Every finding on record at Fox Run at Orchard Park

Based on observation, interview, and record review conducted during the Standard survey completed on 3/7/25, the facility did not ensure that as needed (PRN) orders for psychotropic drugs are limited to 14 days. Except if the attending physician or prescribing practitioner believes that it is appropriate for the order to be extended beyond 14 days; they should document their rationale in the resident's medical record and indicate the duration for the as needed order. Specifically, for one (1) (Resident #24) of five (5) residents reviewed for unnecessary medications an as needed psychotropic antianxiety medication was ordered longer than 14 days. Additionally, there was no documented physician rationale to extend the duration of the order. The finding is: The policy and procedure titled Psychotropic Medication Use dated 11/2021, documented antianxiety medications are considered psychotropic medications and are subject to prescribing, monitoring and review requirements specific to psychotropic medications. Psychotropic medications are not prescribed or given on an as needed basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. As needed orders for psychotropic meditations are limited to 14 days. If the prescriber or attending physical believes it was appropriate to extend the as needed order beyond 14 days, they would document the rationale for extending the use and include the duration for the as needed order. A medication may be considered as unnecessary if it meets the following criteria: an extended duration. Resident #24 had diagnoses including traumatic brain injury, anxiety disorder and dementia. The Minimum Data Set (a resident assessment tool) dated 12/26/24 documented Resident #24 was cognitively intact, understood and understands. The assessment tool documented that Resident #24 had no behavioral symptoms and received antianxiety medications in the 7-day look back period. The Comprehensive Care Plan revised 1/8/25, documented Resident #24 had a history of anxiety and depression. Interventions included to monitor for any changes in mood state, provide support and reassurance and 1:1 intervention. The care plan documented that Resident #24 received antianxiety medication due to anxiety and delusional/paranoid ideations. Interventions included to administer medication as ordered and observe for possible side effects. Review of the Physician's Orders dated 3/6/25 documented Resident #24 had the following as needed by Ativan orders: -0.5 milligrams every 6 hours as needed for anxiety from 8/8/23-8/29/23; 10/29/23-11/26/23; 11/26/23-12/26/23; 1/2/24-1/22/24; 1/22/24-2/13/24; 2/13/24-3/14/24; 3/15/24-4/15/24; 4/26/24-5/25/24; 5/25/24-6/24/24; 6/26/24-7/5/24; 7/5/24-8/4/24. -0.5 milligrams every 6 hours as needed for extreme behaviors from 9/2/24-9/23/24. -1 milligrams every 4 hours as needed for anxiety from 9/23/24-10/21/24; 11/17/24-12/16/24; 12/16/24-1/12/25; 1/12/25-1/15/25; 1/15/25-2/9/25 and 2/10/25-3/10/25. Review of the paper Medication Records from 3/1/24-3/31/25, Resident #24 received: -Ativan 0.5 milligrams as needed on 6/9/24, 9/19/24, 9/20/24 and 9/21/24, -Ativan 1 milligram as needed on 9/23/24, 9/24/24, 9/25/24,10/20/24, 11/23/24, 11/28/24 and 2/7/24. Review of the medical providers progress notes from 3/11/24 - 2/25/25 revealed there was no documented evidence that Resident #24's Ativan ordered was reevaluated every 14 days with a rationale to extend the order or documented duration of the order. Review of the mental health providers notes from 3/18/24 - 3/3/25 revealed there was no documented evidence that Resident #24's as needed Ativan order was reevaluated every 14 days with a rationale to extend the order or documented duration of the order. During intermittent observations from 3/3/25 - 3/6/25 between the hours of 9:14 AM and 3:02 PM, Resident #24 was observed self-propelling in their wheelchair, walking in the hallway with therapy, in their room or in the dining. Resident #24 was well kempt, pleasant, cooperative with staff and no behaviors were displayed. During an interview on 3/6/25 at 3:02 PM, Resident #24 stated that their anxiety was stable, and they only have anxiety about going home. During a telephone interview on 3/6/25 at 3:15 PM, Certified Nurse Aide #1 stated that Resident #24 has had no behaviors or increased anxiety in the past month or so. They stated Resident #24 used to refuse assist with care, but that was no longer an issue. During a telephone interview on 3/6/25 at 3:44 PM, Nurse Practitioner #1 stated they were familiar with Resident #24, and they started to provide mental health services for the resident the past couple months. Nurse Practitioner #1 stated their understanding was Resident #24 was ordered as needed Ativan was for seizures. Nurse Practitioner #1 stated they were not the prescribing clinician for the as needed Ativan and did not have remote access to Resident #24's electronic medical record so they could not verify the indication of the Ativan. Nurse Practitioner #1 stated from their understanding, Resident #24 anxiety level had improved significantly, and they were the most cognitively clear they have been. During a telephone interview on 3/6/25 at 4:14 PM, the Consultant Pharmacist stated Resident #24's psychotropic medications have been adjusted and that Resident #24, by choice, wanted a standing order for Ativan along with an as needed dose. The Consultant Pharmacist stated they thought that Resident #24's as needed Ativan was only ordered for 14 days at a time and the pharmacy should have only allowed for a 14-day order. The Consultant Pharmacist stated as needed Ativan should only be ordered for 14 days and then reviewed by a medical provider. The medical provider should document the rational for continuation in their progress notes. During a follow up interview on 3/7/25 at 9:50 AM, the Consultant Pharmacist stated they could not locate any documentation of rationales for the continued use of the as needed Ativan from the providers. During a telephone interview on 3/7/25 at 9:04 AM, the Medical Director stated they were familiar with Resident #24 and their Ativan use. They stated that Resident #24 was previously on multiple seizure medications, different psychotropic medications, had delusional thoughts and anxiety. The Medical Directors stated that within the past six months Resident #24 went on hospice care and hospice care weaned the resident off their antiseizure medications. Resident #24 bounced back after their seizure medications were discontinued with improvement in their behaviors. The Medical Director stated the indication for the as needed Ativan was anxiety and any extreme behaviors. They stated Resident #24 was the best point they have ever seen them and recently been discontinued from hospice care. The Medical Director stated that they were aware that an as needed Ativan should be only order for a 14-day time frame with documented rational for continued use and was unsure how Resident #24's as needed order got overlooked. During an interview on 3/7/25 at 9:23 AM, Register Nurse Supervisor #1 stated Resident #24's behaviors had gotten much better since the seizure medication had been discontinued. They stated Resident #24 had been more cooperative, much more pleasant and their anxiety was much better in the past three months. During an interview on 3/7/25 at 9:36 AM, Registered Nurse Supervisor #2 stated that Resident #24's behavior had been good in the past few months. They stated the resident had been on hospice care did a complete positive change and hospice care had been discontinued. Registered Nurse Supervisor #2 stated any nurse receiving a new order from a medical provider entered the new order into the electronic medical record. The pharmacy was integrated with the electronic medical record and therefore received the new order as well. Registered Nurse Supervisor #2 stated the pharmacy should know an as needed psychotropic medication was only ordered for 14 days and a standing order was for 30 days. Registered Nurse Supervisor #2 stated when a narcotic was coming to the end of the 30 days it could be ordered. The night shift nurse was responsible for reordering the medication and the medical provider would receive an alert that a signed script was needed. During an interview on 3/7/25 at 9:46 AM, the Social Worker stated all residents on psychotropic medications were reviewed in behavioral modification agent reduction committee meetings at least every three months. They stated they were aware Resident #24 had an intramuscular as needed Ativan order every 6 hours for an active seizure and a by mouth as needed Ativan order every 4 hours as needed for anxiety. The Social Worker stated that an as needed antianxiety medication should only be ordered for 14 days. After review of Resident #24's electronic provider orders, the Social Worker stated Resident #24's by mouth as needed Ativan order had a duration of 30 days, they were unsure why, but it should have been only for 14 days. The Social Worker stated Resident #24's anxiety improved when their health status improved. During an interview on 3/7/25 at 10:42 AM, the Director of Nursing stated their expectations for an as needed by mouth Ativan order was that the order be written for only for 14 days, and then it would need to be reviewed by the medical provider. They stated they were unsure how Resident #24 had their as needed by mouth Ativan reordered about every 30 days and they could not speak for the medical provider. The Director of Nursing stated that Resident #24 had a turn around after their seizure medication was discontinued and the resident was positive, and they were participating in life. They stated Resident #24 had no active seizure activity in a long time. 10 NYCRR 415.12(l)(2)

