Every finding on record at Finger Lakes Health

Based on interviews and record review, the facility failed to ensure an alleged violation involving abuse was immediately reported to the State agency as required for one of seven residents reviewed (Resident #10). Specifically, on 06/21/2026, Resident #10 told Certified Nursing Assistant #2 and Certified Nursing Assistant #3 that Certified Nursing Assistant #1 had yelled at them and handled them roughly during the previous shift. Licensed Practical Nurse #1 became aware and sent an email to the Director of Nursing and Registered Nurse Manager #1 on 06/21/26 at 6:47 PM notifying them of the allegation. Documented evidence revealed the allegation was not reported to the facility Administrator until 06/22/2026 at 10:45 AM and was not reported to the New York State Department of Health until 06/22/2026 at 12:43 PM.The findings include:The facility policy titled, Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property, last revised on 05/08/2026, included that any staff who witnessed, heard or suspected that abuse took place should report the information to their supervisor immediately so that prompt interventions can occur to protect the resident(s). The supervisor would be responsible for notifying the Administrator or designee immediately upon allegations of abuse and the Nursing Home Administrator or designee will report abuse to the New York State Department of Health, or other entity per New York State and Federal requirements. All alleged violation involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, as reported immediately, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. Resident #10 had diagnoses including encounter for palliative care (care provided for symptom relief and support to people living with serious illnesses), malignant neoplasm (a cancerous tumor or growth) of ascending colon (colon cancer), and a right bungle-branch block (a heart condition caused by a block or delay in electric signals to the heart). The Minimum Data Set (a resident assessment tool) dated 08/01/2026 revealed Resident #10 had severe cognitive impairment and required assistance with toileting and personal hygiene. Review of the Comprehensive Care Plan last revised 06/22/2026 revealed Resident #10 had self-care performance deficits, communication problems related to hearing loss, and impaired cognitive function related to terminal abdominal cancer and memory loss. Review of the New York State Incident Reporting System revealed an incident on 06/21/2026, in which Resident #10 reported to nursing staff that during the overnight shift (06/20/2026 into 06/21/2026), a certified nursing assistant (subsequently identified as Certified Nursing Assistant #1) had yelled at them after they requested assistance with toileting and was rough with them. The Incident Intake included that facility staff first became aware of the incident on 06/21/2026 at 7:00 PM and the facility Administrator was made aware on 06/22/2026 at 10:45 AM. The incident was reported to the New York State Department of Health on 06/22/2026 at 12:43 PM. A handwritten document signed by Certified Nursing Assistant #2 and Certified Nursing Assistant #3, dated 06/21/2026, included that Resident #10 had complained about being yelled at in the face (by Certified Nursing Assistant #1) when they had to get up and go to the bathroom. Additional documentation included that Resident #10 complained about being handled very roughly and did not want Certified Nursing Assistant #1 back in their room. Resident #10 reported being very afraid at night and scared to fall asleep.In an email sent to the Director of Nursing and Registered Nurse Manager #1, dated 06/21/2026 at 6:47 PM, Licensed Practical Nurse #1 documented that they were informed by Certified Nursing Assistant #2 and Certified Nursing Assistant #3 that evening that Resident #10 had reported that Certified Nursing Assistant #1 had been mean to them the previous night, they were yelled at for sitting on the side of the bed, and the resident stated they did not want Certified Nursing Assistant #1 to care for them in the future.In an email sent to the Director of Nursing and Registered Nurse Manager #1 on 06/21/2026 at 11:48 PM, Registered Nurse Clinical Leader #1 documented that they spoke with Resident #10, who stated Certified Nursing Assistant #1 had yelled in their face, threw the resident's legs and upper body onto the bed and that that Resident #10 was afraid of retaliation by Certified Nursing Assistant #1. During an interview on 08/17/2026 at 11:09 AM, Certified Nursing Assistant #2 stated that on 06/21/2026, Resident #10 told them and Certified Nursing Assistant #3 that Certified Nursing Assistant #1 had yelled at them and put them back in bed roughly after using the bedside commode. Certified Nursing Assistant #2 stated once Resident #10 said that, they reported the incident to Licensed Practical Nurse #1 and completed a written statement with Certified Nursing Assistant #3.During an interview on 08/18/2026 at 10:43 AM, Resident #10 stated a certified nursing assistant got close to their face and shouted at them. Resident #10 stated they spoke with two certified nursing assistants after the incident and spoke with an additional staff member after talking with their family. During an interview on 08/18/2026 at 2:45 PM, Registered Nurse Manager #1 stated they would notify the Director of Nursing right away via email when suspected abuse occurred on a weekend evening and they would call the Director of Nursing if no acknowledgement was received after 30 minutes. Registered Nurse Manager #1 stated the Director of Nursing was responsible for reporting allegations of abuse to the New York State Department of Health.During an interview on 08/18/2026 at 4:17 PM, the Director of Nursing stated they would be notified via phone or email of abuse allegations, they would ask for details of the situation and look in the resident's chart to make a determination (if reportable to the State). The Director of Nursing said either they or the Assistant Administrator were responsible for reporting events to the New York State Department of Health in accordance with regulations. In a follow-up interview on 08/19/2026 at 9:24 AM, the Director of Nursing stated they were aware of the regulation to report a suspicion of abuse to the New York State Department of Health and the facility Administrator within two hours, they did not know when the Administrator was notified of the allegation, and that the alleged incident was reported to the Department of Health on 06/22/2026 at 12:42 PM. The Director of Nursing stated the alleged incident was not reported to the facility Administrator or the Department of Health within two hours because they did not have access to their computer. Title 10 New York Codes, Rules and Regulations 415.4(b)(2)

Based on interviews and record review, the facility failed to ensure allegations of abuse were responded to timely, thoroughly investigated, and that residents were protected from further potential abuse for one of seven residents reviewed (Resident #10). Specifically, Resident #10 reported allegations of potential physical and verbal abuse to nursing staff, and the facility failed to immediately remove the involved staff member from resident care while the investigation was in progress in an effort to prevent further potential abuse. The findings include:The facility policy titled Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property last revised on 05/08/2026, included that residents would be protected from abuse, neglect, and harm while at the facility. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation (producing feelings of fear) or punishment with resulting physical harm, pain, or mental anguish. Residents would be protected from alleged offender(s) and procedures to provide the residents with a safe, protected environment included, but were not limited to the immediate removal of the accused employee from the facility with continued removal pending the results of a thorough investigation. Resident #10 had diagnoses including encounter for palliative care (care provided for symptom relief and support to people living with serious illnesses), malignant neoplasm (a cancerous tumor or growth) of the ascending colon (colon cancer), and a right bungle-branch block (a heart condition caused by a block or delay in electric signals to the heart). The Minimum Data Set (a resident assessment tool) dated 08/01/2026 revealed Resident #10 had severe cognitive impairment and required assistance with toileting and personal hygiene. Review of the Comprehensive Care Plan last revised 06/22/2026 revealed Resident #10 had self-care performance deficits, communication problems related to hearing loss, and impaired cognitive function related to terminal abdominal cancer and memory loss. Review of the New York State Department of Health Incident Intake, dated 06/22/2026 at 12:43 PM, revealed that on 06/21/2026, Resident #10 reported to nursing staff that during the overnight shift (06/20/2026 into 06/21/2026), a certified nursing assistant (subsequently identified as Certified Nursing Assistant #1) had yelled at them after they requested assistance with toileting, and was rough with them. The Incident Intake included that the incident occurred in the North building and that facility staff first became aware of the incident on 06/21/2026 at 7:00 PM.A handwritten document signed by Certified Nursing Assistant #2 and Certified Nursing Assistant #3, dated 06/21/2026, included that Resident #10 had complained to them about being yelled at in the face (by a staff member) when they had to get up and go to the bathroom. Additional documentation included that Resident #10 complained about being handled very roughly and did not want the alleged staff member back in their room. Resident #10 reported being very afraid at night and scared to fall asleep.In an email sent to the Director of Nursing and Registered Nurse Manager #1, dated 06/21/2026 at 6:47 PM, Licensed Practical Nurse #1 documented that they were informed by Certified Nursing Assistant #2 and Certified Nursing Assistant #3 that evening that Resident #10 had reported that Certified Nursing Assistant #1 had been mean to them the previous night, they were yelled at for sitting on the side of the bed, and the resident stated they did not want Certified Nursing Assistant #1 to care for them in the future. Licensed Practical Nurse #1 documented that Certified Nursing Assistant #1 should be on another team (unit) if they worked later that night.In an email sent to the Director of Nursing and Registered Nurse Manager #1 on 06/21/2026 at 11:48 PM, Registered Nurse Clinical Leader #1 documented that they spoke with Resident #10 and their family member, Resident #10 stated Certified Nursing Assistant #1 had yelled in their face, threw the resident's legs and upper body onto the bed, and that Resident #10 was afraid of retaliation by Certified Nursing Assistant #1. Registered Nurse Clinical Leader #1 documented that Certified Nursing Assistant #1 was being moved to another floor (unit) that night.Review of the facility's Investigation Summary Report signed by the Director of Nursing dated 08/18/2026 revealed that upon notification from Registered Nurse Clinical Leader #1, the facility's immediate response to the event included reassigning Certified Nursing Assistant #1 to another building and a different unit. Review of facility timecards dated 06/20/2026 to 06/26/2026 revealed Certified Nursing Assistant #1 worked in the facility during the overnight shifts from 06/20/2026 at 10:47 PM to 06/21/2026 at 7:01 AM, and from 06/21/2026 at 11:00 PM to 06/22/2026 at 5:00 AM. Review of Task documentation revealed Certified Nursing Assistant #1 documented care provided to a resident in the South building on 06/22/2026 at 3:53 AM. The facility's investigation included the Resident's Incident Report Form (document containing Certified Nursing Assistant #1's statement) related to the incident on 06/20/2026 into 06/21/2026 involving Resident #10 and Certified Nursing Assistant #1. The form included Certified Nursing Assistant #1's version of the incident, which was signed by Certified Nursing Assistant #1 on 06/23/2026 at 8:29 AM.During an interview on 08/18/2026 at 10:43 AM, Resident #10 stated a certified nursing assistant got close to their face and shouted at them. Resident #10 stated they spoke with two certified nursing assistants after the incident and spoke with an additional staff member after talking with their family. Resident #10 stated they found the certified nursing assistant degrading and did not think anyone deserved that.During an interview on 08/18/2026 at 2:45 PM, Registered Nurse Manager #1 stated if a staff member was accused of abuse, neglect or mistreatment, they would be given an opportunity to write a statement and would not be allowed to work at the facility until the investigation had a proven outcome. Registered Nurse Manager #1 stated if an accused staff member was cleared to return to work, the Director of Nursing would notify them. During an interview on 08/18/2026 at 4:17 PM, the Director of Nursing stated if a staff member was accused or implicated in potential resident abuse, the facility could suspend them or reassign them to a different building, so they were not in the same building as the resident while the investigation was in progress. The Director of Nursing stated that it was determined that Certified Nursing Assistant #1 was appropriate to work with other residents after Resident #10's allegation of abuse due to no other concerns or issues with Certified Nursing Assistant #1 and following a team discussion. During a follow-up interview on 08/19/2026 at 9:24 AM, the Director of Nursing stated they did not specifically document that Certified Nursing Assistant #1 was safe to return to work and noted that they reassigned Certified Nursing Assistant #1 (to another unit). The Director Nursing stated at the time, they did not 100 percent believe there was a suspicion of abuse, neglect or mistreatment, they did not have all the details, and they moved the certified nursing assistant (to another unit). During an interview on 08/19/2026 at 4:50 PM with the Director of Nursing and the Assistant Administrator, the Director of Nursing stated three other residents were interviewed following the allegation of abuse involving Certified Nursing Assistant #1, two residents complained about Certified Nursing Assistant #1 and feared retaliation from the staff member. Title 10 New York Codes, Rules and Regulations 415.4(b)(3)

