone with the resident, so they went outside, and the resident stated they were waiting for the bus. They brought the resident

44838 Based on observation, record review, and interviews during the abbreviated survey (NY00354300), the facility failed to ensure correct installation, use, and maintenance of bed rails to ensure there was no gap between the bed rail and mattress wide enough to entrap a resident's head or body for 55 of 55 residents (Residents #1-#16 and #18-#56) reviewed. Specifically, Resident #1 had a contour mattress and a right side bed rail. The facility did not inspect and regularly check the mattress and bed rail for areas of possible entrapment. Additionally, the facility did not evaluate alternatives to bed rails, review the risks and benefits of bed rails with the resident or resident representative or obtain informed consent prior to the installation of bed rails for Resident #1 and all 54 residents with bed rails (Refer to F689). Subsequently, on [DATE], Resident #1was found with their body out of their bed with their head wedged between the bed rail and the mattress. The resident had no pulse or respirations and was pronounced deceased . This resulted in Immediate Jeopardy for Resident #1 and placed the remaining 54 residents with bed rails at risk for the likelihood for serious injury, serious impairment, serious harm, or death. Findings include: The facility policy, Side Rail Use, revised/reviewed [DATE], documented the facility would ensure correct installation, use, and maintenance of bed rails for resident safety when rail use was necessary to treat a resident's medical symptoms or assist with mobility and/or transfer. Entrapment was an event in which a resident was caught, trapped, or entangled in the spaces in or about the side rail, mattress, or hospital bed frame. Seven zones for potential bed entrapment were identified including Zone 3, between the side rail and the mattress. Risks to the resident related to rail use included but were not limited to: accident hazards/barrier to residents from safely getting out of bed; a resident could crawl over rails and fall from greater heights increasing the risk for serious injury, and entrapment.; when installing and using side rails, following the manufacturer recommendations/specifications and inspect regularly and checking the mattress and side rails for areas of possible entrapment, ensuring there was no gap wide enough to entrap a resident's head or body. References used included U.S. Food & Drug Administration (FDA) Bed Rail Safety, Recommendations for Health Care Providers about Bed Rails, Updated: [DATE]. Hospital Bed Safety Workgroup, and Clinical Guidance for the Assessment and Implementation of Bed Rails in Hospitals, Long Term Care Facilities, and Home Care Settings. [DATE]. The U.S. Food & Drug Administration (FDA) Bed Rail Safety, Recommendations for Health Care Providers about Bed Rails, updated: [DATE], documented to follow the recommendations in their guidance Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment dated [DATE]. Dimensional limits for entrapment Zones,d+[DATE] to reduce the risk for entrapment. Zone 3 was the space between the inside surface of the rail and the mattress compressed by the weight of a patient's head. The space should be small enough to prevent head entrapment when taking into account the mattress compressibility, any lateral shift of the mattress or rail, and degree of play from loosened rails. The recommendations were for a dimension of less than 4 ,d+[DATE] inches because the head is presumed to enter the space before the neck. The undated facility policy, Safe Environment, documented the facility would ensure regular inspection, testing (if applicable), and maintenance of emergency safety equipment, facility systems, and equipment would be completed in accordance with manufacturer's recommendations/specifications and all pertinent Federal, State, and municipality requirements. Examples included, but were not limited to, beds and bed rails. On [DATE], the facility provided a list of 54 residents in the facility who currently had bed rails on their beds. Resident #1 had diagnoses including Alzheimer's disease. The [DATE] Minimum Data Set Assessment documented the resident had severely impaired cognition, required partial to moderate assistance for rolling left to right and sitting on the side of the bed, supervision or touching assistance to stand and for chair/bed to chair transfer, and did not use bed rails. A [DATE] at 7:49 AM Registered Nurse #3 progress note documented they were called to the resident's room at approximately 5:45 AM. The resident was found beside the bed in a kneeling position, with their head caught between the bed rail and the mattress. The resident was moved back to the bed for assessment and was found to be without respirations or audible heart tones. A [DATE] facility incident report documented the resident was last observed at approximately 4:30 AM for incontinence care. At 5:45 AM, when Licensed Practical Nurse #4 entered the resident's room to administer medication, the resident was observed with their head and neck between the right side bed rail and mattress. After assessment by Registered Nurse #3, the resident was pronounced deceased . The Certificate of Death documented the resident expired at approximately 5:45 AM on [DATE] with immediate cause of death listed as probable positional asphyxiation. The certificate was signed by the coroner. During an interview on [DATE] at 9:33 AM, Facilities Supervisor #6 stated maintenance put mattresses and bed rails on beds. Work orders were placed by nursing for mattresses or bed rails. The different types of mattresses were regular, raised side mattresses, and some air mattresses. All facility staff were able to access work orders and prioritize according to importance. There were two bed sizes in the facility: regular width and bariatric. Bariatric beds were wider than regular beds. Mattresses were specific to bed size; proper sized mattresses were important to make sure residents did not fall out of bed. Bed safety checks were done annually and were inspected for all wheels, brakes, assist bars, headboard, and bed control operation. A visual inspection was done every other month. Bed rails used at the facility were referred to as assist rails and they were smaller and narrower than a regular bed rail. They were meant to be used for a resident to get in and out of bed. Bed rails should have a work order and should not be placed or removed without a work order from nursing or therapy. Maintenance checked brakes to make sure they were engaged, and the bed did not move, the bed controller for proper functioning, and the mattress for its current condition. Staff should be looking at mattresses when changing linen and when cleaning. They did not have a bed measuring tool or process for measuring entrapment risk zones. They had heard about guidelines for bed safety but did not have specific measurements to check for. The facility only had one brand of bed, and the assist rails were manufacturer specific to those beds. Their checklist did not include entrapment guidelines. Any gaps for residents to become entrapped put residents at risk for injury or worse. During an interview on [DATE] at 10:30 AM, Facilities Director #7 stated they oversaw maintenance for the whole campus for about the last year-and-a-half. They were not very familiar with guidelines for prevention of bed entrapment. Facility staff did the inspections, mattress changes were done by maintenance, and they were not sure if they inspected via the checklist at the time of any change. The facility used manufacturer specific mattresses and bed rails to try to ensure resident safety. Some bed rails had been removed following the incident on [DATE]. During observations on [DATE] between 1:00 PM and 3:00 PM, bed entrapment zones were measured as identified by the U.S. Food and Drug Administration's Hospital Bed Safety Workgroup Clinical Guidance for the Assessment and Implementation of Bed Rails in Hospitals, Long Term Care Facilities, and Home Care Settings using a bed system measurement tool. A total of 7 beds were sampled (Residents #1, #4, #5, #6, #7, #8 and #9). All 7 beds were out of compliance with Zone 3 entrapment guidelines (the space between the mattress and the side rail should be no greater than 4 and ,d+[DATE] inches). One of the 7 measured beds belonged to Resident #1. On [DATE] the facility provided their bed preventative maintenance inspection chart completed annually by maintenance. It included parts of a bed that were found worn or defective and should be replaced. There was no documented evidence the facility measured beds for entrapment risk. During an interview on [DATE] at 1:18 PM, the Administrator stated bed rail use was determined by an assessment, generally at the request of resident or family member. The Interdisciplinary Team then determined need, an assessment was completed by nursing using an assessment tool, and then discussion to make sure bed rails were appropriate and safe based on assessment criteria. It would be expected that an observation of the resident using bed rails would take place during the assessment. Maintenance installed bed rails at the request of nursing. They should be checking that the bed rail fit appropriately and was consistent with manufacturer's guidelines and U.S. Food and Drug Administration entrapment zones. Maintenance performed bed safety checks, making sure beds were safe and in good working order. They were not performing specific measurements regarding U.S. Food and Drug Administration entrapment guidelines. Risks associated with bed rail use included serious bodily injury and death. There had been no specific training in the past year regarding bed rail use. 10NYCRR 415.12(h)(1)(2) *************************************************************************************** Immediate Jeopardy was identified, and the Administrator was notified on [DATE] at 4:39 PM. Prior to survey exit the Administrator was notified on [DATE] at 3:55 PM that Immediate Jeopardy was lifted retroactively to [DATE] based on the following corrective actions taken: -Maintenance was trained on entrapment zones and how to measure per FDA guidelines. 100% completed on [DATE]. -An audit tool that contained all aspects of bed safety, compatibility of bed, mattress, and bed rails; mattress inspection, and entrapment zones was completed for all beds in the facility on [DATE]. -The updated bed rail policy and procedure was provided which included Maintenance will check the bed model and install a compatible bed rail. Once installed the bed will be checked prior to use for entrapment zones, and if any are determined to be non-compliant the device will be un-installed immediately and nursing will be informed. Maintenance will close out the work order ticket once completed and update nursing of completion. Staff education as of [DATE] was 98%. -A bed rail process and procedure audit tool was developed to monitor alternatives tried, bed rail assessment completed, Interdisciplinary Team review, care plan update, consent after provision of information, order in place, maintenance measured, monitoring resident safety, and physical restraint assessment. -Continued education provided to all direct care workers, housekeeping, maintenance, social work, therapy, and activities are reminded of bed safety, entrapment zones, bed placement and potential for creating entrapment zones. Mattresses should not move on the bed frame. Mattress stops located on the 4 corners of the bed frame. Staff are responsible for reporting any entrapment zone issues or concerns. All staff who are actively employed by the facility have been trained. -Education of staff that has not received training (due to illness, vacation, or leave of absence) will be completed before reporting to their workstations on their next schedule day.