Based on observation, interview and record review completed during a Standard survey conducted from 6/27/22 through 7/1/22, the facility did not ensure that each resident who was unable to carry out activities of daily living (ADL's) receives the necessary services to maintain grooming and personal hygiene for one (Resident #31) of one resident reviewed for ADL's. Specifically, staff provided incomplete incontinence care, including retraction of the foreskin to Resident #31. Additionally, staff did not change their gloves and perform hand hygiene after they provided fecal incontinence care and prior to applying Resident #31's clean brief and clothing. The finding is: The facility policy and procedure (P&P) titled ADL-Incontinent Care revised 12/2019, documented for male urine incontinence, wash, rinse, and dry groin area. Wash penis starting with meatus and work down from head of the penis to scrotum using a clean section of the washcloth for each stroke. Rinse in the same manner and dry. If uncircumcised male, retract foreskin, clean, and return foreskin. The facility P&P titled Handwashing with revision date 5/2020, documented that proper and appropriate handwashing techniques will aid in the prevention of the transmission of infections. The P&P documented that handwashing must be performed under the following conditions: after contact with blood, body fluids, secretions excretions, mucous membranes, or broken skin; after handling items potentially contaminated with a resident's blood, body fluids, excretions, or secretions; and after removing gloves. 1. Resident #31 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, a resident assessment tool) dated 5/12/22 documented that Resident #31 had moderate cognitive impairment, was understood by others and understands others, was frequently incontinent of bladder and bowel, and required extensive two person assist for toileting and hygiene. Review of the Profile of Care (used by Certified Nurse Aide (CNA) to guide care) dated 5/22/22, documented Resident #31 required total assist of 2 people with toileting hygiene, lower extremity bathing and extensive assist of 2 people for dressing. During an observation of incontinent care on 6/29/22 at 11:48 AM to 12:03 PM, CNA #1, CNA #2, and Licensed Practical Nurse (LPN) #1 were present for care. CNA #1 and #2 performed hand hygiene and donned (put on) gloves. CNA #2 unfastened Resident #31's brief and tucked it down between their thighs. Resident #31 was incontinent of urine and fecal matter. CNA #2 did not retract the foreskin (skin covering the end of the penis) to clean the urinary meatus (opening of the urethra-allows urine to pass out of body) while performing urinary incontinence care. Using 2 assist, the resident was turned onto their right side where CNA #2 provided fecal incontinence care and fecal matter was observed on the washcloth. CNA #2 was observed to flip the washcloth to utilize a clean area which placed the soiled part of the washcloth with fecal matter against both of their gloved hands. CNA #2 did not change their gloves or perform hand hygiene, then used their soiled gloved hands and handled a clean towel, dried the resident's skin, applied a clean brief, sweatpants, and t-shirt with assist from CNA #1. During an interview on 6/29/22 at 12:05 PM, CNA #2 stated they should have retracted Resident #31's foreskin for cleaning as that was part of incontinent care. CNA #2 stated they did not complete this as they forgot and that it was important to do so the resident didn't develop an infection. CNA #2 stated they should have changed their gloves and washed their hands because they were soiled. CNA #2 stated hand hygiene should be completed when incontinent care was over. During an interview on 6/29/22 at 12:53 PM, CNA #1 stated that CNA #2 didn't pull back Resident #31's foreskin during incontinent care and should have in order to prevent an infection, like a [CONDITION(S)]. CNA #1 stated that CNA #2 gloves should have been changed after becoming soiled and their hands sanitized prior to continuing care to prevent cross contamination. During an interview on 6/29/22 at 4:45 PM, LPN #1 stated the foreskin should be rolled back and washed during incontinent care because it was a dark, moist environment where bacteria can be harbored. LPN #1 stated that hand hygiene should be done as soon as possible if in contact with stool to prevent cross contamination when handling clean linens and briefs. During an interview on 7/1/22 at 8:57 AM, Resident #31 stated they would like foreskin pulled back to be washed. Resident #31 stated, When I washed myself I did it, don't want any junk down there. During an interview on 7/1/22 at 9:30 AM, the Director of Nursing (DON) stated they expected the CNA to retract the foreskin, clean the penis, and replace the foreskin during incontinent care on an uncircumcised resident. The DON stated that this was important for infection control, hygiene, dignity, and comfort. During a follow up interview at 1:09 PM, the DON stated they expected that staff would wash their hands and change gloves prior to going to a clean area for infection control purposes. 415.12 (d)(1)

Based on interview and record review conducted during the Focused Infection Control COVID-19 survey completed on 1/13/21, the facility did not establish and maintain an Infection Control Program to ensure the health and safety of residents to help prevent the transmission of COVID-19. Specifically, the facility did not ensure employees were screened for COVID-19 symptoms (e.g., fever, cough, difficulty breathing, or other respiratory symptoms), including temperature checks every 12 hours while on duty. The finding is: The NYS DOH (New York State Department of Health) Commissioner of Health letter to Nursing Home (NH) Administrators, dated April 29, 2020, required all staff to be checked for COVID-19 symptoms (e.g., fever, cough, difficulty breathing, or other respiratory symptoms), including temperature checks upon the start of each shift and every 12 hours while on duty. Review of a CMS (Centers for Medicare and Medicaid Services) memorandum (QSO 20-14-NH) updated 9/28/20 documented facilities should screen all staff at the beginning of their shift for fever and respiratory symptoms. Actively take their temperature and document absence of shortness of breath, new or change in cough, or sore throat. The Centers for Disease Control and Prevention (CDC) guidance, Preparing for COVID-19 in Nursing Homes, updated 11/20/20 documented: Screen all healthcare personnel (HCP) at the beginning of their shift for fever and symptoms of COVID-19. Actively take their temperature and document absence of symptoms consistent with COVID-19. The facility policy and procedure (P&P) titled COVID-19 with revision date July 2020 documented facility will implement symptom screening for all staff including a temperature check at the start of shift and monitoring throughout shift and require all staff to wear a mask. Facility will follow all NYSDOH/CDC guidelines which include: Monitor temperature and symptom for residents and staff. Review of facility's untitled computer-generated documents from 1/6/2021 through 1/13/2021 revealed no evidence that (Certified Nurse Aide) CNA #1 was screened on 1/9/21 prior to working their shift. In addition, CNA #1, (Licensed Practical Nurse) LPN #1, LPN #2, and LPN #3 were not re-screened after working 12 hours. Review of Weekly Timecard Report dated 1/6/21 through 1/13/21 revealed: -CNA #1 worked greater than 12 hours on 1/9/21 and 1/10/21. -LPN #1 worked greater than 12 hours on 1/6/21, 1/7/21 and 1/12/21. -LPN #2 worked greater than 12 hours on 1/7/21 and 1/8/21. -LPN #3 worked greater than 12 hours on 1/6/21 and 1/10/21. An interview on 1/13/21 at 9:11 AM, CNA #1 stated they worked 13-hour shifts. Screening took place at the front entrance of the building and was completed at the start of the shift. CNA #1 further stated they were not re-screened during their shift. An interview on 1/13/21 at 12:10 PM, LPN #1 stated they work three, 13-hour shifts per week. Typically, temperatures were checked, and questions are answered on the kiosk upon coming into work. LPN #1 further stated they were not re-screened during the 13-hour shift. An interview on 1/13/21 at 1:20 PM, LPN #2 stated they have a tablet thing, that recorded temperature and required screening questions. Staff are required to complete once a shift. LPN #2 further stated they worked 6 AM to 7 PM and were screened once at the beginning of the shift and were not rescreened after 12 hours of working. An interview on 1/13/21 at 1: 28 PM, LPN #3 stated questions and temperatures were confirmed on the kiosk. LPN #3 further stated they worked from 6:00 AM to 7:00 PM and were screened prior to the start of the shift and were not rescreened after 12 hours of working. An interview on 1/13/21 at 1:50 PM, the Director of Nursing and Infection Control Preventionist (DON/ICP) stated that the computer system tracks who had been screened. Shifts had been changed from 8 hours to 13 hours on 11/1/20 for nursing staff. Employees were expected to login into the computer system and performed online self-screening prior to the start of their shift, I'm trusting that they know that it is part of their job. The DON further stated the computer system was not monitored and there was no system to verify when staff were not screened. An interview on 1/13/21 at 3:45 PM the CEO stated the computer system was instituted for screening purposes. Personal training sessions were provided to facility staff and are ongoing. 415.19 (a) (1-2) 400.2

Based on interview and record review during a Standard Survey completed on 9/28/18, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility did not conduct a Legionella risk assessment of the building to identify where Legionella and other opportunistic pathogens could grow and spread in the building's water system. This affected one (Second Floor of the Health Center) of one resident unit. The finding is: On 9/26/18, a review of the facility's Legionella policy, dated of 1/2018, revealed the policy did not contain documentation that a Legionella risk assessment had been conducted for the building. During an interview on 9/27/18 at 12:42 PM the Administrator and the Director of Facilities stated, the facility had not conducted a Legionella risk assessment for the building. The facility had been in contact with three outside contractors during (YEAR) and each contractor informed the facility that the facility did not have to conduct a Legionella risk assessment because the facility did not have cooling towers. In mid-December of (YEAR) the facility became aware of the Legionella requirements and hired an outside contractor to collect water samples from the facility water supply on 2/1/18. Per Centers for Medicare & Medicaid Services Survey and Certification Letter S&C 17-30 subject: Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD) dated 6/2/17 and revised 6/9/17: Healthcare Facilities must conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system. 415.19(a)(1)

Based on observation, interview and record review conducted during the Standard Survey completed on 8/3/17, the facility did not ensure that each resident receives adequate supervision and assistance to prevent accidents. One (Resident #24) of one resident reviewed for accidents had an issue with the lack of limited assistance during meals as planned and lack of follow-up and professional assessment of the resident's swallowing after staff observed the resident pocketing food in the oral cavity after meal consumption. The finding is: 1. Resident #24 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 6/24/17 revealed the resident has moderate cognitive impairment, sometimes understands and is sometimes understood. In addition, the MDS documented that the resident has no swallowing deficit and requires limited assistance with eating. Review of an Occupational Therapy MDS Screen dated 6/13/17 revealed the resident had a left sided cerebral infarct (stroke), has a right facial droop and requires limited assistance with feeding and food cut up into small pieces. Review of a Nutrition Risk assessment dated [DATE] revealed the resident feeds himself independently. The physical examination did not indicate that the resident pocketed food and/or had dysphagia (swallowing difficulty). The Nutrition Risk Assessment documented that the resident receives a regular diet with regular liquids which is tolerated well; the responsible party stated that the resident does well with food cut into small pieces; and the resident requires limited assistance for feeding with adaptive equipment in place. Review of the Physician Admission and History dated 6/13/17 revealed the resident has a history of COPD and a CVA in 2013; over the last few months the resident's health status has declined; and he was receiving Hospice services at home prior to admission. The Physical Examination documented that the resident has a facial droop. Review of the comprehensive Care Plan (CCP) dated 6/15/17 revealed the resident has the potential for altered communication due to the CVA and right sided facial drooping and potential problems with self-care related to COPD, status [REDACTED]. In addition, the CCP documented that the resident is at nutrition risk with interventions to provide a regular diet with regular liquids; provide necessary assistance at meal times; allow the resident to eat at his own pace; and monitor food and fluid intake. Intermittent observations on 7/31/17 and 8/1/17 during breakfast and lunch and on 8/2/17 during breakfast revealed the resident was eating his breakfast in his room independently in bed without staff assistance or monitoring. On 8/2/17 at approximately 9:00 AM, the resident was independently eating oatmeal with whole raisins and had a pronounced right sided facial droop. Additional observation on 8/2/17 at approximately 9:30 AM revealed the resident's breakfast tray was removed and the resident was in bed watching television. Additional observation on 8/2/17 at approximately 10:55 AM revealed a Hospice Certified Nursing Assistant (CNA) provided oral care to Resident #24 and removed food debris from the resident's mouth. The emesis (vomit) basin contained approximately one teaspoon of unchewed oatmeal and whole raisins seen earlier on the resident's breakfast tray. The CNA used a toothbrush to brush the resident's teeth. When the CNA provided water to rinse the resident's mouth, he began coughing up copious amounts of light yellow phlegm, and the CNA provided assistance clearing the phlegm from the resident's mouth into the emesis basin. During an interview on 8/2/17 at approximately 10:58 AM, the Hospice CNA stated that she removes food debris from the resident's mouth all the time when she provides oral care and stated that she provides electronic reports of her care which are submitted to Hospice. During an interview on 8/3/17 at approximately 8:15 AM, the Registered Nurse (RN) Supervisor stated the resident does not have any problems eating and that he did have a swallowing evaluation because he entered the facility on a regular diet. The RN Supervisor stated that Hospice staff communicate with the facility staff daily and she did not receive any report of solid foods being removed from the resident's mouth during oral care the day before. The RN Supervisor stated that staff should probably inform her if that is happening. During an interview on 8/3/17 at approximately 8:46 AM, the Occupational Therapist (OT) stated that when she completed the resident's initial evaluation on 6/13/17, the resident required limited assistance with eating, specifically verbal cuing, and she was just looking at the food. The OT stated she did not see any pocketing of food and the resident had no dripping or coughing on intake; however, she did not perform an inspection of the resident's oral cavity after chewing. The OT stated the resident does have a right sided paresis (muscular weakness caused by nerve damage or disease) from an old stroke. The OT stated if staff are removing solid food from the resident's mouth during oral care, the OT should be informed to provide further evaluation. During an interview on 8/3/17 at approximately 11:50 AM, the Diet Technician stated that she and the previous Registered Dietician (RD) performed the initial Nutrition Risk assessment dated [DATE]. The Diet Technician stated the RD completed the resident's physical examination; the RD inspects the mechanics of how the resident eats/ swallows; and the RD is no longer employed at the facility. Review of a policy and procedure (P&P) entitled Evaluation PT (physical therapy)/OT dated May 2010 and identified as current, revealed it is the policy of the facility to assess the resident's ADL (activities of daily living) functional status to plan appropriate treatment. Review of a P&P entitled Swallowing Disorders dated September 2007 and identified as current, revealed it is the policy of the facility to have an assessment of the oral phase of the swallowing structure and function to plan appropriate food consistency. The policy does not define which resident conditions/ [DIAGNOSES REDACTED]. 415.12(h)(2)