Based on observations, interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and did not ensure adequate supervision and assistive devices were provided to prevent accidents for four (4) of eight (8) residents reviewed (Residents #65, #75, #98, and #101). Specifically, Residents #65, #75, and #101 were at risk for accidents related to inconsistent and unsafe use of full body lift slings (a fabric device used with a mechanical lift to support and transfer a resident) including use of incorrect sling sizes and reuse of disposable slings. Resident #98 experienced a fall on 11/11/2025 from a full body lift, resulting in a head injury that required staples. This resulted in actual harm for Resident #98 that was not Immediate Jeopardy.The findings include: The facility policy Lift and Transfer last reviewed 05/05/2024 included all direct care employees will receive training on mechanical lift use and transfer techniques including use of slings, and the Nurse Manager or designee is responsible for ensuring employee training is complete and ensuring transfer information is updated.1. Resident #98 had diagnoses including stroke, neuropathy (peripheral nerve damage), and hemiplegia (weakness or paralysis affecting one side of the body). The Minimum Data Set (a resident assessment tool) dated 03/02/2026 documented the resident had moderately impaired cognition and was dependent for transfers. Record review on 04/01/2026 of Resident #98's Comprehensive Care Plan did not include the use of a mechanical lift for transfers.Record review of Resident #98's Kardex (used by certified nursing assistants to guide resident care), last revised 11/11/2025, documented the resident required a full body lift with assistance of two (2) staff for transfers. The size of the sling was not documented.Record review of manufacturer guidelines and Resident #98's weight of 179.9 pounds (as of 11/10/2025) revealed the resident required a large sling.Record review of the facility Incident and Accident report dated 11/11/2025 documented Resident #98 fell from a full body lift during a transfer, sustained a head laceration with bleeding, and was transferred to the emergency room for evaluation.Record review of Emergency Department documentation dated 11/11/2025 revealed Resident #98 sustained a head laceration requiring staples following a fall from a lift.During an interview on 04/01/2026 at 4:01 PM, Certified Nursing Assistant #2 stated during the transfer, Resident #98 tipped backward and fell from the sling, and they did not think the sling was properly positioned before the lift was moved.During an interview on 04/07/2026 at 3:46 PM, Nurse Practitioner #1 stated no one could determine exactly what caused the fall and no statements were requested from them.During a telephone interview on 04/07/2026 at 4:55 PM, the Medical Director stated they would have expected the facility to have performed an investigation into the event involving Resident #98 on 11/11/2025 so an event like that did not happen again.During an interview on 04/07/2026 at 5:40 PM, the Director of Nursing stated the facility could not locate documentation of a completed investigation and could not determine what caused the fall.2. Resident #101 had diagnoses including hemiparesis (weakness or partial paralysis affecting one side of the body), osteoarthritis (joint disease that causes pain, stiffness, and reduced mobility), and hypertension (high blood pressure). The Minimum Data Set, dated [DATE] documented the resident had severely impaired cognition and was dependent for transfers.Record review of Resident #101's Comprehensive Care Plan, last revised 01/14/2026, current Kardex reviewed on 04/02/2026, and assignment sheet dated 04/06/2026, revealed the resident required a full body lift with assistance of two (2) staff for transfers. The size of sling was not documented.Record review of manufacturer guidelines and the resident's most recent weight of 146.4 pounds revealed the resident required a size medium sling.During an observation on 04/02/2026 at 1:47 PM, Certified Nursing Assistant #9 and Certified Nursing Assistant #10 were preparing to transfer Resident #101 using an extra-large sling. The surveyor intervened and stopped the transfer. During an interview on 04/02/2026 at 1:56 PM, Registered Nurse Manager #2 stated Resident #101 required a medium sling, but the staff used an extra-large sling to transfer Resident #101 because it was the only sling available at that time. 3. Resident #75 had diagnoses including hemiplegia, convulsions, and muscle spasm. The Minimum Data Set, dated [DATE] documented the resident was cognitively intact and dependent for transfers.When reviewed on 04/02/2026, Resident #75's current Kardex documented the resident required a full body lift with an extra-large sling.Review of Resident #75's most recent weight on 04/02/2026 revealed the resident weighed 275 pounds.During an observation on 04/02/2026 at 12:06 PM, Resident #75 was seated in a recliner with a large sling in place.During an interview on 04/02/2026 at 12:06 PM, Registered Nurse Manager #3 stated that based on weight, the resident should have been in an extra-large sling, and the incorrect sling size was used.During an interview on 04/03/2026 at 10:10 AM, Certified Nursing Assistant #5 stated on 04/02/2026 they transferred Resident #75 using a large size sling and acknowledged it should have been an extra-large sling.4. Resident #65 had diagnoses including chronic pain (persistent pain lasting longer than three (3) to six (6) months), peripheral vascular disease (a blood circulation disorder that affects the arteries in the legs), and heart failure (a condition where heart cannot pump enough blood to meet the body's needs. The Minimum Data Set, dated [DATE] documented the resident had moderately impaired cognition and required maximum assistance for transfers.Review of Resident #65's Kardex reviewed on 04/02/2026 documented the resident required a full body lift with assistance of two (2) staff for transfers. The sling size was not documented.During an observation on 04/02/2026 at 2:34 PM, a disposable sling with a visible wash indicator marking it as unsafe for use was observed on the resident's wheelchair. When interviewed at 2:39 PM, Certified Nursing Assistant #1 stated the sling was intended to be reused.During an interview on 04/02/2026 at 8:44 AM, Certified Nursing Assistant #6 stated sling size selection was based on a visual inspection of the resident.During an interview on 04/02/2026 at 8:50 AM, Licensed Practical Nurse #1 stated they would ask a certified nursing assistant or refer to the care plan to determine sling size and were not trained on lift use.During an interview on 04/02/2026 at 8:54 AM, Certified Nursing Assistant #9 stated sling size was determined by experience and familiarity with the resident's body size.During an interview on 04/02/2026 at 9:03 AM, Certified Nursing Assistant #7 stated they would use the sling available in the room or ask a nurse.During an interview on 04/02/2026 at 9:10 AM, Licensed Practical Nurse #2 stated sling size was not documented in the care plan or Kardex.During an interview on 04/02/2026 at 9:25 AM, Certified Nursing Assistant #5 stated they did not know where sling size was documented.During an interview on 04/02/2026 at 9:50 AM, Registered Nurse Manager #2 stated sling size should be determined based on weight and manufacturer guidelines, but staff often relied on a visual inspection of a resident's physical appearance and body size.During an interview on 04/02/2026 at 9:07 AM, the Director of Nursing stated the facility had experienced issues with sling availability and compatibility and disposable slings were being used in place of reusable slings.During an interview on 04/02/2026 at 2:05 PM, the Director of Nursing stated if the correct sling size was not available, staff should obtain the correct size from another unit and should not proceed with the transfer using an incorrect sling.Title 10 New York Code of Rules and Regulations, Section 415.12 (h)(1)

Based on observations, interviews, and record review, the facility failed to ensure care and services were provided in accordance with the resident's needs and professional standards for two (2) of eight (8) residents reviewed (Residents #96 and #131). Specifically, Resident #96 who had a diagnosis of dysphagia (difficulty swallowing that can lead to choking, coughing, or food feeling stuck in the throat), received a diet inconsistent with their swallowing needs due to failure to implement and communicate a diet recommendation and supervision needs, and experienced a choking episode requiring abdominal thrusts. Additionally, Resident #131 sustained thermal burns (a skin injury caused by contact with heat sources like hot liquids, causing tissue damage) after staff failed to follow safe food reheating practices. This resulted in actual harm for Residents #96 and #131 that was not Immediate Jeopardy.The findings include: The facility policy Change in Condition, Management and Notification last revised 04/05/2023, included all changes in a resident's physical, social, or mental condition will be reported to the charge nurse or registered nurse immediately. Conditions to be reported to the nurse include, but are not limited to, physical illness, complaints or indicators of pain, and deterioration of functional ability including eating. The medical provider, and the resident and/or resident representative will be notified when there is an accident involving the resident which results in injury and has the potential for requiring medical intervention or a need to alter treatment significantly. The medical provider will be notified when a recommendation is made by other disciplines or consultants, which may affect the resident's plan of care and all disciplines will update the plan of care accordingly.The facility policy Reheating Resident Food and Microwave Use dated 11/21/2025 included only facility staff may use microwave ovens, staff must be present during reheating, reheated foods must reach a minimum internal temperature of 135 degrees Fahrenheit for hot holding, and soups or leftovers must be reheated to 165 degrees Fahrenheit. Staff are required to obtain two (2) internal temperature readings and document the product name, time, and temperature readings on the Cooking and Reheating Temperature Log.1. Resident #96 had diagnoses including dysphagia, dementia, and stroke. The Minimum Data Set (a resident assessment tool) dated 10/27/2025 documented the resident was cognitively intact and required set-up assistance with eating.Review of Resident #96's Comprehensive Care Plan dated 03/14/2025 revealed the resident had nutritional problems related to diet restrictions and dementia. Interventions included: staff were to monitor, document, and report signs of dysphagia including pocketing food, choking, coughing, drooling, holding food in mouth, and several attempts at swallowing, and the Registered Dietician to evaluate and make diet change recommendations as needed.Review of Resident #96's medical orders revealed a swallow evaluation due to dysphagia dated 10/03/2025, a swallow evaluation due to a choking episode dated 11/02/2025, a carbohydrate consistent diet, minced and moist level five (5) texture (soft, moist, and easily formed into a mass of food requiring minimal chewing) with honey thick fluids dated 11/02/2025, and a carbohydrate consistent diet soft, bite sized level six (6) texture (tender, moist, bite-sized pieces requiring some chewing) with regular fluids dated 11/03/2025.A facility investigation dated 11/03/2025 documented during a care plan meeting on 10/02/2025, Resident #96's family reported difficulty swallowing and need for reminders to slow down while eating. A recommendation was made for a speech evaluation and diet downgrade. An order was entered into the electronic health record; however, it was not transferred to the dietary system. On 11/02/2025, the resident choked on a ground meatball and required six (6) to seven (7) abdominal thrusts.During an interview on 04/01/2026 at 1:21 PM, Registered Nurse Manager #1 stated after a medical order is entered into the electronic health record, nursing is responsible to confirm the order, document it, and enter it into a separate system used to communicate with other departments, including dietary. Registered Nurse Manager #1 stated it was likely the order was confirmed in the electronic health record but not entered into the second system and they had observed orders being partially entered before.During an interview on 04/06/2026 at 10:03 AM, Registered Nurse Manager #1 stated Resident #96 required set-up assistance and supervision with meals and both should be documented so staff would not leave the resident alone while eating. Registered Nurse Manager #1 stated the supervision requirement may have been accidentally deleted. The Kardex was last updated on 11/03/2025.During an interview and observation on 04/06/2026 at 10:18 AM with the Clinical Informatics Registered Nurse and Registered Nurse Manager #1, the Clinical Informatics Registered Nurse stated they could not produce documentation reflecting what the Kardex indicated at the time of the choking event. Review of historical documentation revealed the resident was listed as requiring set-up assistance. Registered Nurse Manager #1 confirmed the resident should have required supervision.During an interview on 04/06/2026 at 10:35 AM with Certified Nursing Assistant #4 and Certified Nursing Assistant #12, Certified Nursing Assistant #4 stated if a resident required supervision, staff must remain with the resident during meals, and if a resident required set-up assistance, staff would assist with meal preparation and were not required to stay. Certified Nursing Assistant #12 reviewed the assignment sheet dated 04/06/2026, which documented Resident #96 required set-up assistance and did not include supervision.During an interview on 04/07/2026 at 10:30 AM, the Rehabilitation Manager/Physical Therapist stated a speech evaluation order was entered on 10/03/2025 but was not received by therapy because it was not entered into the second system used to communicate orders, and the evaluation did not occur.During an interview on 04/07/2026 at 3:14 PM, the Medical Director stated if a recommended diet change was not implemented and the resident continued to receive a regular diet, it would subject the resident to a swallowing hazard.During an interview on 04/07/2026 at 3:34 PM, the Director of Nursing stated the diet should have been downgraded following the care plan meeting on 10/02/2025 and staff should have had documentation in place to prompt supervision and reminders to slow down while eating.2. Resident #131 had diagnoses including a left tibia fracture (broken shinbone), anxiety, and bipolar disorder (a mental health condition characterized by emotional highs and lows). The Minimum Data Set, dated [DATE] documented the resident was cognitively intact and required set-up assistance with eating.Review of Resident #131's comprehensive care plan, last revised 02/17/2026, revealed the resident required set-up assistance with eating and received a regular diet with thin liquids.A facility Incident and Accident report dated 01/20/2026 documented Resident #131 spilled hot soup onto their face, chin, and chest after reheating by staff.Review of the New York State Department of Health Incident intake dated 01/21/2026 revealed Resident #131 sustained redness and blistering to the chin and chest following the incident.Review of the medical provider progress note dated 01/21/2026 revealed Nurse Practitioner #2 documented Resident #31 was assessed for second degree burns and was found to have small intact blisters to the chin and upper chest with surrounding redness.Review of the Cooking and Reheating Temperature Log dated 01/20/2026 revealed no documentation was available for the reheated soup.During an interview on 04/01/2026 at 4:14 PM, Certified Nursing Assistant #13 stated they reheated the soup in the microwave for multiple intervals and obtained a temperature of 130 degrees Fahrenheit and did not document the temperature because a log was not available.During an interview on 04/02/2026 at 9:07 AM, the Director of Nursing stated Certified Nursing Assistant #13 did not follow the reheating policy, did not obtain required temperature readings, and this information was not included in the facility investigation.Title 10 New York Code of Rules and Regulations, Section 415.12

Based on observations, interviews, and record review, the facility failed to ensure allegations and incidents were thoroughly investigated and documented, including identification of root cause and implementation of corrective actions, for two (2) of eight (8) residents reviewed (Residents #98 and #131). Specifically, the facility failed to conduct a thorough and complete investigation for Resident #98 following a fall from a full body lift resulting in a head injury, and for Resident #131 following a thermal burn (a skin injury caused by contact with heat sources like hot liquids, causing tissue damage) incident related to reheated food. The findings include:The facility policy Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property last reviewed 06/27/2024 included alleged violations will be thoroughly investigated, including collection of statements, review of relevant documentation, and identification of contributing factors, and appropriate corrective actions will be implemented to prevent recurrence.1. Resident #98 had diagnoses including stroke, neuropathy (peripheral nerve damage), and hemiplegia (weakness or paralysis affecting one side of the body). The Minimum Data Set, dated [DATE] documented the resident had moderately impaired cognition and was dependent for transfers.Review of the facility incident and accident report dated 11/11/2025 revealed Resident #98 fell from a full body lift during a transfer and sustained a head laceration requiring transfer to the emergency room.Review of emergency department documentation dated 11/11/2025 revealed Resident #98 required staples for a head laceration following the fall.Review of the facility Incident and Accident report dated 11/11/2025 revealed no documented evidence of a completed investigation, including no documented root cause analysis, no determination of contributing factors, and no documented corrective actions.During an interview on 04/01/2026 at 3:38 PM, Registered Nurse Supervisor #2 stated they completed the initial report and collected statements, and the Nurse Manager and Director of Nursing were responsible to continue the investigation.During an interview on 04/07/2026 at 4:03 PM, Registered Nurse Manager #1 stated they were not aware if an investigation had been completed.During an interview on 04/07/2026 at 3:46 PM, Nurse Practitioner #1 stated no one requested a statement them and no one could determine what caused the fall.During an interview on 04/07/2026 at 5:40 PM, the Director of Nursing stated the facility could not locate documentation of an investigation and could not determine the cause of the incident.2. Resident #131 had diagnoses including a left tibia fracture (broken shinbone), anxiety, and bipolar disorder (a mental health condition characterized by emotional highs and lows). The Minimum Data Set, dated [DATE] documented the resident was cognitively intact and required set-up assistance with eating.Review of the facility Incident and Accident report dated 01/20/2026 revealed Resident #131 sustained thermal burns to the face and chest after spilling reheated soup.Review of the New York State Department of Health incident intake dated 01/21/2026 revealed Resident #131 sustained redness and blistering following the incident.Review of the facility investigation did not include documented evidence if reheating temperatures were obtained, did not include review of the Cooking and Reheating Temperature Log, and did not include whether staff followed the reheating policy.During an interview on 04/01/2026 at 4:14 PM, Certified Nursing Assistant #13 stated they reheated the soup and obtained a temperature reading but did not document it.During an interview on 04/08/2026 at 8:43 AM, the Director of Nursing stated the investigation should have included review of temperature logs and staff compliance with reheating procedures, and absence of this information resulted in an incomplete investigation.Title 10 New York Code of Rules and Regulations, Section 415.4 (b)(3-4)