Based on observation, record review, and interviews during abbreviated surveys (NY00354147 and NY00354300), it was determined the facility and governing body failed to ensure that residents received appropriate quality of care by allowing the following deficient practices to exist, placing residents at risk for serious injury, serious harm, serious impairment, or death: F 689 Accident Hazards and F 700 Bedrails. Specifically, the facility's governing body did not establish and implement policies regarding the management and operation of the facility. Subsequently, there were outdated and a lack of operational policies and equipment to ensure resident safety. Findings include: The facility policy Quality Assurance Performance Improvement, dated ,d+[DATE] defined governing body as individuals who were legally responsible for establishing and implementing policies regarding the management and operations of the facility. A quality deficiency was anything the facility considered to be in need of further investigation and correction or improvement. Examples included problems such as accidents. It was the responsibility of the Governing Body to maintain accountability and responsibility for the facility (Quality Assurance Performance Improvement) program, ensuring the ongoing Quality Assurance Performance Improvement program was defined, maintained, and addressed identified priorities. The Governing Body was also responsible for holding the facility responsible and accountable for collaborating with the governing body and ensuring that the ongoing Quality Assurance Performance Improvement program was sustained during transitions in leadership and staffing. Refer to Free of Accident Hazards/Supervision/Devices (F 689), Elopement: - Resident #17 did not have behaviors consistently monitored and documented prior to elopement on [DATE]. Subsequently, Resident #17 exited the building at 7:37 PM, crossed a 4 lane road to a gas station, and was returned to the facility at approximately 8:25 PM. - The facility policy/procedure and checklist for door tests were not updated timely. Subsequently, the exterior doors of the facility were not consistently monitored, and their working condition was not documented. - This resulted in Immediate Jeopardy for Resident #17 and all residents at risk for elopement with wandering behaviors. Refer to Free of Accident Hazards/Supervision/Devices (F 689), Bedrail Assessments: - Resident #1 had a contour mattress, a right bedrail, and the left side of the bed was against the wall. The facility failed to assess the resident for appropriate alternatives to bedrails or review the risks and benefits of bedrails with the resident representative and obtain informed consent with the resident representative. Subsequently, on [DATE], the resident was found with their body out of the bed, their head wedged between the bedrail and the mattress, and they were pronounced deceased . This resulted in Immediate Jeopardy for Resident #1 and all 54 residents with bedrails. Refer to Bedrails (F 700), Bedrail Maintenance: - Resident #1 had a contour mattress, a right bedrail, and the left side of the bed against the wall. The facility did not inspect and regularly check mattresses and bedrails for areas of possible entrapment per Food and Drug Administration guidelines. Subsequently, on [DATE], Resident #1 was found with their body out of the bed and their head wedged between the bedrail and the mattress. The resident had no pulse or respirations and was pronounced deceased . This resulted in Immediate Jeopardy for Resident #1 and all 54 residents with bedrails. During an interview on [DATE] at 2:09 PM, the Administrator stated they were the Chief Operations Officer for the organization and became the Acting Administrator on [DATE]. As Chief Operations Officer they monitored the facility operations as part of the corporate team. The facility reported monthly operational reviews that included clinical, financial, and overview of everything from nursing to dietary and admissions. The former Administrator reported up to the Chief Operations Officer on everything including plant operations. The senior leadership of the organization and clinical operations team were responsible for updating policies and procedures. The Administrator should have been overseeing the maintenance department and identifying the lack of bedrail measurements. They should have also noticed the door check policy was not appropriate given the equipment in the policy was no longer in the building. They stated they implemented a new door check policy on [DATE]. 10NYCRR 415.26(b)(3)(1)

Based on record review and interviews during the recertification survey conducted 8/19/2024-8/22/2024, the facility did not make prompt efforts to resolve resident grievances for 3 of 8 anonymous residents and for 5 additional grievances (Residents #38 [2 grievances], #47, #79, and #94) reviewed. Specifically, 3 residents from the Resident Council meeting stated their grievances were not always acted upon or resolved and they were not provided with a reason why. Additionally, there were five grievances that did not have documented resolution. Findings include: The facility policy Grievances, reviewed 8/2017, documented the facility would ensure prompt resolution of all grievances regarding the resident's rights. The Grievance Official was responsible for overseeing the grievance process through to its' conclusion and issuing written grievance decisions to the resident. Prompt efforts to resolve included the facility acknowledgement of the grievance and active work toward the resolution of the grievance. A written grievance decision was a document that included the intake, investigation and resolution process for each grievance received. When a group presented grievances or recommendations concerning policy or operational decisions affecting resident care and life in the facility, the facility must consider the views of the resident and/or group and be able to demonstrate facility response, rational for such response, and communicate the response to the resident and/or group. The facility policy. Resident Rights, reviewed 2/1/2024, documented residents had the right to voice grievances and have the facility respond to those grievances. During a Resident Council meeting on 08/20/2024 at 10:59 AM, three anonymous residents stated the facility does not always act upon grievances or recommendations. They were not always told why the facility did not follow through on a grievance or concern. One anonymous resident stated they had asked for gluten-free pasta, and they had not received a response. Three anonymous residents stated they brought up the garden in the courtyard was overgrown with weeds that blocked the view from some of the resident windows and made sitting out in the courtyard unenjoyable. The facility had not taken care of it, and the courtyard was still overgrown. The Resident Council meeting notes dated 8/12/2024, documented a resident had asked that the garbage cans be removed from under the American flag in the dining room. The facility response on the resident council minutes documented the garbage cans would be removed and signs would be put up not to place things in that area. During an observation on 8/21/2024 at 10:36 AM, the American flag in the first floor dining room had a trash can directly to the right of the flag with the bottom of the flag just about touching the top of the trash can. There were signs that documented Do not place items under the flag to the left of the flag and behind it. During an observation on 8/21/2024 at 10:38 AM, the courtyard garden along the right-side windows of the building on the first floor was overgrown with weeds, plants, and grass. The overgrowth blocked the views of 4 windows in resident rooms [ROOM NUMBERS]. Grievances from 8/2023 to 8/2024 documented the following: - An undated grievance form for Resident #94 documented the resident was missing a wheelchair that was personally bought and brought in by the resident's family. The form documented the facility had searched for the wheelchair and had not found it. There was a note on the grievance documenting if the family wished for the wheelchair to be replaced, a receipt needed to be brought in for replacement. There was no documented resolution or notification provided to the resident or family. - A grievance form dated 10/6/2023 for Resident #38 documented the resident was missing a left hearing aide. A search was completed by the facility, the hearing aid was not located, and a voicemail was left for the resident's responsible party. There was no documented resolution to the grievance or a date the grievance had been resolved. - A printed email from Resident #47's family member dated 12/4/2023 documented Resident #47 was missing dentures and a personal television remote control. There was no grievance form completed. The email had handwritten documentation Complete review and investigation completed. Unable to locate the dentures or emote. Email notification sent on 12/12. There was no documented resolution to the grievance. - A grievance form dated 12/10/2023 for Resident #79 documented the resident had received a curdled glass of milk with dinner. The action documented the Food Services Director was to call the resident's family regarding the issue. There was no documentation the Food Service called the family or of a resolution. - A grievance form dated 1/22/2024 for Resident #38 documented the resident's left hearing aid was stepped on and broken by a nurse. A call was placed to the resident's family and the facility would replace the hearing aid when the hearing aid company was located. There was no follow up or resolution documented on the grievance form or a date the grievance was resolved. During an interview on 8/22/2024 at 8:48 AM, the Social Services Director stated the process for grievances was the residents came to them with a grievance, and they documented it. They notified the appropriate staff and the resident or family member of the follow up or resolution if there was one. They do not know what the exact time frame to resolve a grievance was, but they tried to resolve grievances as soon as possible. If a resident had a missing item that was unable to be located, the facility usually replaced it. The facility had only started using paper forms as of 8/2023 when they switched to their new electronic medical record system. Previously, the grievances had been logged and completed in their old electronic medical record. Each grievance should have documented follow up and resolution. The Social Services Director reviewed the five grievances from binder without resolutions and stated they would not know by looking at the forms the grievances were resolved. Each one should have documented follow up and the date it was resolved. They were aware that residents had an issue with the courtyard garden being overgrown. They were unaware if anyone had followed up with the residents regarding a resolution to the overgrowth in the courtyard. They stated residents informed them they did not feel the concerns they brought up were being addressed. During an interview on 8/22/2024 at 10:44 AM, the Administrator stated the Social Services Director was the Grievance Officer. The facility asked the resident's to put grievances in writing and the Grievance Officer would follow up with the appropriate people for resolution. If the grievance was unable to be resolved, it came back to them to try to settle on a resolution. The resolution to the grievance should be documented on the grievance form because staff change and if anyone inquired about the status of the grievance, it would be documented if it was resolved or not resolved. They were aware of all five grievances that did not have a resolution documented and they should have as they were unable to tell if they were resolved. They were aware the residents were unhappy with the overgrown garden in the courtyard. They used to have a volunteer that weeded the garden but no longer did. It was also maintained by the activities department in the past, but it had been a crazy summer and had not been maintained. They were unaware residents felt their concerns and grievances were not being resolved. 10NYCRR 415.3(C)(1)(ii)