Based on interview and record review conducted during the Standard survey, completed on 8/3/17, the facility did not ensure that SCREEN Forms DOH (Department of Health)-695 were completed as required. Specifically, one (Resident #24) of two residents receiving Hospice Services reviewed for preadmission SCREENS did not have the SCREEN completed by a qualified screener. The finding is: 1. Resident #24 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS-a resident assessment tool) dated 6/20/17 revealed the resident is moderately impaired for decision making. Review of a SCREEN Form DOH-695 (2/2009) dated 6/5/2017 revealed the Screener Identification Number had only five digits as opposed to the required ten digits. Interview with the Admissions Coordinator on 8/2/17 at 11:24 AM revealed the individual that completed the SCREEN is not certified to complete SCREENS. The individual that completed the SCREEN works for Hospice and doesn't know the process for completion. Usually, we have an independent Screener complete the SCREENS when the resident is admitted from home or the community. We will have someone come in today and complete the SCREEN. During a later interview with the Admission Coordinator on 8/3/17 at 11:50 AM revealed it is her responsibility to make sure the SCREEN is complete prior to the resident being admitted to the facility but was not aware there needed to be a ten- digit screener identification number and would be looking for that in the future. 400.11

Based on interview and record review conducted during the Standard Survey completed on 8/24/16, the facility did not periodically review and revise the Comprehensive Care Plan. Two (Residents #11,56) of 14 residents reviewed for Care Plans had did not have Care Plan revisions to include changes with the development of a pressure sore and treatment (Resident #11) and missing hearing aids for a resident who is hard of hearing (Resident #56). The findings are: 1. Resident #11 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS-a resident assessment tool) dated 7/19/16 revealed the resident is severely impaired for decision making. Review of the Care Plan initiated 7/24/16 revealed the resident had a potential for alteration in skin integrity d/t (due to) incontinence and decreased mobility.The plan was to complete a Braden (assessment tool for potential skin breakdown) Score quarterly and prn ( when needed). Weekly skin checks on shower day by a nurse. Pressure reducing mattress and a cushion in wheel chair. Review of the Braden Scale dated 7/12/16 revealed a score of 14 indicating a risk for skin breakdown. Review of the Wound Evaluation Form dated 8/8/16 revealed the resident developed a Stage 1 pressure sore on right buttocks measuring 9 cm (centimeters) x 1 cm. A treatment of [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the Care Plan Review and Update sheet revealed a lack of revision to the care plan to include the development of the pressure sore and treatment plans. Interview with Registered Nurse (RN#1) Unit Manager on 8/23/16 at 12:05 PM revealed she just got back from vacation and had not gotten to the documentation. 2. Resident #56 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 7/14/16 revealed the resident is understood, understands and is cognitively intact. Review of the facility Missing Property Report dated 8/9/16 revealed the resident's hearing aids were missing. Review of the Hearing Aid Accountability Form dated August 2016 revealed the resident's hearing aids were missing. Review of the current Comprehensive Care Plan (CCP) revised 8/2/16 revealed a potential for alteration in communication d/t resident is hard of hearing and wears bilateral hearing aids. Review of the Care Plan Review and Update sheet revealed a lack of revision to the care plan to include the hearing aids were missing. Interview with Licensed Practical Nurse (LPN#2) on 8/23/16 at 11:15 AM revealed the hearing aids were missing on 8/10/16 and he initiated a Missing Property Report and notified the Supervisor.I did not make the change to the Care Plan. Interview with Registered Nurse (RN#1) Unit Manager on 8/23/16 at 11:28 AM revealed she just got back from vacation and was waiting to hear from the Social Worker if they had ordered new hearing aids before she made the change. During an interview on 8/24/16 at 8:18AM, the Director of Nursing (DON) stated I would expect the Care Plan to have been revised at the time the hearing aids went missing. I usually fill in for the Unit Coordinator or the shift Supervisor would be expected to make the change. Review of the Policy and Procedure labeled Care Plan Interdisciplinary revised April 2013 revealed it is the facility policy to provide Interdisciplinary Care Plan outlining the care and treatment of [REDACTED]. The goals and timetables are measured and directed toward achieving and maintaining each resident's optimal physical, psychosocial and functional needs. 415.11(c)(2)(iii)

Based on observation, interview and record review conducted during the Standard Survey completed on [DATE], the facility did not provide a resident having pressure sores with necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Three (Resident's #7,11, and 63) of three residents reviewed for pressure sores had issues with a lack of a complete Registered Nurse (RN) assessment of a newly identified pressure ulcer including staging and measurement (Resident #7), lack of ongoing measurements and follow up documentation regarding the status of a pressure sore (Resident #11), and the hands of a Licensed Practical Nurse (LPN) were not washed between removing a soiled wound dressing and placing a new one (Resident #63). The findings are: 1. Resident #7 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated [DATE] revealed the resident is cognitively intact, understands and is understood. Review of the Profile of Care (guide used by staff to provide care) dated [DATE] revealed the resident requires two extensive assist from staff for bed mobility, requires a mechanical lift for transfers and is non ambulatory. Review of the Care Plan Review and Update form dated [DATE] revealed the resident developed a right heel blister, the plan was to apply skin prep (protective barrier) to the right heel blister every shift (qs) until resolved. Review of the Interdisciplinary Notes dated [DATE] written by a Licensed Practical Nurse (LPN) revealed AOC (area of concern) to right heel, UC (Unit Coordinator) ordered tx (treatment) for site. Further review of the Interdisciplinary Notes dated [DATE] written by a Registered Nurse (RN) revealed resident has blister to right heel, skin prep applied qs until resolved. There is no assessment documented to include the type of wound, staging or measurements. Review of the Physician's Orders dated [DATE] revealed an order to apply skin prep to the right heel blister every shift until resolved. Review of the facilities skin book (a three ring binder) revealed that there were no Wound Evaluation Flowsheets for Resident #7. During an interview on [DATE] at approximately 9:59 AM the RN Unit Manager stated that the resident did not have any pressure ulcers. During an interview on [DATE] at approximately 2:18 PM the RN Unit Manager stated that she did not know the resident had a heel blister as she had been on vacation. Additionally, during this interview the RNUnit Manager and the Director of Nursing (DON) stated that there is not an initial assessment of the pressure ulcer. The RN Unit Manager stated what should happen is that the nurse finding the area of concern should notify the supervisor. Then the supervisor should have assessed the pressure ulcer and completed a skin sheet. An observation on [DATE] at approximately 2:28 PM (in the presence of the RN Unit Manager) revealed an unstageable pressure ulcer on the resident's right heel measuring approximately 2 centimeters (cm) in length (1) x (by) 2 cm in width (w). During this observation, the resident stated that the pressure ulcer is tender at times and stings a little when the nurses apply the treatment. At this time, the RN Unit Manager stated that she would now complete the Wound Evaluation Flow Sheet. Review of the Wound Evaluation Flowsheet dated [DATE] completed by the RN Unit Manager revealed the resident has an unstageable right heel blister that was not present on admission and measured 1.8 cm (1) x 2.3 cm (w). The pressure ulcer is described as a reabsorbed blister that has dry dark tissue. During an interview on [DATE] at approximately 10:25 AM the DON stated that when the RN Unit Coordinator is off, if any new skin concerns are noted the nurses can notify the physician, get a treatment started and complete the skin sheet. I should be notified, so that I can follow up. Review of the policy and procedure entitled Wound Management Protocol dated [DATE] revealed if the resident is identified to have a pressure ulcer, the nurse identifying the ulcer will initiate a pressure ulcer flow sheet and will notify the RN Nurse Manager. The Nurse Manager/ Supervisor will be responsible to notify the Director of Nursing. 2. Resident #11 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS-a resident assessment tool) dated [DATE] revealed the resident is severely impaired for decision making. Review of the Care Plan initiated [DATE] revealed the resident had a potential for alteration in skin integrity due /to (d/t) incontinence and decreased mobility. The plan was to complete a Braden Score (assessment tool for potential skin breakdown) quarterly and when needed (prn). Weekly skin checks on shower day by a nurse. Pressure reducing mattress and a cushion in wheel chair. Review of the Braden Scale dated [DATE] revealed a score of 14 indicating a risk for skin breakdown. Review of the Wound Evaluation Form dated [DATE] revealed the resident developed a Stage 1 pressure sore on right buttocks measuring 9 centimeters( cm) x 1 cm. A treatment of [REDACTED]. Review of the Medication Administration Record [REDACTED].Further review of the Wound Evaluation Form revealed no further documentation regarding the pressure sore. Review of the Interdisciplinary Notes dated [DATE] through [DATE] revealed a lack of documentation regarding the pressure ulcer measurements and status. Review of the skin check sheets dated ,[DATE] revealed the resident had no new issues identified. Interview with Registered Nurse (RN#1) Unit Manager on [DATE] at 12:05 PM revealed she just got back from vacation and hadn't gotten to the documentation and then the resident expired. Interview with the Director of Nursing (DON) on [DATE] at 1:00 PM revealed she would generally fill in when the Unit Manager is on vacation (or a Supervisor) and did not remember anything in regards to the resident's pressure ulcer. Review of the facility policy Entitled Wound Management Protocol dated ,[DATE] if the resident is identified to have a pressure ulcer, the nurse identifying the ulcer will initiate a pressure ulcer flow sheet and will notify the RN Nurse Manager. The Nurse Manager/ Supervisor will be responsible to notify the DON. The Interdisciplinary team led by the DON will do weekly rounds on all residents with pressure ulcers. The Pressure Ulcer/Wound Management Flow Sheet will be updated at that time. 3. Resident #63 has [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS - an assessment tool) dated [DATE] revealed that the resident is severely cognitively impaired. Review of the nursing admission assessment dated [DATE] revealed that the resident had an unstageable right heel blistered area that measure five centimeters (cm) wide by six centimeters (cm) long. Review of the comprehensive care plan dated [DATE] revealed that the resident was care planned for an unstageable right heel wound that was present on admission. Review of the wound evaluation flowsheet dated [DATE] revealed the right heel had yellow slough (a layer of dead cells in the wound that is similar to pus) and there was no odor. Review of the physician ' s order dated [DATE] revealed that the resident had orders for wound treatment consisting of applying Santyl (an ointment that cleans pressure sores so healthy tissue may grow back) with a dry, clean dressing after cleansing. Observation on [DATE] at approximately 9:52AM revealed a wound treatment for [REDACTED].#1 (LPN #1) washed her hands and put on gloves. LPN #1 then removed the old dressing that was placed the day before.The LPN showed the old dressing to the surveyor and there was a moderate amount of bloody, grayish drainage on it. The LPN #1 then removed her gloves and put on new gloves then cleansed the wound with normal saline solution. LPN #1 changed her gloves and applied the Santyl with a wooden spatula. LPN #1 changed her gloves again and then applied the dry, clean dressing on top of the wound. LPN #1 did not wash hands or use hand sanitizer in between removing the soiled dressing and replacing the clean dressing. Interview on [DATE] at approximately 10:17AM with LPN #1 revealed that she should have washed her hands between removing the soiled dressing and replacing it with the clean one. Interview on [DATE] at approximately 10:20AM with Registered Nurse #1 (RN #1) revealed that she expects her staff to wash their hands in between removing a soiled dressing and replacing with a clean one. Interview on [DATE] at approximately 10:25AM with the Director of Nursing revealed that she expects her staff to wash their hands in between taking off the soiled dressing and putting on the clean dressing. Review of the policy Dressings - Soiled dated ,[DATE] revealed that in the procedures section it states wash hands after disposing soiled dressing and removing gloves . 415.12 (c)(1) 415.12 (c)(1)