Based on observations, interviews, and record review, the facility failed to ensure an allegation of neglect and an incident involving an injury of unknown source was reported to the State Survey Agency for one (1) of eight (8) residents reviewed (Resident #98). Specifically, Resident #98 experienced a fall from a full body lift resulting in a head injury requiring staples, and the facility did not report the incident to the State Survey Agency as required.The findings include:The facility policy Abuse, Neglect, Mistreatment, and Misappropriation of Resident Property last reviewed 06/27/2024 included alleged violations involving abuse, neglect, or mistreatment, including injuries of unknown source, will be reported to the State Survey Agency within required timeframes, including within two (2) hours if the events involve serious bodily injury.Resident #98 had diagnoses including stroke (a condition where blood flow to the brain is interrupted), neuropathy (peripheral nerve damage), and hemiplegia (weakness or paralysis affecting one side of the body). The Minimum Data Set (a resident assessment tool) dated 03/02/2026 documented the resident had moderately impaired cognition and was dependent for transfers.Review of Resident #98's comprehensive care plan and Kardex (care plan used by certified nursing assistants to direct care) last revised 11/11/2025 documented the resident required a full body lift with assistance of two (2) staff for transfers.Review of the facility incident and accident report dated 11/11/2025 documented Resident #98 fell from a full body lift during a transfer and sustained a head laceration with bleeding.Review of emergency department documentation dated 11/11/2025 revealed Resident #98 sustained a head laceration requiring staples following the fall.During an interview on 04/01/2026 at 3:12 PM, the Director of Nursing stated the incident was not reported to the State Survey Agency because they did not consider it reportable.During an interview on 04/07/2026 at 3:46 PM, Nurse Practitioner #1 stated no one could determine what caused the fall.During an interview on 04/07/2026 at 5:40 PM, the Director of Nursing stated the facility could not determine the cause of the incident.Title 10 New York Codes, Rules and Regulations, Section 415.3(h)

Based on observations, interview, and record review conducted during the Recertification Survey at the Geneva Living Center North, Geneva Living Center South, and Huntington Living Centers 8/28/23 to 9/1/23, it was determined that the facility did not ensure compliance with all applicable State codes. Specifically, the facility was not in compliance with Section 915 of the 2015 Edition of the International Fire Code as adopted by New York State, which requires the use of carbon monoxide detection in a building that has fuel-burning appliances. The findings are: Observations during the initial tour of the Geneva Living Center North on 8/28/23 at 2:45 PM included natural gas-powered hot water heaters in the basement boiler rooms. Additionally, there was a single station carbon monoxide detector located on the wall in the corridor outside the boiler room. Record review on 8/29/23 at 10:10 AM included a spreadsheet of completed work orders related to the maintenance and testing of two carbon monoxide (CO) detectors in the Geneva Living Center North building identified to be located by the women's locker room and outside the boiler room. The completed work order spreadsheet listed testing of the CO detectors on 8/1/23, 5/1/23, 2/1/23, and 5/4/22. No documentation was provided to show that the two carbon monoxide detectors had been tested at least monthly. Observations during the initial tour of the Geneva Living Center South on 8/28/23 from 11:03 AM to 11:30 AM included a natural gas-powered generator and hot water heaters in the basement generator and boiler rooms. Additionally, there were single station carbon monoxide detectors located on the wall in the corridor outside the generator and boiler rooms. Record review on 8/29/23 at 9:03 AM included a spreadsheet of completed work orders related to the maintenance and testing of two carbon monoxide detectors in the Geneva Living Center South building identified as asset #009 and #004. The completed work orders listed testing of asset #009 on 8/24/23, 5/11/23, 2/15/23, 11/22/22, and 8/15/22. The completed work orders listed completed testing of asset #004 on 8/24/23, 5/5/23, 4/7/23, 11/22/22, and 8/15/22. No documentation was provided to show that the two carbon monoxide detectors had been tested at least monthly. Observations during the initial tour of the Huntington Living Center on 8/28/23 from 9:25 AM to 11:42 AM included a natural gas-powered cooking range in the first-floor main kitchen and natural gas-powered dryers in the first-floor laundry room. Record review on 8/28/23 at 2:59 PM included completed work orders related to the maintenance and testing of carbon monoxide detectors. The completed work orders contained a procedure titled 'Carbon Monoxide Alarm Battery Change and Test' which included that the facility would test the alarm per manufacturer's directions. Further review included that the facility completed the carbon monoxide alarm battery change and test on carbon monoxide detectors located throughout the facility on 9/7/23, 9/8/23, 3/24/23 and 3/27/23. No documentation was provided to show that that any carbon monoxide detector in the facility had been tested at least monthly from 7/22/22 (time of last survey exit) through the current date of 8/28/23. During an interview on 8/28/23 at 3:50 PM, the Lead Mechanic stated that it looked like they were testing the carbon monoxide detectors semi-annually. During an observatoin on 8/28/23 at 4:03 PM a single-station, Kidde-brand carbon monoxide detector was located on the wall on the first floor of the facility near the Nurse Practitioners office. Further observation included that the manufacturer had printed instructions on the detector to test weekly. The 2015 Edition of the International Fire Code requires that carbon monoxide alarms shall be maintained in accordance with NFPA 720. The 2012 Edition of NFPA 720, Standard for the Installation of Carbon Monoxide Detection and Warning Equipment, requires that single-station carbon monoxide alarms shall be inspected and tested in accordance with the manufacturer's published instructions at least monthly. 10NYCRR: 415.29(a)(2), 711.2(a)(1), 400.2; 42 CFR: 483.70(b); 2015 IFC: Section 915, 915.6; 2012 NFPA 720: 8.7.1

Based on observations, interviews, and record reviews conducted during a Recertification Survey at Huntington Living Center 8/28/23 to 9/1/23, it was determined that for one (Resident #12) of 37 resident's reviewed for care planning, the facility did not ensure the residents person-centered Comprehensive Care Plan (CCP) was implemented to meet the resident's medical needs as identified in the CCP and their physician orders. Specifically, Residents #12 did not have a strap securing their indwelling catheter and did not have wound care done according to their physician orders and their CCP. This was evidenced by the following: Resident #12 had diagnoses including neurogenic bladder (lack of bladder control due to a spinal cord injury) requiring a suprapubic (s/p) catheter (a catheter tube inserted directly into the bladder through the abdomen to drain urine into an attached drainage bag), paraplegia and multiple pressure ulcers. The Minimum Data Set assessment dated [DATE] documented that Resident #12 was cognitively intact (scoring 15/15), had an indwelling catheter and multiple pressure ulcers at the time of the assessment. Resident #12's CCP documented that the resident has a history of pressure ulcers to the buttocks with a goal to remain ulcer free and any impaired skin will show signs of healing and remain free of infection. Interventions included but not limited to, for staff to administer treatments as ordered and monitor for effectiveness. The CCP also documented that the resident has a s/p catheter with an intervention to remain free from catheter related trauma and infection. Interventions included but not limited to, catheter care as ordered by the provider. Resident #12's Kardex (care plan used by the Certified Nursing Assistants (CNAs) to provide daily care) documented that the resident had a catheter and for staff to keep the securing device in place at all times. Current physician orders included: a. Medihoney gel wound/burn dressing external paste, apply to left buttocks/thigh topically every day shift every two days for excoriated open area and cover with a telfa (non-adhering) pad. b. Medihoney to perineum/scrotum area stage two (pressure ulcer) every two days and cover with telfa. c. Change s/p catheter from side to side each day. Use a leg strap to help hold. Document to keep track daily for relieving pressure to the area around the s/p catheter. During an observation and interview on 8/29/23 at 1:31 PM, Resident #12 stated that they had the catheter for several years and that they did not have a strap on their leg to secure the catheter from pulling. The drainage bag was attached to the wheelchair and the green clip (attached to the tubing also used to secure the catheter and prevent pulling) was not attached to anything. Resident #12 stated that they have had urine infections but not recently and that they have had the catheter accidently pulled out in the past. During an observation and interview on 8/31/23 at 10:49 AM the resident's catheter bag was on the floor and the green clip was not attached to anything. CNA #3 and CNA #4 rolled Resident #12 side to side several times to provide incontinence care. The catheter was pulled several times creating tension at the insertion site. There was no leg strap on to prevent tension and the green clip remained unattached to anything. At 11:09 Registered Nurse Manager (RNM) #2 arrived to do the resident's wound care. Both buttocks were excoriated (incontinent of stool) and had two open areas noted, one on the left buttocks (quarter size) and one on the scrotum (nickel size). The areas were cleansed and covered with aloe vesta barrier cream including both open areas (versus Medihoney and a telfa pad). RNM #2 stated at the time that they were putting aloe vesta cream on the open areas that come and go. During an interview on 8/31/23 at 1:32 PM Resident #12 stated that they used to have a strap on their leg to hold the catheter in place but if fell off and it never got replaced. Resident #12 stated that it was probably a good idea to wear one and would try it out. During an interview on 8/31/23 at 1:15 PM CNA #4 stated that they do use the straps to secure the catheters, but that Resident #12 did not like them. CNA#4 stated they had not cared for Resident #12 in past 2 weeks and were unaware if the open areas on the resident's buttocks or scrotum were new. During an interview on 9/1/23 at 10:52 AM RNM#2 stated that the resident should be wearing a leg strap to secure the catheter from pulling and that staff should attempt to put one on and notify the RNM if the resident refused. RNM #2 stated that Resident #12 had been on Medihoney for a long time and that they should notify the medical team if it is not working and get new orders. 10 NYCRR 415.11 (c)(1)