48675 Based on observation, record review, and interview during the recertification survey conducted 8/19/2024-8/22/2024, the facility did not develop and implement a comprehensive person-centered care plan to meet the resident's medical and nursing needs for 4 of 8 residents (Resident #3, #58, #74, and #93) reviewed. Specifically, Resident #93's comprehensive care plan did not include pain management and hospice services; Resident #47's comprehensive care plan did not include the use of antipsychotic medications; Resident #74's comprehensive care plan did not include self-medication administration or diabetes; and Resident #3's comprehensive care plan did not include ordered interventions for edema (swelling). Findings include: The undated facility policy, Resident-Centered Standards of Care and Exceptional Care Planning, documented the facility utilized standards of care and developed exceptional resident-centered care plans that were culturally competent and consistent with the resident's specific conditions, risks, needs, history, behaviors, preferences, and with current standards of practice to meet the resident's medical, nursing, mental, and psychosocial needs. The interdisciplinary team would periodically reassess the resident and review/update the resident's plan of care: when there was a change in condition, when the desired outcome was not met, when the resident was readmitted after a hospital stay, when the care plan was no longer consistent with the resident's wishes and treatment goals, when revisions were requested by the resident, and at a minimum after each comprehensive and quarterly review assessment. 1) Resident #93 had diagnoses including palliative care, bladder mass, and pain in the right and left hip. The 6/27/2024 Minimum Data Set assessment (resident assessment tool) documented the resident had severely impaired cognition, required partial/moderate assistance with most activities of daily living, was frequently in pain, received routine and as needed pain medication, and received hospice care (program that focuses on quality of life and comfort near the end of life). The 3/22/2024 physician order documented morphine sulfate (an opioid pain medication that treats moderate to severe pain) oral solution 0.25 milliliters every 2 hours as needed for severe pain and refer the resident to hospice services. The resident was admitted to hospice services on 3/25/2024 through a local hospital contract. The hospice plan of care included pain interventions and symptom management. Interventions included notify physician if reported pain was above the resident's tolerable level of 4 out of 10 (pain scale 1-10) and unrelieved by current treatment. The 4/24/2024 hospice progress note documented the hospice Social Worker and Registered Nurse Case Manager had a joint visit to see the resident due to two falls and increased frequency of morphine use. The resident complained of vaginal pain. Nursing progress notes dated 5/1/2024-8/17/2024 did not document collaboration or communication with hospice regarding the resident's condition. The 8/15/2024 Family Nurse Practitioner #22 progress note documented the resident was seen for increased pain, was given an extra dose of morphine for breakthrough pain, and they would increase the morphine to 10 milligrams four times a day and 10 milligrams every hour as needed. There was no documented evidence the Comprehensive Care Plan included a coordinated plan of care with the hospice provider to ensure the needs of the resident were addressed, including pain management. During an interview on 8/21/2024 at 2:26 PM, Certified Nurse Aide #10 stated they looked at the resident's care plan or care instructions (Kardex) to know how to properly care for them. They stated Resident #93's care instructions did not include their hospice plan or pain management. If staff was not familiar with Resident #93, they would not know what to monitor for. During an interview on 8/21/2024 at 2:38 PM, Licensed Practical Nurse #15 stated they were unsure of the care planning process, they did not initiate or update care plans, and the registered nurses were responsible for resident's care plans. They stated care plans were started upon admission and they were unsure how often they were reviewed. Care plans were resident specific, and it was important to keep them updated so staff would know how to properly care for the resident. If they were not accurate there was a risk the resident would not receive the care they needed. They stated Resident #93 was on hospice, in lots of pain, and was receiving pain medications frequently. Resident #93's care plan should have included their pain, pain medications, and hospice services so the staff would know what was going on with the resident and how to care for them. 2) Resident #47 had diagnoses including severe dementia with agitation, anxiety, and insomnia. The 6/21/2024 Minimum Data Set (a health assessment tool) documented the resident was rarely or never understood, had severely impaired cognitive skills for daily decision making, had no behavioral symptoms, was dependent for care, received an antipsychotic daily, and a gradual dose reduction was clinically contraindicated. The 9/19/2023 comprehensive Minimum Data Set assessment documented psychotropic drug use was triggered and care planned. A 1/9/2024 physician order documented risperidone (antipsychotic) 0.5 milligrams 1 tablet two times daily for dementing illnesses with associated behaviors. The 9/1/2023 Comprehensive Care Plan documented the resident had impaired cognitive function related to dementia without behavioral disturbance. The interventions included ask yes/no questions to determine the resident's needs, refer to the activities care plan, use task segmentation to support short-term memory, and reminisce with the resident using photos of family and friends. There was no documented evidence the resident had a care plan for use of an antipsychotic medication. During an interview on 8/22/2024 at 9:40 AM, the Registered Nurse Unit Manager #6 stated the care plans were an interdisciplinary team approach, but they did the care plans for the nursing problems and most medications. Antipsychotics should be included in the care plan. Both social work and nursing were responsible for the antipsychotic medication care plans. As the Unit Manager they would try to make sure it was in the care plan. Registered Nurse Unit Manager #5 stated the resident did not have a care plan for their antipsychotic medication and they should. It was important to have the medication care planned for so the resident could be monitored for any adverse reactions, like tardive dyskinesia (involuntary movements, a possible side effect of antipsychotics), how the resident tolerated the medication, and for gradual dose reduction. 3) Resident #74 had diagnoses of acute pancreatitis (inflammation of the pancreas), myasthenia gravis (a disease causing weakness in voluntary muscles), and diabetes. The 8/2/2024 Minimum Data Set assessment (a health assessment tool) documented the resident had intact cognition, required minimal assistance with activities of daily living, and received insulin every day. Physician's orders documented: - on 4/27/2024 Creon delayed release particles 36000-114000 unit (enzymes to aid in digestion) 1 capsule by mouth before meals for digestive support, unsupervised self-administration. Resident kept medication in blister pack in locked drawer and was able to self-administer medication. Pyridostigmine bromide oral tablet 60 milligrams (a medication used to treat myasthenia gravis) give 1 tablet by mouth before meals for myasthenia gravis, unsupervised self-administration. Resident keeps medication in blister pack in locked drawer and was able to self-administer medication. -6/21/2024 Novolog (insulin aspart) inject per sliding scale before meals and at bedtime for diabetes mellitus. There was no documented evidence the Comprehensive Care Plan included the diagnosis of diabetes or the resident's ability to self-administer medication with associated goals and interventions. During an interview on 8/22/2024 at 9:45 AM, Registered Nurse Unit Manager #2 stated staff looked at resident care plans and care instructions (Kardex) to know how to properly provide care. Care plans were resident specific and communicated the resident's safety needs, preferences, diagnoses, risks, and medications that needed monitoring. The care plan information generated onto the care instructions, so staff were aware of the resident needs or changes in their care. Registered Nurse Unit Managers and other disciplines were responsible for developing and updating care plans. Resident #93 should have had a pain care plan in place and a hospice care plan should have been initiated when Resident #93 was started on Hospice services. Resident #74 should have a care plan in place for diabetes mellitus, and self-administration of medications. During an interview on 8/22/2024 at 10:49 AM, the Assistant Director of Nursing stated care plans were used to provide proper care based on each resident's preferences, safety needs, diagnoses, and medications. Diabetes, pain, anticoagulants, antipsychotics, should all have a care plan to identify risks and monitor effects of interventions. Resident #93 should have a pain care plan so staff was aware, and it would have included non-pharmacologic (methods that did not include medications) interventions that could have been effective. Resident #93 should also have a hospice care plan initiated when they started services that included interventions to maintain their comfort and quality of life. Resident #74 should have a care plan for diabetes to monitor for signs of hyper/hypoglycemia (high and low blood sugar level). There should also be a self-medication administration care plan for Resident #74 addressing safe storage of medications, and monitoring of compliance by nursing. 10NYCRR 415.11(c)(1)

48895 Based on observation and interview during the recertification and abbreviated (NY0032236) surveys conducted 8/19/2024-8/22/2024, the facility did not ensure each resident received food and drink that was palatable, flavorful, and at an appetizing temperature for 2 or 2 meal test tray (the 8/20/2024 and 8/21/2024 lunch meals) reviewed; for 8 of 8 anonymous residents present at the Resident Council meeting, and for 6 additional residents (Residents #3, #35, #36, #44, #63, and #74) interviewed during initial screening. Specifically, the 8/20/2024 and 8/21/2024 lunch meals were not served at palatable and appetizing temperatures and were not flavorful. Additionally, 8 anonymous residents at the Resident Council meeting and Residents #3, #35, #36, #44, #63, and #74 stated the food was cold and unappetizing. Findings include: The undated facility policy, Campus Policy & Procedure: Temperatures, documented the service temperatures for a hot entree was 135-170 degrees Fahrenheit, cold beverages were 40-50 degrees Fahrenheit, and vegetables were 135-170 degrees Fahrenheit. During initial screening interviews on 8/19/2024, the following residents expressed concerns about the food served at the facility: - at 10:18 AM, Resident #74 stated hot food was not always hot enough. - at 10:44 AM, Resident #44 stated the hot food was not hot enough. The plates were heated, and the facility sometimes served sandwiches on them. - at 10:59 AM, Resident #3 stated the hot food was not hot. - at 11:05 AM, Resident #35 stated they did not like the food, it looked unappetizing and tasted poorly. - at 11:14 AM, Resident #36 stated hot food was not hot enough, and the scrambled eggs were cold. - at 11:36 AM, Resident #63 stated the food did not always taste good and was cold. During a Resident Council group interview on 8/20/2024 at 10:59 AM, 8 anonymous residents stated the food was cold and unappetizing. During an observation on 8/20/2024 at 12:09 PM, Resident #35 received their lunch meal tray that included meatloaf, mashed potatoes, and a cookie bar for dessert. The meatloaf was minced meat formed into a