Every finding on record at Ideal Senior Living Center

Based on observations, record review, and interviews during the recertification survey, the facility failed to ensure each resident received adequate supervision to prevent accidents for one (1) of five (5) residents(Resident #36) reviewed. Specifically, Resident #36 had dysphagia (difficulty swallowing) and was not supervised during meals as ordered.Findings include: The facility policy Daily Routine, Care of Resident, revised 11/2024, documented meals would be served to each resident. Verbal, physical encouragement, and/or assistance was given as needed per resident preference and plan of care. Resident #36 had diagnoses including dysphagia. The 12/16/2025 Minimum Data Set assessment documented the resident had severely impaired cognition, required set up assistance for eating and did not have a swallowing disorder. The 06/08/2022 physician order documented a regular diet; supervision with meals; cut meat into small pieces, encourage small bites, slow rate, and alteration of solids/liquids. The 06/08/2022 Comprehensive Care Plan documented a potential for alteration in nutrition and respiratory status due to impaired ability to swallow related to oral pharyngeal dysphagia. Interventions included encourage small bites, slow rate, and alteration of solids/liquids; regular textures; cut meat into small bites/pieces; thin liquids; and upright position as tolerated. The care plan did not include supervision at meals. The undated care instructions documented the resident required setup or clean-up assistance at meals and did not include the need for supervision. The 08/06/2025 Speech Language Pathologist #1 evaluation and plan of care documented a recommendation for supervision with meals; meat cut into small pieces; and encouragement of small bites, a slow rate, and alternation of solids/liquids. The 02/17/2026 lunch meal tickets documented supervision with meals. During an observation on 02/17/2026 at 12:19 PM, Resident #36 was eating their lunch alone in their room. At 12:23 PM, Certified Nurse Aide #3 entered the room to ask the resident if they needed anything, then exited the room. The 02/19/2026 lunch meal ticket documented supervision with meals. During an observation on 02/19/2026, Certified Nurse Aide #3 delivered Resident #36's lunch tray at 12:42 PM and exited the room, leaving the resident alone to eat. At 12:50 PM, the resident consumed most of their meal. The tray was removed from the room at 1:09 PM. No staff were observed entering the resident's room between 12:42 PM and 01:09 PM. During an interview on 02/20/2026 at 01:31 PM, Certified Nurse Aide #3 stated the level of assistance a resident needed was on their care plan; it was their responsibility to make sure items on the tray matched the meal ticket; and if the ticket documented supervision with meals, then someone had to keep an eye on the resident while they ate. They stated they passed Resident #36's lunch trays on 02/17/2026 and 02/19/2026 and did not stay in the room while the resident ate and they should have. The resident preferred to eat lunch in their room and had been doing so for a while, so they thought the lack of supervision was an oversight. During an interview on 02/20/2026 at 12:31 PM, Speech Language Pathologist #1 stated they recommended Resident #36 be supervised during meals on 08/06/2025. They were not aware the resident ate lunch alone in their room. Staff should provide supervision in the resident's room. They expected their recommendations to be followed. During an interview on 02/20/2026 at 1:22 PM, Licensed Practical Nurse #2 stated the level of assistance needed with eating was in the resident's care plan. It was the responsibility of the person passing the meal tray to check the meal ticket to ensure all instructions, including supervision, were followed. Supervision meant the resident should be watched during their entire meal. On the days Resident #36 ate in their room, staff should stay with them. During an interview on 02/23/2026 at 9:48 AM, Registered Nurse Unit Manager #4 stated anyone who passed a meal tray was responsible for looking at the meal ticket and if it said supervision with meals, then supervision should be provided. If a resident preferred to eat in their room, then someone should be assigned to stay in their room with them while they ate. They were not aware Resident #36 ate alone in their room last week. If they knew they would have followed up to make sure someone was present with the resident when they ate in their room. If there was an order for supervision, then someone should supervise the resident to keep them safe. 10 New York Codes, Rules and Regulations 415.12 (h)

Based on observations, record review, and interviews during the recertification survey, the facility failed to ensure residents maintained acceptable parameters of nutritional status for one (1) of two (2) residents (Resident #9) reviewed. Specifically, Resident #9 had significant weight loss and did not have nutritional assessments reflecting current nutritional needs and interventions to prevent further weight loss; and the medical provider did not address the resident's weight loss.Findings include:The facility policy Weight and Reweight, revised 05/2025, documented monthly weights would be obtained on all residents unless an order indicated otherwise and a reweight would be obtained if a resident weight changed five pounds or more from last recorded weight. Weight changes of five pounds or more after the reweight would be reported to the charge nurse, dietitian, and provider. The facility procedure for estimating energy needs, revised 11/29/2017, documented energy needs would be estimated using Mifflin-St Jeor for all residents. Per the Academy of Nutrition and Dietetics Nutrition Care Manual for Adults, the Mifflin-St Jeor Equation is a formula used to estimate Basal Metabolic Rate (BMR), which was the number of calories the body needed at rest to maintain vital functions such as breathing and circulation. The Mifflin-St. Jeor Equations was used to estimate resting energy expenditure only. Adjustments to activity would be needed. Physical activity should be carefully considered when estimating total energy expenditure. Activity energy included activities of daily living, fidgeting, and maintaining posture. Injury factors would be assessed in addition to activity factor if indicated. The facility procedure for estimating protein needs, revised 11/29/2017, documented protein needs would be estimated at 15 to 16% for mild to moderate stress, 17 to 18% for surgical wounds and Stage 1 or 2 pressure ulcers, and 19 to 20% for stage 3 or 4 pressure ulcers and deep tissue injuries. The procedure did not designate what to calculate the percentage from, or what to do with the percentage calculated.Resident #9 had diagnoses including hip fracture, leg fracture and dementia with mood disturbance. The 11/29/2025 significant change Minimum Data Set (assessment tool) documented the resident had severe cognitive impairment, weighed 138 pounds, and had no weight changes. Resident #9's weight record documented on 07/30/2025 the resident weighed 155.8 pounds.The 08/01/2025 Registered Dietitian #6 nutrition progress note documented the resident had poor intake and their family member agreed to trial Ensure Plus (nutritional supplement).The 08/04/2025 Registered Dietitian #6 nutritional assessment documented Resident #9 was admitted for surgical repair of right hip fracture, weighed 155.6 pounds, had poor intake below 50%, and had an order for Ensure Plus three times a day, which was poorly accepted. Kilocalories were estimated as 1541 daily (Resting Metabolic Rate (1142) multiplied by a stress factor of 1.35) and protein needs were 66 grams (under one gram per kilogram body weight. No activity factor was included in calorie estimation). They documented calorie needs were increased, and protein needs were increased to 17% of calorie needs, and yogurt and pudding were added between meals.Resident #9's weight record documented on 08/13/2025, the resident weighed 145.3 pounds without a documented reweigh (6.7% severe weight loss in two weeks).The 08/14/2025 Registered Dietitian #6 progress note documented Resident #9 weighed 145.3 pounds (66 kilograms) and had a 6.6% weight loss in one month with meal intakes of 64%. They recommended decreasing the Ensure Plus supplement from three times a day to two times a day. They requested a reweight for a 4.7 pound weight loss in one week and there was no need to re-estimate needs because intake was good. They would follow up if new interventions were needed.The 09/22/2025 Registered Dietitian #10 nutrition progress note documented meal intake had declined to 42% and their weight was 145.7 pounds on 09/17/2025. They decreased the Ensure Plus from three times daily to twice a day because of stable weights.The Comprehensive Care Plan, revised 10/23/2025, documented the resident had behavioral issues with agitation and yelling out, fair intake of 58%, was overweight, was meeting needs, and had supplements in place. The resident received Ensure Plus (nutritional supplement) 237 milliliters once daily as of 09/22/2025. There was no documented evidence the care plan included severe weight lossResident #9's weight record documented on 08/13/2025 the resident's weight was 145.3 pounds (6.8% loss in one month).There was no documented evidence of follow-through on the reweight, estimated nutritional need changes or nutritional interventions to prevent further weight loss following the confirmation of weight loss on 08/20/2025 with a reweight of 145.1 pounds. The 08/29/2025 Nurse Practitioner #9 routine visit note documented nutrition notes had been reviewed, the resident weighed 143.8 pounds, and weights were overall stable.The 11/02/2025 Registered Dietitian #10 quarterly nutrition note documented meal intake was 51-75% daily, Ensure Plus was provided twice a day, weight was 145 pounds (66 kilograms), and the resident had a 6.9% weight loss in three months, which was a notable issue. Kilocalories were estimated as 1200 daily (Resting Metabolic Rate 994 multiplied by a stress factor of 1.2) and protein needs were 46 grams (under 0.7 grams per kilogram body weight). No activity factor was included in calorie estimation. They documented excess energy intake related to exceeding estimated needs.The 11/27/2025 documented weight was 138 pounds (4.9% loss in one month, 11.3% loss in four months).The 12/03/2025 documented weight was 135 pounds (4.2% loss in one month, 7.3% loss in three months, 13.4% loss in five months).The 12/03/2025 Registered Dietitian #6 nutritional assessment documented Resident #9 was readmitted from the hospital following surgical repair of a tibia fracture, had a deep tissue injury to the right hip, weighed 138 pounds (63 kilograms), was eating 51-75%, and had no weight changes in one, three, or six months. They received Ensure Plus once a day. Kilocalories were estimated as 1310 (Resting Metabolic Rate 971 multiplied by a stress factor of 1.35) and protein needs were 56 grams (under one gram per kilogram body weight). No activity factor was included in calorie estimation. They documented calorie needs were increased, and protein needs were increased to 17% of calorie needs because of the deep tissue injury.The 12/09/2025 Registered Dietitian #6 nutritional progress note documented the resident weighed 135 pounds, received Ensure Plus once a day, ate 86% of their meals, and exceeded their needs. There was no documented evidence of assessment of weight status or estimated needs.The 12/18/2025 Registered Dietitian #11 nutritional progress note documented the resident had significant weight loss over three months, consumed 89% of meals, received Ensure Plus twice a day, and weight gain would be beneficial. There was no documented evidence of estimated nutritional need changes or nutritional interventions to prevent further weight loss. The resident received Ensure plus once a day.The 12/23/2025 Nurse Practitioner #9 routine visit note documented nutrition notes had been reviewed, the resident weighed 136.6 pounds, and weights were slowly improving.The 12/24/2025 documented weight was 132.2 pounds (4.2% loss in one month, 9.3% loss in three months). There was no documented evidence of estimated nutritional need changes or new nutritional interventions to prevent further weight loss.The 01/07/2026 documented weight was 133.2 pounds (8.2% loss in three months, 14.4% loss in six months).The 1/20/2026 Physician #12 progress note documented the resident weighed 133 pounds and weights were stable.The 01/21/2026 Registered Dietitian #11 nutritional progress note documented the resident had significant weight loss over three months, was eating 86% of meals, and no changes were needed to the plan because weight was stabilizing. There was no documented evidence of estimated nutritional need changes or new nutritional interventions to prevent further weight loss.The 02/10/2026 documented weight was 132.6 pounds (11.6% loss in six months).The 02/13/2026 Nurse Practitioner #9 routine visit documented the dietitian noted some weight loss and added supplements and snacks. There was no documented evidence of the addition of any new nutritional supplements or snacks.During an interview on 02/20/2026 at 9:44 AM, Certified Nurse Aide #13 stated they obtained re-weights when the nurse told them to. If a resident refused a meal or snack, they would encourage, reapproach, and offer other items. If they had concerns about weight loss or poor intake they told their charge nurse. Resident #9 ate in the dining room, and they would encourage and coax them to eat. They did not see dietitians out in the dining rooms during meals.During an interview on 02/20/2026 at 9:53 AM, Licensed Practical Nurse #14 stated they compared the weights when they entered them into the electronic medical record, and requested a reweight on those with four-pound fluctuations. Resident #9 usually fed themself and ate well but needed encouragement at times. They recorded solids, fluids, and supplements on a form at the nursing desk daily and the certified nurse aide entered the data into the electronic medical record. If they refused to eat something, staff encouraged and offered something else. The dietitians were not usually around for meals, but they let them know if they had any concerns. During an interview on 02/20/2026 at 10:00 AM, Registered Nurse Unit Manager #15 stated the certified nurse aides obtained weights, and the charge nurse entered them into the electronic medical record. If the weight difference was five pounds or more a re-weight was obtained that day. Resident #9 usually ate the meal themself but needed to be watched for encouragement. When the resident first came to the floor in August of 2025, they were very agitated, anxious, and could not sit still. They tried Seroquel (antipsychotic medication) but that did not help the agitation, so it was tapered off and they started Rexulti (antipsychotic) with favorable results. When the resident refused to eat, the nurses offered them strawberry ice cream and other items. They lost weight recently, after their injury and prior to starting Rexulti. Nutrition staff tried Ensure but the resident's fluid intake was not the best. They usually notified nutrition, family, and medical of any nutritional concerns. Dietitians occasionally rounded at meals, but nursing usually told them about any changes. Dietitians usually attended the interdisciplinary care plan meetings, but not always. They did not attend the significant change care plan meeting in November of 2025.During an interview on 02/20/2026 at 11:16 AM, Registered Dietitian #6 they printed a weight report every morning and looked for five-pound discrepancies. They made a re-weight list through electronic mail or the electronic medical record for nursing. They brought up any weight concerns in the daily morning meeting. The charge nurse or nurse manager entered them into the electronic medical record. If a resident had significant weight loss they were changed to weekly weights and discussed at the monthly weight management meeting. If it was new weight loss, they sent an electronic mail to the interdisciplinary team and provider, assessed why the weight loss happened, talked with resident and family, and implemented what they were willing to eat. They documented monthly on residents with significant weight loss, including diet, intake, supplements, skin, bowels, labs, and any goals. Nutritional needs were estimated on any complete nutrition assessments, weight changes, new skin issues, or referrals. Energy needs were calculated using Mifflin-St Jeor and protein needs were estimated with a percentage of calorie needs. Resident #9 needed supervision with touch assistance with meals. The resident lost weight and had poor intake on admission. They had no recent weight loss, but they had lost weight back in November of 2025 when they had a fracture and went to the hospital. They could not recall if they notified anyone of the weight loss. During the significant weight loss in August of 2025, they asked for a reweight and the resident was provided Ensure Plus, yogurt, and pudding. No additional changes were made since the weight loss in August of 2025. They did not see the resident at meals and was not taught to do meal rounds. They followed resident meal intakes and any issues through nursing and nursing documentation, and reviewed meal documentation when assessments were due. The resident's weights had stabilized recently, however when weight loss continued, they thought they were responsible for notifying the provider. Nutritional intervention changes were communicated to the interdisciplinary team through electronic mail, care plan meetings, and the morning meeting. They attended the care plan meetings on the rehabilitation floor, and another dietitian attended Resident #9's care plan meetings when they were available. Protein needs were assessed based on a percentage of calorie needs per the facility policy, which they had not seen before in practice, including their internship. Energy needs were estimated using Mifflin-St Jeor and multiplying an injury factor as needed. They did not use an activity factor because their policy did not include one. If calorie needs were underestimated, protein needs would be underestimated. If a resident's weight status was not addressed or assessed, they could continue to lose weight. Registered Dietitian #6 stated on 08/04/2025, an injury factor was used to calculate energy needs for the surgical wound. Protein needs were estimated at 17% of energy needs. On 8/14/2025, a re-weight was requested due to significant weight loss, but they did not follow up on the re-weight, assess the weight status or add an intervention other than decreasing the Ensure Plus from three times a day to twice a day. On 11/02/2025, the previous dietitian helped complete the assessment from a remote location using what was in the electronic medical record. On 12/3/2025, an injury factor was used to calculate energy needs for the surgical wound and deep tissue injury. Protein needs were estimated at 17% of energy needs. No new interventions were implemented except Ensure Plus was decreased to once a day. On 12/09/2025, when the new weight of 135 pounds (4.2% loss in one month, 7.3% loss in three months, 13.4% loss in five months) was obtained, they talked about it in the weight management meeting that month, and the resident was getting Ensure Plus daily. No changes were made, and nutritional needs were not addressed. During an interview on 02/20/2026 at 12:17 PM, Physician #12 stated they were made aware of significant weight changes through dietitian updates. Once notified they reviewed the resident to see if any medical interventions were indicated. Weights were monitored because they correlated with clinical functioning and overall wellbeing. Physician #12 did not acknowledge being notified of the resident's weight loss in August 2025, December 2025, or January 2026. They stated there were monthly weight meetings and they were open to constructive feedback regarding why the information was not reflected in the electronic medical record. 10 New York Codes, Rules and Regulations 415.12 (i)