Based on observation, interviews, and record review conducted during an Recertification Survey at Huntington Living Center and Geneva Living Center North, from 8/28/23 to 9/1/23, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one of five residents reviewed for unnecessary medications, and for one of one resident reviewed for edema (swelling of the tissues due to excess fluid). Specifically, the facility did not ensure that the bowel protocol was initiated as ordered by the physician for Resident #158. For Resident #36, the facility did not ensure that the resident's soap was used appropriately per manufacturer's guidelines or as ordered by the physician for a chronic skin condition. This is evidenced by the following: The facility policy Bowel Management Guidelines and Protocol, dated reviewed/revised on 11/22/21, included: Nursing staff will monitor resident's bowel elimination status by reviewing the clinical alerts at the start of the shift and communicate alterations in bowel elimination through shift to shift report. For residents who have not had a bowel movement recorded in two days (six shifts) the appropriate medications/protocol will be administered/implemented. (See Bowel Protocol) If the resident has not had a bowel movement by day three, the nurse manager/Registered Nurse (RN) will assess the resident's bowel status, including to check the resident for signs of possible constipation and/or impaction, assess routine medications for trends or patterns relative to bowel function, and notify the medical provider if the clinical findings warrant further intervention. The following protocol will be followed for all residents unless contraindicated, or otherwise ordered by the medical provider and include but not limited to that if no bowel movement in two days (six shifts) staff to administer milk of magnesium (laxative) and lactulose (laxative). If no bowel movement on day three, administer bisacodyl suppository (laxative) rectally. If no bowel movement, contact medical provider for further recommendations and orders. 1.Resident #158 had diagnoses that included Alzheimer's disease, mood disorder, and constipation. The Minimum Data Set (MDS) assessment dated [DATE], documented that the resident was severely impaired cognitively, required extensive assist for toileting and was occasionally incontinent of bowel. Review of Resident # 158's current Physician orders revealed Miralax (a laxative) daily, senna tablet (stool softener) daily and changed on 8/22/23 to sennosides-docusate (stool softener + laxative) daily and bisacodyl suppository rectally as needed for constipation-bowel protocol-no BM for three days. Additionally, the provider ordered sennosides two times a day for no BM for eight days on 8/23/23 and discontinued on 8/25/23 and an enema due to no BM for eight days (may repeat in one hour if no results)was also ordered on 8/23/23. The August 2023 BM report documented that Resident #158 had no documented bowel movement for six days (8/9/23-8/14/23) and again for seven days (8/24/23- 8/30/23. Review of the Medication Administration Record (MAR) dated 8/1/23 - 8/31/23, and the August 2023 BM report revealed neither the bowel protocol nor the physician orders had been followed promptly for the two periods of no BM for more than three days. Additionally, an enema was required on 8/24/23 (day eight) when no BMs had been recorded after seven days. During an interview on 8/31/23 at 1:21 PM, Licensed Practical Nurse (LPN) #1 stated if a resident had a BM, the Certified Nurse Assistant (CNA) should document in the electronic medical record (EMR) and notify the nurse. If the CNA does not notify the nurse, the nurse should check the EMR. LPN #1 stated that if a resident had not had a BM in two or three days (some residents have orders for two days), the EMR will send an alert to the nurse, which they are supposed to check every shift and depending on the physician order, they should start the bowel protocol and administer a medication. During an interview on 8/31/23 at 3:29 PM, CNA #1 stated that if a resident had a BM, the CNAs document it in the EMR and include the size and consistency. CNA #1 stated that they also document in the EMR if the resident did not have a BM. During an interview on 9/1/23 at 10:11 AM, Registered Nurse Manager (RNM) #1 stated that they check the EMR every morning for resident alerts if no BM in two to three days. RNM #1 stated that their expectation is that the nurses check the EMR BM alerts at the beginning of their shift and if the resident had not had a BM in three days, the nurses should review the resident's orders to see what medications should be administered. RNM #1 stated that almost every resident should have an order for a medication if no BM in three days, but if they did not, they would expect the nurse to notify them and they would contact the Nurse Practitioner. RNM #1 stated that Resident #158 is often on the bowel list (list of residents with no BM in three days). After review of Resident #158's Bowel Record and MAR for August 2023, RNM #1 stated that the nurses had not followed the bowel protocol. 2. Resident #36 had diagnoses including obesity, lymphedema (swollen extremities due to damage to the lymph nodes), skin excoriation disorder (chronic skin-picking), and a stage 2 pressure ulcer (shallow open skin ulcer). The MDS assessment dated [DATE] documented that the resident was cognitively intact, had moisture associated skin damage and a pressure ulcer. Review of the Comprehensive Care Plan dated 10/14/21 documented that Resident #36 would get a weekly bed bath and required extensive assistance with daily bathing. Review of the Physician orders dated 4/22/22 revealed an order for Hibiclens (antiseptic skin cleanser) Liquid 4%, apply to skin topically every morning and at bedtime for skin hygiene to abdominal folds, groin, perirectal, and the front and back of both legs. Review of the August 2023 Medication Administration Record revealed the Hibiclens had been documented by a nurse as being administered as ordered twice daily. In a medical provided note dated 6/13/23 Nurse Practioner (NP) #1 documented that Resident #36 was evaluated for an open area to their left ankle. The physical exam revealed the resident had a small open are to their calf that was reddened and macerated (skin breakdown due to moisture). The cause was most likely due to friction and lack of complete drying after being bathed and the plan for treatment included to dry all skin folds well after bathing. In a nursing progress note dated 6/29/23 the Director of Nursing (DON) documented that Resident #36's posterior left thigh continued to be grossly excoriated and was breaking down due to increased moisture. In a nursing progress note dated 8/7/23 LPN #6 documented that the resident continued with a treatment to the back of their left thigh. During an observation on 8/31/23 at 11:05 AM, CNA #5 and CNA #9 were providing care to Resident #36. The resident had severe lymphedema to both legs and multiple areas of excoriation to the back of both legs, the left hip, and abdominal folds. Using a wet washcloth, CNA #5 squeezed approximately 1/4 cup of Aloe Vesta Body Wash and Shampoo (facility stock of liquid bath soap) onto the washcloth without diluting (reducing the concentration of a liquid) the soap. The two CNAs proceeded to wash the resident's entire body, including the front and back of both legs, with the soapy washcloth which produced a white lather on the resident's skin. The CNAs then pat dry the resident's skin without rinsing off the lather. Review of the manufacturer's instructions for use of the Aloe Vesta Body Wash and Shampoo revealed that for 'no rinse' bathing two fluid ounces of the solution should be diluted in one gallon of warm water and then used with a washcloth to gently cleanse the skin and pat dry. During an interview on 8/31/23 at 2:48 PM, CNA #5 and CNA #9 both stated they had used the Aloe Vesta Body Wash and Shampoo and that it was a no-rinse liquid soap. When asked if they aware of the soap requiring dilution both CNAs stated they did not dilute it and that they used as they were instructed to. During an interview on 8/31/23 at 4:12 PM, LPN #4 stated they thought the soap used by the CNAs to wash Resident #36 was the Hibiclens liquid that was prescribed for the resident and that they (LPN #4) signed off for. LPN #4 stated skin breakdown was a big concern for this resident. During an interview on 9/1/23 at 10:05 AM, Registered Nurse Manager (RNM) #4 stated they were unaware that the Aloe Vesta Body Wash and Shampoo needed to be diluted. 10 NYCRR 415.12

Based on observations, interviews, and record reviews conducted during a Recertification Survey 8/28/23 to 9/1/23, it was determined for one (Resident #104) of one resident reviewed for range of motion (ROM) services at Huntington Living Center and for one (Resident #150) three residents reviewed for position and mobility at Geneva Living Center South, the facility did not ensure that a residents with limited ROM received appropriate treatment and equipment to prevent a further decline. Specifically, for Resident #104 the facility did not ensure the resident who had increased edema (swelling) and limited ROM to both hands was evaluated by a therapist per physician orders in a timely manner. For Resident #150, the facility did not ensure the resident had wheelchair safety equipment in place as recommended by Physical Therapy (PT) for proper and safe positioning. This evidenced by the following: 1.Resident #104 had diagnoses including dementia, depression, and unspecified edema. The Minimum Date Set (MDS) assessment dated [DATE] documented that Resident #104 had severely impaired cognition, required extensive assistance with eating, and had no functional impairment of the upper extremities. The facility policy Initiating Rehabilitation Therapy Services, dated 4/20/22 documented rehabilitation therapy services will be initiated with notification to the rehabilitation services department. A notification that a therapy order has been written is sent to the rehabilitation service printer. The notification is placed in the appropriate therapist's mailbox. The therapist adds the patient to his/her schedule and sees the patient. Review of the Comprehensive Care Plan dated 11/15/21 revealed that Resident #104 had an Activities of Daily Living (ADL) self-care performance deficit or limited physical mobility related to dementia with interventions that included PT and Occupational Therapy (OT) evaluation and treatment per physicians' orders. During an observation and interview on 8/30/23 at 1:51 PM, Resident #104 was sitting in a chair and both hands were observed in a fisted position and slightly swollen. The resident was unable to open their fingers on command and stated that they had pain in their hands but could hold a fork. Resident #104 stated they did not wear any splints. Physician orders dated 8/18/23 documented an order to obtain an OT evaluation for contractures (tightening of muscle, tendons, ligaments, or skin that prevents normal movement and can cause pain) of both hands. Review of Resident #104's electronic medical record and the resident's paper chart 8/18/23 through 9/1/23 did not include any documented evidence that an OT evaluation was completed per physician' order. During an interview on 8/31/23 at 10:12 AM, Unit Clerk (UC) #1 stated all therapy notes are on paper and located in the paper chart. If a resident is seen for an evaluation, the therapist will usually bring the paper copy to them the same day. During an interview on 8/31/23 at 12:17 PM, Certified Nursing Assistant (CNA) #2 stated they were familiar with Resident #104 and had noticed in the past couple months that their fingers were more often in a fisted position. CNA #2 stated that the resident could not feed themself or hold a cup and when they try to range the resident's fingers the resident complains of pain. During an interview on 8/31/23 at 12:42 PM, Licensed Practical Nurse (LPN) #2 stated PT/OT referrals are sent verbally and that they call on the phone or let them know if they see them on the unit. There was no written form used. LPN #2 said that Resident #104's hands had been that way for a while and that they did not use a splint or wash cloth rolls in their hands. LPN #2 was unsure if an evaluation had been ordered. During an interview on 8/31/23 at 3:20 PM, the Rehabilitation Manager (RM) stated during morning meeting physician orders are discussed and should be on the 24-hour report. Nursing will stop in or call on phone to communicate to therapists the need for an evaluation. The RM said that there was an OT evaluation ordered on 8/18/23 but the order was not in the PT/OT computer system which is how nursing and therapy communicate together. The RM stated that nursing is responsible for putting the order in the system but that it was not currently in the system and the evaluation which should have been done by now was not completed. Resident #104 was last seen in June 2023 During an interview on 9/01/23 at 8:44 AM, Registered Nurse Unit Manager (RNM) #1 stated they noticed Resident 104's hands were contracted a couple of weeks ago and reported it during morning report. The physician order was obtained and would usually go to the UC who would enter it in the computer system for PT/OT. In this case, the night shift nurse signed off on the order before the UC could see it, so the order never made it to PT/OT. 2. Resident #150 had diagnoses including intellectual disabilities, failure to thrive and dysphagia (difficulty swallowing). The MDS assessment dated [DATE] documented that Resident #150 had severely impaired cognition and required assist ADLs. Resident #150's current CCP, and Kardex (care plan used by the CNAs for daily care) did not include the use of footrests and/or a calf pad (a pad attached to the wheelchair for safety and positioning). Review of physician orders following a recent readmission from the hospital revealed orders for PT and OT evaluations status post readmission to the facility. Review of PT discharge summary dated 7/21/23, revealed for wheelchair mobility on and off the unit, Resident #150 was dependent in a wheelchair with bilateral (both left and right) footrests and a calf pad on the wheelchair. During observations on 8/28/23 at 9:52 AM and again on 8/30/23 at 9:44 AM Resident #150 was in their wheelchair across from the nurse's station with their bare feet on floor. There was no footrest or calf pad on the wheelchair. During an interview on 8/30/23 at 3:18 PM the RM stated that when residents return from hospitalization s a therapy evaluation is ordered and Resident #150 was picked up by PT on 7/3/23. During an interview on 9/1/23 at 9:55 AM RNM #4 stated PT would communicate recommendations and provide the calf pads, but the resident's unit should have the footrests for the wheelchair. During an interview on 9/1/23 at 11:40 AM Physical Therapist #1 stated if therapy had recommendations for a resident, it should be written in a note in the resident's electronic medical record, therapy would then communicate with nursing and therapy would provide the calf pads. 10 NYCRR 415.12 (e)(2) 38878

Based on observations, interviews and record reviews conducted during the Recertification Survey at Geneva Living Center South 8/28/23 to 9/1/23, it was determined that for one (Resident #86) of one resident reviewed for smoking, the facility did not ensure that the resident environment remained free of accident hazards as possible. Specifically, Resident #86 was observed smoking in an unsafe area several times and the facility was unable to provide evidence that the resident had been assessed for safe smoking. This is evidenced by the following: The facility policy Smoking Assessment Guidelines, review date of 3/30/23, included that smoking is not allowed on facility property. A resident who is physically and cognitively able to leave the facility property with the intent of using tobacco products will be assessed for their capability to smoke unsupervised and unattended. If a resident chooses to smoke off facility property, a Smoking Safety Screen (an assessment) will be completed by the interdisciplinary team. Review of the list of residents who smoke provided by the facility revealed that the facility had no current residents that smoke. Resident #86 was recently admitted to the facility with diagnoses that included gangrene to bilateral legs (death of body tissue due to lack of blood flow), bipolar (mood swings from depressive lows to manic highs), and pain. The Minimum Data Set assessment dated [DATE], included that Resident #86 was cognitively intact, required assistance to leave the resident's unit and was a current tobacco user. Review of current Physician orders did not include any smoking cessation products. Resident #86's current Comprehensive Care Plan and Kardex (the care plan used by the Certified Nursing Assistant (CNA) for daily care) did not include any information regarding smoking or a history of smoking. A Physical Therapy Assessment completed 8/1/23 included that Resident #86 had been instructed on wheelchair mobility in their room, on their unit and on the facility's front patio. The Assessment did not include any other areas or offsite of the facility. In an interdisciplinary progress note dated 8/1/23, Social Worker (SW) #1 documented that Resident #86 was found outside in the employee parking lot smoking a cigarette with a CNA. The resident and the CNA were made aware that smoking should take place off the property at all times. In observations on 8/29/23 at 7:58 AM, 9:50 AM, and again at 3:22 PM Resident #86 was seated in a wheelchair located in the street in front of the facility smoking cigarettes. On two of the occasions the resident was in the crosswalk smoking and on the third occasion, the resident wheeled themselves backward up a hill and remained in the street smoking while vehicles drove by, and a staff member walked past the resident without stopping. During an interview on 8/30/23 at 11:50 AM SW#1 stated they were aware that Resident #86 was going further than the patio due to a smoking incident that occurred about a month ago when they saw a CNA and the resident smoking in the parking lot. SW #1 stated they were aware that the resident was outside smoking again today and that the resident told them they received cigarettes from visitors. During an interview on 8/30/23 at 12:01 PM Registered Nurse Manager (RNM) #1 stated there was a smoking episode when Resident #86 was first admitted . When observed smoking on 8/1/23, RN #1 stated that a progress note should have been written and a Smoking Safety Assessment should have been completed. RNM #1 stated the CCP had not been updated, and smoking cessation had not been offered or ordered because Resident #86 had not been mobile at that time and had stated they were not going to smoke. During an interview on 8/31/23 at 2:46 PM the DON stated any Registered Nurse could complete the smoking assessment and one should be completed when there is a history of smoking or in cases where a resident is observed smoking outside. The DON stated they did not know why a smoking assessment had not been completed for this resident but should have been. During an interview on 8/31/23 at 3:46 PM the Administrator stated safe smoking assessments should be completed when the facility has knowledge that a resident has a preference for smoking. The Administrator stated that they were not aware of the smoking incident on 8/1/23 or that Resident #86 kept smoking materials in their room. 10 NYCRR 415.12(h)(1)