Based on observation, interview and record review conducted during a Standard survey completed on 8/24/16, the facility did not maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete and accurately documented. One (Resident #12) of nineteen residents medical records reviewed for accuracy had issues involving an inaccurate physician order [REDACTED].>The finding is: 1. Resident #12 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS, a resident assessment tool) dated 7/21/16 revealed the resident is moderately cognitively impaired, understands and is usually understood. During a medication pass observation on 8/23/16 at approximately 7:11 AM Licensed Practical Nurse (LPN #2) administered the following medications; Senna S two tablets (used to treat constipation), [MEDICATION NAME] 20 milligrams (mg) (used to treat depression), aspirin 81 mg, [MEDICATION NAME] 6.25 mg (used to treat heart failure and HTN), [MEDICATION NAME] 5 mg (used to [MEDICAL CONDITIONS]) and [MEDICATION NAME] 20 mg (promotes excretion of urine). Review of the physician's orders [REDACTED]. Review of the Medication Record dated 8/2016 revealed an order for [REDACTED]. During an interview on 8/24/16 at approximately 8:40 AM the Registered Nurse (RN) Unit Manager (UM) stated that she would need to review the original order for the Vitamin D and follow up with the surveyor. During an interview on 8/24/16 at approximately 8:41 AM LPN #2 stated that Vitamin D 50,000 units is usually a monthly dosing. The order should read that the medication is to be given monthly not daily. Additionally LPN #2 stated that the nurses do medication checks at the end of each shift. The nurses initial in the medication record that the checks have been completed and the error should have been caught. During an additional interview on 8/24/16 at approximately 10:28 AM the RN UM stated that the Vitamin D 50,000 units is to be given monthly. Additionally the RN UM stated that somehow last year on the nightshift during turnover between May 2015 and June of 2015 the order got changed to daily and that she is working on correcting the error now. 415.22 (a) (2)

F 371 E THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED ON 1/29/15. Based on observation and interview during the Standard survey completed on 8/26/15, the facility did not store, prepare, distribute and serve food under sanitary conditions. Issues include; food items that were removed from their original packaging were not labeled or dated with the date that they were opened and removed from their original packaging, and partially wrapped with plastic wrap, food items that were opened and kept in their original packaging were not labeled with the date that they were opened for use, coffee pots were not properly washed or stored, packaged food was stored in contact with water, and non-food-contact surfaces had accumulations of dust, food debris, unknown substances and water. This affected two (Main kitchen and Second floor kitchen) of two kitchens. The findings are: 1. Observation in the Main kitchen on 8/24/15 at approximately 10:36 AM revealed the following: a) Approximately 30 frozen fish fillets that were individually wrapped in plastic wrap were stored on two trays in the walk-in freezer. Neither the individual fish fillets nor the trays were labeled or dated. Interview with the Director of Dining Services at this time of observation revealed the fish fillets were left over from the Friday fish fry on 8/21/15. Further interview with the Director of Dining Services at this time revealed the fish fillets should have been individually wrapped in plastic wrap and each of the trays of fish fillets should have been wrapped in plastic wrap labeled, dated, and then stored in the freezer. b) The splash shield and protective cage of an approximate four foot tall electric mixer was soiled with brown and tan colored residue and food debris, and the area where the mixers attachments connected to the mixer was soiled with chunks of a gelatinous tan colored substance. Further observation at this time revealed this floor mixer was located near the locked storage cage containing various bottles of alcohol. Interview with the Director of Dining Services and two dietary staff at the time of the observations revealed they were not sure when the floor mixer was last used. c) The salad cooler contained an opened five pound plastic package of parmesan cheese that contained approximately five ounces of cheese and was not labeled with a date as to when the package was opened. d) The salad cooler contained an opened five pound plastic package of blue cheese crumbles that contained approximately three pounds of cheese and was not labeled with a date as to when the package was opened. e) The bottom shelf of the salad cooler was covered with an approximately one quarter inch deep layer of water. A plastic container containing lettuce, and plastic containers containing salad dressing were stored on the shelf in the water. f) Observations at the beverage station: Ten of eleven thermal coffee carafes were stored upright under the beverage station. Each of the ten carafes had an approximate one quarter inch deep layer of residual water inside of them. The exteriors of four of the eleven carafes that were stored upright under the beverage station were soiled with a brown substance. Interview with the Director of Dining Services at this time of observation revealed the thermal coffee carafes that were stored under the beverage station were supposed to be clean and ready for use. Further interview with the Director of Dining Services at this same time revealed the thermal coffee carafes that were stored under the beverage station should have been turned upside down to drain excess water and air dry after they were washed. The counter top located below the beverage machine and the coffee urns was covered with an approximate one quarter inch deep layer of water. g) Observations in the walk-in cooler: An approximate three pound piece of what appeared to be bologna was not completely covered with plastic wrap and was not labeled or dated as to when it had been removed from its original packaging. An approximate three pound piece of what appeared to be salami was not completely covered with plastic wrap and was not labeled or dated as to when it had been removed from its original packaging. An open, undated approximate ten pound plastic package of ham that contained approximately eight pounds of ham was partially covered in its original package and partially covered with plastic wrap. An open, undated five pound plastic package of ready to eat roasted red peppers that contained two pounds of peppers. An open, undated approximate two pound plastic package of sliced Monterey jack cheese that contained approximately one pound of cheese was stored in a plastic bag. An open, undated approximate five pound package of shredded mozzarella cheese that contained approximately two pounds of cheese. 2. Observation in the Heath Building, Second floor Kitchen on 8/24/15 at approximately 11:25 AM revealed the following: a) Three, three inch long by two inch wide by one inch think areas of black debris located on the counter top below the flat grill and char grill. An approximate four foot long section of pipe located behind the flat grill and char grill was covered with an approximate one quarter inch thick layer of dust and gray debris. An approximate three foot long by two inch wide area of the floor between the char grill and wall was covered with tan and black substances. An approximate three foot long by three foot wide area of the wall next to the char grill was covered with tan and black substances. b) An approximate six foot long by four inch wide area of the wall near the K-type fire extinguisher was covered with an approximate one quarter inch thick layer of dust and gray debris. c) An approximate three foot long by two inch wide area of the floor between the dishwasher and an approximate five gallon bucket of dishwashing soap was covered with an approximate one quarter inch thick layer of a greasy tan and black colored substances. 415.14(h) New York State Sanitary Code Subpart 14-1 14-1.40(a) 14-1.42 14-1.43(d) 14-1.43(e) 14-1.110(d) 14-1.110(e) 14-1.116 14-1.170 14-1.171