Based on record review, observation, and interviews during the recertification survey conducted [DATE]- [DATE], the facility failed to establish mechanisms for documenting and communicating the resident's choice regarding advance directives to the staff responsible for the resident's care for 1 of 24 residents (Resident #87) reviewed. Specifically, Resident #87 updated their Medical Orders for Life Sustaining Treatment (MOLST) during a hospitalization to reflect a change from wanting cardiopulmonary resuscitation (CPR) to do-not-resuscitate (DNR) code status. When the resident was readmitted to the facility their medical record and code status indicators were not revised to reflect the resident's advance directive wishes and the facility continued with cardiopulmonary resuscitation orders. Subsequently, the facility's failure to have a system to ensure code status changes were properly identified and implemented, placed all 117 residents in the facility who had advance directives in place, at risk. This resulted in Immediate Jeopardy to resident health and safety. Findings included: The facility policy, Advance Directives reviewed [DATE], documented all properly executed advance directives are honored including do-not-resuscitate orders, living wills, health care proxies, and electronic Medical Orders for Life-Sustaining Treatment. The Admissions department, social worker, Nurse Manager, and physician are all responsible to assess advance directives and electronic medical orders for life sustaining treatment to assure that the advance directives have been expressed in a clear and convincing manner. The facility policy, Cardiopulmonary Resuscitation: Skilled Nursing Home revised [DATE], documented all residents who have a valid do-not-resuscitate order will have a purple dot placed on their name band and in the electronic medical record program. Any changes to a resident's cardiopulmonary resuscitation or do not resuscitate status will be communicated to staff immediately upon the change. When a resident changed status from cardiopulmonary resuscitation or do not resuscitate the staff were to update the medical record and print/apply a new name band. Resident #87 was readmitted to the facility with diagnoses including syncope (loss of consciousness) and collapse, chronic kidney disease, and hypothyroidism (underactive thyroid). The [DATE] Minimum Data Set documented the resident had intact cognition and participated in the assessment and goal setting. Resident #87's comprehensive care plan effective [DATE] documented the resident had advance directives of cardiopulmonary resuscitation per their wishes and an electronic Medical Orders for Life Sustaining Treatment. Resident #87's Medical Orders for Life Sustaining Treatment in effect prior to their hospitalization on [DATE], was signed by the resident on [DATE] and documented attempt cardiopulmonary resuscitation when they had no pulse and/or was not breathing. A hospital discharge summary documented the resident was hospitalized [DATE]-[DATE] for syncope after blacking out during a shower at the nursing facility. The resident's code status at discharge was do not resuscitate/do not intubate (placement of a breathing tube). The electronic Medical Orders for Life Sustaining Treatment electronically signed by the resident on [DATE] at 6:16 PM and by the hospital physician on [DATE] at 8:59 PM documented the resident's wishes included do not attempt resuscitation (allow natural death). The section for review and renewal of the medical orders for life sustaining treatment included a review by the hospital physician on [DATE] at 8:59 PM and documented the previous form was voided and a new form was completed. The resident's medical record face sheet with a last admitted [DATE] at 1:30 PM, documented the resident had advance directives of full cardiopulmonary resuscitation (CPR), refer to the electronic Medical Orders for Life Sustaining treatment. The [DATE] at 11:08 AM medical readmission order by nurse practitioner #20 documented advance directives, full cardiopulmonary resuscitation. Refer to electronic Medical Orders for Life Sustaining Treatment. The electronic Medical Orders for Life Sustaining Treatment section for review and renewal was signed on [DATE] at 8:25 PM by facility physician #6 and documented the outcome of the review was no change. The resident's comprehensive care plan revised on [DATE] by social worker #9 documented the resident had advance directives of cardiopulmonary resuscitation per their wishes and an electronic Medical Orders for Life Sustaining Treatment. There was a cardiopulmonary resuscitation order in place. During observations on [DATE] at 3:17 PM and [DATE] at 9:54 AM, Resident #87's identification bracelet on their right wrist did not have a purple dot to indicate do-not-resuscitate. The electronic medical record documented the code status indicator for Resident #87 as full cardiopulmonary resuscitation and the resident had an electronic medical order for life sustaining treatment. During an interview on [DATE] at 12:06 PM, Resident #87 stated they had signed a do-not-resuscitate order and that was what they wished to remain. During observations on [DATE] at 4:08 PM and [DATE] at 9:55 AM, there was a list of residents with their code status posted in the Tulip Court (third floor) open breakroom. The list documented Resident #87 was a full code, meaning the resident wished to receive cardiopulmonary resuscitation. During an interview on [DATE] at 2:50 PM, licensed practical nurse #1 stated they would check resident's chart for their code status. A resident would have a purple dot next to their name in the chart if they had a do-not-resuscitate order. The resident's medical orders also indicated their code status. The licensed practical nurse stated they would also check the resident's identification bracelet as they would have a purple dot on the bracelet if they had a do-not-resuscitate order. During an interview on [DATE] at 4:08 PM, Registered Nurse Unit Manager #2 stated they posted a listing of what residents were to receive cardiopulmonary resuscitation and what residents had do-not-resuscitate orders, so staff had a visual of what the code status was for the residents on the unit. The listing was updated weekly and as needed if a code status changed. They stated in the event of an emergency, the nursing staff would respond to the resident and check the resident's identification bracelet. If the resident had a purple dot on their identification bracelet it meant they had a do-not-resuscitate order. During an interview on [DATE] at 10:06 AM, certified nurse aide #10 stated they would look in the electronic medical record and on a resident's identification bracelet for code status. The purple dot on the resident's identification bracelet meant the resident was a full code (cardiopulmonary resuscitation). During an interview on [DATE] at 10:10 AM, certified nurse aide #7 stated they would look at a resident's identification bracelet for their code status. If there was a purple dot, the resident was a full code (cardiopulmonary resuscitation). During an interview on [DATE] 10:16 AM, certified nurse aide #11 stated they would look at the resident's identification bracelet for code status. If the resident had a green or red dot that meant they were a full code. During an interview on [DATE] at 10:16 AM, certified nurse aide #8 stated they would look at a resident's wrist band for code status. A purple dot meant the resident wanted cardiopulmonary resuscitation. During an interview on [DATE] at 10:19 AM, licensed practical nurse #15 stated if a resident was found unresponsive, they would check the resident's identification band for a purple dot as that meant the resident was a do-not-resuscitate. They would also look in the resident's orders in the electronic medical record. They would not check the resident's electronic Medical Order for Life Sustaining Treatment as they did not have access to the system where it was located. Their access expired. During an interview on [DATE] at 10:23 AM, certified nurse aide #12 stated they would look at the resident's identification bracelet for code status. A blue dot meant the resident was a full code. If there was no dot, the resident had a do-not-resuscitate order. During an interview on [DATE] at 10:26 AM, physician #6 stated when a resident was admitted to the facility, part of the initial discussion was about what their current advance directives were and if the resident wanted to keep their current advance directives or make changes. If the resident wanted their advance directives changed, the social worker completed a new electronic Medical Orders for Life Sustaining Treatment form, and the physician would sign off once completed. For a readmission, the nurse that took report reviewed the electronic Medical Orders for Life Sustaining Treatment at the time of admission and the social worker reviewed the resident's advance directives with the resident within 24 hours of admission. The advance directives were not always reviewed by the physician immediately upon readmission. Physician #6 stated they expected staff to check the patient lists on the unit or the resident's identification bracelet for their code status. A resident's identification band was marked if the resident had a do-not-resuscitate order. It was important that the electronic Medical Orders for Life Sustaining Treatment matched the physician order in the computer, so the wrong directive was not provided during an emergency. At 11:42 AM, Physician #6 stated if cardiopulmonary resuscitation was provided against the resident's wishes, it could prolong life when the resident did not want it prolonged. It also had the potential to cause suffering as ribs could be broken during cardiopulmonary resuscitation and possibly lead to hospitalization and intubation. If a resident was not provided cardiopulmonary resuscitation when they requested, the person could pass away. During an interview on [DATE] 10:42 AM, Director of Nursing stated the nursing staff checked the resident's identification bracelet to determine code status; a purple dot meant the resident was do-not-resuscitate and no dot meant cardiopulmonary resuscitation. The code status was also listed in the resident's orders. When a resident was admitted or readmitted , the admitting nurse received a nurse-to-nurse report in addition to the hospital records. The admitting nurse entered the advanced directive orders. The unit secretary doubled checked the resident's identification band against the advance directive order in the resident's record for accuracy before it was applied to the resident. The electronic medical order for life sustaining treatment was mostly used when the resident needed to be transferred to the hospital, not for day-to-day or emergency use. The written order and the electronic medical order for life sustaining treatment should match. If a resident who wished to be do-not-resuscitate was resuscitated, they could be injured in the process, and it would be against their wishes. If a resident wanted to be resuscitated and was not, they would die. During an interview on [DATE] at 11:26 AM, Administrator #3 stated when a resident was admitted , they received hospital notes with advance directives and the admission nurse would verify the code status with the electronic Medical Order for Life Sustaining Treatment. The verification would be done by the physician. The unit secretary printed an identification band with the resident's code status. The Administrator was not sure if the dot on the identification band meant cardiopulmonary resuscitation or do-not-resuscitate. They were unaware of how the resident's chart or electronic Medical Order for Life Sustaining Treatment was updated if a resident's wishes changed. At 12:05 PM, Administrator #3 stated they expected the admitting nurse to confirm the paperwork from the hospital matched the facility's regarding advance directives and they should enter the order accurately in accordance with the electronic Medical Orders for Life Sustaining Treatment. During an interview on [DATE] at 12:53 PM, Licensed Practical Nurse Unit Coordinator #14 stated they were responsible for admissions, readmissions, and discharges. Advance directives were a part of admission and readmission. Advance directive orders were entered and were received by the nurse-to-nurse report and through the paperwork provided by the hospital. The social worker also confirmed advance directives. After the advance directive order was entered by nursing, the social worker verified it with the electronic Medical Orders for Life Sustaining Treatment, if the resident had one. Staff would check the resident's orders for code status. They stated they did not check Resident #87's electronic Medical Order for Life Sustaining Treatment when the resident was readmitted . During an interview on [DATE] at 1:44 PM, social worker #9 stated they discussed a resident's advance directives with the resident and/or the resident's family within 24 hours of admission. They checked the paperwork that came from the hospital and the electronic Medical Orders for Life Sustaining Treatment. A resident's advance directives were always reviewed either by nursing or by social work. They did not always document the advance directive was reviewed on readmissions. Both social work and nursing were responsible for a resident's advance directive plan of care and to make sure the facility records were updated if a resident came back from the hospital with a change in their electronic Medical Order for Life Sustaining Treatment. It was important the electronic Medical Orders for Life Sustaining Treatment and the physician's order in the resident's medical record matched so a mistake was not made if the resident had an emergency. _____________________________________________________________________________________________ Immediate Jeopardy was removed on [DATE] at 11:34 AM prior to survey exit based on the following corrective actions taken: -Resident #87's advance directives were reviewed and discussed with the resident who wished to have a do-not-resuscitate order. A do-not-resuscitate order was entered into the electronic medical record and the comprehensive care plan was updated. -The facility would no longer post code status sheets and staff would be required to look in the computer for code status. -100% of residents will be audited to ensure electronic Medical Orders for Life Sustaining Treatment, physician order in electronic medical record, care plan, and header in electronic medical record match. - Policies for advance directives were updated to include a review of any existing electronic Medical Orders for Life Sustaining Treatment and the inclusion of a triple check for all admissions and readmissions. The triple check will be conducted by the Admissions Nurse, social worker, and the medical provider. -Education was provided to the Admission Nurse, social worker, and Medical Director regarding the policy change. -All staff will be educated where to access advance directives and will be included in the orientation of new employees. -All staff will be educated on the termination of the use of purple dots on the identification bracelets as an identifier for code status. -An audit tool was developed to compare the electronic Medical Orders for Life Sustaining Treatment and the physician orders match the residents' wishes. -All staff identified for education received education on [DATE] and [DATE]. The staff that did not receive education were to complete the education upon their return, prior to the start of their shift. -Interviews were completed on [DATE] to determine compliance with staff training and education including the Admissions Nurse, social worker, the Medical Director, and various interdisciplinary team members. 10NYCRR 400.21(c)