Based on observation, interviews, and record review conducted during the Recertification Survey 8/28/23-9/1/23 the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, one (Huntington Living Center) of two main kitchens had issues with the dish machines' wash cycle that did not reach adequate temperatures for sanitizing and was being logged by facility staff as inadequate multiple times for August 2023, with no action taken by the facility. In addition, a dietary employee with not wearing a beard guard/net over their facial hair while serving on the food tray line. The findings are: The facility policy Dishwashing revised 2016 documented the purpose is to prevent the transmission of disease carrying organisms. Dish machine temperatures are taken and recorded after each meal at the beginning of the wash cycle. Temperatures should be monitored throughout the process to ensure they stay at required minimum levels. If the dish machine temperatures do not meet minimum requirements of wash at 160 degrees Fahrenheit ( F) and final rinse 180 F, stop and notify your supervisor. The undated facility policy Professional Dress Standards documented professional dress standards were adopted to facilitate a healing environment and to ensure that all employees maintain personal cleanliness, good grooming, and appropriate dress while at work. New York State Department of Health requires all food service employees to wear a hair net or bonnet which completely contains the hair. Men choosing to have facial hair must wear a beard cover at all times when working around or serving food. 1. During an observation on 8/29/23 at 9:26 AM the breakfast trays were being washed through the high temperature dish machine. While the dish machine went through three cycles of washing, the wash temperature gauge did not move off of the 140 F line for all three cycles. Above the gauges on the machine there was a metal plate by the manufacturer which read Wash 160 F, Rinse 180 F. Review of the Dishwashing/Warewashing Machine Temperature Log dated August 2023 revealed for the high temperature machine: (Refer to machine data plate for temperature requirements) Temperature Requirements: Wash 160+, Final Rinse 180+. Between the dates 8/1/23 to 8/29/23, out of 85 meals recorded, 28 wash temperatures were below 160 F and 16 were blank. Review of the Manufacturer Service Reports for the high temperature dish machine with service appointment dates revealed the following: On 6/9/23 replaced parts listed and tested -ok. Found unit has a faulty wash temperature gauge. Ordered part. On 6/12/23 while replacing water gauge, the adapter broke into pieces. Plugged hole so customer can use and ordered adapter parts. On 6/16/23 the unit was leaking at prewash motor gasket. Ordered parts. Installed adaptor and thermometer. Verified proper temperature. On 6/30/23 wash temperature not maintaining 160 F minimum while in use. Thermostat set to shut off at 164 F. Increased to maintain 160 F. tested operational. Review of the Manufacturer Service Report for the dish machine dated 8/29/23 (after surveyor interventions) revealed upon arrival customer stated wash tank wasn't getting up to temperature, tested water temperature and found thermometer faulty. Will order part. During interviews on 8/29/23 at 9:43 AM and again at 1:50 PM the Food Service Manager (FSM) stated the dish machine is a high temperature dishwasher and that 140 F is not acceptable for the wash cycle. They stated the wash cycle should be at least 160 F as they go by the tag on the machine which states 160 F. The FSM stated the last time the manufacturer was in to look at the machine they were told the machine was ok and working properly. The FSM stated that the temperatures for the dish machine are recorded by the supervisors at the beginning of each meal wash on the dish machine temperature log. The FSM stated if the temperatures are not adequate, they would expect the supervisors to take corrective action such as calling the manufacturer which they should have done when they first noticed the machine was not getting up to temperature. During an interview on 8/30/23 at 2:49 PM Food Service Supervisor (FSS) #1 stated they take the temperatures for the dish machine prior to washing the meal dishes. They stated they record the temperatures on the temperature log and if there is an issue with the temperatures, they would call the manufacturer to come in to look at the machine and fix it. The FSS #1 stated they have contacted the manufacturer and they were told that the water is up to temperature, and it was just the temperature gauge not working properly. The facility was unable to provide any plans for fixing the temperature gauge. 2. During a lunch tray line observation on 8/30/23 between 11:55 AM to 12:20 PM Dietary Aide (DA) #1 had facial hair approximately 1/2 of hair growth on the cheeks, chin/under the chin and below the nose with no beard net on the face. DA #1 placed cold beverages and desserts on the resident's trays which had plates of uncovered food. Additionally, they were standing directly across from the hot food station that contained uncovered food. During an interview on 8/30/23 at 1:50 PM the FSM stated DA #1 should have been wearing a beard net. The FSM stated DA #1 had been spoken to about this before regarding wearing them anywhere around food and that there should be beard nets available next to the hairnets in the kitchen. In an observation at this time, there were no beard nets found, and the FSM stated they would get some from their other facility. During an interview on 8/30/23 at 2:28 PM DA#1 stated they were told a while ago that they need to wear a beard net and that there used to be beard nets in a area by the hair nets, but there were none over there. They stated they have asked where they were but was not given an answer. 10NYCRR: 415.14(h) 14-1.72(c), 14-1.113(b)

Based on observation, interviews and record review conducted during the Recertification Survey at Huntington Living Center 8/28/23-9/1/23 the facility did not ensure for one (Resident #104) of six residents reviewed for Activities of Daily Living (ADL's), that staff members (non-nursing) working in the facility and feeding residents had successfully completed a New York State approved training program. Specifically, the facility did not ensure that a unit clerk (UC) who was observed feeding a resident had been trained through a state approved paid feeding assistant program per the regulations. This is evidenced by the following: Resident #104 had diagnoses including dementia, depression, and unspecified edema (swelling in the extremities). Review of the Minimum Date Set assessment dated [DATE] documented that Resident #104 had severe impairment of cognitive function and required extensive assist with eating. The comprehensive care plan dated 11/15/21 documented Resident #104 had an ADL self-care performance deficit or limited physical mobility related to dementia with interventions that included under Eating that the resident is totally dependent and assistance level may vary depending on the resident's willingness to participate in the task. During an observation and interview on 8/31/23 at 12:44 PM UC #1 brought a lunch tray into Resident #104 room, opened all the items on the tray and sat down and began to feed Resident #104 who was sitting up in a chair. UC #1 stated they were not a Certified Nurse Assistant (CNA) or Paid Feeding Assistant but that they were able to feed Resident #104 and had done so in the past. UC #1 stated that Resident #104 was unable to feed their self for a long time now. UC #1 said they had taken a feeding course when hired but was unsure if the program was state approved. During an interview on 8/31/23 at 1:23 PM the Director of Nursing (DON) stated the three UCs were trained in feeding assistance. The DON was unsure who trained the UCs or if it was a state approved program. The DON also stated they did not have a policy on the training program. During a phone interview on 9/01/23 10:07 AM the CNA Program Coordinator (for long term education) stated that their previous educator put the feeding program together but was not sure if it was state approved. They also believed the feeding program was put together to train staff during the covid waiver. They were unsure if there was a policy available. During a phone interview on 09/01/23 at 1:10 PM the Registered Nurse/CNA Program Coordinator stated they were unable to find the state approval documentation for the facilities Paid Feeding Assistant Program or a policy. During the pre-exit interview on 9/1/23 at 1:50 PM the Administrator for Geneva Living Center North and South stated that staff members were allowed to assist feeding residents during COVID and that they (the facility) never followed up on the issue (regarding appropriate training) after COVID. 415.26 (k) (1)

Based on interviews and record review conducted during an Abbreviated Survey (#NY00305250) completed [DATE] it was determined that for one (Resident #1) of three residents reviewed the facility did not ensure that all nursing staff possessed the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being. Specifically, the facility did not provide education and review competency for initiating, responding and participating in a resident medical emergency such as cardiac arrest. Resident # 1 experienced a cardiac arrest and licensed staff did not activate a code response and did not initiate CPR (cardio-pulmonary resuscitation) in a timely manner. This was evidenced by the following: The facility policy Basic Life Support (BLS), CPR and AED (automated external defibrillator), dated [DATE], included that all staff shall receive education regarding the facility's BLS policies and procedures. All nurses must undergo training/renewal of BLS for Health Care Providers every two years. Training shall be conducted by certified instructors of the American Heart Association. CPR Guidelines for Residents without 'Do Not Resuscitate' status (including AED use) included that the first staff member to recognize an actual or threatening cardiopulmonary arrest situation must page Code 99. The following staff must respond to the unit where the code occurs: the Nurse Manager/Supervisor, the Charge Nurse of the unit, other CPR trained staff as designated by the nurse leading the code, and any licensed practitioner in the building at the time of the code. The staff member responsible for directing the code shall assess the need for and request the AED. The staff member closest to the AED device must bring it to the designated area. The charge nurse must initiate cardio-pulmonary resuscitative efforts and direct other staff until such time that another RN or EMS personnel arrive on the scene. The facility must conduct bi-annual drills to demonstrate and evaluate compliance with the facility's policy and acceptable standards of practice with respect to the identification of resuscitative status, response to a resident event, and the administration of BLS in the facility. A written record of each drill shall be retained in the Nursing Administration office. Resident #1 was admitted to the facility [DATE] for short term rehabilitation with diagnoses that included a recent knee injury, gastroesophageal reflux disease or GERD, a history of drug use, a recent urine tract infection and high blood pressure. The Minimum Data Set assessment dated [DATE], included that the resident was cognitively intact. Physician orders dated [DATE], included the resident was a Full Code (indicating that CPR would be initiated in the event of cessation of heart rate or respirations). Review of the facility investigation, signed by the Director of Nursing (DON) and dated [DATE], revealed that on [DATE] the Registered Nurse (RN) Supervisor received a call shortly after 3:05 p.m., from Licensed Practical Nurse (LPN) #1 that Resident #1 was not breathing and without a pulse. The RN Supervisor informed LPN #1 that the resident was a full code. When the RN supervisor arrived at the resident's room a few minutes later LPN #1 and LPN #2 were both standing outside the resident's room and the resident was in a recliner chair in an upright position. Neither LPN had initiated CPR, called the code (overhead page) or called 911. The RN Supervisor verified that the resident was in cardiac arrest, instructed the LPNs to begin CPR and get an ambu bag (bag used to give breaths), told the Certified Nursing Assistant (CNA) #1 to call 911, and the RN Supervisor went to get an AED machine (instead of initiating CPR). The investigation included that the Police arrived, moved Resident #1 to the floor and initiated CPR. The facility investigation revealed the RN Supervisor was called shortly after 3:05 p.m. and 911 was not called until 3:13 p.m. When LPN #1 was asked why they did not start CPR or call the code overhead, LPN #1 stated they were waiting for the Supervisor to evaluate. Of note, Resident #1 was properly identified as a FC with a green label on the binder of the medical record, green dot on name plate outside room, and a green ID bracelet (per facility policy). The facility investigation conclusion included multiple staff failed to follow BLS policy, failed to activate the code timely, and failed to initiate CPR timely. Review of the Ambulance Report, dated [DATE], revealed that the resident airway was fully obstructed by large amounts of coffee ground emesis (usually an indication of internal bleeding) and resuscitation was not successful. The resident was pronounced deceased at 3:51 p.m. When requested, the facility was unable to provide any documented evidence of education and/or competencies related to Cardiac Events or the process for a FC event in the past year. Review of full house audit of licensed staff CPR certifications revealed that all staff certifications were current. During an interview on [DATE] at 2:24 p.m. the RN Supervisor stated when a resident who is a FC is found without a pulse and not breathing, CPR should be started immediately. The RN Supervisor stated they did not begin CPR because there was no ambu bag and did not instruct staff to initiate CPR. The RN Supervisor stated they did not call the code over head as they felt they had enough help. During an interview on [DATE] at 3:04 p.m. LPN #1 stated they were CPR certified and when one comes upon an unresponsive patient, they should call for help and start CPR. The LPN stated they knew Resident #1 was a FC and that they called the supervisor. When asked why they did not start CPR immediately, LPN #1 did not provide an answer. LPN #1 stated they had never been involved in a code before and had never found someone with no pulse or respirations. The LPN stated the facility had not provided education on the process during a code or had ever practiced a code but that they did practice CPR quarterly via an online Heart Association Program. When interviewed on [DATE] at 11:55 a.m. CNA #1 stated if they were asked to get emergency equipment such as AED or an ambu bag they did not know where they were located. During an interview on [DATE] at 1:45 p.m., and again on [DATE] at 12:22 p.m., the Director of Nursing (DON) stated their expectation was that if a nurse entered a resident's room, who was a full code, and determined the resident was not breathing and/or had no pulse, the nurse should initiate CPR. The DON stated CNAs are supposed to get training on their role in an emergency and should know where emergency equipment is kept. The DON stated they could see education was needed on code response. When interviewed on [DATE] at 8:24 a.m., the medical provider stated that the evidence of coffee ground emesis and blood in the resident's airway would indicate a medical event had occurred. The medical provider indicated the medical event could have contributed to the outcome for the resident. The medical provider indicated the documentation of the events would be completed after the event and therefore they would question if there had been a delay. 10 NYCRR 415.13

Based on observations, interviews, and record reviews conducted during a Recertification Survey at the [MEDICATION(S)] North and South and [CONDITION(S)] Living Centers, completed on 7/22/22, it was determined that for six (Residents #112, #150, #330, #329, #163, and #336) of eight residents reviewed for Baseline Care Plans (BCP), the facility did not ensure that the BCP was reviewed with, and a written copy provided to the resident and/or the resident representative as per the regulations. This was evidenced by the following: Review of facility policy Baseline Care Plan, dated as last reviewed on 11/22/21, documented that the policy of the facility was to develop a BCP within 48 hours of admission and that a summary of the BCP would be provided to the resident and/or their representative to provide information on the initial plan for delivery of care and services. The BCP summary should include initial goals for the resident, a list of current medications, dietary instructions, services and treatments to be administered by the facility, and any updated information based on details of the admission comprehensive assessment as necessary. In addition, a copy will be maintained in the medical record, signed by an Interdisciplinary Care Team representative, and the resident or their responsible party. The facility has the option of completing a Comprehensive Care Plan (CCP) instead of a BCP if the CCP is completed within 48 hours and follows the Resident Assessment Instrument process (the assessment and care planning process for all long-term care residents to ensure quality of care from admission and ongoing) requirements. A written summary of the CCP must then be provided to the resident and resident representative in a language they can understand. 1.Resident #150 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Date Set (MDS) assessment dated [DATE], documented that the resident was moderately impaired cognitively. The BCP Summary dated 6/8/22, included that the resident was admitted for long term care services and was on a regular diet. The rest of the form (Social Services, Therapy, Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility could not provide evidence that the BCP Summary or the CCP was reviewed with, and a copy of the summary or CCP provided to the resident and/or their representative. During an interview on 7/21/22 at 8:57 a.m., Registered Nurse Manager (RNM) #1 stated that the resident's BCP Summary consisted of a form that was completed by various disciplines (i.e., Physical Therapy, Dietary, Social Services, Medical, etc.), with input on the resident's diet, activities of daily living such as transfer status, and any additional information obtained from Social Work. RNM #1 stated that the BCP Summary form is usually filled out starting on the day of the resident's admission, completed within 24-48 hours, signed by those completing the form and the resident or their representative, and filed in the resident's paper chart. RNM #1 stated that the resident's Kardex, (the care plan used by the Certified Nursing Assistants that includes all activities of daily living and assist needed) is printed and reviewed with the resident or their representative within a week. RNM #1 stated that there is no specific individual designated as being responsible to review the BCP Summary or Kardex with the resident or their representative, as it is a group effort amongst the involved disciplines. During an interview on 7/22/22 at 10:23 a.m., Director of Nursing (DON) #1 and Assistant Director of Nursing (ADON) both stated that CCPs are developed within 48 hours of a resident's admission, instead of a BCP and that each discipline completed their related part of the care plan as soon as possible. DON #1 stated that the expectation was that the BCP Summary is then reviewed with the resident and/or their representative and that a progress note is written documenting the discussion. The DON and ADON said that the BCP forms should have contained all the appropriate information related to the residents' plan of care and should have been signed by either the residents or their representatives. 2.Resident #329 was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Assessment, dated 7/6/22, revealed the resident was cognitively intact. Review of the resident's Electronic Medical Record (EMR) did not include evidence that a BCP Summary or the CCP was reviewed with the resident or their representative. 3.Resident # 330 was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Assessment, dated 7/16/22, revealed the resident was moderately impaired cognitively. Review of the resident's Electronic Medical Record (EMR) did not include evidence that a BCP Summary or the CCP, dated as initiated 7/12/22, was reviewed with the resident or their representative. During an interview 7/20/22 at 9:46 a.m. RNM #2 stated a full CCP should be completed the day of admission and a copy offered to the resident/family during the interdisciplinary care meeting if they want one. The RNM stated the meeting is usually within the first two weeks of admission. During an interview on 7/20/22 at 11:27 a.m., DON #2 stated they typically do not complete a BCP on the transitional care unit, they develop the CCP the day of admission. DON #2 stated when the team meets, they should review the CCP with the resident and/or their family. DON #2 stated the RNM should provide a written copy which should include a medication list and document who the copy was provided to but this was not done. 10NYCRR 415.11(c)(1)