Based on observation,interview and record review conducted during the Standard survey completed on 8/27/15, it was determined facility staff did not provide care in a manner that enhanced residents' dignity. Five (Residents #1, 14, 39, 46, 53) of 25 residents reviewed for dignity, had issues that involved the staff did not ask resident's permission to place clothing protectors on them. The findings iclude but are not limited to: 1. Resident #14 has [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS - a resident assessment tool) dated 6/11/15 revealed that the resident is cognitively impaired, understood and understands. Review of the certified nurse aide care guide dated 8/22/15 revealed that the resident is a supervision with set up for eating. Observation in the Main Dining Room during the lunch time meal service on 8/24/15 at approximately 12:27 PM revealed that the staff member placed the clothing protector around the resident's neck without asking the resident's permission. Observation in the Main Dining Room during the breakfast time meal service on 8/26/15 at approximately 8:46 AM revealed that the staff member placed the clothing protector around the resident's neck without asking the resident's permission. Review of the resident's care plan revealed there was no notation that the staff may place a clothing protector on the resident without their permission. Interview with the Registered Nurse Unit Manager (RN UM) on 8/26/15 at approximately 10:00 AM revealed the RN UM expects staff to ask permission or ask if it is okay to put a clothing protector on the resident. Interview with the Director of Nursing (DON) on 8/27/15 at approximately 9:29 AM revealed staff should be asking permission or at least explain to the resident what they are doing regarding placement of a clothing protector. The DON also stated it's a dignity thing. 2. Resident #46 has [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS - a resident assessment tool) dated 7/30/15 revealed the resident is severely cognitively impaired with short and long term memory problems, understands, and usually understood. Review of the certified nurse aide (CNA) care guide dated 8/7/15 revealed that the resident is a supervision with set up for eating. Observation in the Main Dining Room during the breakfast time meal service on 8/26/15 at approximately 8:26 AM revealed that the staff member placed the clothing protector around the resident's neck without asking the resident's permission. Review of the resident's care plan revealed there was no notation that the staff may place a clothing protector on the resident without their permission. Interview with the Registered Nurse Unit Manager (RN UM) on 8/26/15 at approximately 10:00 AM revealed the RN UM expects staff to ask permission or ask if it is okay to put a clothing protector on the resident. Interview with the Director of Nursing (DON) on 8/27/15 at approximately 9:29 AM revealed staff should be asking permission or at least explain to the resident what they are doing regarding the placement of a clothing protector. The DON also stated it is a dignity thing. Interview with the Certified Nurding Aide(CNA) on 8/27/15 at approximately 10:05 AM revealed I should have asked for permission to place a clothing protector on the resident.It is a dignity thing. 3. Resident #53 has [DIAGNOSES REDACTED]. Review of the certified nurse aide care guide dated 8/25/15 revealed that the resident is supervision with set up for eating. Observation in the Main Dining Room during the lunch time meal service on 8/24/15 at approximately 12:57 PM revealed that the staff member placed the clothing protector around the resident's neck without asking the resident's permission. Review of the resident's care plan revealed there was no notation that the staff may place a clothing protector on the resident without their permission. Interview with the Registered Nurse Unit Manager (RN UM) on 8/26/15 at approximately 10:00 AM revealed the RN UM expects staff to ask permission or ask if it is okay to put a clothing protector on the resident. Interview with the Director of Nursing (DON) on 8/27/15 at approximately 9:29 AM revealed staff should be asking permission or at least explain to the resident what they are doing regarding the placement of a clothing protector. The DON also stated it's a dignity thing. 415.5(a)

Based on observation and interview conducted during the Standard survey completed on 1/29/15, the facility did not store, prepare, distribute and serve food under sanitary conditions. One (Main Kitchen) of two kitchens observed for food storage had undated and unlabeled food items in the freezer. Specifically, there were approximately 19 individually wrapped frozen fish filets on two racks in the main freezer that were undated and unlabeled. Additionally, One (Nourishment Room) of one nourishment room observed had 17 expired single serve cups of Thick and Easy stored in a drawer of the Nourishment Room. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy. The findings are: 1. Observation of the Main Kitchen on 1/28/15 at approximately 11:39 AM revealed approximately 19 individually wrapped fish filets on two trays in the freezer that were undated and unlabeled. During an observation of the Main Kitchen's freezer racks on 1/29/15 at approximately 11:44 AM, the Food Service Director (FSD) stated the undated and unlabeled frozen filets were left over from the prior Friday's fish fry. Fresh fish is delivered every Thursday for the Friday meal. The left over filets from the week prior are used first and any remaining fish filets are individually wrapped and frozen for the next week. Review of the undated facility policy entitled Food and Supply Storage Procedures revealed that all frozen foods are to be labeled, dated and rotated. 2. Observation of the Nourishment Room on 1/26/15 at approximately 9:30 AM revealed the following: - Five "Thick & Easy" brand 4 ounce (oz) cups of apple juice with a 12/14/14 expiration date. - Six "Thick & Easy" brand 4 oz cups of cranberry juice with a 12/21/14 expiration date. - Six "Thick & Easy" brand 4 oz cups of orange juice with a 1/4/15 expiration date. Interview with a Server/ Cook on 1/26/15 at approximately 9:30 AM, the Server/ Cook stated that the Cooks were responsible to check the Nourishment Room for expired foods daily and stated that she would dispose of the expired cups of juice immediately. 415.14(h)

Based on observation, interview and record review conducted during the Standard survey completed on 1/29/15, the facility did not promote care in a manner that enhanced the resident's dignity. Six (Residents #3, 10, 22, 26, 40, 56) of 19 residents observed had issues that involved transfer sling leg straps crossed over and looped on the resident's legs while in a common area with other residents and staff. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy. The findings include but are not limited to: 1. Resident #40 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 11/27/14 revealed the resident has severely impaired cognition, rarely or never understands. The resident is totally dependent on two persons to transfer. Review of the certified nurse aide (CNA) Profile of Care dated 12/9/14 revealed the resident requires total assist of two staff members with a mechanical lift transfer with instructions that staff "may leave sling under res (resident) when up in chair." During observations of the resident sitting in a recliner chair outside the dining room, between approximately 7:15 AM through 8:00 AM on 1/26/15 through 1/29/15, the resident was observed to have the leg straps of the mechanical lift sling looped together and crossed over the top of each leg. Interview with the resident's family member on 1/29/15 at 11:30 AM revealed the family member did not like the transfer sling straps exposed on the top of the resident's legs. 2. Resident #56 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has moderate cognitive impairment, usually understands and is understood. The resident is totally dependent on two persons to transfer. Review of the Profile of Care dated 1/27/15 revealed the resident requires total assist of two staff members with a mechanical lift for transfer with instructions that staff "may leave sling under res (resident) when up in chair." During an observation of the resident on 1/28/15 at approximately 10:40 AM, the resident was observed to have the leg straps of the mechanical lift sling looped together and crossed over the top of each leg. During an observation of the resident in a wheelchair on 1/29/15 at approximately 11:30 AM, revealed the leg straps of the mechanical lift sling were crossed over the top of the resident's legs. 3. Resident #22 has [DIAGNOSES REDACTED]. Review of the Profile of Care dated 1/27/15 revealed the resident uses a mechanical lift for transfers. Intermittent observations of the resident on 1/26, 1/27, 1/28, and 1/29/15 between approximately 8:00 AM through 12:00 PM revealed the resident's transfer sling leg straps were crossed over and looped on the resident's lower legs while she was seated in a common area in view of residents and staff. Interview with a CNA on 1/29/15 at 7:55 AM revealed the straps from the transfer sling should be positioned under the resident's legs for dignity issues. 4. Resident #10 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has moderate cognitive impairment, usually understands and is usually understood. The resident requires total staff assistance for all activities of daily living (ADLs). Observation of the resident on 1/26/15 at 1:36 PM revealed the resident was sitting in his room in a geri-chair with transfer sling leg straps were crossed over and looped on the resident's lower legs. Additional observation on 1/27/15 at 10:45 AM revealed the resident was attending activities with other residents (approximately 20) sitting in the geri-chair with transfer sling leg straps crossed over and looped on the resident's legs. Additional resident observation on 1/27/15 at approximately 3:30 PM revealed the resident located in the hallway in the geri-chair with the transfer sling leg straps crossed over and looped on the resident's legs/thighs. Interview on 1/29/15 at 10:34 AM with the Registered Nurse (RN) Unit Manager (UM) revealed after a mechanical lift transfer, it is a facility expectation staff are to place the sling loops neatly underneath the resident where they are not visible. 415.5(a)

Based on interview and record review conducted during a Complaint investigation (Complaint # NY 122) during the Standard survey completed on 1/29/15, the facility did not perform an accurate assessment, using the Resident Assessment Instrument (RAI) specified by the State, of resident's functional mobility. One (Resident #53) of 22 residents residents reviewed for comprehensive assessments did not have a therapy screen or assessment prior to completion of a quarterly Minimum Data Set (MDS - a resident assessment tool). There was no harm with potential for more than minimal harm that is not immediate jeopardy. The finding is: 1. Resident #53 has [DIAGNOSES REDACTED]. Review of the quarterly MDS dated [DATE] revealed the resident has severely impaired cognition, sometimes understands and is sometimes understood. The resident requires extensive assistance by staff for bed mobility, hygiene and toileting. The resident is dependent on the staff for transfers and does not ambulate. Review of the quarterly MDS dated [DATE] revealed the resident requires extensive assistance of two persons with bed mobility and is totally dependent with the assist of two persons to transfer. The resident does not walk in the room or corridor. Review of the current undated Comprehensive Care Plan revealed the resident has an alteration in functional mobility due to dementia. The resident requires extensive assistance with bed mobility, is non ambulatory, is to receive active assist range of motion (ROM) to both lower extremities five times a week and requires a mechanical lift for transfers out of bed or chair. The resident has a potential for alteration in safety due to dementia. Physical Therapy (PT) and Occupational Therapy (OT) are to complete assessments. Review of the Medical Record, both in paper and electronically, revealed the resident did have an OT screen completed on 6/3/14 but did not have a PT screen for this date. Interview with the Director of Therapy (DT) on 1/29/15 at approximately 11:11 AM revealed all residents have an annual and quarterly MDS screen completed by PT and OT. The screen is completed by directly observing the resident; then the report is placed in the chart. The PT Department is responsible for completion of Section G, level 300 and 400 as well as Section O of the MDS if the resident is on an active therapy program. The DT reviewed the MDS completed on 6/4/14 and stated Therapy did complete section G level 300 and 400. The DT reviewed the entire Medical Record, the entire electronic medical record and files in the PT Department and stated a PT Evaluation and Screen was not completed for the resident for this MDS. The DT stated that all residents need a direct screen and review to assure that accurate information is on the resident's MDS. Review of the facility policy entitled PT Screen dated 5/2010 revealed it is the policy of the facility to assess the resident's ADL (activities of daily living)/ functional status to determine need for evaluation, to establish a plan of care and to communicate recommendations to nursing. A PT screen is completed for initial reviews on residents without a rehab diagnosis, quarterly or significant change reviews and at readmission. The indication for the screen and completion date is entered in the ID (interdisciplinary) note as well as recommendations for nursing such as ambulation, transfer, bed mobility status and ROM program. The care plan is completed on the unit and online for any changes made to the resident's plan of care. The screen is to be signed, dated and list the screener's credentials. 415.5(a)(2)