Based on observation, interview and record review during the recertification survey conducted 4/1/2024-4/5/2024, the facility did not ensure staff were educated on the policy and procedure regarding the use and storage of foods brought to residents from outside the facility to ensure safe and sanitary storage, handling, and consumption for 3 of 3 resident units (Units 1, 2, and 3). Specifically, staff were not aware of the policy and procedure to properly reheat, and measure temperatures of resident food brought in from outside the facility. Refer to F 561 Self Determination. Finding include: The facility policy Use and Storage of Food Brought to Residents from the Outside dated 1/2021, documented training would be provided by dining services on safe food handling practices and the policy regarding food brought to residents from the outside. If prepared food must be reheated before service, it may be reheated in the microwave oven available on the resident unit. Nursing should ensure that foods are reheated to 165 degrees Fahrenheit for at least 15 seconds before being served to the resident. These foods may not be brought into, or reheated in, the dining services department (main kitchen). The facility policy Food Brought into Patients from the Outside dated 1/2022, documented if food prepared outside of the food and nutrition services department was allowed, nursing must verify that the patient was prescribed a regular diet. Nursing should document in the patient's chart the food items that were brought to the patient. If prepared food must be reheated before service, it may be reheated in the microwave oven available on the resident unit. Nursing should ensure that foods are reheated to 165 degrees Fahrenheit for at least 15 seconds before being served to the resident. These foods may not be brought into, or reheated in, the dining services department. During an interview on 4/1/2024 at 10:57 AM Resident #87 stated while living on the 1st floor they were allowed to have a Sunday treat which consisted of a bagel with melted cheese. The resident's friend brought in the cheese, and the bagel came from the facility kitchen. The cheese was melted on the bagel in the facility's microwave. When the resident relocated to the 3rd floor, they were told staff could not microwave food received from outside sources. They stated they were upset because they could no longer have the bagel and melted cheese, they had become accustomed to having every Sunday. The following observations were made on 4/3/2024 between 2:25 PM and 2:45 PM: - the 3rd floor Daffodil Court unit had a microwave, an internal probe thermometer, and a copy of the 1/2022 policy Food Brought into Patients from the Outside in the employee breakroom. - the 3rd floor Tulip Court unit had a microwave, an internal probe thermometer, and a copy of the 1/2022 policy Food Brought into Patients from the Outside in the employee breakroom. - the 2nd floor [NAME] Court unit had a microwave, an internal probe thermometer, and a copy of the 1/2022 policy Food Brought into Patients from the Outside in the employee breakroom. - the 2nd floor Lily Court unit had a microwave, an internal probe thermometer, and a copy of the 1/2022 policy Food Brought into Patients from the Outside in the resident dining room. - the 1st floor [NAME] Court unit had a microwave, an internal probe thermometer, and a copy of the 1/2022 policy Food Brought into Patients from the Outside in the employee breakroom. - the1st floor [NAME] Court unit had a microwave, an internal probe thermometer, and a copy of the 1/2022 policy Food Brought into Patients from the Outside in the employee breakroom. During an interview on 4/1/2024 at 11:15 AM, registered nurse #2 stated that staff do not heat up residents' food for them and there was no microwave that could be used. Residents could have cold foods held in the dining room refrigerator or they would have to eat the food cold as staff could not heat up the foods brought from outside. Staff were not trained on how to reheat food or what temperatures should be reheated to. During an interview on 4/1/24 at 2:21 PM, the Food Service Director stated residents could not reheat food brought into them and were not allowed to use microwaves. They were unaware of any nursing staff that had been trained on how to reheat food or what temperature to reheat food. Food service staff could not do anything with foods brought in from the outside. During an interview on 4/3/24 at 2:25 PM, licensed practical nurse #24 stated there was only a microwave for staff in the staff breakroom and it was not for resident use. They were unsure why there was a policy and thermometer at the microwave as they were not able to heat up residents' food on the units. They had not been trained on proper reheating temperatures or procedures. Nursing staff would not check thermometers for proper accuracy or calibration. They were also unsure if the thermometers were sanitized or how to do so. During an interview on 4/3/24 at 2:35 PM, licensed practical nurse #23 stated they were not formally trained on how to reheat residents' food brought in from the outside. Depending on the type of food and container, staff could try to reheat food for residents. They believed food service staff would calibrate thermometers if needed. The only microwave on the unit was in the staff breakroom. Lily court was the only unit that had a microwave in the dining room area. During an interview on 4/3/24 at 2:39 PM, licensed practical nurse #22 stated food from the outside was often cold food and would not need to be reheated. There were guidelines on the unit but there was no official training. Sani cloth wipes could be used to wipe down thermometer probes between uses. During an interview on 4/3/24 at 2:45 PM, licensed practical nurse #21 stated staff should not use microwaves to reheat food for residents. There should be a microwave for staff use and one for residents to use, but they were not sure where a microwave was for resident use. They were not sure why there was a policy or thermometer in the staff breakroom as they do not use them. During an interview on 4/3/24 at 2:51 PM, the Administrator stated only Lily court had a microwave available to use in the dining room for reheating residents' food. There were policies on the units, but they were not sure if staff were trained on the policy and procedure. The facility tried to only take food that would not require reheating. They stated there should be one policy and procedure. Staff should not know what to do with food brought in from the outside. 10NYCRR 415.14(h)

Based on observation, record review, and interviews during the recertification survey conducted 4/1/2024 - 4/5/2024, the facility did not ensure residents had the right to make choices about aspects of their life in the facility that were significant to 1 of 1 resident (Resident #87) reviewed. Specifically, Resident #87 was not allowed to have cheese (brought in from the outside) melted on a bagel in the facility's microwave oven when they were relocated to different unit in the facility. Findings Include: The facility policy Use and Storage of Food Brought to Residents from the Outside dated 1/2021, documented training would be provided by dining services on safe food handling practice and on the policy regarding food brought to residents from the outside. If prepared food must be reheated before service, it may be reheated in the microwave oven available on the resident unit. Nursing should ensure that foods were reheated to 165 degrees Fahrenheit for at least 15 seconds before being served to the resident. These foods may not be brought into, or reheated in, the dining services department. The facility policy Food Brought into Patients from the Outside dated 1/2022, documented if food prepared outside of the food and nutrition services department was allowed, nursing must verify that the patient has been prescribed a regular diet and nursing should document in the patient's chart the food items that were brought to the patient. If prepared food must be reheated before service, it may be reheated in the microwave oven available on the resident unit. Nursing should ensure that foods are reheated to 165 degrees Fahrenheit for at least 15 seconds before being served to the resident. These foods may not be brought into, or reheated in, the dining services department. Resident #87 was admitted to the facility with diagnoses including hypertension and renal (kidney) disease. The 1/21/2024 Minimum Data Set documented the resident was cognitively intact and required set up assistance with eating. The comprehensive care plan initiated 12/20/2022 documented a focus of nutritional status with interventions including identify food preferences and cater to food preferences. The comprehensive care plan initiated 6/9/2023 documented a focus of resident preferences. Preferences would be individualized to promote autonomy, quality of life, and physical and emotional well-being. Interventions did not include the resident's preference for a bagel with melted cheese, During an interview on 4/1/2024 at 10:57 AM Resident #87 stated while living on the first floor they were allowed to have a Sunday treat which consisted of a bagel with melted cheese. The resident's friend brought in the cheese, and the bagel came from the facility kitchen. The cheese was melted on the bagel in the facility's microwave. When the resident relocated to the third floor, they were told staff could not microwave food received from outside sources. They stated they were upset because they could no longer have the bagel and melted cheese, they had become accustomed to having every Sunday. During an interview on 4/1/2024 at 11:15 AM registered nurse #2 stated that staff did not heat up residents' food for them and there was no microwave that could be used. Residents could have cold foods held in the dining room refrigerator, but they would have to eat the food cold as staff could not heat up the foods brought from outside. They stated they were not trained on how to reheat food or what temperatures food should be reheated to. During an interview on 4/1/2024 at 2:21 PM, the Food Service Director stated residents could not reheat food brought into them and were not allowed to use microwaves. They were unaware of nursing staff that had been trained on how to reheat food or what temperature to reheat food to. Food service staff could not do anything with foods brought in from outside the facility. During an interview on 4/3/2024 at 2:25 PM, licensed practical nurse #24 stated there was only a microwave in the staff breakroom and was not for resident use. They were unsure why there was a policy and thermometer near the microwave as they were not able to heat up residents' food on the units. They had not been trained on proper reheating temperatures or procedures. During an interview on 4/3/2024 at 2:35 PM, licensed practical nurse #23 stated they were not formally trained on how to reheat residents' food brought from the outside. Depending on the type of food and the container, staff could try to reheat food for residents. The only microwave on the 3rd floor unit was in the staff breakroom. The 1st floor was the only unit that had a microwave in the dining room area. During an interview on 4/3/24 at 2:39 PM, licensed practical nurse #22 stated food from the outside was often cold food and would not have needed to be reheated. There were guidelines on the unit for reheating food but there was no official training. During an interview on 4/3/24 at 2:45 PM, licensed practical nurse #21 stated staff could not use microwaves to reheat food for residents. They were not sure why there was a policy or thermometer in the staff breakroom as they do not use the microwave for residents. During an interview on 4/03/24 at 2:51 PM, the Administrator stated only the 1st floor had a microwave available to use in the dining room for residents' food to be reheated. They were not aware there were multiple policies for foods brought in from the outside which could be confusing for staff on reheating food. There were policies on the units for reheating food, but they were not sure if staff were trained. 10 NYCRR 415.5(b)(3)

Based on observation, interview, and record review during the recertification survey conducted 4/1/2024-4/5/2024, the facility did not ensure residents were provided special eating equipment when consuming meals and snacks for 1 of 1 resident (Resident #57) reviewed. Specifically, Resident #57 was not provided with a two handled cup with a spout lid at meals as ordered. Findings include: The facility policy Assistive Eating Devices revised 1/2024 documented assistive eating devices were available to any resident for whom the equipment would be beneficial in assisting the resident's ability to self-feed. Nursing was responsible for ensuring that each individual received the assistive devices ordered for each meal. Resident #57 was admitted to the facility with diagnoses including transient ischemic attack (stroke), Alzheimer's disease, and dysphagia (difficulty swallowing). The 2/5/2024 Minimum Data Set assessment documented the resident had severe cognitive impairment, required substantial assistance with eating, and required a mechanically altered diet. The comprehensive care plan initiated 3/2/2022 documented a focus of activities of daily living with compromised self-sufficiency. Interventions effective 1/1/2024 included set-up and clean up assistance for feeding and a 2 handled cup. The comprehensive care plan initiated 7/10/2023 documented the resident had dysphagia (impaired swallowing). Interventions included alternate liquids and solids, and small bites/swallows. An intervention effective 9/18/2023 documented nectar thick liquids via a sippy cup with a spout. A 1/12/2024 speech language pathologist #18 evaluation documented the resident had mild to moderate oral/pharyngeal dysphagia. Recommendations included nectar thick liquids with a sippy cup with spout. A 1/12/2024 physician order documented nectar thick liquid with a sippy cup with a spout. A 4/1/24 occupational therapist #16 evaluation documented the resident was referred by nursing for improvements in feeding skills. Staff reported the resident was able to feed themself after set-up. The resident was seen during mealtime and was appropriately managing a 2 handled cup for drinks and regular silverware for food. The resident declined offers for assistance. The resident's care plan and certified nurse aide care card updated to reflect improvement. No skilled occupational therapy was warranted at that time. The 4/3/2024 occupational therapist #16 discharge summary documented the resident was able to feed themselves after set-up and required a two handled cup for drinks. The care instructions dated 4/1/2024 documented the resident received a pureed no added salt diet, nectar thick liquids, a 2 handled sip cup with a spout. Upright position during meals and 30-45 minutes after. During an observation on 4/1/2024 at 12:36 PM Resident #57's meal ticket documented adaptive equipment of a two handled cup with a sippy lid. During the following observations the resident was not provided with a two handled cup with a sippy lid for beverages: - on 4/1/2024 at 12:37 PM drinking cocoa. - on 4/2/2024 at 8:41 AM drinking milk and orange juice. - on 4/2/2024 at 12:22 PM drinking hot cocoa. - on 4/2/2024 at 12:27 PM licensed practical nurse #13 gave the resident a protein shake in a carton with a straw. - on 4/3/2024 at 8:40 AM drinking juice and a protein shake with a straw in the carton. - on 4/3/2024 at 10:54 AM drinking cocoa. - on 4/3/2024 at 12:37 PM drinking a protein shake with a straw from a carton. - on 4/5/2024 at 8:39 AM drinking a protein shake in a carton and juice from a cup with a straw. During an interview on 4/5/2024 at 8:45 AM, certified nursing aide # 8 stated the meal ticket indicated if adaptive equipment was needed, and staff checked for the presence of adaptive items if they were included on the meal ticket. If the resident was supposed to have adaptive equipment and did not, it could negatively impact them if they spilled the cup and got burned or they could choke. During an interview on 4/5/2024 at 9:04 AM, occupational therapist #16 stated it was not appropriate to give resident #57 a protein shake in a container or any cup with a straw and they should only have a two handled mug with a spout lid for beverages. It was important for this resident to have a two handled mug with a spout lid as it allowed them the highest level of independence with meals. During an interview on 4/5/2024, licensed practical nurse # 17 stated their role at mealtimes was to make sure residents did not choke. They stated if a resident required adaptive equipment for meals, it would be on their meal ticket. If the meal ticket documented a double handled cup with a spout, they should have received it. If the cups were not supplied, they should call the kitchen for a replacement. They stated it was important for a resident to have the adaptive equipment ordered because of choking risk. During an interview on 4/5/2024 at 11:24 AM, speech and language pathologist # 18 stated they evaluated the resident for a decline. They attempted to have the resident drink with a straw and the resident was not able to do so. They determined the two handled cup with a spout was the most appropriate device for the resident. They expected the resident to have the two handled cup with a spout for all liquids. They did not think a straw in the protein shake container was appropriate because the resident was not able to use it when previously evaluated. It was important for a resident to have the proper adaptive equipment for meals to prevent aspiration (food or liquid entering the lungs). During an interview on 4/5/2024 at 11:37 AM, registered nurse Unit Manager #2 stated when a resident required adaptive equipment for meals it was listed on their meal ticket and in the care plan. If the equipment was not delivered, staff should call the kitchen for the equipment. They stated a straw in a protein shake container or a regular cup with a flat lid and straw were not appropriate for Resident #57. No substitutions could be made to a resident's adaptive equipment before being evaluated by occupational therapy, physical therapy, or a speech and language pathologist. They stated Resident #57 required the adaptive equipment for safety reasons because they did not previously have the strength to suck from a straw. 10NYCRR 415.14(g)