Based on observations, interviews, and record reviews, conducted during the Recertification Survey, completed on 7/22/22, it was determined that for one ([CONDITION(S)] Living Center) of two main kitchens, the facility failed to store, prepare, distribute and serve food in accordance with professional standards (U.S. Food and Drug Administration's Food Code) for food service safety. Specifically, there were multiple open, undated, and unlabeled food items and a non-food contact surface within the kitchen was not maintained in a clean and sanitary condition. This is evidenced by the following: The facility policy, 'Food Storage', reviewed/revised March 2022, included that all foods stored after opening or preparation would be securely covered, labeled, and dated. The facility policy, 'Equipment Sanitation', reviewed/revised March 2022, included that a cleaning and sanitizing schedule, with procedure, was established and followed by assigned personnel. Adherence to the schedule is the responsibility of the Food Service Supervisor and is monitored by the Food Service Director. Observations during the initial brief tour of the main kitchen on 7/18/22 from 10:30 a.m. to approximately 11:30 a.m. revealed the following: a. A container of what was identified by the Kitchen Supervisor as pesto, was undated and unlabeled, in the walk-in refrigerator. b. A carton of egg substitute, a five-pound (lb.) bag each of mozzarella cheese and cheddar cheese, two large bags of parmesan cheese and an eight lb. container of macaroni salad were opened and undated, in the walk-in refrigerator. c. A large bag each of what were identified by the Kitchen Supervisor as chicken fingers, tortellini, stuffed shells, chicken nuggets, pork chops, french fries, french toast, shrimp, meatballs and tator tots were opened and undated, in the walk-in freezer. d. A large bag each of egg noodles, rotini, spaghetti, tri-color pasta, penne, elbows, a large box of spice cake, containers of what were identified by the Kitchen Supervisor as powdered sugar, mashed potato mix, cornflakes, and milk powder were open and undated, in the dry storage area. Observations during the follow-up tour of the main kitchen on 7/20/22 at 11:32 a.m. to approximately 12:40 p.m. revealed the following: a. A carton of egg substitute, a bag each of parmesan cheese, flour wraps and cooked green peas, and an eight lb. container each of macaroni salad were opened and undated, in the walk-in refrigerator. b. The non-food contact surfaces of a piece of grill-top cooking equipment in the cook's area were covered in an accumulation of dried-on brown and tan drips and food debris. c. A bag each of what was identified by the Kitchen Supervisor as beef fajita pieces, mozzarella sticks, shrimp, chicken pieces, and fried green beans were open and undated, in the walk-in freezer. During an interview on 7/18/22 at 11:15 a.m., the Kitchen Supervisor stated that everyone is responsible for labeling and dating and that they were not aware that food required dating after opening. During an interview on 7/20/22 at 12:11 p.m., the Kitchen Supervisor stated that all kitchen staff have cleaning tasks assigned to them and a daily sanitation audit was completed to ensure cleaning tasks were completed. The Kitchen Supervisor stated that they were responsible to make sure all equipment is cleaned. The Kitchen Supervisor stated that sometimes it doesn't get done. During an interview on 7/21/22 at 10:40 a.m., the Registered Dietitian stated that they were clinically based (not involved with kitchen issues). During an interview on 7/22/22 at 10:40 a.m., the Director of Nutritional Services stated that everyone should have contributed, and that cleaning is built into daily staff assignments. The Director of Nutritional Services stated that the supervisors were responsible to make sure the required tasks were done at each site. 10NYCRR: 14-1.10, 14-1.21, 14 -1.31, 14-1.43, 14-1.110 U.S. Food and Drug Administration's (FDA) Food Code Centers for Disease Control and Prevention's (CDC) food safety guidance

Based on observations, interviews, and record reviews, conducted during the Recertification Survey, completed on 7/18/22 to 7/22/22, it was determined that for one ([CONDITION(S)] Living Center) of two facility sites, the facility failed to dispose of garbage and refuse properly. Specifically, the garbage dumpster outside the facility was not equipped with a tight-fitting lid, door, or cover, which created a potential feeding and harborage area for pests. This is evidenced by the following: The facility policy, 'Environmental Sanitation', revised 2016, included that garbage cans will have a tight-fitting lid and that a pest control policy was in place and should be followed accordingly. Observations during the follow-up kitchen tour on 7/20/22 at approximately 12:15 p.m. revealed a large, rectangular, open-top, roll-off garbage dumpster outside the facility. There were garbage bags accumulating at the bottom of the dumpster and flying insects were evident around the dumpster. During an interview on 7/20/22 at 12:40 p.m., the Kitchen Supervisor stated that the garbage dumpster had been in place for one year and was emptied once a week and would become very malodorous. The Kitchen Supervisor stated there was never a tight-fitting lid, cover or door on the dumpster. The Kitchen Supervisor stated they have sighted racoons in the past three weeks and bees which some staff members were allergic to. During an interview on 7/22/22 at 9:52 a.m., the Director of Nutritional Services stated that they were aware that the garbage dumpster stored outside the facility should have had a tight-fitting lid. The Director of Nutritional Services stated they did not play a role in obtaining or negotiating the contract for the current garbage dumpster but had challenged the acquisition of the garbage dumpster but was unsuccessful in obtaining an alternate. The Director of Nutritional Services stated that they and maintenance were aware of the pests. 415.14 (h) 10NYCRR: 14-1.150(c)

Based on observations, interviews and record review conducted during a Recertification Survey at [MEDICATION(S)] Living Center South, completed on 7/22/22, it was determined that for one (Resident #163) of one resident reviewed for dental, the facility did not ensure the accuracy of the Minimum Data Set (MDS) Assessment. Specifically, the MDS Assessment did not identify Resident #163's oral status accurately. This was evidenced by the following: The facility policy Dental Services dated December 2017, included an initial screening of each resident's oral health status will be conducted within 24 hours of admission to determine need for emergency dental care. The facility policy MDS Assessments, dated 4/24/18, included that the MDS Assessment should accurately capture the resident's status at the time the MDS Assessment was completed and documentation in the medical record must support the MDS coding. To ensure accurate data exists nursing personnel will be responsible to complete a series of assessments to support MDS coding. Resident #163 was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Nursing Admission Assessment, dated 5/17/22 and completed by a Registered Nurse (RN), included that the resident had their own teeth and did not have any broken or carious teeth. Oral Assessments, completed by a RN and dated 5/20/22 and 5/27/22, included that Resident #163 had no obvious or likely cavities or broken natural teeth. The Admission MDS Assessment, dated 5/27/22, revealed that Resident #163 was cognitively intact and did not have any obvious or likely cavities or broken natural teeth. The Comprehensive Care Plan, dated 5/17/22 and revised 6/10/22 included that Resident #163 was independent with oral care, was at risk for nutritional issues and had a 9% weight loss since admission. The CCP did not include any indication of dental issues or interventions. During an observation and interview on 7/19/22 at 9:24 a.m., Resident #163 was observed to have some missing and some broken teeth and some likely cavities. The resident stated they had lost their top front teeth in an accident. During an observation and interview on 7/20/22 at 10:09 a.m., the RN Manager (RNM) stated they had completed Resident #163's nursing admission assessment, oral assessments and the MDS section for oral status. When observed at this time the RNM stated that Resident #163 did have some missing teeth, some broken teeth and some carious teeth. The RNM stated the nursing assessments and MDS were not accurate, and that Resident #163 should have been care planned for dental issues. During an interview on 7/20/22 at 11:27 a.m. the Director of Nursing stated a RN conducts the initial assessment which includes an oral exam, and the information should be accurate on the MDS Assessment and care planned for. 10NYCRR 415.11(b)

Based on observations, interviews, and record reviews conducted during a Recertification Survey at [MEDICATION(S)] Living Center North, completed on 7/22/22, it was determined that for one (Resident #100) of one resident reviewed for [CONDITION(S)], the facility did not ensure a Comprehensive Care Plan (CCP) was developed and implemented to meet the resident's medical, physical, mental, and psychosocial needs as identified in the comprehensive assessment. Specifically, Residents #100 's CCP did not address the monitoring or care required for their AV fistula (arterial venous surgical site used as an access for [CONDITION(S)] treatments). This was evidenced by the following: Review of the facility policy titled Care of Hemodialysis AV Fistulas, Vein Grafts, Or Catheters, dated September 2014, revealed that the AV fistula should be checked every shift for patency and that findings should be documented on the Medication Administration Record (MAR). Resident #100 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set Assessment, dated 5/31/22, revealed that Resident #100 was moderately impaired of cognitive function and received [CONDITION(S)] treatments. Review of the current CCP included that Resident #100 had renal failure due to [CONDITION(S)] ([CONDITION(S)]) and was receiving hemodialysis three time a week. The CCP did not address information related to the resident's AV fistula, goals, monitoring of, or interventions. Review of the current physician orders and Treatment Administration Record (TAR) revealed that Resident #100 was ordered to have their [CONDITION(S)] catheter checked every shift. The TAR was signed off that the resident's [CONDITION(S)] catheter had been checked every shift. There was no mention in the TAR related to the resident's AV fistula. Review of a nursing progress note dated 7/14/22 revealed that the resident had returned from [CONDITION(S)] with complaints of pain at their fistula site. During an interview on 7/20/22 at 11:27 a.m., the Director of Nursing (DON) stated a [CONDITION(S)] fistula should be checked for bruit and thrill (assess the blood flow to ensure patency of the fistula) every shift. The DON stated that following [CONDITION(S)] the pressure dressing over the fistula should remain in place for a period of time. The DON stated the site should be monitored for drainage, redness, and warmth (indications of infection). The DON stated there should be an order and it should be included on the TAR and addressed on the CCP. During an interview on 7/21/22 at 12:23 p.m. the Nurse Practitioner (NP) stated they expected the nurses to check the fistula site for bruit and thrill, monitor the site for bleeding and ensure the pressure dressing was left in place for two hours. The NP stated there should be orders for the care and monitoring of the AV fistula site. In an interview on 7/21/22 at 4:13 p.m., the Licensed Practical Nurse (LPN) stated that they check the bruit and thrill for a fistula as standard practice once a shift, signed off on the TAR and that the pressure dressings should stay on 24 hours after [CONDITION(S)]. The LPN stated that Resident #100's orders to check the [CONDITION(S)] catheter (as opposed to a fistula) were vague. 10NYCRR 415.11(i)