Based on interview and record review conducted during the Standard survey completed on 1/29/15, the facility did not periodically review and revise the comprehensive care plan (CCP). One (Resident #30) of three residents reviewed for dental care plans did not have a care plan revision to address the resident's existing dental problems of his natural teeth and request for dental [MEDICATION NAME] (preventative service) in accordance with the resident/ responsible party wishes. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy. The finding is: 1. Resident #30 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 10/30/14 revealed the resident has severe cognitive impairment, understands and is understood. The resident requires extensive staff assistance for personal hygiene. Review of a Dental Services visit dated 3/20/14 revealed the resident received a periodic cleaning. The resident had ten missing teeth, five in the rear uppers and five in the rear lowers, with a carious (tooth decay) #10 upper tooth. The resident has sensitivity at times in lower tooth #21 with plans to maintain "[MEDICATION NAME]" care every three months as requested by family (cleaning every three months). Review of a Physician Visit Form (Out of Office) dated 5/6/14 revealed the resident was evaluated by the Dentist for "vague" mouth pain. The examination revealed the resident has poor hygiene and X-rays revealed deep caries under existing tooth #5 and an extraction of tooth #5 was performed, with recommendations for salt water rinses four times per day for three days. Review of a Physician Visit Form (Out of Office) dated 11/25/14 revealed the resident was treated by the Dentist for [MEDICATION NAME] and replacement of crown #9. Review of the annual Dental Examination dated 1/14/15 revealed the resident has two broken teeth #2, 12. Tooth #4 is loose and the resident has heavy plaque, next visit [MEDICATION NAME]. Review of a Medical Clearance form dated 1/14/15 revealed the resident has no contraindications for teeth cleaning. Review of the current CCP revealed the resident has a potential for alteration in nutrition due to aging; the resident has his own teeth; with plans for dental consults yearly and as needed. There is no documentation of the resident's existing dental problems, or plans for [MEDICATION NAME] cleaning every three months as requested by the family. Interview with the Registered Nurse (RN) Unit Manger (UM) on 1/29/15 at 10:30 AM revealed, the RN UM completes the CCP and does not document the condition of the resident's natural teeth in the care plan; it merely reflects if they have their own teeth. When asked how she knows the resident has a dental problem, the RN UM stated the staff will bring it to her attention when the resident exhibits a problem and she will make out a request using the Dental Visit Form. The RN UM stated dental care plan standards are yearly and "as needed" and if the plan is more specific than that, the Dentist tracks this on their office schedule. 415.11(c)(2)(iii)

Based on interview and record review conducted during the Standard survey completed on 1/29/15, the facility did not promptly provide or obtain from an outside resource, routine dental services to meet the needs of each resident. One (Resident #30) of three residents reviewed for dental services had an issue involving the lack of a timely dental [MEDICATION NAME] (preventative services) in accordance with the resident/ responsible party wishes. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy. The finding is: 1. Resident #30 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 10/30/14 revealed the resident has severe cognitive impairment, understands and is understood. The resident requires extensive staff assistance for personal hygiene. Review of a Dental Services visit dated 3/20/14 revealed the resident received a periodic cleaning. The resident had ten missing teeth, five in the rear uppers and five in the rear lowers, with a carious (tooth decay) #10 upper tooth. The resident has sensitivity at times in lower tooth #21 with plans to maintain "[MEDICATION NAME]" care every three months as requested by family (cleaning every three months). Review of a Physician Visit Form (Out of Office) dated 5/6/14 revealed the resident was evaluated by the Dentist for "vague" mouth pain. The examination revealed the resident has poor hygiene and X-rays revealed deep caries under existing tooth #5 and an extraction of tooth #5 was performed, with recommendations for salt water rinses four times per day for three days. Review of a Physician Visit Form (Out of Office) dated 11/25/14 revealed the resident was treated by the Dentist for [MEDICATION NAME] and replacement of crown #9. Review of the annual 1/14/15 Dental examination revealed the resident has two broken teeth #2, 12. Tooth #4 is loose and the resident has heavy plaque, next visit [MEDICATION NAME]. Review of a Medical Clearance Form dated 1/14/15 revealed the resident has no contraindications for teeth cleaning. Review of the current Comprehensive Care Plan revealed the resident has a potential for alteration in nutrition due to aging; the resident has his own teeth; with plans for dental consults yearly and as needed. There is no documentation of the resident's existing dental problems, or plans for [MEDICATION NAME] cleaning every three months as requested by the family. Interview with the Registered Nurse (RN) Unit Manger (UM) on 1/29/15 at 10:30 AM revealed, the RN UM completes the CCP and does not document the condition of the resident's natural teeth in the care plan; it merely reflects if they have their own teeth. When asked how she knows the resident has a dental problem, the RN UM stated the staff will bring it to her attention when the resident exhibits a problem and she will make out a request using the Dental Visit Form. The RN UM stated dental care plan standards are yearly and "as needed" and if the plan is more specific than that, the Dentist tracks this on their office schedule. Interview with the Health Information Manager (HIM) on 1/29/15 at 11:05 AM, the HIM stated the resident is seen by the Dentist every three to six months or sooner if there are issues. Nursing Staff fill out a request form which gets sent to herself (HIM) and she makes the appointments and tracks them in a log. Review of the facility's dental tracking log revealed the resident had the dental visits described above; however, the resident has not received periodic cleaning every three months in accordance with the family's wishes. 415.17