perfect half-sphere, the 2 scoops of potatoes were also half-spheres pushed together, and all items on the plate were covered with a thickened, gelatinous gravy. Resident #35 attempted to cut their cookie bar with their utensils and was unable to break the cookie into smaller pieces. The resident stated it was so hard they could not eat it. When they picked it up with their fingers, they stated it was too hard to chew. During a lunch meal observation on 8/20/2024 at 12:48 PM, Resident #103 was served their lunch meal tray. Their lunch tray was tested , and a replacement tray was provided. In the presence of Certified Nurse Aide #10 the spinach temperature was measured at 130 degrees Fahrenheit, the apple juice was 57.7 degrees Fahrenheit, the lactose free milk was 57.7 degrees Fahrenheit, and the water was 57.2 degrees Fahrenheit. The mashed potatoes and chopped spinach lacked flavor. During an interview on 8/20/2024 at 12:55 PM, Certified Nurse Aide #10 stated hot food should be served around 160 degrees Fahrenheit and cold food should be colder than 57 degrees Fahrenheit. It was important to serve food at the proper temperatures so that residents did not get sick. Residents liked hot food to taste hot, and cold food and drinks to be cold. During a lunch meal observation on 8/21/2024 at 11:57 PM, Resident #35 was served their lunch meal tray. The tray was tested , and a replacement tray was ordered for the resident. Certified Nurse Aide #11 was present for the temperature readings of the lunch tray. The hot chicken sandwich temperature was measured at 127 degrees Fahrenheit, and the gelatin was 57.2 degrees Fahrenheit. The bun for the chicken sandwich had hard edges on the bottom, and the meat was minced. Certified Nurse Aide #11 stated when they heated and served food to the residents it had to be hotter than 140 degrees Fahrenheit. During an interview on 8/22/2024 at 9:02 AM, the Director of Social Work stated Resident Council members had voiced concerns about the food. The Food Service Director came to the resident council meetings. The Director of Social Work stated they thought there were dietary concerns that were not addressed. During an interview on 8/22/2024 at 10:00 AM, the Dining Service Director stated they did test trays once a month. The test tray was completed to check for timeliness, temperature, accuracy, and palatability. They took the last tray from the cart; temperatures were taken, and the presentation of the tray was noted. They had received complaints about food and food service. They stated that food palatability was subjective. Food should be appealing to the eye, and enjoyable to eat. Food was expected to be serviced at appropriate temperatures. Service temperatures for hot food was greater than 135 degrees Fahrenheit and cold food was between 40 and 50 degrees Fahrenheit. Temperatures between 57 and 58 degrees Fahrenheit for cold beverages and 57.2 degrees Fahrenheit for gelatin were too high for service. The hot spinach temperature measured 130 degrees Fahrenheit and was borderline low. The chicken sandwich measured 127 degrees Fahrenheit and was low, but the holding temperature for the chicken was good when it left the kitchen, and it was placed on a bun. 10NYCRR 415.14(d)(1)(2)

Based on observation, record review, and interview during the recertification survey conducted 8/19/2024-8/22/2024, the facility did not ensure food was stored and prepared in accordance with professional standards for food service safety in the main kitchen. Specifically, in the main kitchen potentially hazardous foods were not cooled properly, there were several unclean areas, and the food storage areas contained unprotected food products. Findings include: The 3/1/2004 facility policy, Food Preparation and Storage, documented potentially hazardous foods requiring refrigeration must be cooled by an adequate method, so that every part of the product was reduced from 120 degrees Fahrenheit to 70 degrees Fahrenheit within 2 hours, and 45 degrees Fahrenheit or below within 4 additional hours. Foods particularly important to meet the requirements included gravies. Gravies should be stirred while the container was in an ice water bath at a depth of equal to or greater than the food depth. The 6/10/2024 facility policy, Food Service Sanitation, documented the facility would maintain the food service area in a clean and sanitary manner. All kitchen and kitchen areas were to be kept clean and free of litter. Kitchen surfaces not in contact with food would be cleaned on a regular schedule and frequently enough to prevent accumulation of grime. The Food Service Manager was responsible for scheduling the staff for regular cleaning of the kitchen. Food service staff were trained to maintain cleanliness throughout their work areas during all tasks, and clean after each task before proceeding to their next task. The facility document, HACCP (Hazardous Analysis Critical Control Point) Cooling Log, did not document any food products cooled on 8/20/2024. The logs provided did not document any stock, sauces, rice, or gravy, only turkey, beef, pork, and chicken. The log provided columns for tracking the cooling time from the start time and temperatures noted initially, after 2 hours, and the final cooled temperature after 6 hours. These time frames did not allow for any corrective actions if an item did not meet the cooling requirements that were listed at the top of the tracking log sheet as: cool from 135 degrees Fahrenheit to 70 degrees Fahrenheit in 2 hours, and cool from 70 degrees Fahrenheit to 41 degrees Fahrenheit in the next 4 hours. 1. Improper Cooling of Potentially Hazardous Foods During an observation on 8/20/2024 at 11:24 AM, the three-door cooler beside the cookline contained a 6-inch quarter hotel pan covered with foil labeled, brown gravy 8/20, that was measured at 126 degrees Fahrenheit. During an observation on 8/20/2024 at 12:08 PM, the brown gravy temperature was measured between 124 and 128 degrees Fahrenheit by [NAME] #21 and confirmed by the surveyor. During an interview on 8/20/2024 at 12:11 PM, the Dining Service Director stated the gravy would have been cooked by the morning cook who would have placed that in the cooler before lunch service. The proper cooling procedure was to get the food temperature down to 70 degrees Fahrenheit within 2 hours, and then another 2 hours to get the food temperature down to 40 degrees Fahrenheit. The kitchen staff should have been trained on that procedure. If the temperature had not changed in the cooler over the past 40 minutes, it would not meet the cooling requirements. They stated it should have been documented on the cooling log that was last completed on 8/13 by [NAME] #21 for a pork loin. The initial temperature was 171 degrees Fahrenheit, after 2 hours was 88 degrees Fahrenheit, and the final after 6 hours was 40 degrees Fahrenheit. The Dining Service Director stated they could not be certain the pork was cooled properly because their log did not provide enough information due to the lack of monitored temperatures. During an observation and interview on 8/20/2024 at 12:50 PM, the brown gravy in the walk-in freezer measured 100 degrees Fahrenheit. The Dining Service Director stated the gravy still did not meet the cooling requirements and would be voluntarily discarded. 2. Unclean Food Preparation and Storage Areas and Unprotected Foods The following observations were made in the kitchen and food storage areas on 8/19/2024: - at 9:29 AM, there was food debris, grease, and grime under and behind the cookline equipment. - at 9:31 AM, a hood filter was out of place. - at 9:35 AM, the walk-in cooler had debris on the floor under the food storage racks, and mold under the shelving and along the walls. The floor was very wet, and the ceiling was dripping condensation throughout the cooler. A rack of desserts (cake with whipped topping) was left uncovered in the middle of the cooler. - at 9:40 AM, the walk-in freezer had debris on the floor under the food storage racks. - at 9:41 AM, the dry food storage room had debris on the floor under the storage racks with cobwebs in the corner of the room. - at 1:46 PM, the old/unused kitchen walk-in cooler had two cases of shell eggs and some individual canned beverages. The shelving had a white moldy substance on it, and the floors were unclean. The following kitchen and food storage areas were observed on 8/20/2024: - at 11:12 AM, the old/unused kitchen walk-in cooler had unclean floors, and shelving with mold and food debris. At that time the cooler contained two cases of shell eggs, one case of beef top rounds, and two cases of raw chicken. The walk-in freezer had excessive ice building up in the doorway, on some cases of food product, the compressor fan, and the floors. - at 11:22 AM, the main kitchen floor was soiled under the cookline and preparation tables with dried on food debris, grease, and grime. - at 11:28 AM, 2 flies landed on multiple uncovered cake desserts, located next to the tray line. - at 11:29 AM, the ice cream cooler (double door upright cooler) contained dried on food spills and debris. During an interview on 8/20/2024 at 12:16 PM, the Dining Service Director stated that the old kitchen walk-in cooler and freezer were used as a back-up. They rotated stock and checked the temperatures daily but did not clean those as often, probably about once a month. The main kitchen coolers were cleaned at least once a week. They stated that some of the cleaning was documented. The facility's most recent Cleaning List was dated 6/2 to 6/15 and documented the walk-in cooler was to have the shelving removed, racks, walls, and floors cleaned, and was not documented as completed. The ECM kitchen (old unused kitchen) was documented as having the walk-in cooler and freezer organized, swept, and mopped on 6/2/2024. The wall behind the cook area was cleaned on 6/10/2024, but sweep under all cooks equipment was not documented as completed. During an observation and interview on 8/21/2024 at 12:19 PM, the Dining Service Director observed and verified the old kitchen coolers were not clean. They stated that all kitchen preparation and storage areas should be kept clean for the health and safety of the residents. 10NYCRR 415.14(h)

Based on observation, record review, and interview during the recertification survey conducted 8/19/2024-8/22/2024, the facility did not ensure a resident's ability to safely self-administer medications was clinically appropriate for 1 of 1 resident (Resident #74) reviewed. Specifically, Resident #74 was observed with medications stored in an unlocked drawer of their dresser, and there was no documented evidence the interdisciplinary team had assessed the resident's ability to safely self-administer medication. Findings include: The facility policy, Medication Self-Administration, dated 5/2005 documented a resident who wished to self-administer medications, was to be determined to be capable of safely doing so by the interdisciplinary team, arrange for storage of medications in locked drawer or box in the resident's room, and observe self-administration until compliance was assured. Resident #74 had diagnoses of acute pancreatitis (inflammation of the pancreas), myasthenia gravis (a disease causing weakness in voluntary muscles), and diabetes. The 8/2/2024 Minimum Data Set assessment (a health assessment tool) documented the resident had intact cognition, required minimal assistance with activities of daily living, and received insulin 7 of 7 days. Physician's orders documented: -On 4/27/2024 Creon (enzymes to aid in digestion) delayed release particles 36000-114000 unit 1 capsule by mouth before meals for digestive support, unsupervised self-administration. The resident was to keep medication in blister pack in locked drawer and was able to self-administer medication. -On 4/27/2024 pyridostigmine bromide (used to treat myasthenia gravis) oral tablet 60 milligrams, give 1 tablet by mouth before meals for myasthenia gravis, unsupervised self-administration. The resident was to keep medication in blister pack in locked drawer and was able to self-administer medication. The August 2024 Medication