Based on observation and interview during the recertification survey conducted 2/1/22-2/4/22, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 3 of 3 residents (Residents #19, 25 and 91) reviewed. Specifically, Residents #19, 25 and 91 had unclean room floors and Resident #19 had a torn/stained floor mattress. Findings include: The facility policy Damp Mopping Hard Floor Surfaces with the Microfiber Mop dated 10/1/18 documents to begin damp mopping the floor by placing microfiber mop on floor and pushing forward along all corners and edges of the floor. This serves to push dirt out of the corners and edges of the room and prevents build-up. As floor is damp mopped, move any furniture or items on floor, sweep floor, and then return items and furniture to proper place. Be sure to mop under and behind the bed and furniture which cannot be moved, push tool and dirt to doorway. The facility policy Environmental Services Equipment dated 10/1/18 documents the care and upkeep of all equipment by the Environmental Services Department is the responsibility of all members of the Department and must be carried out on daily basis. The following observations were made on 2/1/22: - at 12:08 PM, Resident #25 was sitting in bed in their room, the floor was unclean with visible smears and spots. - at 4:40 PM, Resident #19 was lying in bed, with a mattress beside the bed on the floor. The mattress was torn, spotted, and stained with white blotches. On 2/2/22 at 2:00 PM, an anonymous resident stated during the resident council meeting, that resident rooms and bathrooms had not been cleaned consistently. The resident stated their room had not been cleaned in the last 3-4 days. The following observations were made on 2/3/22: - at 12:26 PM, Resident #19 was lying in bed with a mattress on the floor beside their bed. The floor mattress had a large tear, approximately 6-8 inches across, and had spots of white liquid on it. - at 12:29 PM, Resident#25 was in their room. The floor was spotted and smeared and had dirty footprints. The following observations were made on 2/4/22: - at 12:49 PM, Resident #91 was observed in their room. The shelving had dust and debris underneath. There was dust buildup in the corners of the floor. The resident stated they were allergic to dust. - at 9:43 AM, the rooms of Residents #19 and 25 had dirty floors with smears and debris. When interviewed on 2/4/22 at 9:43 AM, housekeeper #1 stated they went to the unit every day to clean, and the resident rooms were wiped down. The housekeeper stated cleaning included wiping down the furniture, cleaning the bathrooms, emptying the garbage, and mopping the floors. The housekeeper stated that the floor solution did not leave floors smeared or streaked and the floors should look clean and not have streaks after they had been washed. During an interview on 2/4/22 at 10:08 AM, the Director of Environmental Services stated that nurses requested the floor mats from environmental services. The floor mats should be in good condition without tears or stains. The condition of the mattress in room Resident #19's room was unacceptable and should have been covered or discarded. During an interview on 2/4/22 at 12:49 PM, Resident #91 stated that the housekeeper came in and barely cleaned anything. The resident stated they did not see the housekeeper dust or wipe any items off and was not mopping the floor daily. 10NYCRR 415.5(h)(2)

Based on observation, record review and interview during the recertification survey conducted 2/1/22-2/4/22, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain personal grooming for 1 of 5 residents (Resident #34) reviewed. Specifically, Resident #34 was not provided with facial hair grooming per their preference. Findings include: The facility policy ADL Assistance revised 2/4/10, documents necessary care and services are provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, subject to the residents right of self-determination. Based on the Comprehensive Care Plan, the facility will ensure that: a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming and personal and oral hygiene. Resident #34 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/21/22 Minimum Data Set (MDS) assessment documented the resident was had moderate cognitive impairment and required extensive assistance of two persons with activities of daily living (ADLs) including personal hygiene and dressing. The comprehensive care plan (CCP) effective 11/1/21 documented the resident had compromised self-sufficiency in ADLs. Interventions included encourage the resident to actively participate in ADLs and provide extensive assistance with upper body dressing and hygiene. The 11/1/21 care instructions documented the resident required extensive assistance of one person with personal hygiene. The certified nurse aide (CNA) ADL documentation record documented the resident was provided extensive assistance with personal hygiene on 2/1/22, 2/2/22 and 2/3/22 on the day and evening shifts. The following observations of Resident #34 were made: - on 2/1/22 at 11:13 AM, the resident had facial hair on their chin, approximately 1 inch in length. The resident stated they did not like the hair on their chin, but they were unable to remove it themself. - on 2/2/22 at 10:49 AM and 1:06 PM; on 2/3/22 at 9:38 AM; and on 2/4/22 at 9:17 AM the resident was in their room, sitting in a recliner chair and had long facial hair on their chin. When interviewed on 2/4/22 at 9:20 AM, CNA #7 stated personal hygiene included toileting, bathing, providing peri care, applying lotion, brushing hair and shaving. The CNA stated they did not ask the Resident #34 if they wanted their chin shaved and did not shave the resident's chin. The CNA stated they should have asked the resident if they wanted to be shaved because the resident had pain in their hands and was unable to shave themself. When interviewed on 2/4/22 at 9:28 AM, licensed practical nurse (LPN) #8 stated personal hygiene included showers, bed baths, denture cleaning, oral hygiene, hair care, ensuring proper footwear, shaving and nail care. The LPN stated a CNA should ask the resident if they wanted to be shaved and shave them if they did. Shaving should be included as part of personal hygiene and should be performed daily if requested by the resident. 10NYCCR 415.12(a)(3)

Based on observation, record review and interviews during the recertification survey, the facility did not ensure the resident environment remained free of accident hazards for 1 of 2 residents (Resident #495) reviewed for accidents. Specifically, Resident #495's portable oxygen tank was observed not secured in a carrier during use for administration of a nebulizer treatment. The 6/2019 Medical Gas Cylinder policy stated all oxygen tanks, full or empty, were to be secured with a chain, in a wheeled base or in an oxygen container rack. Resident #495 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 8/20/19 Minimum Data Set (MDS) assessment documented the resident was cognitively intact and required moderate assistance with activities of daily living (ADLs). The 8/18/19 physician order [REDACTED]. On 8/20/19 at 1:40 PM, LPN #1 was observed administering a nebulizer treatment to the resident. She removed the oxygen tank from the carrier located on the resident's wheelchair and placed it, unsecured, on the floor in front of the resident. The resident was seated upright in his recliner and the oxygen tank was within 3 feet of the recliner. LPN #1 prepared the nebulizer solution into the administration chamber, attached the administration tubing to the oxygen tank, placed the mask on the resident and turned on the oxygen. She set a timer on her cellphone to remind her when to return and disconnect the nebulizer. She returned to the resident's room when the alarm sounded on her phone, disconnected the nebulizer from the oxygen tank and returned the tank to the carrier on the wheelchair. The 11/30/18 Nursing Orientation Competence Verification Form documented licensed practical nurse (LPN) #1 was competent in oxygen therapy including the use and storage of portable oxygen tanks. When interviewed on 8/20/19 at 1:50 PM, LPN #1 stated there were only two nebulizer machines on the unit and a power cord had to be shared between them. The power cord was in use, so she used the oxygen tank to administer the nebulizer. She stated she was not aware of a policy or any reason why an unsecured oxygen tank could not be used. When interviewed on 8/21/19 at 11:15 AM, registered nurse (RN) Unit Manager #2 stated oxygen tanks were expected to always be secured. She stated if the tank had fallen over it would have become a rocket (projectile) and was a safety issue. She stated oxygen storage was taught in initial orientation and when a new employee was oriented to the unit. When interviewed on 8/22/19 at 9:20 AM, the Director of Maintenance Services stated all oxygen tanks were stored in metal racks or wheeled carriers to prevent the tanks from being tipped over. He stated it was not acceptable to ever use an oxygen tank that was not secured. He stated there would be a rocketing effect if the tank tipped over and the top came off. He stated the unsecured oxygen tank was dangerous. 10NYCRR 415.12(h)(1)

Based on observation, record review, and interview during the recertification survey, the facility did not maintain drug and biological storage and labeling in accordance with currently accepted professional standards for 1 of 4 medication room refrigerators (Violet Unit), and 2 of 4 medication carts (Violet and Daisy Units) reviewed for medication storage and labeling. Specifically, expired biologicals and medications were observed in medication carts and medication room refrigerators. Findings include: There was no facility policy regarding expired medication checks. During a medication storage observation on 8/20/19 at 8:55 AM with licensed practical nurse (LPN) #4, the(NAME)medication room refrigerator contained an undated opened stock vial of [MEDICATION NAME] ([MEDICATION NAME] test serum). There was an undated opened stock vial of [MEDICATION NAME] (local anesthetic) in the top drawer of medication cart #1. During a medication storage inspection on 8/20/19 at 9:15 AM with LPN #5, the Daisy medication cart contained an open bottle of aspirin 325 milligrams (mg) with a manufacturer's expiration date of 7/2019. When interviewed on 8/20/19 at 1:21 PM, LPN #4 stated the nurse was supposed to write the opened date on the vial and box when they first accessed a stock vial. She stated a stock vial expired 28 days after it was first opened. If it was not dated, the bottle was considered expired. She stated the nurse manager was responsible to check expiration dates in the medication rooms, the medication refrigerators, and the medication overstock on a monthly basis. The medication nurses were to check each medication expiration date prior to administering the medication. The [MEDICATION NAME] and [MEDICATION NAME] were undated and were considered expired. She was not aware of any resident receiving either medication. When interviewed on 8/20/19 at 2:21 PM, LPN #5 stated the medication nurse was responsible for checking the expiration date prior to administering the medication, and there were no residents receiving aspirin on the day shift medication pass. She stated the stock bottle of aspirin was expired. She was unsure of who was responsible to routinely check the medication room, refrigerators, or carts for expired medications. When interviewed on 8/20/19 at 2:48 PM, registered nurse (RN) Unit Manager #2 stated stock medications were to be checked on a weekly basis by the full-time overnight nurse, and she was not aware of a check sheet that was implemented. She expected each nurse to check the expiration dates prior to administering each medication. She stated the nurse opening the vial was supposed write the date it was opened on the vial or box, preferably both. If it was not dated, the vial was considered expired. The vials were good for 28 days once opened. She stated the [MEDICATION NAME] should not have been in the top drawer of the medication cart as it was not presently being used and should have been discarded. When interviewed on 8/20/19 at 3:26 PM, RN Unit Manager #7 stated mock survey rounding was done monthly and included checking for expired medications. A random leadership team member was responsible for checking medication expiration dates during the monthly rounding. He stated the medication expiration checks were not specifically documented, and he expected the nurse administering a medication to check the expiration date of that medication. When interviewed on 8/22/19 at 9:45 AM, the Director of Nursing (DON) stated there was no policy for checking expired medications, and it was an unwritten practice that the night shift nurse was responsible for cleaning medication carts monthly, which included checking for expired medications. She stated the night shift nurse was responsible for checking the medication room refrigerators for expired medications when checking the refrigerator temperatures nightly. The night shift nurse was also responsible for checking the stock medications on the shelves in the medication rooms. She stated resident specific [MEDICATION NAME] was labeled by the pharmacy and should have been discarded if used for a one time only dose. The [MEDICATION NAME] serum should have been dated by the nurse when they opened it and was good for 28 days. If not dated, it was to be considered expired and should have been discarded. The medication cart cleaning and checking expiration dates were not documented. All nurses should check dates prior to them administering each medication. 10NYCRR 415.18(d)(e)(1-4)