Based on observations, interviews, and record reviews conducted during a Recertification Survey at [MEDICATION(S)] North Living Center and [CONDITION(S)] Living Center, completed on 7/22/22, it was determined that two of eight residents reviewed did not receive the necessary services to maintain good grooming and personal hygiene. Specifically, Resident #131's was not provided assistance with nail care and Resident #143 did not receive nail care or skin care to the palm of a severely contracted hand. This is evidenced by the following: The facility policy, Nail Care, dated December 2020, included that care givers are responsible for cleaning fingernails and toenails weekly on the resident's scheduled shower day and as needed. Fingernails and toenails will be evaluated by the nurse on a weekly basis to determine if intervention is required. The nurse will either cut the nails, if indicated, or direct the Certified Nursing Assistant (CNA) to cut the nails. Note: CNAs are not to be directed to cut the nails of residents with diabetes, [CONDITION(S)], or on anticoagulant therapy (including aspirin). 1. Resident #131 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) Assessment, dated 6/7/22, documented that the resident had severely impaired cognitive function and was totally dependent on staff for personal hygiene. The Comprehensive Care Plan (CCP), dated 11/18/21, included that Resident #131 had a self-care performance deficit related to a stroke, was legally blind, and was scheduled to receive a shower on Wednesdays which required extensive assistance. During an observation on 7/18/22 at 11:43 a.m., Resident #131 fingernails were long with black debris under the nails. In an interview on 7/19/22 at 2:18 p.m., CNA #1 stated that Resident #131 required total dependence with activities of daily living (ADL) and that they had not been directed to check skin or nails during shower days but, that nail care is provided a couple times a week by an unknown staff member. In an interview on 7/20/22 at 9:35 a.m., Registered Nurse Manager (RNM) #1 stated that nail care should be done on a resident's shower day and is done by the CNAs, nurses, and/or activities staff. RNM #1 stated that Resident #131 is dependent on staff for all care. Review of the 'Weekly Skin and Grooming Check' note, dated 7/20/22 at 10:54 a.m. and signed by Licensed Practical Nurse (LPN) #1, revealed that Resident #131's nails had been cleaned and trimmed but when observed at 1:45 p.m., Resident #131's fingernails remained long with black debris under the nails. In an interview on 7/20/22 at 2:48 p.m., CNA #2 stated that they provided care for Resident #131 that day and did not trim or clean their fingernails. CNA#2 stated they knew that they needed to get done and that per facility policy nail care should be done on shower days. CNA #2 stated nail care had not been done due to Resident #131 being sick earlier in the day. CNA #2 stated that if care did not get done, it should be reported to the nurse. In an interview on 7/21/22 at 10:00 a.m., LPN #1 stated that CNAs provide nail care on resident shower days and as needed. LPN #1 stated that they had documented in Resident #131 electronic medical record (EMR) that their nails had been cleaned and trimmed because they were told by the CNA that nail care had been done. 2. Resident #143 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment dated [DATE], documented that the resident had severely impaired cognition and was totally dependent on staff for all ADL. The CCP for bathing and showering, dated 12/28/17, directed staff to check nail length, trim, and clean on bath day and as necessary, and report any changes to the nurse. The CCP for contractures, dated 12/28/17, documented that Resident #143 had contractures of the right hand and directed staff to provide skin care daily to keep clean and prevent skin breakdown. The current physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's interdisciplinary progress notes revealed that the last skin check and fingernails care was documented as completed on 6/28/22. The shower schedule located at the nurses' station listed Resident #143's shower day as Monday during the 3 p.m. to 11 p.m. shift. When observed on 7/18/22 (Monday) at 11:01 a.m., 7/19/22 at 8:37 a.m., 7/20/22 at 8:23 a.m., and 7/21/22 at 9:49 a.m., Resident #143's fingernails on both hands were approximately one-half inch in length. In an interview on 7/21/22 at 10:25 a.m., CNA #3 stated that night staff get Resident #143 up in the morning and provided morning care. CNA #3 stated that if they noticed that a resident needed nail care, they would either cut them or if the resident was diabetic, they would tell the nurse. In an interview on 7/21/22 (Thursday) at 10:13 a.m., RNM #2 stated that either the nurse or the CNA should cut resident's fingernails depending on whether the resident was diabetic or not. RNM #2 stated that Resident #143 is fully dependent on staff for all care. After reviewing Resident #143's EMR, RNM #2 stated that there was no documentation indicating that Resident #143 had a shower or a skin check in July 2022, but it was documented that Resident #143 had been bathed daily. During an observation at this time RNM #2 stated that the Resident #143's fingernails were long and needed to be cut. RNM #2 stated that the resident's nails should have been taken care of on Monday evening. RNM #2 then opened Resident #143's contracted right hand, and the palm was crusty with dried skin. RNM #2 stated that morning and evening care should include washing the resident's hands. [10 NYCRR 415.12 (a)(3)]

Based on observations, interviews, and record reviews conducted during the COVID-19 Focused Infection Control Survey at [CONDITION(S)] Living Center, it was determined that for 1 of 123 residents reviewed for COVID-19 infections, the facility did not establish and maintain an infection prevention and control program designed to help prevent the development and transmission of COVID-19. Specifically, the facility did not protect one resident confirmed negative for COVID-19 (Resident #7) who was residing in the same room with a resident who was confirmed positive for COVID-19. This resulted in actual harm that was not Immediate Jeopardy to Resident #7. This is evidenced by the following: Review of the Center for Medicare and Medicaid Services COVID-19 Long-Term Care Facility Guidelines, dated 4/2/20, included that long-term care facilities should separate residents who have COVID-19 from residents who do not, or have unknown status. The New York State Department of Health DAL (Dear Administrator Letter), dated April 29, 2020, documents the following: As care pertains specifically to COVID-19, state and federal rules and regulations require nursing homes must adhere to appropriate safety measures including, but not limited to: Having protocols to separate residents into cohorts of positive, negative, and unknown as well as separate staffing teams to deal with COVID-positive residents and non-positive residents. In order to effectuate this policy, nursing home facilities should transfer residents within a facility, to another long-term care facility, or to another non-certified location if they are unable to successful[[NAME]] separate out patients in individual facilities. The facility policy, Novel Coronavirus Disease COVID-19, dated May 2020, included that residents with confirmed COVID-19 are considered exposed and should be kept in a single room for 14 days, if possible, and not be housed with an unexposed resident. Preferentially pair this roommate with another potentially exposed resident, if feasible, or someone else from the same unit. Resident #4 COVID-19 laboratory test, dated 12/7/20, revealed that the resident was positive for COVID-19. Resident #7 COVID-19 laboratory test, dated 12/7/20, revealed the resident was negative for COVID-19. On 12/11/20 at 11:20 a.m., Residents #4 and #7 were observed in the same room. The privacy curtains between the residents were open, and neither resident was wearing a mask. There was no signage on the room door that included the residents were on contact and droplet precautions. When interviewed on 12/11/20 at 11:36 a.m. and 2:50 p.m., the Nurse Practitioner (NP) stated that she knew one of the residents was COVID-19 positive, and the other resident was COVID-19 negative but did not know which room they were in because they move people all the time. She said she would not put residents that were negative for COVID-19 in with residents who were positive for COVID-19. In an interview on 12/11/20 at 12:45 p.m., the Infection Preventionist stated that she was not sure why the resident who was COVID-19 negative was still in the same room with the resident who was COVID-19 positive. In an interview on 12/11/20 at 2:30 p.m., the Administrative Director of Nursing (DON) stated that because it is a Neurobehavioral Unit, and residents are walking around and touching everything, she did not feel it was appropriate to move the resident who was COVID-19 negative out of the room with the resident who was COVID-19 positive to another unit and put that unit at risk. The DON stated the decision was made by the facility Inter-Disciplinary Team, which normally included the Administrator, the DON, the Nurse Manager, and the Social Worker. She said that she was not present at that meeting. In an interview on 12/11/20 at 3:25 p.m., the Medical Director stated that he was not aware of a positive COVID-19 resident being in a room with a negative COVID-19 resident. The Medical Director stated that a positive COVID-19 resident and a negative COVID-19 resident should not be in the same room. In an interview on 12/11/20 at 3:40 p.m., the Facility physician stated she did not know until that day that a positive COVID-19 resident was in the same room with a negative COVID-19 resident. The physician stated that the residents should be separated in different rooms. When interviewed by telephone on 12/11/20 at 4:00 p.m. and again at 5:50 p.m., the Administrator said that the neuro behavior unit had a census of 30 with a bed capacity of 40. She said there were empty beds on the unit. She said that she was aware that the residents were in the same room. She said she understood from epidemiology that Resident #7 could remain in the same room because they were on a dementia unit, and that Resident #7 had already been exposed to the positive COVID-19 resident. A rapid test was then completed for Resident #7 (after surveyor intervention), and the test result was positive for COVID-19. Based on the test results Resident #7 was to remain in their current room with Resident #4. [10 NYCRR 415.19(b)(1) 400.2]

Based on interviews and record reviews conducted during the Abbreviated Survey (complaint #NY 256) at [MEDICAL CONDITION] Living Center completed on 11/15/18, it was determined that for one (Resident #1) of four residents reviewed for medications, the facility did not ensure each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used without adequate monitoring and in the presence of adverse consequences. Specifically, a resident receiving [MEDICATION NAME] (blood thinner) did not have blood levels (PT/INRs, [MEDICATION NAME] Time/International Normalized Ratio, a blood test that measures how long it takes blood to clot) obtained as ordered to prevent blood clots in the resident's extremities. The resident developed bleeding and required a hospital stay including blood [MEDICAL CONDITION] and Vitamin K therapy to reverse excessive anticoagulation (blood thinning). This is evidenced by the following: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 10/13/18 Minimum Data Set Assessment revealed that the resident was cognitively intact and received an anticoagulant medication. The (MONTH) 2009 facility policy, Medication Administration Protocols, included that residents receiving anticoagulant therapy will have monitoring of coagulation times (PT/INR) as ordered. When a PT/INR is drawn, that day's dose is held until the results are reviewed with the licensed practitioner or results fall within parameters already ordered. Review of the 9/25/18 Comprehensive Care Plan revealed that the resident was on anticoagulation therapy due to a history of [MEDICAL CONDITION]. The goal was that the resident will be free from discomfort or adverse reactions related to anticoagulant use. The interventions included to administer anticoagulant medications as ordered by physician, monitor for side effects and effectiveness every shift, labs as ordered, and report abnormal lab results to the physician. Monitor, document, and report adverse reactions of anticoagulant therapy as needed including blood tinged or red blood in urine, black tarry stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, and significant or sudden changes in vital signs. Physician orders, dated 9/17/18, included [MEDICATION NAME] 5 milligrams (mg) daily on Monday and Thursday and 2.5 mg on Tuesday, Wednesday, Friday, Saturday, and Sunday. PT/INR tomorrow (9/18/18) and every week. The 9/18/18 PT was 12.9 (normal range is 9.9 - 13.6 seconds), and the INR was 1.1 (therapeutic range for prevention of embolism is 2 - 3). Physician orders, dated 9/19/18, included to draw a PT/INR on 9/21/18. The 9/21/18 PT was 16.2 and the INR was 1.4. The 9/21/18 physician orders [REDACTED]. The labs drawn on 9/25/18 included a PT of 25.2 and an INR of 2.1. There were no further physician orders [REDACTED]. The Medication Administration Record, [REDACTED]. There was no documentation that the PT/INR blood work had been done. The laboratory book revealed no entries for a PT/INR for (MONTH) (YEAR) and (MONTH) (YEAR). The dates of 10/18/18 and 10/25/18 were highlighted and had hash marks through the dates. Review of the integrated progress notes revealed on 11/5/18 the resident complained of not feeling well, vomited a moderate amount of undigested food and medications after breakfast, and the Nurse Practitioner (NP) was notified. After lunch the resident complained of dizziness and her blood pressure was 88/50 with a pulse of 60. The resident's skin was warm and dry but extremely pale. The NP ordered a x-ray of the abdomen and blood work that included a complete blood count and a comprehensive metabolic panel. The evening charge nurse took the resident's vital signs at 4:10 p.m. which revealed an oxygen saturation level of 83 percent on room air, respirations of 20, a blood pressure of 90/58, and a pulse of 74. The NP was again notified, and oxygen was started at 2 liters per minute via nasal cannula, and the resident's oxygen saturation increased to 89 percent. The resident's lab results were returned at 5:41 p.m., which revealed her hemoglobin (red blood cell responsible for transporting oxygen in the blood) was 3 (normal is 12 - 15), and her hematocrit (measures the proportion of red blood cells in your blood) was 10 (normal is 37 - 47). The resident was sent to the hospital emergency department. Review of the Event Report, dated 11/5/18, revealed that the resident's PT/INR ordered for every week was drawn on 9/18/18, 9/21/18, and 9/25/18. The resident received [MEDICATION NAME] 5 mg daily. The lab work was entered into the Meditech (direct computer access to hospital laboratory) system for (MONTH) (YEAR) by the Unit Clerk but not for (MONTH) (YEAR) or (MONTH) (YEAR). There was no documentation that the lab work orders and the entry in the Meditech system were double checked by a nurse. The resident was transported to the hospital with acute blood loss on 11/5/18. Interviews conducted on 11/8/18 included the following: a. At 2:40 p.m., the Registered Nurse Manager (RNM) stated that she initiated an investigation into what happened to the resident. She said she looked at Meditech to see when the last PT/INR was drawn and saw that none had been drawn since September. She said she questioned the Unit Clerk as to whether she put the lab orders into Meditech, and the Unit Clerk said she was confused and thought they were ordered every other week. The RNM said that did not make any sense because the lab work did not get done every other week, it did not get done at all in October. She said that when a medical provider orders a PT/INR, the nurse has to look in the Meditech system to verify that the order was there or enter the order. She said it also documented in a lab book if it is a repeat order like a weekly PT/INR. b. At 3:40 p.m., the evening shift Certified Nursing Assistant (CNA) stated that on 11/5/18 at approximately 3:30 p.m. he checked the resident's vital signs. The CNA said the resident could not breathe. He said when he took her oxygen saturation, he could not get it to register high enough. He said the resident was pasty white and he reported it right away to the nurses. c. At 3:50 p.m., evening Licensed Practical Nurse (LPN) #1 said that when she came into work on 11/5/18 for the evening shift, the resident said she did not feel well. LPN #1 said the resident's blood pressure was 90 and she reported it to her supervisor. LPN #1 stated that when the lab results returned, the resident was transferred to the hospital. LPN #1 said that she administers [MEDICATION NAME] on the evening shift and she was giving it to the resident every day. LPN #1 said that lab work is drawn early in the day and the day shift notifies the NP of the results. She said [MEDICATION NAME] was not routinely put on hold for PT/INR results. LPN #1 said [MEDICATION NAME] was ordered so she just keeps giving the [MEDICATION NAME]. LPN #1 said to the best of her knowledge the PT/INRs are being done, but that was not something she checks. Interviews conducted on 11/9/18 included the following: a. At 8:30 a.m., the Unit Clerk said that when lab work is ordered it is documented in a lab book and then entered into the Meditech system. She said 90 percent of the time, she is the one responsible to enter the lab work into the Meditech system. The Unit Clerk said she was trained to do that but does not know the reason for it to be done. The Unit Clerk said the entries in the lab book for the resident are in her handwriting. The Unit Clerk said she does not know why there were no entries for September. She said there were entries for (MONTH) but there was nothing in the Meditech system. The Unit Clerk reviewed the 9/17/18 admission orders [REDACTED]. b. At 9:15 a.m., Day Shift LPN #2 stated that on 11/4/18 after breakfast, the resident vomited a moderate amount of emesis of food and pills. She said she checked the resident's vital signs, and her blood pressure was 104/62, pulse was 83, respirations were 18, temperature was 97.3 degrees Fahrenheit, and her oxygen saturation level was 99 percent. LPN #2 said she reported that to the RNM. LPN #2 said that after lunch the resident did not eat well and complained of not feeling well. She said the resident's blood pressure was 88/50 and her pulse was 60. She said that she reported that to the RN Clinical Leader who paged the NP. c. At 10:00 a.m., the NP stated that when the PT/INR on 9/18/18 and 9/21/18 were subtherapeutic, she increased the [MEDICATION NAME] to 5 mg daily. She said the INR on 9/25/18 was 2.1 which was the lower end of the therapeutic level she wanted (2 - 3). The NP said weekly PT/INRs had been ordered and she thought they would be done. The NP said that ultimately it was her responsibility to look for the lab work but there was not a system in place that was working well. She said that when she saw the resident on 11/5/18 after lunch, the resident said she was not feeling well, was sipping ginger ale, and was pale. She said she ordered an x-ray of the abdomen which was done at 3:00 p.m. and was negative. She said the resident's oxygen saturation was low at 83 percent on room air and she ordered oxygen. The NP said she ordered a complete blood count, and when the results were called to the facility from the lab, the hemoglobin was 3 and the hematocrit was 10.2 which are both critically low. The NP said that a hemoglobin and hematocrit that low could cause [MEDICAL CONDITION](fast heart rate), [MEDICAL CONDITION], or death. She said she did not order a PT/INR on 11/5/18 because her focus was to check the resident's hemoglobin and hematocrit and get the resident to the hospital if needed. The NP said the INR done at the hospital was 16 (therapeutic level 2 - 3), and the resident had positive stool for occult blood (an indication of gastro-intestinal bleeding). When asked if the resident was harmed as a result of that incident, the NP said that she was not aware of any permanent damage and was hoping there would not be a long-[MEDICATION NAME] effect on the resident. She said the resident had to be admitted to the hospital for a week, received fresh frozen plasma (blood frozen to preserve clotting factors), a unit of blood, Vitamin K (medication used to counteract the anticoaugulant effects of [MEDICATION NAME]), and had tests to detect gastro-intestinal bleeding. d. At 12:15 p.m., the RN Clinical Leader said she saw the resident on 11/5/18 at about 1:50 p.m. to double check her blood pressure and it was 88/50 with a pulse of 60. She stated that the resident was complaining of dizziness, was pale, and the NP was notified and saw the resident. The RN Clinical Leader said that she expects the evening nurses to check for PT/INR results and notify her if the lab was not drawn. She said there was no place on the electronic MAR for the documentation of a PT/INR result, but there used to be a place on the paper MAR. She said when there is an order for [REDACTED]. e. At 1:00 p.m., the Administrator and Director of Nursing (DON) stated that they began an investigation into the 11/5/18 incident on 11/6/18 when they were notified about it. They discovered that PT/INRs had not been done. They reported it to the New York State Department of Health due to the critical nature of the incident. They said that the lab work was ordered by the NP and taken off by the RNM, but the Unit Clerk did not put the lab work into the Meditech system, so the laboratory would know to come draw the lab work. They said when a nurse does a second check of lab work, they do not check that the orders were entered into Meditech, but they would have expected them to do that. They said the Pharmacy Consultant reviewed the resident's medications on 10/10/18 but admitted to them that he did not look at the lab work. They said the NP was expected to monitor the labs especially when doing routine visits and reviewing medications. They said that they found that the electronic MARS does not include the monitoring of PT/INR results. They stated that the causative factors were that the PT/INR was not entered into the Meditech program, there was a lack of a clearly defined process for second checks, the Consulting Pharmacist did not verify the PT/INR results, the medical provider did not review lab work to ascertain weekly PT/INR results to determine appropriate dosing, and the nursing staff did not understand [MEDICATION NAME] and the affects as it relates to the monitoring of PT/INR labs. Review of the Hospital Discharge Summary, dated 11/12/18, revealed that the resident was admitted to the hospital for [MEDICAL CONDITION], acute blood loss [MEDICAL CONDITION], urinary tract infection with hematuria (bleeding in the urine), supratherapeutic INR (higher than what is used in treatment of [REDACTED]. In the emergency roiagnom on arrival to the hospital, the resident was hypotensive (low blood pressure) at 82/36, her hemoglobin was 2.7, and her INR was 16. She was admitted to the Intensive Care Unit and received a total of 7 units of packed red blood cells (blood transfusion used to treat hemorrhage, [MEDICAL CONDITION], and to improve oxygen delivery to tissues), 2 units of fresh frozen plasma (blood frozen to preserve the clotting factors), and fluids, [MEDICATION NAME] (medication to decrease the amount of acid in the stomach that can cause ulcers), and Vitamin K (medication to counteract the anticoagulation effects of [MEDICATION NAME]) intravenously (medication administered through a needle into the vein). When interviewed by telephone on 11/15/18 at 11:48 a.m., the Medical Director said that he is not the physician for the resident but was made aware of the incident. He said anyone on [MEDICATION NAME] should have regular PT/INR lab work, usually weekly, especially if they are new on it or if the dosage was changed. He said the PT/INR was not done for far too long resulting in an INR of 16 at the hospital which is far too high. The Medical Director said the most worrisome problem with a supratherapeutic PT/INR was bleeding. He said a resident can leak blood from anywhere like the nose, mouth, bruises, cuts or in this case, the gastrointestinal tract from gastritis (inflammation of the stomach lining) or colon polyps (growths). The Medical Director said as the INR increases, the places of potential bleeding increases. The Medical Director said an INR of 16 is quite significantly higher than a normal therapeutic range of 2 - 3. He said the resident had significant [MEDICAL CONDITION] and required blood [MEDICAL CONDITION] and a gastrointestinal work-up. He said the resident was lucky she did not have a [MEDICAL CONDITION] or stroke, and he thinks she will make a full recovery. He said [MEDICATION NAME] is a medication that has to be monitored because it is level dependent. He said the facility is working on finding a better system to track the PT/INRs. (10 NYCRR 415.12(l)(1))