Administration Record documented Creon delayed release particles 36000-114000 unit 1 capsule by mouth before meals for digestive support, unsupervised self-administration. Resident keeps medication in blister pack in locked drawer and was able to self-administer medication. Pyridostigmine bromide oral tablet 60 milligrams give 1 tablet by mouth before meals for myasthenia gravis, unsupervised self-administration. Resident keeps medication in blister pack in locked drawer and was able to self-administer medication. Both medications were documented as self-administered unsupervised daily at 7:00 AM, 11:30 AM and 4:30 PM from 8/1/2024-8/19/2024. The Comprehensive Care Plan did not include self-administration of medications and interventions. There was no documented evidence of a resident assessment for medication self-administration. During an observation on 8/19/2024 at 12:25 PM, Resident #74 had a small medicine cup containing a white pill, and a capsule with a blue end. They stated they would self-administer these medications. During a medication administration observation and interview on 8/20/2024 at 12:06 PM, Licensed Practical Nurse #1 provided the glucose meter and resident's insulin pen to the resident. They stated the resident was being provided oversight and teaching for self-administration of insulin. They stated the resident also self-administered their Creon and pyridostigmine. They signed in the medication administration record that those medications were taken but did not have to count the pills or directly observe the resident taking them. They were not sure where the resident kept the pills, but they should be kept in a locked space. During a lunch observation and interview on 8/20/2024 at 12:26 PM, the resident had pills in a medication cup at the dining room table. They stated the medications were Creon and pyridostigmine bromide. They kept them in their top dresser drawer which did not lock. They stated they did not have a key for any drawers. The nurse did not check on the medication, but they let the nurse know when they needed more ordered. They received permission to self-administer medications. They stated other residents did not wander into their room. During an interview on 8/20/2024 at 1:12 PM, Registered Nurse Unit Manager #2 stated residents were assessed for safe self-administration of medications. Resident #74 did self-administer Creon and pyridostigmine, and they were not sure if an assessment had been completed. The medications were supposed to be kept in a locked drawer, so they were not accessible to other residents. They observed the resident's unlocked top dresser drawer which contained 2 full blister packs and one partial blister pack of the pyridostigmine (81 total pills), and 1 full blister pack and 1 partial blister pack of the Creon (57 total pills). Registered Nurse Unit Manager #2 stated the medications were not counted by nursing, and the resident should have been provided one blister pack at a time. When pharmacy delivered the medication, all the blister packs must have been given to the resident. During an interview on 8/22/2024 at 10:49 AM, the Assistant Director of Nursing stated that residents should have an assessment for safe self-medication administration, and a care plan that documented a resident specific plan. Medications should be kept locked so they could only be accessed by the resident and should be checked by nursing to ensure compliance. 10NYCRR 415.3(e)(1)(vi)

Based on observation, interview, and record review during the recertification survey conducted 8/19/2024-8/22/2024, the facility did not ensure the right to reside and receive services with reasonable accommodation of resident needs and preferences for 1 of 1 resident (Resident #71) reviewed. Specifically, Resident #71's call bell was not in reach as care planned. Findings included: The facility policy, Call System, dated 1/7/2016 documented residents in their rooms, toilet, and bathing areas should have a means of directly contacting caregivers and should be responded to in a timely manner. Upon admission, attempt to orient the resident to the purpose for and use of the call system. Ensure that the resident could use the call system device, making adaptations for limited hand dexterity or other physical limitations to the extent reasonable. Ensure the call system device was in reach of the resident if the resident was capable of using it. Resident # 71 had diagnoses including Alzheimer's disease and dysphagia (difficulty swallowing). The 7/14/2024 Minimum Data Set assessment (a health status assessment tool) documented the resident was usually able to make themself understood and understood others, had severely impaired cognition, was independent with bed mobility, transfers, and ambulation, and required moderate to maximal assistance with personal hygiene and dressing. The Comprehensive Care Plan initiated 8/1/2023 documented the resident was at high risk for falls related to gait/balance problems. Interventions included anticipate and meet resident's needs, and to be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. The resident needed prompt response to all requests for assistance. The following observations were made: - on 8/19/2024 at 9:54 AM, the resident was in bed, their call bell was hooked to itself at the wall out of the resident's reach. - on 8/20/2024 at 9:09 AM, the resident was in bed, their call bell was under a chair out of the resident's reach. - on 8/20/2024 at 1:10 PM, the resident was in bed, their call bell was on the floor under a chair out of the resident's reach. During an interview on 8/20/2024 at 1:55 PM, Certified Nurse Aide #18 stated residents should have their call bells in reach. They stated the call bell was currently under the chair at the resident's bedside and was not in the resident's reach. Certified Nurse Aide #18 thought the resident could use the call bell and it was important to keep the call bell in reach so the resident could communicate if they needed something. During an interview on 8/20/2024 at 2:34 PM, Registered Nurse Unit Manager #2 stated call bells should always be in resident's reach. It was important so a resident could call for assistance or if they needed something. They stated it should be care planned if a resident needed an alternative call device or was unable to use a call bell. They thought Resident #71 could use the call bell but was not sure if they would. During an interview on 8/22/2024 at 10:18 AM, Licensed Practical Nurse #1 stated resident call bells should be in reach, so residents were able to communicate needs. Keeping them in reach could help prevent falls or accidents. If a resident was unable to use a call bell, an alternative should be provided, and their care plan should be updated. Resident # 71 may not cognitively be able to use the call bell. If they could not use a call bell, it should have been in the care plan. During an interview on 8/22/2024 at 10:49 AM, the Assistant Director of Nursing stated resident call bells were used to communicate a resident need or an emergency. If a care plan stated to keep the call bell in reach, it should be kept in reach. If a resident was unable to use a call bell, other alternatives should have been put in place. They were not sure if Resident #71 was able to use their call bell. 10NYCRR 415.5(e)(1)

Based on observation, record review, and interview during the recertification and abbreviated (NY00322036) surveys conducted 8/19/2024-8/22/2024, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for 2 of 3 residents (Residents #6 and #71) reviewed. Specifically, Residents #6 and #71 were not assisted with toileting as planned. Findings include: The facility policy, Activities of Daily Living- Functional Impairment, dated 5/2019 documented residents would maintain dignity and self-esteem related to activities of daily living self-performance. Nursing provided the resident activity of daily living support at the level required, as specified in the electronic health record plan of care. 1) Resident #6 had diagnoses including dementia and history of urinary tract infections. The 6/12/2024 Minimum Data Set assessment (a health assessment tool) documented the resident had severe cognitive impairment, did not reject care, was dependent on staff for transfers, bed mobility and toileting, and was always incontinent of bladder and bowel. The comprehensive care plan initiated 8/15/2023 documented the resident had bladder and bowel incontinence related to dementia. Interventions included to check and change the resident every 2 hours, monitor for signs of a urinary tract infection, monitor skin for redness, breakdown, or irritation, and offer the bedpan every 4 hours (per urology recommendations). The resident had an activity of daily living self-care performance deficit related to limited mobility. Interventions included to check and change every 2 hours, and the resident required total staff assistance for bed mobility and toileting care. The resident care information (Kardex) documented to check the resident every 2 hours and assist with toileting care as needed and to provide total assistance with toileting care. The resident care task form for August 2024 documented on 8/20/2024 the resident was checked and changed at 4:18 AM, 9:41 AM, and 4:00 PM. During a continuous observation on 8/20/2024 at 9:33 AM Resident #6 was assisted in their wheelchair to the common area. The resident remained in the common area until 12:15 PM when they were assisted to the dining room for lunch. At 1:55 PM the resident was assisted to their room for care. Certified Nurse Aides # 18 and 19 entered the resident's room to provide care. The resident was transferred to their bed using a mechanical lift. The resident's brief was wet. The resident stated they were unsure how long their brief had been wet. The resident was not checked or provided incontinence care from 9:33 AM to 1:55 PM (approximately 4 1/2 hours). During an interview on 8/20/2024 at 2:10 PM, Certified Nurse Aide #19 stated Resident #6 was not on their assignment today. They were asked to assist with care after lunch, and that was the first care they had given the resident that shift. Residents should be checked and changed every 2-4 hours depending on the resident. Being in a wet brief was uncomfortable for the resident, and not good for their skin. During an interview on 8/20/2024 at 2:15 PM, Certified Nurse Side #18 stated they provided morning care for Resident #6 and brought them to the family room about 9:30 AM. They had not provided any care to the resident since the morning care. The resident was supposed to be checked and changed (if needed) every 2 hours. It was important to check and change frequently due to risk for urinary tract infections or skin breakdown. They were not sure why they had not checked the resident prior to lunch. 