Based on interview and record review conducted during the standard and abbreviated survey (NY 468), 1 of 3 residents (Resident #142), reviewed for abuse/neglect and mistreatment, the facility did not ensure all alleged violations involving mistreatment, neglect, or abuse were thoroughly investigated or reported timely. Specifically, Resident #142 had bruises of unknown origin and the facility did not conduct an investigation to rule out abuse, neglect or mistreatment and did not report to New York State Department of Health (NYSDOH) as required. Findings include: The facility Abuse policy dated 10/03/16 documented when an incident occurred the facility was required to initiate an investigation. If the resident had an injury without know incident and the facility was unable to rule out abuse, neglect or mistreatment or care plan violation then that was to be reported to the New York State Department of Health (NYSDOH). Resident #142 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was moderately impaired with a brief interview for mental status score (BIMS) of 9. She required extensive assistance with most activities of daily living (ADLs) with the exception of requiring limited assistance with walking and independence with eating. The nursing progress note dated 03/01/17 at 12:49 PM documented staff reported the resident had a bruise on her right forearm, she had a treatment in place and staff were continuing to monitor the bruise. There was no documented evidence the facility investigated the bruise to determine how or when it may have occurred and to rule out abuse, neglect or mistreatment. The comprehensive care plan (CCP) did not identify the bruise or interventions for prevention. The registered nurse (RN) progress note dated 03/04/17 at 4:29 AM documented the resident was found to have a bruise to her left middle finger starting at the first knuckle down the anterior finger. The finger was bluish and purple in color. The resident was unable to recall how the bruising occurred. The plan was to monitor the bruise daily until resolved. The facility investigation dated 03/04/17 documented the resident had a bruise to her left middle finger of unknown origin. The report identified the resident's plan of care was followed with new preventive measures to remove chairs from around the resident's bed, check hand placement while at meals and the facility identified there was no abuse, neglect or mistreatment. The attached voluntary statement documented the certified nurse aide (CNA) found the bruise and notified the nurse. There were no additional documented statements or interviews conducted to determine the cause of the bruise or to rule out abuse, neglect, or mistreatment. The CCP did not reflect the bruise or interventions for prevention. The facility investigation report dated 03/05/17 at 4:00 PM documented the resident had a bruise to her left outer calf measuring 0.7 centimeters (cm) x 1.2 cm purple in color. The bruise was described to have likely occurred when the family visited as they had metal chairs around the bed. Staff had observed the resident moving her legs off the bed and she likely swung out and struck the metal chair. The resident did not provide a statement. The documented preventive measure was to remove the chairs from next to the bed after the family left. The attached statement documented the licensed practical nurse (LPN) was approached by the family and alerted of the bruise, the Supervisor was notified and the resident had a history of [REDACTED]. The investigation determined the plan of care was followed and there was no abuse, neglect or mistreatment identified. There was no documented evidence the CCP reflected the bruise or interventions for prevention. There was no documented evidence to support the facility ruled out abuse, neglect or mistreatment. The facility investigation report dated 03/07/17 at 12:11 AM documented the resident had a dark red bruise to her right forearm, she had multiple documented bruises related to bumping nearby objects and her radio was in the bed near her right arm. The radio was removed and placed on the bedside table and the resident did not provide a statement. The report documented the CCP was followed, there was no evidence of abuse, neglect or mistreatment and the CCP was updated. The attached statement documented at the change of shift the bruise was identified and reported. There were no further documented statements or interviews conducted and the CCP did not document any updated changes or preventative measures. There was no documented evidence to support the facility ruled out abuse, neglect or mistreatment. The facility investigation report dated 03/09/17 at 07:00 PM documented the resident had a 1.9 cm x 1.4 cm deep red bruise on her left forearm. The resident likely bumped her arm on the table or side rail. The report documented the CCP was followed and there was no evidence of abuse neglect or mistreatment. The preventative measure was to keep the bed free from clutter and place items within reach. The attached statement documented the LPN was made aware of the bruise by the family and the Supervisor was notified. There were no other documented statements or interviews conducted and the CCP did not document any updated changes or preventative measures. There was no documented evidence to support the facility ruled out abuse, neglect or mistreatment. When interviewed on 04/06/18 at 09:37 AM, RN Unit Manager #5 stated the resident had bruising. The facility process was when the bruise was identified was to notify the supervisor to assess the area and during the assessment she was to find out how the bruise may have occurred. The medical provider and the family were to be notified. If the staff were unable to determine how they believed the bruise occurred they conducted a complete investigation which included interviewing staff. If still unable to determine what caused the bruise they would notify the Director of Nursing (DON). When interviewed on 04/06/18 at 10:51 AM, CNA #4 stated she had been the resident's primary CNA while at the facility. The resident required extensive assist for all ADLs, she had behavioral issues and often refused care. She was unable to recall if the resident had any bruising. She stated the facility policy when a bruise was identified was to report the area to the nurse or supervisor and an assessment was completed. The staff were expected to provide a statement including when the area was found and the staff attempted to determine how the area occurred. When interviewed on 4/6/2018 at 12:59 PM, the DON stated the facility policy was all incident and accidents were reviewed to determine the root cause of the incident. The facility looked for care plan violations, conducted a chart review for contributing factors, and determined if abuse, neglect or mistreatment had occurred. The investigation process consisted of interviews with staff, completing assessments, notifying the medical providers and the family. During the investigation staff were expected to notify the team leader once a bruise was identified, assess the area and the information was to be documented in the resident's medical record. The incident was reviewed during the morning report and if determined by the interdisciplinary team to be abuse the incident was reported to NYSDOH. She was unable to state why there was no documentation of an incident report for the incident that occurred on 03/01/17. Other incidents on 03/04, 03/05, 03/07 and 03/09/17 did not seem to be caused by abuse as they had contributing factors. She stated when the facility identified an injury of unknown origin and the facility was unable to rule out abuse the incident was to be reported to the NYSDOH within 24 hours and she did not know when the investigation was expected to be completed. When interviewed on 04/06/18 at 1:30 PM, the Administrator stated she expected when a bruise was observed an incident accident form to be completed. She stated she was unable to locate an incident report for the bruise that occurred on 03/01/17. She stated not all bruises of unknown origin were reportable incidents. If the facility was unable to rule out abuse, neglect or mistreatment it was a reportable incident. 10 NYCRR 415.4(b)

Based on record review, observations and interview conducted during the recertification survey, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for 2 of 29 residents (Residents #42 and 85) reviewed. Specifically, Resident #85 displayed mood and behavioral symptoms and the comprehensive care plan (CCP) did not include person-centered interventions. Resident #42 did not have a plan of care in place to address her bed height. Findings include: 1) Resident #42 was re-admitted on [DATE] with [DIAGNOSES REDACTED]. The 01/23/18 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition, required extensive assistance of 1 with bed mobility and most activities of daily living (ADLs), was always incontinent of urine and frequently incontinent of bowel, and had no bed alarm. The 09/13/16 CCP documented the resident was at risk for falls and had impaired mobility related to poor balance. Interventions included to answer call bell promptly, call bell in reach, monitor for fall risk, extensive assist with bilateral half side rails, limited assist with toileting and encourage glasses when out of bed. The 03/01/18 updated CCP documented the resident had impaired physical mobility, a visual deficit, at risk for falls, and established her own goals. Interventions included extensive assist of 1 with bed mobility, transfer via mechanical lift, leave furniture in the same position, eyeglasses when awake, answer call bell promptly, call bell in reach, allow to wear hospital gown and stay in bed per her choice. There was no documented evidence the resident preferred her bed in a high position. The 12/14/17 at 10:43 PM nursing progress note documented the resident was alert with usual confusion, and remained in bed throughout the day as usual. The 01/05/18 physician order [REDACTED]. The 01/22/18 fall risk assessment documented the resident was a high risk due to cardiac and hypoglycemic medications, being incontinence, and having arthritis and glasses. She did not have a history of falls. The 01/23/18 at 1:24 PM interdisciplinary team progress note documented the resident was resistive to participating in exercises, and preferred to stay in a hospital gown in her room. The resident was observed lying on her back in bed with the bed in the high position, upper half side rails up, call bell in reach, wearing a hospital gown and uncovered: - On 04/03/18 at 12:00 PM, 12:33 PM, and at 01:49 PM; - On 04/04/18 at 08:31 AM, 09:40 AM, 11:23 AM, 02:32 PM, and 04:24 PM; - On 04/05/18 at 09:25 AM and 11:26 AM; and - On 04/06/18 at 09:14 AM. When interviewed on 04/04/18 at 08:42 AM, the resident stated staff raise and lower the bed depending on the care they provided. They had asked her that morning to lower it a little. She stated she liked it elevated and preferred to remain in bed throughout the day. When interviewed on 04/06/18 at 09:18 AM, physical therapist (PT) #8 stated the resident preferred the bed at that height, preferred to remain in bed, and could not turn in bed by self as she needed assist from staff to roll in bed. She stated she thought nursing would be responsible for documenting the bed height preference in the CCP. When interviewed on 04/06/18 at 09:44 AM, licensed practical nurse (LPN) #9 stated the resident stayed in bed for the majority of the time, was forgetful with short term memory issues, could turn herself minimally by turning to the left side about half way on her own, and could not turn by self to the right. She preferred her bed positioned with her head down with TV off, wanted the head of bed up when watching TV or eating. Typically, the bed should be in the lowest position unless it was on the resident care guide and was care planned for the bed to be raised. She did not think the resident could physically roll out of bed on her own. When interviewed on 04/06/18 at 11:17 AM, registered nurse (RN) Unit Manager #2 stated the CNAs knew how to provide care to a specific resident via the care guide. The resident's bed should be positioned in the lowest position possible due to the absence of specific care directions according to her CCP, and staff knows she does not want her bed in the low position. He stated the resident had moderate cognitive impairment and could not always give a reasonable rationale for her decisions. The resident stayed in her bed per her choice. He stated her choice of the bed not being in the lowest position should be on the CCP and Kardex, and should have been done by the RN Manager. When interviewed on 04/06/18 at 12:21 PM, the Director of Nursing (DON) stated she expected the CCP to be updated or ensure updates were done by the RN Unit Manager. She stated the resident's high bed should be care planned as per her preference. 2) Resident #85 was admitted on [DATE] and had a [DIAGNOSES REDACTED]. The 02/16/18 Minimum Data Set (MDS) assessment documented the resident was severely cognitively impaired; did not exhibit behavioral symptoms; and required extensive assistance with most activities of daily living (ADLs). The undated Behavior Monitoring Protocol documented staff were to document specific behaviors observed, interventions taken, and the effectiveness of those interventions. The 09/01/17 comprehensive care plan (CCP) documented the resident could be resistive to care and verbally aggressive. Staff were to offer assistance with ADLs related to the resident's behaviors. Staff were to redirect, encourage participation, explain procedures, and give time to de-escalate. The CCP was updated on 04/05/18 and documented the resident had physically aggressive behavior towards staff. The CCP did not include person-centered interventions for direct care staff to utilize to address the resident's physically behavioral symptoms directed towards others. The 01/2018 certified nurse aide (CNA) instructions documented the resident was verbally abusive, socially inappropriate, resisted care, and had disruptive behavior. The instructions did not include interventions or a plan for direct care staff to follow to address the resident's behavioral symptoms. Nursing progress notes documented: - On 02/03/18, the resident was resistive to care and threw the CNAs glasses. - On 02/09/18, the resident was very rude to staff. - On 02/25/18, the resident was very behavioral, yelling, and swinging out. - On 03/01/18, the resident yelled at a CNA, and butted her head. - On 03/09/18, the resident was very resistant to care, grabbed the CNA by the back of the head, and threatened her. - On 03/16/18, the resident was upset during care and bumped his elbow. - On 03/31/18, the resident was very aggressive with care, yelled at the CNA, swore, pulled staff hair and hit a second CNA. - On 04/05/18, the resident kicked staff and the CNA yelled out and stated she would not care for him anymore. The 03/2018 and 04/2018 CNA resident behavior detail documented the resident had behavioral symptoms including kicking, hitting, abusive language, threatening behavior, resisted care, negative statements, persistent anger, repetitive physical movements, yelling and screaming on 03/02, 03/03, /3/09, 03/12, 03/13, 03/15, 03/16, 03/17, 03/18, 03/19, 03/21, 03/22, 03/23, 03/26, 03/27, 03/31, 04/03, and 04/04/18. During an interview with the resident's representative on 04/05/18 at 11:30 AM, she stated the staff have been telling her that the resident was difficult to care for and had been exhibiting behavioral symptoms. During an interview with CNA #10 on 04/06/18 at 11:08 AM, she stated it was very difficult to care for the resident as he could be combative and resistive to care. She stated the resident had not made physically aggressive contact with her, but he would swing out like he was going to hit her. He could sometimes be physical with other staff during care. He was verbally inappropriate towards staff. There were not any interventions for direct care staff to use with the resident. His mood fluctuated from good to worse, she had not received a lot of information related to residents that exhibited behavioral symptoms, and there was not a specific plan for this resident. During an interview with licensed practical nurse (LPN) #11 on 04/06/18 at 11:20 AM, she stated she did not know how to look at CNA instructions to determine if there were instructions for residents with behavioral symptoms and what approaches could be used, if staff approached her for assistance. During an interview with LPN #12 on 04/06/18 at 11:37 AM, she stated the resident could be behavioral both physically and verbally. Staff had not been able to identify any specific triggers for the resident and his mood and behaviors fluctuated from day to day. The resident did not like a change in his routine. The resident's behaviors at times occurred so quickly that they were not able to contact family for guidance. She stated there had not been any changes in the resident's plan of care or interventions to address his mood and behavioral symptoms. During an interview with CNA #13 on 04/06/18 at 11:50 AM, he stated the resident was difficult with care and would be verbally inappropriate to staff. The resident was angry a lot, and was frustrated with his placement at the facility and with his loss in life roles. His mood and behavior varied by day. Sometimes the staff could bring him a snack that would distract him, which he learned from other CNAs, and this intervention did not work recently. During an interview with social worker #14 on 04/06/18 at 12:06 PM, she stated the resident had a history of [REDACTED]. The resident recently hit a staff person. She had just put in a physical abuse care plan this week. She stated she would put interventions in place based on talking with nursing and CNAs. The staff had yet to find what would work for him. The social worker stated she and the interdisciplinary team would be responsible for updating the plan of care. She had not updated the care plan like she should, to include individualized interventions attempted or planned for the resident. During an interview with RN Unit Manager #5 on 04/06/18 at 01:13 PM, she stated the resident had a grumpy personality. She stated some staff had a better approach than others and this could change his type of response to care. Recently there had been a staff member he slapped in the face and he had pulled another staff member's hair. The resident had a lot of losses in his life and was having a difficult time. She stated staff should step away and keep him safe when he was being aggressive with care. It would be the interdisciplinary team's responsibility to review the resident's care plan and determine what a good approach would be. She stated they had discussed potential changes with the resident and had only put in to place the intervention to re-approach. They were not able to determine any specific triggers for the resident. He had behavioral symptoms since admission including physical aggression toward staff, such as slapping and pulling hair, resisting care and verbal abuse. The behavioral symptoms had increased recently. He did not receive any antipsychotic medications. There had been new staff on the floor and that may have led to a change in his mood. 10 NYCRR 415.11(a)(2)