Based on observation, interview and record review conducted during a complaint investigation (Complaint #NY 868) during an Extended Survey completed 6/6/14, the facility did not ensure that the resident environment remains as free of accident hazards as possible, and each resident received adequate supervision and assistive devices to prevent accidents. There was a lack of adequate supervision for residents attending a planned activity in an area of the facility not secured with the Wanderguard alarm system. One (Resident #48) of nine residents reviewed identified at risk for wandering and elopement wearing a Wanderguard (device to detect wandering) was able to exit the building through a first floor door that was not Wanderguard protected. This was a pattern of no actual harm that is IMMEDIATE JEOPARDY AND SUBSTANDARD QUALITY OF CARE TO RESIDENT HEALTH AND SAFETY. The Immediate Jeopardy was removed on 6/6/14, prior to completion of the survey. The findings are: 1. Resident #48 is a [AGE] year-old with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS - an assessment tool) dated 5/1/14 revealed the resident has moderately impaired cognitive skills for daily decision making, is usually understood, and usually understands. Additional review of the MDS revealed wandering behavior occurred 3 days in the previous 7 days, and the resident experienced two falls with no injury in the previous 92 days. Review of a facility "Risk Assessment for Falls" dated 5/12/14 revealed a total score of 17, and that a "total score of 10 or above represents HIGH RISK." Review of a facility "Wandering Risk Scale" dated 5/12/14 revealed a total score of "11-above represents High Risk for Wandering." Review of a facility "Elopement Risk Assessment" dated 5/12/14 revealed a total score of 18, and that "10 or more = RISK." The "Evaluation" portion of the "Elopement Risk Assessment" dated 5/12/14 revealed Resident #48 is at risk for elopement, a monitoring bracelet was applied, and door alarms utilized. Review of the Comprehensive Care Plan (CCP) dated 5/13/14 revealed an alteration in functional mobility with an approach to "ambulate independent with or without rolling walker (RW) 200 feet or to tolerance" and "has a history of wandering with approaches that include to provide supervision, and place Wanderguard on resident". Further review of the CCP dated 5/13/14 revealed a potential for low activity participation related to wandering with a goal that included resident safety will be maintained. Approaches included staff to provide environmental cues to decrease exit behavior. Review of the "Profile of Care" (Care Guide for certified nurse aides (CNAs)) dated 5/12/14 revealed the resident is at high risk for elopement and unsafe wandering. Review of a Physician Note dated 4/24/14 revealed the resident is oriented to person, lacks capacity for health care decisions, and walks with a shuffling gait. The resident was observed by a New York State Department of Health (NYS DOH) surveyor on 6/4/14 at 3:35 PM ambulating with a slow unsteady shuffling gait, unsupervised by staff or family, on a concrete sidewalk outside of the building that contained the skilled nursing facility (SNF). The resident was walking towards the blacktop parking lot. The NYS DOH surveyor approached the resident at the point where the sidewalk met the parking lot. The resident had a confused, anxious look. When asked where he was going, he stated that he needed to find his home. The surveyor walked the resident back towards the entrance of the facility (approximately 150 feet) and was met by another NYS DOH surveyor that was exiting the facility. At approximately 25 feet from the entrance of the facility, an unidentified female employee who was observed to be standing at the reception desk, came out of the building entrance when she saw the resident and surveyors approach the facility. An Activity Leader followed immediately after her. The Activity Leader took the Resident's hand and continued toward the entrance and was met by the Activity Director between the double doors of the entrance. No alarm sounded at the main entrance to the facility. Resident #48, Activity Leader, Activity Director, and the two surveyors approached the elevator. While waiting at the elevator door, the resident turned to the Activity Leader and stated, "I'm scared." The Activity Leader reassured him that everything was okay. When he entered the elevator, an alarm began to sound that was manually overridden by the Activity Director. Interview on 6/4/14 at approximately 4:00 PM with Activity Director revealed that the resident's wife brought him down to the planned group activity in his wheelchair. At 3:00 PM, the wife informed the Activity Director she was leaving. The Activity Director stated she was the first staff member to take another resident with wander issue back to the skilled facility on the Second Floor. When she returned to the area where the activity occurred, she noticed the resident's wheelchair was empty and began to look for him. The Activity Director stated that usually ambulatory residents of the Assisted Living Memory Care Unit will leave an activity first with a staff member. When that staff member returns, they will start transporting SNF residents, with priority to those residents that wander or are anxious. The Activity Director stated that the Activity Leader of the Assisted Living Memory Care Unit was off that day so the routine was off. The Activity Director stated that "someone is always downstairs with residents". Interview on 6/4/14 at approximately 4:15 PM with the Activity Leader of the SNF revealed, that she was delivering mail in the Assisted Living Facility (ALF) and SNF during the activity. She returned downstairs to the activity as it was finishing and the Activity Director brought "someone" up to the SNF. The Activity Leader stated that she was preparing others to come upstairs. The Activity Leader stated that she then took "probably two residents" up to the SNF via the elevator and passed the Activity Director coming off elevator upstairs. The Activity Leader stated the volunteer/ college intern and a part-time Activity Leader of the ALF were left in the room with the remaining residents where the activity had just occurred. Interview on 6/5/14 at approximately 9:15 AM with the part-time Activity Leader of the ALF revealed she took an ALF resident back to the memory impairment unit because the resident's husband asked her to do so. She stated that the volunteer/ college intern and "dietary aides" were left with the residents remaining after the activity. She stated that when she returned, she noticed the resident's wheelchair was empty and notified activity and ALF personnel in person and they began a search. The part-time Activity Leader stated that the ALF case worker stayed with the remaining residents from the activity. The part-time Activity Leader of ALF stated that she receives a daily list of resident at risk for wandering and that all activity staff are responsible for oversight of the residents. On 6/5/14 at approximately 9:30 AM during a follow up interview with the Activity Director, it was clarified that the "dietary aides" the part-time Assisted Living Activity Leader referred to were the facility's Registered Dietitian (RD) and the Diet Technician (DT). On 6/5/14 at approximately 3:00 PM interview with the facility RD revealed that the activity that occurred on the afternoon of 6/4/14 was an activity involving food and a video that she had planned and presented. The RD stated that after the activity was completed, she was cleaning up the food and retrieving the DVD. The RD stated she does not have any resident supervision responsibilities but she is aware of residents who are at risk for wandering by communication with Registered Nurse (RN) Unit Manager (UM) of the SNF. The RD stated the DT ended her work day at 3:00 PM and was not present when it was identified that the resident was missing. On 6/5/14 at approximately 4:00 PM, interview with Activity Director revealed the volunteer was a college student completing a 100 hour internship on the Assisted Living Memory Care Unit. The volunteer's orientation included volunteer duties, wheelchair safety, Assisted Living Resident Characteristics and the Dementia Program. The Activity Director stated that the volunteer/ college intern is expected to be with staff at all times, preferably an Activity Leader when with a resident. The Activity Director stated that the RD is not considered a staff member for supervision of the residents and the volunteer/ college intern should not have been left alone in room following the activity. The Activity Director stated that the volunteer/ college intern would not have knowledge of which SNF residents were at risk for elopement or wandering. During interview and observation on 6/4/14 between approximately 4:10 PM to 4:25 PM, with the Director of Facilities and the Director of Nursing (DON) revealed the SNF Wanderguard alarm is a 2-part system that alarms when someone with a Wanderguard approaches the elevators on the second floor where the SNF is located. The Wanderguard system will then not allow the elevator to function when a Wanderguard is in the immediate area of the elevator. According to the Director of Facilities, the Wanderguard system is limited to the two elevators that open on to the second floor of the SNF and stated that the facility also has another alarm system on the Assisted Living Memory Care Unit. The Director of Facilities demonstrated the proper functioning of the Wanderguard alarm on the two elevators that serve as exits from the SNF and demonstrated that the four stairwells on the floor have locked doors, accessible only with a key pass or open by the fire alarm system. The DON stated, "We check the system all the time, we have the indicator that checks the wrist bands, and we check the elevators all the time with the residents who go on and off the unit or walk by the elevator." Interview on 6/5/14 at approximately 12:00 PM with the RN UM revealed that residents with potential to wander would leave the SNF with either family members or the Activity Department. Family members would have to sign out the resident, and be responsible for the resident while out of the SNF. The Activities Department also has a log that they would sign out the resident, in order for staff to know which resident was off the SNF at an activity. The Activity Department would be responsible for the resident when the resident was off the SNF floor. On occasion, for a large group activity, the Activity Department may ask nursing staff to help with transport of the resident only. The RN UM explained, "For instance, if there were a number of residents waiting on the elevator and the CNA was going on break, the CNA may help get the resident to the activity. But once the resident was at the activity, the activity department was responsible for the resident." The RN UM stated that the CNAs helping with transport would only happen occasionally for large group activities and most of the time the activities aides or volunteer would transport the residents. The volunteers would not be responsible for the residents, activities would be responsible. The RN UM stated, "I have been the Unit Manager here for over 2 years and it has been the practice for residents to go off the unit (SNF) to activities for as long as I have been here." Interview and observation on 6/5/14 at approximately 1:30 PM with the Director of Facilities revealed that the facility thought the resident exited the facility from a door at the end of the hall on the first floor of the ALF where he was found by the DOH surveyor. The Director of Facilities demonstrated that this door was able to be opened with a push bar that was not alarmed or delayed. When the door latched, it could not be opened from the exterior. The door opened on to the sidewalk that led to the parking lot where the resident was found by the DOH surveyor. Review of the facility Wandering Resident Policy and Procedure (P&P), dated September 2007, revealed that "should an elopement episode occur, the contributing factors, as well as the interventions tried, will be documented on the Nurses' Notes" and "If a resident is discovered to be missing, a search shall begin immediately." Review of a Resident Elopement P&P, dated September 2007, revealed a procedure the facility would implement upon learning that a resident was missing and subsequent procedure once the missing resident is located. Additional review of both P&Ps revealed no documented evidence of a procedure to assure the safety of a resident, at risk for wandering and elopement, while attending activity programs under the supervision of facility staff in an area not secured with the Wanderguard system. Interview with the Administrator on 6/6/14 at approximately 10:30 AM revealed that a plan was developed and implemented to ensure the safety of residents at risk for wandering and elopement, while attending activities off of the SNF. The plan included the development, implementation and education of staff and families of a new policy to address the attendance of residents at risk for wandering and elopement while at activities off the SNF. The plan included receipt of quotes to upgrade the facility's security system to include audible alarms on four of five exit doors in the ALF. Also included was the creation and placement of a "wandering resident" list along with pictures of the resident at the reception desk of entrance to the SNF and ALF. Interview with the Administrator on 6/6/14 at approximately 10:30 AM revealed approximately 75% of the SNF, ALF and Assisted Living Memory Care Unit had received face-to-face verbal in-service training on the new P&P. Interviews with facility staff on 6/6/14 between approximately 12:00 PM and 1:00 PM, regarding the new P&P for attendance of activities off the SNF of resident at risk for wandering and elopement revealed the following; - The DON, RN UM and Activity Director each stated the need of a resident at risk for wandering and elopement to have 1:1 observation when off of the SNF and the use of a new sign out log that identify which activity staff member is responsible for a resident. - The Activity Director revealed she planned to continue face-to-face training of all activity staff on the first day, each staff member returns back to work. - The Activity Leaders of SNF and ALF revealed in-servicing had occurred with the Activity Director and each was able to verbalize the need for 1:1 observation of a resident at risk for wandering and elopement and the implementation of a new activity sign out log on the SNF Unit. Two CNAs and the Range of Motion (ROM) aide revealed that they had received training and were aware of the facility's plan that included: how to identify residents at risk for wandering and elopement, the need for one on one supervison of residents at risk when taken off the SNF and the use of the sign out log. 415.12 (h)(1)(2)