2) Resident # 71 had diagnoses of Alzheimer's disease and Crohn's disease (chronic inflammation of the bowel that can cause diarrhea). The 7/14/2024 Minimum Data Set assessment documented the resident was usually able to make self understood and to understand others, had severely impaired cognition, rejected care 1 to 3 days, was dependent on staff for toileting hygiene, required moderate to maximal assistance with personal hygiene and dressing, was at risk for developing pressure ulcers, and was always incontinent of bladder and bowel. The comprehensive care plan initiated 8/1/2023 documented the resident had an activity of daily living self-care performance deficit. Interventions included total assistance of one for toileting care and encourage the resident to use the call bell for assistance. The comprehensive care plan initiated 8/6/2023 documented the resident had urinary and bowel incontinence. Interventions included check and change the resident every 2 hours. During a continuous observation on 8/20/2024 at 9:09 AM the resident was in a low bed with a hospital gown on and their call bell was under a chair at their bedside. At 1:10 PM they remained in bed in a hospital gown with lunch on the overbed table with the drinks covered, and their call bell on floor under chair at bedside. At 1:38 PM they remained in bed, with no call bell in reach. They were awake with no staff interaction observed during the meal and a urine odor was noticeable in the room. The resident was not toileted from 9:09 AM-1:38 PM. The resident care task form for August 2024 documented on 8/20/2024 the resident was checked and changed at 4:12 AM, 9:38 AM, and 2:39 PM. During an interview on 8/20/2024 at 2:15 PM, Certified Nurse Aide #18 stated Resident #71 was supposed to be checked and changed every 2 hours. The resident was resistive, very combative, refused to get out of bed, and refused care. They stated they did not report the refusal of care to anyone and was not sure if they were supposed to report refusals to the nurse. They did not ask anybody else to approach the resident to try to provide care or get up assistance. The resident had received no care on the day shift. The lack of care could increase the risk for skin breakdown and urinary tract infection. During an interview on 8/20/2024 at 2:27 PM, Certified Nurse Aide #20 stated Residents # 6 and #71 were not on their assignment today and they had not provided care to either resident. If a resident was combative, they should be reapproached or ask another aide to approach. They had not been asked to assist with any resistive residents today. Residents not receiving timely care were at risk for skin breakdown and further discomfort. Care refusals should be reported to the nurse. During an interview on 8/20/2024 at 2:34 PM, Registered Nurse Unit Manager #2 stated residents should be checked for incontinence every 2 hours and changed if needed. If they were left without care they were at risk for increased urinary tract infections and skin breakdown. Poor hygiene could negatively affect the resident's dignity. Residents' refusal of care should be reported to the nurse. Staff should reapproach and sometimes another aide could try. They had not been notified of Resident #71's refusal of care. During an interview on 8/22/2024 at 10:18 AM, Licensed Practical Nurse #1 stated every refusal of attempted care should be communicated to the nurse so the nurse could attempt and document. All residents should be checked or offered toileting every 2 hours. If care was refused, it must be attempted again, and a different staff member should try. Checking and changing the resident should be done at least every 2 hours, to prevent skin breakdown and promote comfort. They had not been notified of Resident #71's refusal of care on 8/20/2024. During an interview on 8/22/24 at 10:49 AM, the Assistant Director of Nursing stated residents should be checked and changed every 2 hours to help maintain skin integrity, decrease risk for urinary tract infections, and promote comfort. If a resident refused care, staff should notify the nurse. They should reapproach the resident or another staff member should try. 10NYCRR 415.12 (a)(3)

Based on observations, record review, and interview during the recertification survey conducted 8/19/2024-8/22/2024, the facility did not ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choice for 1 of 1 resident (Resident #3) reviewed. Specifically, Resident #3 did not have their elastic compression bandage (ACE wrap) applied as ordered. Findings include: The facility policy, Assistance with Compression Stockings, Wraps, and Other Compression Devices, dated 3/29/2016 documented aid with donning and doffing (applying and removing) compression stockings, wraps, and other compression devices would be provided to those residents who were unable to complete the activity independently. Compression wraps were specialized wraps used to improve blood flow in the legs by applying gentle pressure. Resident #3 had diagnoses including lymphedema (tissue swelling due to ineffective drainage by the lymphatic system), and localized edema (extra fluid in the tissues). The 7/13/2024 Minimum Data Set assessment documented the resident had intact cognition, did not reject care, and was dependent for lower body dressing. The 8/10/2023 physician order documented apply ACE wraps every day, on in the morning, off at bedtime every day and evening shift, with a start date of 9/1/2023. The comprehensive care plan initiated 9/1/2023 documented the resident had a self-care performance deficit and required extensive assistance of staff for dressing. The care plan did not include the use of ACE wraps. The 8/19/2024 Physician #7 progress note documented the resident's bilateral lower extremity edema was chronic and had not worsened. The left was greater than the right with some lymphedema and the plan was to continue Bumex (diuretic, water pill) and ACE elastic compression wraps. The resident was observed at the following times: - on 8/19/2024 at 11:05 AM their ankles were swollen, and they were not wearing ACE wraps. The ACE wraps were on the dresser and the resident stated staff did not always apply them. - on 8/20/2024 at 9:23 AM sitting up in their wheelchair. They had bilateral lower extremity edema bilaterally and they were not wearing ACE wraps. The ACE wraps were on the dresser. - on 8/20/2024 at 1:07 PM they were not wearing ACE wraps on their lower legs. The resident stated they were not put on by staff. The 8/2024 Treatment Administration Record documented apply ACE wraps (elastic compression wraps) daily, on in the morning, off at hour of sleep daily. with a start date of 9/1/2023. The ACE wraps were documented as applied and removed as ordered 8/1/2024-8/20/2024. Licensed Practical Nurse #1 signed the Treatment Administration Record the ACE wraps were applied during the day shift on 8/19/2024 and 8/20/2024. During an interview on 8/22/2024 at 9:45 AM, Registered Nurse Unit Manager #2 stated resident care information was in the care plan and the computer. ACE wraps were applied by nursing. If ACE wraps were signed for, they should have been on. Resident #3 should wear ACE wraps every day for lower extremity edema as it helped to promote venous return. Excess edema could increase their risk for skin issues and improper clotting. During an interview on 8/22/2024 at 10:18 AM, Licensed Practical Nurse #1 stated ACE wraps were applied by the nurses, and if it was signed for in the Treatment Administration Record, they were applied. Resident refusals should be documented in the Treatment Administration Record or progress notes. Resident #3 had an order for ACE wraps due to edema and needed to be worn to help reduce the edema. They were not sure if they had applied the ACE wraps on 8/19/2024 or 8/20/2024. They stated if they signed for them, they should have made sure the wraps were on. 10NYCRR 415.12

Based on observation, record review, and interview during the recertification survey conducted 8/19/2024-8/22/2024, the facility did not ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for 2 of 2 residents (Resident #31 and #58) reviewed. Specifically, Resident #31 did not have a pillow between their left arm and body for pressure relief as care planned, and Resident #58 did not have pressure relief for their heels as planned. Findings include: The undated facility policy, Pressure Ulcer Prevention, documented the interdisciplinary team was to plan appropriate interventions to remove or modify risk factors that were modifiable and to monitor the impact of interventions and modify as appropriate. Staff was to use appropriate devices to offload pressure from heels that are at high risk. If a resident refused recommended care and treatment, the interdisciplinary team was to evaluate the reason for the refusal, identify potential alternatives, and implement alternatives as the resident allows. The undated facility policy, Resident-centered Standards of Care and Exceptional Care Planning, documented the facility would develop exceptional resident-centered care plans that were consistent with the resident's specific conditions, risks, needs, history, behaviors, preferences, and with current standards of practice to meet the resident's medical, nursing, mental, and psychosocial needs. It was the responsibility of the interdisciplinary team to implement and communicate the resident's plan of care. 1) Resident #31 had diagnoses including a Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer of the left elbow and Alzheimer's disease. The 6/21/2024 Minimum Data Set (an assessment tool) documented the resident had severely impaired decision making ability, was dependent for all activities of daily living, had one Stage 4 pressure ulcer not present upon admission, had a pressure reducing device for their chair and bed, received pressure ulcer care, nutrition or hydration interventions, and applications of ointments/medications. The 7/19/2024 revised care plan documented the resident had a Stage 4 pressure ulcer to the left elbow. Interventions included a towel or pillow must be between the resident's left elbow and their body at all times. Evaluate the ulcer characteristics, presence of drainage, obtain cultures, measure the ulcer at regular intervals, monitor for signs of infection, provide wound care per the treatment order, and notify the provider if there were no signs of improvement with the treatment regimen. The resident care card (care instructions) documented a towel or pillow must be between the resident's left elbow and their body at all times. The 8/14/2024 Wound Evaluation completed by Registered Nurse Unit Manager #6 documented the resident had a Stage 4 pressure ulcer on the left elbow, was in-house acquired, and was stable. Treatments included dressings, cushion, foam mattress, incontinence management, moisture barrier, nutritional supplementation, and repositioning devices. The following observations were made of Resident #31: - On 8/19/2024 at 10:30 AM, the resident's left arm was slightly behind the resident's body in their padded wheelchair. The arm was slightly obscured by a blanket, the left shoulder was rotated slightly forward and there was no pillow or towel. between the left elbow and the body. - On 8/21/2024 at 9:26 AM there was a dressing on the left elbow. There was no pillow or towel between the resident's body and elbow. The resident's left elbow positioned against the side of the chair. - On 8/22/24 at 8:44 AM brought out of their room by Certified Nurse Aide #13 without a pillow or towel under their left elbow. The elbow was tucked against their body and against the curve of the wheelchair where the back meets the seat. During an interview on 8/22/2024 at 9:51 AM, Certified Nurse Aide #12 stated they knew what care a resident needed by looking at the care plan for each resident on their assignment prior to providing care each shift. Positioning and pressure relieving devices were on the plan of care. They stated Resident #31 had something on their elbow and the certified nurse aides had to position the resident a certain way, so the pressure was kept off their elbow. They assisted the assigned certified nurse aide to get the resident up with the mechanical lift that morning but was unaware if the resident had the care planned pillow between their body and their elbow. During an interview on 8/22/2024 at 10:04 AM, Certified Nurse Aide #13 stated they knew how to care for a resident by their care plan. They got their assignment and looked at the care plan for each resident. Pressure relieving devices were on the resident care card. They stated Resident #31 had heel cups for their heels and a pillow to hold up their arm in bed for pressure relieving devices. They put the resident's personalized picture pillow in the chair with the resident this morning and placed it between their back and their side in the chair to hold the resident up. They were not aware if the resident's care plan documented to put the pillow between their left arm and body, but they liked to put the pillow in the chair to assist in positioning the resident. It was important to apply pressure relieving devices as ordered so the resident's wound did not get worse. During an interview 8/22/2024 at 10:21 AM, Licensed Practical Nurse #17 stated that pressure relieving devices were applied by the certified nurse aides under the direction of the nurses and were on the resident's care plan. The certified nurse aides should put the pillow under Resident #31's left arm due to the wound on the left elbow. The pillow should be applied as care planned or the wound could worsen. During an interview on 8/22/2024 at 10:25 AM, Registered Nurse Unit Manager #6 stated pressure relieving devices were documented on the care plan and should be implemented by staff. If Resident #31's pillow between their left arm and their body was not applied, the Stage 4 wound on their elbow could worsen. 