Based on observation, record review and interview conducted during the recertification survey for 1 of 5 residents (Resident #86) reviewed for [MEDICAL CONDITION] medication use with [DIAGNOSES REDACTED]. Specifically, Resident #86 did not have a care plan that reflected an individualized, person-centered approach with measurable goals, timetables and specific non-pharmacological interventions. The care plan did not include monitoring and/or adjustments to the interventions based on their effectiveness to improve or maintain the resident's mental and psychosocial well-being. In addition, the resident was administered an as needed (prn) anti-anxiety medication without documentation of non-pharmacological interventions attempted before its administration. Findings include: The undated Behavior Monitoring Protocol documented staff were to document specific behaviors observed, interventions taken, and the effectiveness of those interventions. Resident #86 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The 02/22/18 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition; exhibited physical, verbal and other behavioral symptoms; required total dependence on staff for most activities of daily living (ADLs); and the resident was taking an anti-psychotic routinely. The 10/29/17 geriatric psychiatry progress note documented the resident yelled out and prn [MEDICATION NAME] had been part of his regiment and had been ineffective most of the time. The resident had periods of increased agitation with staff and peers; had been yelling since admission and had become more intense; had been sexually inappropriate and purses lips; and had been trying to kick his peers. Non-pharmacological interventions could include calming behaviors, music, quiet room, decrease stimulation; determine cause of upset; encourage good 6-8 hours of sleep; and rule out pain. The 11/20/17 comprehensive care plan (CCP) documented the resident had verbal and physical behaviors directed towards others. Staff were to coach the resident through the process when delusions were forthcoming; have geri psych see prn; monitor for signs of depression; and encourage visits from friends and family. The CCP did not include person-centered individualized interventions to address the resident's mood and behavior symptoms. The CCP did not include what behavior symptoms the resident had been exhibiting and if a plan had been implemented to monitor the resident during a gradual dose reduction (GDR). A 01/18/18 nurse practitioner (NP) note documented the resident had paranoia and was not exhibiting behaviors or actions that had the potential risk of harm to self or others. The goal was to have less than 2 panic attacks by next evaluation. The 01/31/18 certified nurse aide (CNA) instructions documented the resident had behavior symptoms including verbally and physically abusive behavior, history of altercation with peers, yelling, screaming, kicking, hitting, pinching, scratching, spitting and resistiveness to care. The CNA instructions did not include interventions for direct care staff to utilize when the resident was displaying these symptoms. physician's orders [REDACTED]. physician's orders [REDACTED]. The CNAs documented in the behavior monitoring history that the resident had been exhibiting behavioral symptoms including negative statements, repetitive verbalizations and movements, persistent anger, yelling, screaming, kicking, hitting, unpleasant mood, resistiveness to care, kicking and hitting. The history detail documented these symptoms were displayed almost daily between 10/2017-03/2018. The 03/2018 and 04/2018 medication administration records (MAR) documented the resident was administered prn [MEDICATION NAME] on 03/21-03/23, 03/25-03/27, 04/03, and 04/04/18. The MAR indicated [REDACTED]. Correlating nursing progress notes did not consistently document interventions attempted by staff and their effectiveness. The 03/15/18 NP progress note documented the resident was stable on current medications and did not document any behavioral symptoms specific to the resident. The resident was observed: - On 04/03/18 at 04:41 PM, seated in his geri chair in the hallway yelling, while other residents were 15 feet away playing a ball toss with staff. At 04:53 PM and 05:00 PM, yelling loudly in the hallway. At 05:15 PM, the resident was yelling in the hallway and other residents were looking at him. - On 04/04/18 at 04:20 PM, seated in his geri chair in the hallway, yelling. A non-nursing staff stopped to talk to him, he quieted, and when they walked away he began yelling again. At 04:53 PM, continued to yell out from the hallway. - On 04/05/18 at 08:28 AM and 08:38 AM, seated in his geri chair in the dining room awaiting his meal and calling out. At 09:57 AM, the resident's yelling could be heard from an adjacent resident nursing unit. The resident's yelling continued through 10:13 AM. At 11:01 AM, seated in the hallway while music was taking place in the unit dining room, making calling-out like noises. During an interview with CNA #10 on 04/06/18 at 11:08 AM, she stated the resident would usually be yelling out rambling sounds. She had not received a lot of information related to addressing residents with behavior symptoms. There were not interventions on the resident's CNA instructions for staff to use with the resident. During an interview with LPN #11 on 04/06/18 at 11:20 AM, she stated the resident was vocal with sounds and words. The resident had prn [MEDICATION NAME] available to use when he was not in pain and was screaming. The nurses were to document they provided the prn, what the behavior was, what staff did to deter the behavior and if the prn given was successful. She did not document any specific interventions. Intervention effectiveness varied depending on the resident's mood. Sometimes the resident would be redirected with food or moving to another area to decrease stimulation. The resident was often vocal, starting before lunch and continuing through the afternoon. She was not aware of any changes or recommendations made for the resident's plan of care. During an interview with social worker #14 on 04/06/18 at 12:06 PM, she stated the resident had good and bad days. The staff would say he's tough. Sometimes 1:1 would work for him, and attempt to determine if he was in any pain. She stated she would put interventions in place based on talking with nursing and CNAs. She and the interdisciplinary team would be responsible for updating the plan of care, she had not updated the care plan like she should have to include individualized interventions attempted or planned for the resident. During an interview with the acting registered nurse (RN) Unit Manager (RN #15) on 04/06/18 at 12:21 PM, she stated the resident was a difficult case and had a decline in his ADLs. The resident yelled out a lot and sometimes picked at the skin on his head. She stated there were things to try such as the sensory room, weighted blanket, and quiet room. The resident had prn [MEDICATION NAME] available and he had received it. A prn [MEDICATION NAME] was to be used as a last resort, and his family member advocated to use the least amount of medications as possible. Staff should document in a progress note what interventions they have tried with the resident. The CNA instructions included a section to document what types of behaviors the resident was exhibiting and what staff should try. She or the social worker were responsible for updating the CCP on interventions that worked for the resident. The resident provoked and agitated other residents. During an interview with physician #16 on 04/06/18 at 01:30 PM, he stated if the resident was displaying anxiety symptoms that could not be addressed by implementing non-pharmacological interventions, then a prn anti-anxiety medication could be used. Staff should be documenting the interventions they attempted prior to using the prn anti-anxiety medication. The resident's dementia had progressed and he had been exhibiting behavior symptoms for quite some time. His main behavioral symptom was yelling out. It had put him at risk of being involved in altercations with other residents who may have triggers. There was not a specific time frame to see if a medication change had positive or negative effects. In follow up, the physician stated physician orders [REDACTED]. 10 NYCRR 415.12(l)(1)

Based on observation, record review and interview conducted during the recertification survey for 1 of 1 residents reviewed for infection control (Resident #111), the facility did not maintain an infection prevention and control program. Specifically, droplet precautions were not maintained for Resident #111. Findings include: The facility 01/14 Guideline for Implementation and Management of Isolation Precautions policy documented influenza was a droplet transmitted precautions, a mask should be worn, and use of gown and gloves per standard precautions. The policy documented standard precautions included the use of gowns and gloves to protect the skin and clothing during activities likely to generate splashes or sprays of body fluids or excretions. The facility 12/17 Standard Precautions policy documented gowns or aprons must be worn during procedures that are likely to generate splashes of blood or other body fluids. The policy documented masks shall be worn whenever splashes, spray, splatter or droplets of potentially infectious material may be generated. Resident #111 was admitted [DATE], and re-admitted [DATE], to the facility with a [DIAGNOSES REDACTED]. The 03/09/18 Minimum Data Set (MDS) assessment documented the resident had full cognition, supervisory assistance from staff with most activities of daily living (ADLs) and required oxygen therapy. The 12/04/17 immunization record documented the resident received a flu vaccination 10/03/17. The 04/04/18 at 03:28 AM nursing progress note documented the resident was assessed by the supervisor for shortness of breath, pallor, increased respirations, felt like he was going to pass out, coughing green sputum, had a high temperature and had diminished lung fields. The note documented the resident was on oxygen that had to be increased, the nurse practitioner (NP) was called, and new orders were received for tests and antibiotics. The 04/04/18 at 04:19 AM nursing progress note documented a chest x-ray and flu swab was done. During an observation on 04/04/18 at 08:49 AM, the resident was sitting up bed. There was an isolation precautions cart outside of his room. Certified nurse aide (CNA) #1 stated he was placed on precautions due to flu like symptoms. On 04/04/18 at 02:49 PM during an observation, the resident was lying on his back in bed covered with linen watching television. He had oxygen on at 2 liters (L) via nasal cannula via concentrator. CNA #1 was talking to him in the room, had on gloves and mask but no gown. The CNA exited the room after removing the mask and gloves and washing her hands. On 04/04/18 at 02:51 PM, CNA #1 was observed entering the room, she did not put on gloves or a gown, and answered the resident's call bell. The CNA was observed standing next to the bed, talking to the resident wearing a mask on her face. She was not wearing gloves or a gown. When she exited the room she did not have a mask on. During an observation on 04/04/18 at 02:57 PM, CNA #1 returned to the room, put a mask on in the room doorway, entered the room, spoke with the resident, and removed the mask as she exited the room. She applied alcohol to her hands from a dispenser in the hallway outside of room and continued walking down the unit hallway. The 04/05/2018 at 02:11 AM nursing progress note documented the resident was complaining of not breathing well, was out in the hallway in wheelchair, his color was pale and pasty, blood glucose was 141, his oxygen saturations were in the low 80 percentages while on 4 L of oxygen, and a non-rebreather mask was applied. The supervisor and NP were made aware, the resident wanted to go to the hospital, he was coughing greenish sputum, EMS was called and the resident went to the hospital. On 04/05/18 at 09:22 AM, the resident was not observed in his room and the isolation cart remained in the hallway outside his room. Laboratory flu results from a nasal swab obtained on 4/4/18 and reported on 4/5/18 at 11:31 AM, documented the resident was negative for Infuenza A and B. When interviewed on 04/06/18 at 10:33 AM, CNA #1 stated an isolation cart outside of room meant the resident was on some type of isolation precautions. Staff were to wear gown and gloves for personal protective equipment (PPE) for precautions, and a mask should be worn for droplet precautions. Hands were to be washed prior to putting on and after removing PPE before leaving the room. She stated she learned how to use PPE and about the different types of precautions during orientation. She was told in report the resident was on precautions due to flu symptoms and she was supposed to wear a mask, gloves and a gown. PPE was worn so that if the resident coughed or sneezed on you, the germs could not be spread to others. She stated she did not wear the gown or gloves when just talking to him, as she was not sure if she should or not. She stated she should have asked the nurse about what PPE to wear. When interviewed on 04/06/18 at 10:50 AM, registered nurse (RN) Unit Manager #2 stated PPE consisted of mask, gown and gloves for droplet precautions. The resident was on droplet precautions due to flu symptoms while waiting for his test results to return. She expected staff to wear a gown, gloves and mask while caring for and within 3 feet of the resident. Staff were educated on PPE in class, orientation, and as needed. When interviewed on 04/06/18 at 12:15 PM, the Director of Nursing (DON) stated PPE and precaution education was done in yearly staff mandatory in-services and in orientation. She expected staff to wear appropriate PPE for the appropriate precautions. She expected a gown, gloves and mask to be worn with droplet precautions for prevention of spread of disease. When interviewed on 04/06/18 at 12:51 PM, Infection Control Nurse #3 stated she expected staff to wear a gown, gloves and mask each time they went into a droplet precaution room as to prevent the resident from contracting a disease from the staff member and to prevent the staff member from carrying the disease from one resident to another. 10 NYCRR 415.19(a)(b)

Based on record review, interview, and observation conducted during the recertification survey, it was determined the facility did not provide a copy of the New York State Department of Health (NYS DOH) statement of deficiencies and plan of correction for all seven posted locations (front lobby, Daffodil Court, Tulip Court,(NAME)Court,(NAME)Court, Daisy Court, and Rose Court). Specifically, the life safety code survey statement of deficiencies and plan of correction were not present in the 2015 Federal survey reports. Findings include: On 12/1/2016 at 10:50 AM, a surveyor reviewing the facility's 8/25/2015 Federal survey report could not find the life safety code survey statement of deficiencies and plan of correction. During an interview with the Executive Secretary on 12/1/2016 at 10:55 AM, she stated she forgot to include the life safety code survey findings. During an interview with the Administrator on 12/1/2016 at 10:58 AM, she stated: - The life safety code survey statement of deficiencies and plan of correction should have been included in the 2015 Federal survey report. - She printed both the life safety code survey and the health survey and then delegated the Executive Secretary to put the documents into a binder and place in the designated locations. - Last week she delegated the Executive Secretary to check if the 2015 Federal survey reports were still present in designated locations and fully complete. On 12/1/2016, between 11:10 AM and 11:21 AM, a surveyor reviewed the 8/15/2015 Federal survey reports that were located on all six resident courts (Daffodil Court, Tulip Court,(NAME)Court,(NAME)Court, Daisy Court, and Rose Court) and the the life safety code survey statement of deficiencies and plan of correction was not present at any of the six Court locations. 10NYCRR 415.3(1)(c)(1)(v)

Based on record review and interview conducted during the standard and abbreviated surveys (NY 787), it was determined for 1 of 14 residents reviewed (Resident #1), the facility did not inform the resident and/or the resident's designated representative when there were changes in the resident's status. Specifically, Resident #1 and/or her designated representative were not informed when the resident's pressure ulcer worsened. Findings include: Resident #1 had [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) dated 8/19/2016 documented the resident was at risk for skin breakdown due to decrease mobility and incontinence. Interventions included incontinence care, turn and position per policy, provide barrier cream for prevention, pressure relieving cushion in the wheelchair, and a pressure relieving mattress for the bed. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment. She required extensive assistance with all activities of daily living (ADLs), did not have pressure areas, and was to have a pressure relieving device for her bed. The registered nurse (RN) progress note dated 8/26/2016 at 6:35 AM documented the resident had a 3 centimeter (cm) red area and a small blister to her left buttock. The note documented the on-call provider was notified of the area, a treatment for [REDACTED]. The nursing progress note dated 9/5/2016 at 12:01 AM documented a late entry note for 9/3/2016. The note documented the physician was notified of the resident's left buttock Stage II open area measuring 0.75 cm and a C-shaped darker area next to it. The physician ordered the area be cleansed with normal saline, and [MEDICATION NAME] (foam dressing) was to be applied to the areas and covered with a dressing. The weekly wound and skin record dated 9/6/2016 documented the resident had a deep tissue injury that measured 3.2 cm x 0.9 cm and was purple in color. The second area was identified as a Stage II area measuring 2.2 cm x 1 cm x 0.1 cm and was red/moist. The physician order [REDACTED]. There was no documented evidence the family or designated representative was notified when the resident's pressure ulcer changed. When interviewed on 11/29/2016 at 3:00 PM, registered nurse (RN) #19 stated she was unable to recall staff reporting any skin issues on the resident's left buttock. She stated she did not remember if she completed an assessment, and did not remember if she contacted the family about the open areas. When interviewed on 11/29/2016 at 4:00 PM, the nurse practitioner (NP) stated her expectation of the staff was for a re-assessment to have occurred on 8/29/2016 to determine if the area was being treated properly. She stated the resident's pressure areas identified on 8/26/2016 had a definite change by 9/6/2016 and appeared to have worsened. When interviewed on 11/30/2016 at 10:11 AM, the Director of Nursing (DON) stated she expected staff to update the family of the progression of the resident's pressure areas. 10NYCRR 415. 3(e)(2)(ii)(b)