Based on observation, interview and record review conducted during a complaint investigation (complaint #NY 868) conducted during an Extended Survey completed 6/6/14, it was determined that the governing body did not develop and implement policies and procedures regarding the management and operation of the facility to ensure that the facility was managed in a manner that protected the health and safety of its residents. The facility did not ensure that the resident environment remained as free of accident hazards as possible, and each resident received adequate supervision and assistive devices to prevent accidents. One (Resident #48) of nine residents reviewed identified at risk for wandering and elopement wearing a Wanderguard (device to detect wandering) was able to exit the building through a first floor door that was not Wanderguard protected. The facility failed to ensure that policies were developed and implemented related to the supervision of residents at risk for elopement when off a secured unit. The lack of oversight by the governing body resulted in a deficiency which was determined to constitute Substandard Quality of Care. This was a pattern of no actual harm that is IMMEDIATE JEOPARDY TO RESIDENT HEALTH AND SAFETY. Refer to F323 - scope and severity - K The Immediate Jeopardy was removed on 6/6/14, prior to completion of the survey. The findings are: 1. Resident #48 is a [AGE] year-old with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS - an assessment tool) dated 5/1/14 revealed the resident has moderately impaired cognitive skills for daily decision making, is usually understood, and usually understands. Additional review of the MDS revealed wandering behavior occurred 3 days in the previous 7 days, and the resident experienced two falls with no injury in the previous 92 days. Review of a facility "Risk Assessment for Falls" dated 5/12/14 revealed a total score of 17, and that a "total score of 10 or above represents HIGH RISK." Review of a facility "Wandering Risk Scale" dated 5/12/14 revealed a total score of "11-above represents High Risk for Wandering." Review of a facility "Elopement Risk Assessment" dated 5/12/14 revealed a total score of 18, and that "10 or more = RISK." The "Evaluation" portion of the "Elopement Risk Assessment" dated 5/12/14 revealed the Resident #48 is at risk for elopement, a monitoring bracelet was applied, and door alarms utilized. Review of the Comprehensive Care Plan (CCP) dated 5/13/14 revealed an alteration in functional mobility with an approach to "ambulate independent with or without rolling walker (RW) 200 feet or to tolerance" and "has a history of wandering with approaches that include to provide supervision, and place Wanderguard on resident". Further review of the CCP dated 5/13/14 revealed a potential for low activity participation related to wandering with a goal that included resident safety will be maintained. Approaches included staff to provide environmental cues to decrease exit behavior. Review of the "Profile of Care" (Care Guide for certified nurse aides (CNAs)) dated 5/12/14 revealed the resident is at high risk for elopement and unsafe wandering. Review of a Physician Note dated 4/24/14 revealed the resident is oriented to person, lacks capacity for health care decisions, and walks with a shuffling gait. On 6/4/14 at 3:35 PM, the resident was observed by a New York State Department of Health (NYS DOH) surveyor ambulating with a slow unsteady shuffling gait, unsupervised by staff or family on a concrete sidewalk outside of the building that contained the skilled nursing facility. When asked where he was going, the Resident stated that he needed to find his home. The surveyor walked the Resident back towards the entrance of the facility (approximately 150 feet). At approximately 25 feet from the entrance of the facility, an unidentified female employee who was observed to be standing at the reception desk, came out of the building entrance when she saw the Resident and surveyors approach the facility. An Activity Leader followed immediately after her. The Activity Leader took the Resident's hand and continued toward the entrance and was met by the Activity Director between the double doors of the entrance. No alarm sounded at the main entrance to the facility. No alarm sounded at the main entrance to the facility. Interview on 6/4/14 at approximately 4:00 PM with the Activity Director revealed that Resident #48's wife brought him down to the planned group activity in his wheelchair. According to the Activity Director, at 3:00 PM the wife informed the Activity Director she was leaving. The Activity Director stated she was the first staff member to take another resident back to the Skilled Nursing Facility (SNF). The Director returned one resident with a wander issue to the SNF on the Second Floor. When she returned to the area where the activity occurred, she noticed the resident's wheelchair was empty at 3:30 PM and began to look for the resident. The Activity Director stated that usually ambulatory residents of the Assisted Living Memory Care Unit will leave an activity first with one staff member. When that staff member returns, they will start transporting SNF residents, with priority to those residents who wander or are anxious being brought back to the SNF first. The Activity Director stated that the Activity Leader of the Assisted Living Memory Care Unit was off that day and "so the routine was off". The Activity Director stated that "someone is always downstairs with residents." Interview on 6/4/14 at approximately 4:15 PM with the Activity Leader of the SNF revealed that she was delivering mail in the Assisted Living Facility (ALF) and SNF during the activity. The Activity Leader stated she returned downstairs to the activity as it was finishing. The Activity Leader stated that while the Activity Director brought "someone" up to the SNF she (Activity Leader) was preparing others to go upstairs. The Activity Leader stated that she then took "probably two residents" up to the SNF via the elevator and passed the Activity Director coming off elevator upstairs. The Activity Leader stated the volunteer/ college intern and a part-time Activity Leader of the ALF were left in the room with the remaining residents where the activity had just occurred. Interview on 6/5/14 at approximately 9:15 AM with the part-time Activity Leader of ALF revealed she took a memory impaired ALF resident back to the memory impairment unit because the resident's husband asked her to do so. The part-time Activity Leader of the ALF stated that the volunteer/ college intern and "dietary aides" were left with the residents remaining after the activity. The part-time Activity Leader of ALF stated that when she returned, she noticed Resident #48's wheelchair was empty and notified activity and ALF personnel in person and they began a search. The part-time Activity Leader stated that the ALF case worker stayed with the residents remaining from the activity. The part-time Activity Leader of ALF stated that she receives a daily list of residents at risk for wandering and that all activity staff are responsible for oversight of the residents. On 6/5/14 at approximately 9:30 AM during a follow up interview with the Activity Director, it was clarified that the "dietary aides," were the facility's Registered Dietitian (RD) and the Diet Technician (DT). When requests for facility policies regarding activities for residents with potential to wander when off the secure unit, the Activity Director stated that the facility did not have a policy. Interview with the facility RD on 6/5/14 at approximately 3:00 PM revealed that the activity that occurred on the afternoon of 6/4/14 was an activity involving food and a video that she had planned and present. The RD stated that after the activity was completed, she was cleaning up the food and retrieving the DVD. The RD stated she does not have any resident supervision responsibilities but she is aware of residents who are at risk for wandering by communication with the Registered Nurse (RN) Unit Manager (UM) of the SNF. The RD stated the DT ended her work day at 3:00 PM and was not present when it was identified that Resident #48 was missing. Interview with Activity Director on 6/5/14 at approximately 4:00 PM revealed the volunteer was a college student completing a 100 hour internship on the Assisted Living Memory Care Unit. The volunteer's orientation included volunteer duties, wheelchair safety, Assisted Living Resident Characteristics and the Dementia Program. The Activity Director stated that the volunteer/ college intern is expected to be with staff at all times, preferably an Activity Leader. The Activity Director stated that the RD is not considered a staff member for supervision of the residents and the volunteer/ college intern should not have been left alone in room following the activity. The Activity Director stated that the volunteer/ college intern would not have knowledge of which SNF residents were at risk for elopement or wandering. Interview on 6/5/14 at approximately 12:00 PM with the RN UM, it was revealed that residents with potential to wander would leave the SNF with either family members or the Activity Department staff. Family members would have to sign out the resident on the SNF, and would be responsible for the resident while out of the SNF. The Activities Department also has a log that staff would sign in order to know which resident was off the SNF at an activity. The Activity Department staff would be responsible for the resident when the resident was off the SNF floor. On occasion, for a large group activity, the Activity Department may ask nursing staff to help with transport of the resident only. The RN UM explained, "For instance, if there were a number of residents waiting on the elevator and the CNA (certified nurse aide) was going on break, the CNA may help get the resident to the activity. But once the resident was at the activity, the Activity Department staff was responsible for the resident." The RN UM stated that the CNAs helping with the transport would only happen occasionally for large group activities and most of the time activity aides or volunteers would transport the residents. The volunteers would not be responsible for the residents, activities would be responsible. The RN UM stated, "I have been the Unit Manager here for over 2 years and it has been the practice for residents to go off the unit (SNF) to activities for as long as I have been here." Interview on 6/5/14 at approximately 1:30 PM with the Director of Facilities (Maintenance) revealed that it was suspected that the resident exited the facility from a door at the end of the hall on the first floor of the Assisted Living Unit where Resident #48 was found by the surveyor. The Director of Facilities demonstrated for the surveyor that this door was able to be opened with a push bar that was not alarmed or delayed. When the door latched, it could not be opened from the exterior. The door opened onto the sidewalk that led to the parking lot where the resident was found by the DOH surveyor. Interview with the Administrator on 6/5/14 at approximately 3:00 PM revealed the facility had no written policy and procedure to address the safety of residents at risk for wandering while at an activity off of the secure unit. This deficiency and the potential serious impact it represents to the quality of care of facility residents, demonstrates a failure on the part of the governing body to ensure effective management and operation of the facility. 415.26(b)(2)(3)

Based on observation, interview and record review conducted during an Extended Survey completed 6/6/14, the facility did not have the most recent New York State Department of Health survey results and any approved plans of correction available to residents without having to ask a staff person. The facility did not have those results in a place readily accessible to residents. This was a pattern of no actual harm with potential for minimal harm. The findings are: 1. Observation of the nursing unit on the Second Floor of the facility and the Reception Area on the First Floor on 6/3/14 from 10:45 AM to 12:00 PM revealed no location where the results of last year's survey are posted and/ or available to read. Follow up observation throughout the day on 6/4/14 from 9:00 AM to 3:00 PM revealed the absence of the survey results from last year. Interview with the Resident Council President on 6/3/14 at 10:50 AM revealed that he was not aware of the New York State Department of Health survey results. He stated he did not know where the survey results may be located, "Perhaps, at the bulletin board at the Nurses' Station where some other items are posted." Interview with the Administrator and Director of Nursing (DON) on 6/4/14 at 2:30 PM revealed the survey results are always posted on the bulletin board by the elevator and Nurses' Station. Inspection of the bulletin board with the DON on 6/4/14 at 2:35 PM revealed the absence of the survey results. After further discussion amongst staff (the nurses at the Nurses' Station) it was determined the facility used to have a table and chairs by the bulletin board, and the survey results were put in a binder and placed on the table. The DON stated that just a week or two ago, the table and chairs were removed and an armoire was put in this space, and the survey binder must have been moved, perhaps to the Nurses' Station counter. It was observed that the DON searched all over the Nurses' Station counter top but did not find the binder. Finally, after searching, the binder was discovered behind the Nurses' Station in a bookcase with other nursing/ medical related binders. Review of the binder entitled "Department of Health Survey Results" revealed it had the most recent Life Safety survey results dated 5/31/13 placed in the front of the binder, but did not have any 2013 Federal Health related survey deficiencies. Review of the facility policy entitled "Department of Health Postings" dated September 2007 documents that "All New York State Department of Health Survey results will be posted for all residents and visitors to access." 415.3 (1)(c)(1)(v)

Based on interview and record review during an Extended Survey completed 6/6/14, it was determined that the facility did not revise the resident's care plan. One (Resident #57) of 15 residents reviewed for care plans and revision did not have a care plan revision to include the resident being a high risk for falls as determined by the Risk Assessment for Falls. This was a pattern of no actual harm with potential for minimal harm. The finding is: 1. Resident #57 has [DIAGNOSES REDACTED]. Review of the current Minimum Data Set (MDS - an assessment tool) dated 5/8/14 revealed the resident has moderately impaired cognitive skills, is understood and usually understands with short and long term memory problems. Review of the Comprehensive Care Plan dated 5/20/14 revealed one of the Falls interventions included "Falls risk assessment quarterly and PRN" (as needed). Review of the Risk Assessment for Falls Form dated 2/13/14 revealed that the resident had a total score of 10 and that a "total score of 10 or above represents HIGH RISK." Review of the Risk Assessment for Falls Form dated 5/19/14 revealed that the resident has a total score of 10. Review of the Profile of Care (certified nurse aide (CNA) Care Guide) dated 5/20/14 revealed under the heading SAFETY that the line "HIGH RISK FOR FALLS" was left unchecked. Review of the facility policy and procedure (P&P) entitled "Falls Prevention" dated 9/07 revealed "The Nurse will utilize the risk assessment and the suggested plan of recommendations to institute a plan of care. The plan will be documented on the Resident Care Plan in the resident's room." Review of the facility P&P entitled "Falls Assessment" dated 3/6/13 revealed "Residents will be assessed for fall risk factors upon admission and with the quarterly, annual, significant change, re-admission review" and that "High risk for falls status will be added to the plan of care". Interview with the Registered Nurse (RN) Unit Manager (UM) on 6/4/14 at 10:15 AM revealed that nursing completes the Risk Assessment for Falls and the Profile of Care. When the Risk Assessment for Falls has a score of 10 or above the Profile of Care should be checked for High Risk For Falls. The RN UM stated "I did not do this for this resident, it was a mistake and I can fix that right now". 415.11(c)(2)(i-iii)