2) Resident #58 had diagnoses including a Stage 2 (partial thickness skin loss) pressure ulcer of the right heel and pressure-induced deep tissue damage (purple or blue discoloration to intact skin due to underlying tissue damage) of the left heel. The 6/13/2024 Minimum Data Set assessment documented the resident was cognitively intact, did not reject care, required partial/moderate assistance with bed mobility, was at risk for pressure ulcers, had 1 Stage 2 pressure ulcer, had 1 unstageable deep tissue injury, and had a pressure reducing device for their chair and bed. The 1/19/2024 physician order documented apply pressure relieving boots while in bed. The comprehensive care plan initiated 1/19/2024 and revised 1/31/2024 documented the resident had a deep tissue injury pressure ulcer to the left heel related to immobility. Interventions included a heel elevator cushion while in bed, administer treatments as ordered, monitor for effectiveness, and to only wear shoes for transfers and ambulation. The unsigned 8/14/2024 Skin and Wound Evaluation documented the resident had an in-house acquired left heel deep tissue injury measuring 0.7 centimeters by 1 centimeter with no drainage and the area was improving. The current treatment was to apply skin protectant and a heel cup (a foam adhesive heel protector) and use a heel suspension/protection device. The 8/2024 Treatment Administration Record did not include pressure relieving measures for the resident's heels. The following observations were made of Resident #58: - On 8/19/2024 at 12:06 PM, lying in their recliner chair with their legs elevated. Their heels were resting directly on the footrest. There was no heel elevator cushion or pressure relieving boot. - On 8/20/2024 at 9:12 AM, lying in their recliner chair with their legs elevated. Their heels were resting directly on the footrest. There was no heel elevator cushion or pressure relieving boot. - On 8/21/2024 at 9:25 AM, lying in their recliner chair with their legs elevated. Their heels were resting directly on the footrest. There was no heel elevator cushion or pressure relieving boot. Resident #58 stated they did not have a heel elevator cushion or pressure relieving boots and they did not elevate their heels while in bed or while lying in the recliner. During an interview on 8/21/2024 at 2:21 PM, Certified Nurse Aid #10 stated they provided care to Resident #58 during the day shift on 8/21/2024. The resident had wounds on their heels. Resident #58 did not have a heel elevator cushion or pressure relieving boots and when they provided morning care and got the resident out of bed, they did not elevate their heels. The heel elevator cushion was listed on the resident's care plan, and they were supposed to elevate their heels when the resident was lying down. It was important to follow the care plan and use the heel elevator cushion to prevent Resident #58 from developing new pressure ulcers and to avoid current pressure ulcers from getting worse. During an interview on 8/21/2024 at 2:31 PM, Licensed Practical Nurse #15 stated when a resident had pressure relieving devices ordered it would usually be on the Treatment Administration Record and would also be included in the resident's care plan. They were unaware if Resident #58 had pressure relieving boots or a heel elevator cushion and they had not seen them being used or in the resident's room. They stated Resident #58 had pressures ulcers on their heels and they provided daily dressing changes. They stated it was important to use pressure relieving devices as ordered to prevent pressure ulcers from getting worse and if they were not used new areas could develop. During an interview on 8/22/2024 at 9:33 AM, Registered Nurse Manager #2 stated Resident #58 had pressure ulcers on their heels, and they were healing well. The licensed practical nurses provided daily dressing changes, and they were unaware if the resident had any pressure relieving devices. They stated if the resident was care planned for pressure relieving devices or had an order, they should have been implemented. They thought Resident #58 had a heel elevator cushion somewhere and they were unsure if they had pressure relieving boots. They stated it was important for Resident #58 to use pressure relieving devices as planned to reduce the friction on their heels and prevent new areas from developing. Their expectation was to be notified by staff if Resident #58 did not have pressure relieving devices so they could provide them. During an interview on 8/22/2024 at 11:05 AM, the Director of Nursing stated the registered nurse or provider would assess the resident and determine what pressure relieving devices were appropriate. They would write an order or update the residents care plan with specifics. They stated Resident #58 had pressure ulcers on their heels. If there was an order for pressure relieving boots and they were care planned for a heel elevator cushion they expected them to be used as planned. They stated it was important for Resident #58 to use the pressure relieving devices as planned to reduce the pressure on their heels and prevent new areas from developing. 10NYCRR 415.12(c)(1) 48675

Based on observation, record review and interview during the abbreviated survey (NY 443), conducted on 9/16/2021, the facility failed to ensure the environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for 2 of 3 residents (Residents #1 and 2) reviewed. Specifically, Specifically, Resident #1 was given a microwaved bowl of soup by a staff member. The resident spilled the soup on their left breast and side, resulting in a blistered burn. The burn worsened and on 7/17/2021, there was serous drainage that was yellow/gold in color, on 7/18/2021, there was 25% slough (dead tissue), and on 7/19/2021, debridement creams (to remove dead tissue) were ordered. The facility documented the resident's hands started to shake and the bowl of soup spilled on their breast. There was no documentation of an occupational therapy (OT) evaluation and no documentation on the comprehensive care plan (CCP) identifying the burn or updates such as interventions or resident education. On 9/14/2021, Resident #2 was observed microwaving food/beverages in the dining room where the microwave was located without supervision. Resident #2 reported to a surveyor they takes their own food to the microwave, heats the food for 6-12 minutes and then takes a washcloth, wraps the bowl with a washcloth, holds the bowl in their hands, and self-propels the wheelchair with their feet back to the room holding the hot bowl. The facility does not have a policy addressing safely re-heating foods. Staff interviewed were not able to state a policy for ensuring food was re-heated to safe temperatures. A resident was observed microwaving foods/beverages unsupervised. Thermometers are not available on the units for staff to monitor the temperatures of the food. The provider's failure to prevent [CONDITION(S)] caused by foods and drinks microwaved to unsafe temperatures places 94 residents at immediate risk to their health and safety and resulted in Immediate Jeopardy and Substandard Quality of Care. Findings include: The 1/2018 facility policy Food Storage documented the facility had probe thermometers available for use by staff, residents, or representatives to check food that is reheated to the proper reheating temperature for resident consumption. There was no documentation what the appropriate temperatures were for reheating foods or fluids using the microwave or where the thermometers were stored. 1) Resident #1 was admitted to the facility with diagnoses including Alzheimer's disease, [CONDITION(S)], and anxiety. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had moderate cognitive impairment and required set-up help with meals. The 4/23/2021 comprehensive care plan (CCP) documented the resident had an activity of daily living (ADL) decline and was at risk for malnutrition. There was no documentation of the resident's eating ability. The 4/23/2021 occupational therapy (OT) evaluation documented the resident was evaluated and OT services were not recommended at that time. The evaluation contained no documentation related to eating ability. The 6/3/2021 at 3:45 PM, registered nurse (RN) #12's progress note documented Resident #1 had increased shaking in their hands and requested a two handled cup with a lid. An OT referral was submitted. The 6/4/2021 at 1:43 PM, registered dietitian (RD) #22's progress note documented OT recommended 2 handled mugs with spouted lids and the plan of care was updated. There was no documentation of an OT referral documenting the recommendation for 2 handled mugs with spouted lids. There was no documentation the CCP was updated to include the use of the 2 handled mugs with spouted lids. The 7/13/2021 skin report completed by RN #12 documented Resident #1 was sitting in the chair, the resident placed a bowl of chicken noodle soup on their abdomen, began to shake when lifting the soup bowl and spilled the soup on their left breast and abdomen. The resident's skin was red, blanchable, without blistering, and the resident did not complain of pain. The physician and family were notified. The possible causative factors were documented as unsteady hands. The Administrator documented the incident was due to the resident's unsafe actions while eating. Interventions to prevent reoccurrence included educating the resident not to place foods on their abdomen and a lower table was obtained to facilitate better placement for eating. Resident #1 agreed to use the table to avoid any further incident. A statement obtained by the facility (and included with the skin report by RN #12) from certified nurse aide (CNA) #1 dated 7/13/2021 documented at around 1:30 PM to 1:45 PM, the resident requested soup and coffee. CNA #1 heated the soup in the microwave for 30 seconds and left to assist another resident. When CNA #1 returned, the soup was cold and they re-heated it for another 15 seconds. CNA #1 made the coffee and delivered the soup and coffee to the resident. A few minutes later, CNA #1 heard the resident scream and when the CNA responded, the soup was on the resident's lap. CNA #1 documented the resident reported the soup spilled due to the resident's shakiness per the resident. Resident #1 was assisted with a clothing change and assessed by RN #12. There was no documented evidence the CCP was updated or changed to prevent further [CONDITION(S)] following the burn on 7/13/2021. The 7/2021 Resident Care Summary (care instruction) documented staff were to provide set-up help with meals. There was no documentation the resident required a specialized tray table or 2 handled mugs with spouted lids. Nursing progress notes and medical orders documented: - On 7/13/2021 at 2:23 PM, by registered nurse (RN) #12, Resident #1 placed a soup bowl on their stomach, their hands started to shake, and the soup spilled on the resident's left breast, stomach, index finger, and thumb. -On 7/13/2021 at 9:55 PM, by RN #13, Resident #1 had an intact blister under the left breast and skin prep (treatment) was applied. - The 7/15/2021 physician's orders documented skin prep was to be applied to the blisters on the left abdomen and breast every shift until healed. - On 7/16/21 at 2:21 PM, by RN #12, the blister on the left abdomen popped. The resident was seen rubbing it. The area was cleansed with normal saline and a 4x10 border gauze had been placed. The NP was updated. - On 7/17/2021 at 3:48 PM, by RN #15, there was yellow/gold serous drainage from the blister on the abdomen. - On 7/18/21 at 10:44 AM, by LPN #19, the area on the left side of abdomen remained