Based on record review and interview conducted during the recertification and abbreviated surveys (NY 230), it was determined for 2 of 3 sampled residents (Residents #2 and 3) reviewed for restraints, the facility did not ensure residents were free from physical restraints not required to treat medical symptoms. Specifically, Resident #2 did not have a physician order [REDACTED].#3 had a restraint that was not reassessed for continued use. Findings include: 1) Resident #2 had [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) updated 6/29/2016 documented the resident had dementia, impaired mobility and a history of falls. Interventions included extensive assistance for bed mobility, total dependence for locomotion, and a bed alarm was in place. The facility investigation dated 7/5/2016 documented the resident stood from her wheelchair and when attempting to sit down, missed her chair and fell to the floor, hitting her left side and her head. Resident #2 was assessed at the time of the incident and transferred to the hospital for evaluation for complaints of pain to her left arm. The investigation summary documented on 7/6/2016 a lap buddy was initiated to prevent falls. Nursing progress notes documented the resident had the lap buddy restraint (inflatable cushion that snugs into wheelchair frame, as reminder not to stand up alone) in place: - on 7/7/2016 at 2:32 PM; and - on 7/9/2016 at 2:03 PM. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severely impaired cognition, required extensive assistance with activities of daily living (ADLs), and did not have a restraint. Nursing progress note documented the resident had the lap buddy restraint in place: - on 7/10/2016 at 2:06 PM; - on 7/11/2016 at 2:02 PM; and - on 7/14/2016 at 11:58 PM. Between 7/6/2016 and 7/14/2016, the resident's record : - did not document a restraint assessment was completed; - did not document the care plan was updated for the restraint; and - did not document a physician order [REDACTED]. The facility restraint policy dated 10/21/2011 documented a restraint order was to be obtained from the physician, and a physical restraint assessment to be completed prior to the use of the restraint. When interviewed on 11/14/2016 at 2:24 PM, certified nurse aide (CNA) #1 stated she provided daily care for Resident #2 and followed the resident's care guide for directions. She stated the resident had multiple falls with ongoing interventions including alarms in and out of bed, and a lap buddy for safety. She stated she was unable to recall when the lap buddy was initiated or how she was made aware it was to be used. When interviewed on 11/15/2016 at 8:24 AM, the Director of Nursing (DON) stated she did not know why a restraint assessment or a physician order [REDACTED]. She stated she would expect the staff to have completed those activities prior to initiating the restraint. 2) Resident #3 had [DIAGNOSES REDACTED]. The physician order [REDACTED]. The order documented the nursing Supervisor/Manager to direct application of restraint and release a minimum of every 2 hours. The restraint assessment form dated 1/27/2016 documented the resident required a seatbelt for poor balance/sitting/standing and inflicting injury to self/staff/other residents. The form documented alternatives included: alarm devices, ambulation, activities, foods/fluids/snacks, keep in areas of high visibility, 1:1, and physical therapy (PT). The form documented the family was notified. On 3/2/2016 and 5/11/2016, the resident's physician orders [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severely impaired cognition. He required extensive assistance with most activities of daily living (ADLs) and had no impairment of arms and legs. He had no behaviors or falls, and he had a trunk restraint in bed. The comprehensive care plan (CCP) dated 7/29/2016 documented restraint use due to risk for injury due to unsafe transfers and ambulation, and physical aggression with staff. Interventions included release every 2 hours and as needed, evaluate continued need for restraints, monitor behaviors, and evaluate for less restrictive device quarterly and with condition change. There was no documented evidence the resident's restraint was reassessed for continued use between February 2016 and July 2016. When interviewed on 12/1/2016 at 12:00 PM, certified nurse aide (CNA) #8 stated the resident used a seatbelt restraint when in his wheelchair, staff released it every 2 hours, and directions for the restraint were in the care plan and on the care guide. She stated the resident fell out of his wheelchair during a recent trial of no restraint. She stated she was not asked for restraint assessment input. When interviewed on 12/1/2016 at 12:20 PM, registered nurse (RN) #9 stated unit nurses do not do restraint assessments. RN #9 stated restraint assessments are completed by the Interdisciplinary Team quarterly. When interviewed on 12/1/2016 at 1:30 PM, the Assistant Director of Nursing (ADON)/RN Manager stated restraint assessments were to be done quarterly at resident care conference and as needed. The ADON stated a non-restraint trial was recently done and the resident failed. He stated there was no RN Manager on the resident's unit from about 4/2016 until 7/2016 and restraint assessments got missed, but should had been completed. 10NYCRR 415.4(a)(2-5)

Based on observation, record review, and interview conducted during the recertification and abbreviated surveys (NY 186), it was determined for 2 of 21 residents reviewed for neglect (Residents #4 and 7), the facility did not conduct a complete and thorough investigation into alleged violations. Specifically, the facility did not ensure licensed nurses provided physician ordered treatments as directed, and did not complete assessments of a resident who had a incident. Resident #4 had a thermal pad placed on her right knee and the pad was not removed as ordered. The following morning the registered nurse (RN) was alerted the pad was still in place and an assessment for injury was not completed. Resident #7 was found with a skin impairment and a complete investigation was not done to rule out neglect. Findings include: The facility nursing guidelines dated 8/15/1995, presented as current during survey, documented when an incident occurred or the resident experienced an unusual occurrence or change in condition, more frequent observation, assessment, and documentation were to be carried out. 1) Resident #4 had [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) dated 8/26/2016 documented the resident was to have pain management. Interventions included to monitor the resident's pain level and implement the use of alleviating factors. The CCP did not document the resident had a physician ordered treatment for [REDACTED]. The physician order [REDACTED]. The order documented the heating pad was to be set at 100 degrees (Fahrenheit) and was to be left on for 15 minutes. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severely impaired cognition and required extensive assistance with her activities of daily living (ADLs). The treatment administration record (TAR) for 10/21/2016 documented initials placed on the record by licensed practical nurse (LPN) #2 after the thermal pad was applied to the resident's right knee. The nursing progress note dated 10/21/2016 by LPN #2 did not document the resident received the physician ordered treatment or the condition of the resident's right knee at the time of the application of the thermal pad. The note documented that staff were to monitor the resident as needed. The facility investigation form dated 10/21/2016 documented certified nurse aide (CNA) #3 provided morning care for the resident and found a thermal heating pad on the resident's right knee. CNA #3 removed the pad and alerted Supervisor #4, who did not complete an assessment at that time. The form documented on 10/22/2016 at 8:00 AM that LPN #3 was alerted Resident #1 had a large red area on her right knee and that she was informed of the incident that occurred on 10/21/2016. An RN assessment was completed at that time by the RN Supervisor, and the nurse practitioner (NP) was notified. The NP ordered the heating pad to be put on hold, and the reddened area to be monitored. The investigation did not identify that the RN failed to complete a incident report, failed to assess the resident at the time of the incident, or provide documented evidence the staff received re-education for the identified issues. The nursing progress note dated 10/22/2016 at 9:37 AM documented CNA #3 reported an area of redness around the resident's right knee. The note documented the nursing Supervisor was notified of the incident, who completed an assessment of the area. The nurse practitioner (NP) progress note dated 10/24/2016 documented the resident was seen for an increase in pain, swelling, and a rash to her right knee. The report documented the heating pad was placed on hold on 10/22/2016 due to the onset of the symptoms. The area was tender when the resident's knee was palpated and increase in swelling was noted. The NP documented the [DIAGNOSES REDACTED] (reddened skin) appeared to be in the pattern of the heating pad. The NP ordered cool compresses, and to discontinue the use of the heating pad. The facility did not have a documented policy and procedure for thermal care in effect prior to the incident. When interviewed on 11/15/2016 at 11:19 AM, the Director of Nursing (DON) stated she was unable to provide documented evidence the staff involved were monitored during the investigation, or re-educated regarding for not completing an assessment of the resident or not completing the treatment as ordered. The DON stated the facility did not have a policy in place for use of a thermal pad. When interviewed on 11/15/2016 at 12:46 PM, CNA #3 stated she saw the thermal pad was on the resident's right knee while providing morning care for the resident on 10/22/2016. She stated that it was unusual for the pad to be on at that time of day, and she notified the RN Unit Manager #4 at that time. She stated that when she arrived the following day, she identified the redness of the right knee had increased, and she alerted the LPN on the unit. She stated she was concerned due to the resident's diabetes and inability to feel her right side due to a [MEDICAL CONDITION]. When interviewed on 11/15/2016 at 1:18 PM, RN Manager #4 stated she was alerted the resident had a thermal pad in place and it was not clear when the pad was applied. She stated she did not complete an assessment at that time. RN #4 stated she had not received any training on the use of the thermal pad prior to the incident, completing an incident accident investigation, or when to complete an assessment. She stated she did not return to evaluate the resident's knee throughout the day or report the incident. When interviewed on 11/15/2016 at 2:48 PM, LPN #2 stated she applied the resident's thermal pad on 10/21/2016 at approximately 10:45 PM. She stated she was assisting the CNAs with care needs and forgot to remove the thermal pad before leaving the facility. She stated she had received training on the use of the thermal pad during her orientation to the facility and had not received recent training. She stated she was not working in the facility for a few days after the incident, and upon return, the DON stated she was not to sign off a completion of the treatment until it had been completed. She stated the DON did not review any other information with her regarding the incident. When interviewed on 11/15/2016 at 3:34 PM, the Administrator stated she would expect documentation of staff who were counseled and re-educated, and she expected staff to document in the resident's record on the findings of the treatment. She stated the facility did not provide monitoring for the staff involved in the incident. She felt this was a complete and thorough investigation, and they had learned there were opportunities for improvement. 2) Resident #7 had [DIAGNOSES REDACTED]. The admission nursing assessment dated [DATE] documented the resident had no skin breakdown or affected areas on the buttocks. The comprehensive care plan (CCP) dated 10/4/2016 documented the resident was at high risk for skin breakdown related to decreased mobility and urinary incontinence. Interventions included certified nurse aides (CNAs) to evaluate skin condition during care and report any skin abnormalities to the nurse. The incident report dated 11/2/2016 at 1:30 PM documented the resident had a moisture related open area measuring 3.0 centimeters (cm) x 0.1 cm, a CNA statement was obtained, and there was no evidence of neglect. The attached statement dated 11/2/2016 at 1:30 PM by CNA #12 documented the CNA found an open area on the upper center of the resident's buttocks and reported it to licensed practical nurse (LPN) #13 on 10/27/2016. LPN #13 told CNA #12 she would look at it later, and the CNA told another nurse the next day. There were no additional staff statements attached to the incident report. Registered nurse (RN) Manager #7 signed the form as completed on 11/3/2016 at 11:20 AM. The nursing progress note dated 11/2/2016 at 1:36 PM documented CNA #12 notified the LPN the resident had a sore on his buttocks, and the area was open with bleeding. The note documented the supervisor was aware, and a voluntary statement from the CNA was obtained. The RN Manager #7 nursing progress note dated 11/3/2016 at 8:23 AM documented an assessment revealed the resident had a 3.0 cm x 0.1 cm moisture related open area within the superior gluteal cleft (upper inner buttocks area) and there was a new order to apply protective ointment every shift and as needed. The physician order [REDACTED]. During record review on 11/30/2016 at 9:04 AM, there was no documentation regarding the open area found on 10/27/2016 until 11/2/2016. When interviewed on 12/1/2016 at 9:48 AM, CNA #12 stated she completed the incident report on 11/2/2016 because she had reported the open skin area the prior week and there was no documentation the area was assessed. She stated she initially saw the open area on the resident on 10/27/2016, reported it to the nurse on duty (LPN #13), noticed the area again on 11/2/2016, and she did not believe anyone had looked at it since she first reported it. When interviewed on 12/1/2016 at 12:23 PM, the Director of Nursing (DON) stated the incident report was not complete and statements from the nurse and other staff should have been obtained. When interviewed on 12/1/2016 at 12:32 PM, LPN #13 stated any open areas found should be reported to the nurse on duty. She stated the RN would do an assessment immediately, decide what treatment to initiate, notify the physician, monitor the area, and document the status of the area for at least three days. She stated she was unaware of any open area on the resident, currently or within the past month. LPN #13 stated it was not reported to her on 10/27/2016, and she had not been asked about it by the DON or RN Manager. When interviewed on 12/1/2016 at 1:30 PM, RN Manager #7 stated she was unaware of the CNA statement attached to the incident report. She stated she completed the report, and would have investigated further by interviewing the nurses named in the statement if she had seen it. RN Manager #7 stated there should have been follow-up to rule out neglect. 10NYCRR 415.4(b)

Based on record review, interview, and observation conducted during the recertification survey, it was determined for 1 of 14 residents (Resident #6) reviewed for dignity, the facility did not promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Specifically, Resident #6 was observed wearing a hospital gown that was too small for her and her skin was exposed. Findings include: Resident #6 had [DIAGNOSES REDACTED]. The updated 10/24/2016 certified nurse aide (CNA) care instructions documented the resident required limited to extensive assistance for dressing. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had intact cognitive function. She required extensive assistance for activities of daily living (ADLs), and experienced chronic pain. The updated 11/11/2016 comprehensive care plan (CCP) documented the resident had impaired physical mobility due to chronic pain and [MEDICAL CONDITION]. Interventions included limited to extensive assistance for dressing. When interviewed on 11/29/2016 at 10:05 AM, the resident stated she wore hospital gowns while in her room. She stated the gowns were usually too small, felt tight around her chest and shoulders, and could not close behind her. The resident was observed at this time to be seated in her recliner in her room, wearing only a hospital gown. The gown appeared tight at her chest, did not close behind her, and her back and shoulders were exposed. During an observation on 11/30/2016 at 9:07 AM, the resident's door was open and she was visible from the doorway. She was observed sitting on the edge of her bed wearing a hospital gown that did not cover her back and shoulders, and her undergarments were exposed. When interviewed on 11/30/2016 at 5:52 PM, CNA #14 stated the resident preferred to wear hospital gowns while in her room, and the resident complained the hospital gowns were too tight. CNA #14 stated sometimes larger gowns were available, but not often, and the CNA would use them if available. CNA #14 stated she had not requested larger gowns for the resident. When interviewed on 12/1/2016 at 1:30 PM, registered nurse (RN) Manager #7 stated the hospital gowns the resident wore were too small. RN Manager #7 stated hospital gowns were not separated by size, and she had not looked for larger gowns, and was unaware if larger hospital gowns were available. 10NYCRR 415.5(a)