Based on staff interviews and record reviews conducted during an Abbreviated Survey (complaint #NY 132) completed on 1/7/14 at [MEDICAL CONDITION] Living Center, it was determined that for one (Resident #1) of three residents reviewed for insulin administration, the facility failed to ensure that residents were free of significant medication errors. Specifically, Resident #1, a diabetic, received three excessive doses of a U-500 insulin, a short acting concentrated insulin. The resident became unresponsive, required hospitalization for prolonged [DIAGNOSES REDACTED] leading to acute metabolic [MEDICAL CONDITION] (brain disease, damage, or malfunction) and Cheyne Stokes (alternating periods of not breathing and deep rapid breathing). The resident required intubation for airway protection. This resulted in actual harm that is not immediate jeopardy, and is evidenced by the following: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 12/16/13, the hospital discharge medication orders were faxed to the physician by Licensed Practical Nurse (LPN) #5. The physician's office called back with new orders for [MEDICATION NAME] R U-500 insulin (an insulin that is five times more concentrated than Regular U-100 insulin), to be given three times a day. The dosage was to be given in cubic centimeters (cc) not units. On that day the physician personally faxed a separate order to the pharmacy for insulin syringes (BD insulin syringe Ult-Fine II, 1/2 milliliter (ml), 31 gauge by 5/16 inch needle), which are to be used specifically when administering U-500 insulin. admission orders [REDACTED]. A physician telephone order was received later in the day at 4:00 p.m. by LPN #3 on 12/16/13 for U-500 insulin, 0.25 cc in the morning, 0.20 cc at lunch and 0.10 cc at dinner. LPN #3 verified and gave the order to the evening Registered Nurse (RN) Supervisor #1, who then transcribed the orders on the December 2013 Medication Administration Record [REDACTED]= 1cc). The medication delivery recorded on the pharmacy delivery sheet on 12/16/13 at 10:45 p.m. included a concentrated insulin vial of [MEDICATION NAME] R-500 U/ML along with 100 syringes size 31 gauge x 5/16 inch. LPN #2 accepted the medications but refused the syringes, due to them not being safe (not safety syringes), and returned them to the pharmacy. The pharmacy label on the U-500 insulin read, "[MEDICATION NAME] R-500 U/ML CONC VIAL, to inject 0.25 cc (125 units every morning, 0.2 cc (100 units) at lunch and 0.1 ml (50 units) at dinner, *CONCENTRATED*." There was also a sticker on the bag that the insulin came in that read, "Caution U-500 Insulin, verify both units and strength before administering." Review of the December 2013 MAR indicated [REDACTED]. Also on 12/17/13, LPN #1 administered the morning and noon dose of the U-500 insulin, and LPN #2 administered the 12/17/13 evening dose. On 12/18/13 at 6:45 a.m., in a nursing progress note, evening RN Supervisor #1 documented that the resident was found unresponsive in bed. The night nurse was unable to obtain a blood glucose reading because the glucometer reading was too low, and the resident's oxygen level dropped. The physician was notified, ordered a [MEDICATION NAME] injection to be given immediately, and to send the resident to the emergency room . The night RN Supervisor #2 called 911. The Emergency Medical Team arrived at the facility at 7:10 a.m., and the resident was transported to the hospital. Interviews on 12/20/13 included the following: a. At 10:30 a.m., the Director of Nursing (DON) and Acting Administrator stated that the U-500 insulin was ordered in ccs not units. When the syringes were sent from the pharmacy, they were returned because they were not safety syringes. The DON stated that all the nurses discussed the packaging of the insulin. LPN #1 went to the Registered Nurse/Nurse Manager (RN/NM) #1, who called the hospital unit where the resident was transferred from for clarification of the insulin. The DON stated that LPN #1 questioned the amount of insulin and called and spoke to the pharmacy technician. The pharmacy technician agreed that it was a large amount of insulin that the resident was receiving, but the label on the insulin vial was correct as written. The DON stated that the resident received five times the dose that should have been administered at breakfast, lunch, and dinner on 12/17/13. b. At 11:30 a.m., LPN #1 stated that LPN #4 was supposed to give the 6:00 a.m. dose of insulin on 12/17/13 but did not because she was uncomfortable with the dose. LPN #1 said on that morning she checked the dosage of the insulin vial with LPN #3 and LPN #4. LPN #1 reported this to RN/NM #1, who called the hospital pharmacy for clarification and left a message. LPN #1 said that she did not hear back from the pharmacy, and it was 8:00 a.m. LPN #1 then called the pharmacy and spoke with the pharmacy technician, who LPN # 1 thought was the pharmacist. The pharmacy technician told her that the order was correct on the insulin label. After talking to the technician, LPN #1 said that she drew up 125 units of U-500 insulin using a U-100 syringe (this dose equaled 625 units of U-500 insulin, which was five times the ordered dosage) and administered it to the resident in the morning. At lunch time, LPN #2 drew up 100 units of U-500 insulin using a U-100 syringe (this dose equaled 500 units of U-500 insulin, which again was five times the ordered dosage) for the lunch dose. c. At 1:45 p.m., RN/NM #1 stated that on 12/17/13, she was approached by LPN #1 and LPN #3 regarding confusion about the insulin dosage and that LPN #4 held the morning insulin because she was uncomfortable with administering the dosage of insulin. The NM then called the pharmacy the morning of 12/17/13 and was told that someone would call back. The NM left the unit for a few hours and upon returning, was told by LPN #1 and LPN #3 that the pharmacy called back and everything was straightened out. d. At 3:00 p.m., RN/NM #2 stated that LPN #2 should have reported her concerns to Night Supervisor #2. She also stated that the pharmacy technician should have referred LPN #2's questions to the pharmacist, and LPN #2 should have known who she was speaking to. Also, NM #2 stated that if a [MEDICATION NAME] syringe had been sent from the pharmacy, the correct ccs would have been drawn up and administered to the resident. e. At 3:20 p.m., LPN #5 stated that she received the U-500 insulin orders. She was not familiar with U-500 insulin, so she called the physician for clarification. The physician gave her a verbal order for the insulin. LPN #5 read it back to him several times, and then faxed the order to the pharmacy. When told that two and a half syringes were filled with the U-500 insulin and given to the resident, LPN #5 said that she would have called the nursing supervisor before administering that amount of insulin. f. At 3:35 p.m., LPN #4 stated that on 12/17/13, when she looked at the U-500 insulin order, she thought that it seemed like a lot of insulin. She questioned herself and was not comfortable with giving such a large dose. She told the night supervisor that she was not comfortable with administering the morning insulin, who told her not to administer it if she felt uncomfortable and to relay the information to the day shift staff (LPN #1 and LPN #3), which she did. g. At 3:50 p.m., the RN night supervisor stated that she recalled the conversation she had with LPN #4 on 12/17/13 and that she told the LPN to report it to the nurses on the day shift. The RN supervisor stated that she did not check the insulin order, and she did not know what type of insulin syringe would be used for U-500 insulin. h. At 4:10 p.m., evening LPN #2 stated that when she read the U-500 insulin order on 12/17/13, she questioned it because it was in ccs and not in units, and it threw her off. She stated that when she drew up the dinner dose of U-500, she drew up 50 units of insulin using a U-100 syringe (which equaled 250 units of U-500 insulin, which was five times the ordered dose) and administered it to the resident. LPN #2 stated that she was not familiar with U-500 insulin. Review of the facility's investigative conclusion, signed and dated 12/23/13 by the DON and the Acting Administrator, revealed that the factors contributing to the medication error included staff lack of knowledge/familiarity with this type of insulin, the labeling of the medication, and lack of communication from pharmacy for proper dosing and administration. Review of the facility's policy, dated July 2010, "Medication Order Transcription," revealed that a nurse may refuse to carry out an order if the nurse feels that the order may be in error or injurious to the resident. Also, the LPN is to contact the NM/designee for clarification and direction. (10 NYCRR 415.12(m)(2))