open with 25% slough/scabby appearance. The peri-wound was pink, the dressing was changed. - On 7/19/2021 at 7:26 PM, by LPN #17, the abdomen dressing was very moist with a large amount of drainage noted and there was slough in the center of the wound. On 7/19/21 (untimed), physician assistant (PA) #23's progress note documented the resident spilled hot soup on the abdominal wall that caused a full thickness abrasion through the skin with devitalized tissue at the base. The treatment was changed to cleanse with normal saline and apply Santyl (to remove dead tissue) to the devitalized tissue (dead tissue), [MEDICATION(S)] to protect the surrounding skin from drainage. Staff were to also apply Alginate (absorbent dressing) over the top, followed by a border dressing and change the dressing daily. Nursing progress notes contained documentation the resident's skin was monitored and treated from 7/20/2021 and on 8/25/21, the resident's skin was healed. The current (undated) Resident Care Summary (care instructions) and documentation of care provided documented the resident was on a regular diet and on 9/14/21, was independent with eating after set-up. The instructions contained no documentation of the 2 handled mugs with spouted lids or the specialized tray table for meals. On 9/13/2021 at 8:40 AM and 9/14/21 at 8:01 AM, Resident #1 was observed in their room. The resident recalled the incident with the spilled soup, reporting a staff member handed the resident the soup and it was scalding hot. The resident stated due to shaky hands, the soup spilled on their left side causing severe pain and blisters. The facility addressed the skin issues and the burn remained for weeks. The resident stated after the incident, soup was placed on a tray so it did not spill again. A white tray table was observed in front of the resident and positioned at the waist level. The resident stated their hands had been shaking for a long time. Spouted cups with lids were observed on the white tray table at the resident's bedside. The resident reported they sat on the edge of the bed and ate meals from the tray table. On 9/14/21 at 10:40 AM, the kitchen on Unit 3 was observed. There was a microwave in the kitchen and no food thermometers were found in the kitchen. On 9/15/21 at 7:55 AM and 8:45 AM, the kitchens were observed on Unit 1 and 2. There were microwaves in the kitchens and no food thermometers were found in the kitchens. On 9/15/2021 at 8:40 AM, CNA #1 stated during an interview, Resident #1 was self sufficient and ate in their room independently and the resident being in the room during meals was always a concern for CNA #1. CNA #1 stated the facility's regular tray tables did not lower enough to be at a good height for the resident when eating in bed or in the recliner chair. CNA #1 stated the facility had lower tables and prior to the resident's incident CNA #1 asked for one from the nurses. CNA #1 stated when the resident had the regular tray table, the resident would place their food on their lap or against their body. After the incident, a lower white tray table was provided. On the day of the incident, Resident #1 was sitting in the recliner chair with a regular tray table that would not lower enough and asked for soup. CNA #1 microwaved the soup for 30-35 seconds and went and helped another resident so when they came back, they heated it for another 15 seconds. CNA #1 stated the soup was not bubbly or overly steamy when they took it to the resident. CNA #1 stated they gave the soup to the resident, reminded them it was hot and after leaving the room, heard the resident say that's hot. The resident had shakiness on and off and used cups with spouted lids for hot and cold drinks. CNA #1 stated there was no set time frame, format, or chart to determine how long to heat things in the microwave and they went by the food on the plate and used common sense when heating foods for residents. CNA #1 stated they were not aware of thermometers available for staff use when heating food for residents. On 9/15/2021 at 10:43 AM, CNA #5 stated in an interview, microwaves were located on all 3 units and used for heating residents' foods. The average time for reheating food was 30 seconds. After they heated residents' foods, they asked the resident if the food was hot enough. CNA #5 stated they did not use a thermometer to check the temperature of the food and was not aware of any thermometers located on the units. CNA #5 stated they did not receive any training or education at the facility on using the microwaves. On 9/14/2021 at 10:15 AM, LPN #2 stated the microwaves were located in all the kitchen areas. Staff used the microwave a couple times daily for warming soup or residents' personal foods. There was no thermometer located on the unit, no protocol for using the microwave and no education or training for using the microwave provided by the facility. On 9/14/2021 11:15 AM, RN #8 stated staff did not typically use the microwave for residents and was unaware how often the microwaves were used. The unit did not have any way of testing the food to see how warm something was and they were not aware of thermometers on the unit. RN #8 stated they were not aware of any policy/protocol and no training or education on using the microwave was provided by the facility. On 9/14/2021 at 11:25 AM, Dietary Services Director stated there was no policy or protocol on using the microwaves. Microwaves were on all units and used to heat soups and any resident requested food. The resident would determine how hot they wanted their food. Thermometers were located on the units, in the kitchenette, however were removed that morning for service. The Director then stated they were removed the previous night for calibration. The Dietary Services Director stated dietary staff was their main focus and they did not know if nursing was aware thermometers were located on the units or if they knew how to use them. On 9/15/2021 at 10:20 AM Occupational therapist (OT) #21 was interviewed and stated Resident #1 was last evaluated on 4/23/2021. At the time of evaluation, the resident was at baseline and was not picked up for therapy. A therapy screen was completed on 6/3/2021 for spouted cups due to shaking of the hands and nothing else was recommended. The therapy department was not aware Resident #1 was burned was not screened or evaluated after the resident sustained the burn. In a second interview at 11:55 AM, OT #21 stated the microwaves on the units were used for staff to reheat foods for residents and there was no formal training for staff or screening for residents on microwave use. They were not aware of any way for staff to determine the temperature of the food in the microwave. On 9/15/2021 at 11:00 RN #21 worked as the in-service director and stated there was no education or training provided to staff on the use of the microwave. On 9/15/2021 at 12:14 PM the Director of Nursing (DON) stated when Resident #1 got burned the facility initiated an investigation. There were no witnesses at the time of the incident and the facility found the resident needed a lower table, there was no documentation provided on the resident's plan of care for the tray table. The DON was not aware of any policy or procedure on using the microwave and no education or training was being done. The resident was not assessed by therapy after the incident. On 9/15/2021 at 12:42 PM The Administrator stated after the incident occurred Administration was made aware. The DON completed the facility investigation and reported a red mark from soup on Resident #1 and staff monitored the area. They reeducated the resident and thought the staff would have been talked to regarding the temperature of the soup. Thermometers were available in the kitchenettes on the units. The proper reheating temperature was 120 to 165 and they did not know if the staff were educated on the appropriate temperature. The policy in effect at the time of the incident did not have any information specific to microwaved food. Most of the residents ate their food off the tray, and nothing was done for the other residents using the microwave. On 9/14/2021 at 10:55 AM the physician stated there should be some policy for the use of the microwave, there was no guess at the length of time needed to heat food and different microwaves needed different amounts of time. Residents should be evaluated to determine what temperature their food needed to be and no resident should be given food that was hot enough to cause a burn. 2) Resident #2 was admitted to the facility with diagnoses including acute respiratory failure with [CONDITION(S)] (low oxygen levels), [CONDITION(S)] of the knee and unspecialized abnormalities of gait and mobility. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact and required set-up help with meals. The resident used a wheelchair independently for locomotion. The 7/13/2021 comprehensive care plan (CCP) documented the resident received a regular diet, staff were to provide cueing and encouragement to promote intake, and the resident had an unspecified decline in activities of daily living (ADL). Interventions included an occupational therapy (OT) evaluation as needed. The resident spent their time preparing their own meals in their room and used the microwave independently. The 2/21/2019 and 2/15/2021 OT screens did not document the resident was evaluated for use of the microwave independently. On 9/14/2021 at 10:40 AM, Resident #2 was observed in the dining room using the microwave. The microwave had a mug inside it and the resident set the microwave for 3 minutes. On 9/15/2021 Resident #2 was interviewed between 8:50 AM and 9:10 AM, using telephone translation services. The resident stated they prepared and heated their food using the microwave after their family brought in the food. The resident stated staff did not assist them with the microwave and no help was needed. When heating food in the microwave, they set the microwave for 6 to 12 minutes and had never been burned from the plates or food. During a second interview on 9/15/2021 at 12:10 PM, using telephone translation services, Resident #2 stated after they microwaved their food, they applied a washcloth around the bowls and carried the bowls with the hands back to their room. They stated they used their feet to propel their wheelchair back to their room. On 9/14/2021 at 11:25 AM, Dietary Services Director stated there was no policy or protocol on using the microwaves. Microwaves were on all units and used to heat soups and any resident requested food. The resident would determine how hot they wanted their food. Thermometers were located on the units, in the kitchenette, however were removed that morning for service. The Director then stated they were removed the previous night for calibration. The Dietary Services Director stated dietary staff was their main focus and they did not know if nursing was aware thermometers were located on the units or if they knew how to use them. On 9/15/2021 at 10:20 AM OT #21 was interviewed and stated Resident #2 had been at the facility since 2017, cognition was fair and at times was difficult to understand. Therapy last saw the resident for a wheelchair screen and positioning on 2/15/2021 The resident would not eat the food at the facility and would not allow staff to assist with meals. No evaluation had been completed for safety for using the microwave. On 9/15/2021 at 11:55 AM, OT #21 was re-interviewed and stated the microwaves on the units were used for staff to reheat foods for residents and there was no formal training for staff or residents on microwave use. They were not aware of any way for staff to determine the temperature of the food in the microwave. --------------------------------------------------------------------------------------------------------- The Immediate Jeopardy was removed on 9/16/21 based upon the following: - All microwaves were removed from each unit dining room. - All staff were instructed on the revised procedure that all food/beverages were to be reheated by dietary staff until all nursing staff have been educated on safe food heating methods. 10 NYCRR 415.12(h)(1)(2)