Based on record review, observation, and interview conducted during the recertification survey, it was determined for 2 of 15 residents (Residents #12 and 14) reviewed for activities of daily living (ADLs), the facility did not ensure the residents' ability to perform ADLs did not diminish. Specifically, Residents #12 and 14 were care planned to be be ambulated daily and were observed throughout survey with no ambulation performed. Findings include 1) Resident #14 had [DIAGNOSES REDACTED]. The physical therapy (PT) progress note dated 6/27/2016 documented the resident was screened after a fall when she fractured her clavicle (collar bone) and was wearing a sling. She was on the ambulation program and was currently unable to continue. The plan was for PT to reassess for mobility after her fracture healed. The comprehensive care plan (CCP) dated 7/28/2016 documented the resident had impaired physical mobility. She was to improve/maintain physical mobility, and was to be in the nursing rehabilitation program. She was to be ambulated 50 feet twice per day in the hallway with a rolling walker, limited assistance, and a wheelchair following. The certified nurse aide (CNA) care instructions dated 7/28/2016 documented the resident was in the nursing rehabilitation program, and was to be ambulated 50 feet twice daily in the hallway, with a wheelchair following. The PT discharge summary dated 8/2/2016 documented the resident received PT services from 7/21/2016 to 8/2/2016 and was functioning at her maximum potential. She was ambulating up to 150 feet with a rolling walker and minimal assistance. The plan was to continue the on unit ambulation program twice daily using a rolling walker with limited assistance and a wheelchair to follow, up to another 100 feet. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had moderately impaired cognitive function. She required extensive assistance for ADLs, did not walk in the room or corridor in the past seven days, did not have any impairments in upper or lower body, and did not participate in physical therapy. The CNA resident documentation record for 9/2016 documented the following: - the resident was ambulated on 4 days (9/1, 9/6, 9/14, and 9/28/2016) for distances no greater than 75 feet; - the resident refused/did not tolerate ambulation on 9/15, 9/16, and 9/19/2016; and - the resident was not ambulated for 23 days (9/2-9/5, 9/7-9/13, 9/17, 9/18, 9/20-9/27, 9/29-9/30/2016). The CNA resident documentation record for 10/2016 documented the the following: - the resident was ambulated on 10 days of the month (10/3, 10/5, 10/8, 10/12, 10/18,10/19, 10/21, 10/26, 10/28, and 10/29/2016) for distances no greater than 75 feet: - the resident refused ambulation on 5 days (10/13, 10/14, 10/17, 10/27, and 10/31/2016); and - the resident was not ambulated for 16 days (10/1, 10/2, 10/4, 10/6, 10/7, 10/9-10/11, 10/15, 10/16, 10/20, 10/22-10/25, and 10/30/2016). The CNA resident documentation record for 11/2016 documented the the following: - the resident was ambulated on 5 days (11/1, 11/2, 11/8, 11/9, and 11/16/2016) for distances no greater than 75 feet; - the resident refused/did not tolerate ambulation on 11/19 and 11/29/2016; and - the resident was not ambulated for 23 days (11/3-11/7, 11/10-11/15, 11/17, 11/18, 11/20-11/28, and 11/30/2016). The resident was observed at lunch on 11/29/2016 from 12:35 PM to 1:15 PM in a wheelchair at the table. At 1:15 PM, she self-propelled the wheelchair with her feet and left the dining room. She sat outside the dining room, across from the nursing station, handling a chair alarm that was on a recliner in the hall. At 1:28 PM, she was brought back to the dining room to have cake and remained there until 2:12 PM. The resident was observed on 11/30/2016 at 8:05 AM and 11:45 AM in her wheelchair at the dining room table. When interviewed on 12/1/2016 at 10:55 AM, CNA #16 stated CNAs were responsible for ambulating residents on the unit ambulation program. She stated the resident was on the nursing rehab walking program and was not ambulated this week. She stated the resident was at an activity yesterday during the time when ambulation was done. When interviewed on 12/1/2016 at 11:30 AM, the registered nurse (RN) Manager #7 stated the nursing rehabilitation walking program was what PT recommended for the residents to maintain their mobility status. Ambulation was done by CNAs as the residents allowed or tolerated. She stated if a resident did not allow or tolerate it, ambulation would be documented as not performed. The CNA should notify the nurse and the nurse should write a progress note. If a resident was not participating, a referral would be sent to PT for re-evaluation. She stated the resident ambulated to the bathroom on occasion and sometimes refused to walk. 2) Resident #12 had [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) updated 7/21/2016 documented the resident had impaired physical mobility. She was to be ambulated to and from the dining room for all meals, and to and from the bathroom with a rolling walker. She was in the nursing rehabilitation program with daily ambulation in the hall, 25 feet with a rolling walker, limited assistance, and a wheelchair following. A physical therapy (PT) progress note dated 7/21/2016 documented the resident was screened for increased difficulty with transfers and ambulation. The resident required extensive assistance for transfers, and ambulated approximately 30 feet with a rolling walker and minimal assistance. The note documented the resident was ambulating up to 100 feet upon last PT discharge. Nursing rehabilitation was to ambulate 25 feet daily in the hallway with the rolling walker, limited assistance, and a wheelchair following. The certified nurse aide (CNA) care instructions dated 11/7/2016 documented the resident was to be in the nursing rehabilitation walking program, and to ambulate the resident in the hall 25 feet once daily with a rolling walker, limited assistance, and a wheelchair to follow. A PT progress note dated 11/7/2016 documented the resident was screened for decline in transfer ability. She was care planned to be ambulated to and from the bathroom, and with nursing rehabilitation to be ambulated daily 25 feet in the hallway, and staff should continue with the ambulation care plan. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment. She required limited assistance for ambulation, and used a walker and a wheelchair. The CNA resident documentation record for 11/2016 documented the following: - the ambulation task was not scheduled 11/1-11/6/2016; - the resident was ambulated on 3 days (11/16, 11/18, and 11/24/2016) with no distances noted; - the resident refused ambulation on 7 days (11/7, 11/11, 11/13, 11/15, 11/19, 11/20, and 11/29/2016); and - the resident was not ambulated/task not performed/not applicable for 14 days (11/8-11/10, 11/12, 11/14, 11/17, 11/21-11/23, 11/25-11/28, and 11/30/2016). The resident was observed on 11/28/2016 at 6:20 PM in her wheelchair in the dining room. At 7:25 PM, a CNA took her to her room in the wheelchair. The resident was observed on 11/29/2016 at 8:08 AM being pushed in her wheelchair from her room to the dining room by a CNA. She had breakfast and then her wheelchair was turned to face the TV until lunch time. At 1:40 PM, a visitor came to the dining room and sat with the resident until 2:20 PM, when she was taken in her wheelchair to the bathroom and then to an activity. The resident was observed on 11/30/2016: - at 8:20 AM, sitting at the dining room table in her wheelchair; - at 9:28 AM, taken to the bathroom in her wheelchair; and - at 9:35 AM, brought back to the dining room and placed in front of the TV, where she slept in her wheelchair until lunch at 12:30 PM. When interviewed on 12/1/2016 at 10:55 AM, CNA #16 stated CNAs were responsible for ambulating residents on the unit ambulation program. She stated the resident was on the nursing rehab walking program and did not walk anymore due to her knees. She stated the resident's legs were stiff and she had difficulty with standing and pivoting. When interviewed on 12/1/2016 at 11:30 AM, the registered nurse (RN) Manager #7 stated the nursing rehabilitation walking program was what PT recommended for the residents to maintain their mobility status. Ambulation was done by CNAs as the residents allowed or tolerated. She stated if a resident did not allow or tolerate it, ambulation would be documented as not performed. The CNA should notify the nurse and the nurse should write a progress note. If a resident was not participating, a referral would be sent to PT for re-evaluation. She stated the resident ambulated in the hallway for short distances and she could not recall the last time she saw the resident ambulated. She stated she was unaware of any decline in the resident's status. 10NYCRR 415.12(a)(1)(ii)

Based on observation, interview, and review of facility documents conducted during the standard survey and abbreviated survey (#NY 496) it was determined the facility failed to ensure their infection control program provided a safe sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Specifically the facility did not ensure 4 of 4 licensed practical nurses (LPNs #1, 4, 5, and 7), observed on 10 occasions, properly handled, and disinfected shared resident glucometers (device used to measure blood sugar levels), between resident to resident use, and before storing the glucometers in the medication cart. And for 1 of 3 resident's (Resident #10) reviewed for infections, the facility did not ensure staff donned appropriate personal protective equipment or performed handwashing, when required, to prevent disease transmission. This resulted in no actual harm that is Immediate Jeopardy to resident health and safety for 34 residents (Residents # 1, 2, 11, 15, 16, 19, 25 - 29, and 31 - 53), who require routine blood sugar testing, and no actual harm with potential for more than minimal harm that is not immediate jeopardy for Resident #10. The immediate jeopardy was removed on 12/5/2013, prior to the survey exit. Findings include: Glucometers 1) On 12/2/2013 from 4:10 PM - 4:55 PM, licensed practical nurse (LPN) #4 was observed as she performed blood sugar fingerstick testing consecutively on the following residents: - LPN #4 obtained Resident #36's blood sugar sample and tested it with the glucometer. LPN #4 placed the glucometer on the medication cart, then picked it up, cleaned it with an alcohol prep pad, and placed it back onto the medication cart. - Without first disinfecting the glucometer, LPN #4 placed it on a side table, near Resident #2, obtained Resident #2's blood sugar sample, and tested it with the glucometer. LPN #4 placed the glucometer on top of the medication cart without cleaning or disinfecting it. - Without first disinfecting the glucometer, LPN #4 took it into Resident #48's room, and placed it on the bedside table. After obtaining and testing the resident's blood sugar sample LPN #4 placed the glucometer on the medication cart without cleaning or disinfecting it. 2) On 12/3/2013 from 11:30 AM - 11:45 AM, licensed practical nurse LPN #1 was observed performing blood sugar fingerstick testing consecutively on the following residents: - LPN #1 entered Resident #44's room with a basket that contained a glucometer, alcohol prep pads, and cotton balls, and placed it on the bedside table. LPN #1 obtained the resident's blood sugar, tested it, and without disinfecting it, put the glucometer back into the basket, and placed the basket on the medication cart. - LPN #1 took the basket holding the glucometer into Resident #47's room, obtained the blood sugar sample and tested it. Then, without disinfecting it, LPN #1 placed the glucometer into the basket and it returned to the top of the medication cart. LPN #1 then placed the basket, holding the glucometer, into the third draw of the medication cart. 3) On 12/3/2013 from 11:30 AM - 11:55 AM, licensed practical nurse (LPN) #7 was observed performing blood sugar fingerstick testing consecutively on the following residents: - LPN #7 brought the glucometer into Resident #36's room and placed it on the bedside table. LPN #7 obtained and tested the resident's blood sugar sample, exited the room and placed the glucometer on the medication cart. She then picked up the glucometer and cleaned it with an alcohol prep pad. - LPN #7 obtained and tested Resident #48's blood sugar sample, and cleaned the glucometer with an alcohol prep pad. - LPN #7 brought the glucometer into Resident #37's room and placed it on the bedside table. LPN #7 obtained and tested the resident's blood sugar sample, returned to the medication cart, and set the glucometer on the medication cart. LPN #7 washed her hands, and stated she was done. In an interview at that time LPN #7 stated she did not clean the glucometer, and she was then observed cleaning it with an alcohol prep pad. When interviewed on 12/3/2013 at 12:15 PM, the Infection Control RN stated the glucometer needed to be cleaned with an alcohol prep pad after each resident use, and they were cleaned daily on the 11 PM to 7 AM shift with a germicidal wipe. She stated the facility followed the manufacturer's recommendations, and had been following this procedure for "a couple of years." The facility Accu-Chek Advantage (type of glucometer) manufacturer's manual, copyright date 2011, documented the glucometer should be cleaned as follows: gently wipe the meter's surface with a soft cloth slightly dampened with 70% alcohol; or mild dishwashing liquid mixed with water; or 10% household bleach solution (1 part bleach in 9 quarts water) made the same day. The facility Nursing Policy for Maintenance of Accu-Chek Advantage Monitor, dated 5/4/2011, documented: - the Accu-Chek should be cleaned between each resident use by a staff nurse; - the Accu-Chek should be disinfected a minimum of daily by a staff nurse; - to clean the monitor between each resident, staff should use a 70% alcohol pad (a solution of mild dishwashing liquid and water or 10% household bleach solution (1 part bleach in 9 parts water) made fresh daily are also acceptable); and - to disinfect the monitor daily, staff should use a cloth, lightly dampened with Sanimaster 4 (a germicidal solution) or Sanimaster 4 wipes, allow it to air dry, and document disinfection on log. When interviewed on 12/3/2013 at 11:55 AM, LPN #7 stated she had been a nurse for 6 months, and was taught to clean shared glucometers with an alcohol prep pad, during her orientation to the facility. When interviewed on 12/3/2013 at 5:10 PM, LPN #4 stated the glucometer was cleaned with an alcohol prep pad after every use, and once a day, on the night shift it, was disinfected with a Sanimaster wipe. When interviewed on 12/3/2013 at 12:28 PM, LPN #5 stated glucometers were cleaned after each use with an alcohol prep pad. When interviewed on 12/3/2013 at 12:35 PM, registered nurse (RN) #2 stated glucometers were cleaned after each resident use with an alcohol prep pad, and the 11 PM to 7 AM shift cleaned the glucometers as well. RN #2 stated she was not sure what was used to clean the glucometers on the 11 PM to 7 AM shift. During an interview on 12/3/2013 at 12:25 PM, RN #1 stated RNs and LPNs were authorized to use the glucometer. She said the infection control policies were available online and in hardcopy and all employees had access to them. RN #1 stated the proper procedure for cleaning the glucometer was to wipe it with an alcohol prep pad before and after each resident use, alcohol prep pads were kept in the medication carts and also with the extra glucometer supplies. She said that Sanimaster wipes (germicidal wipes) were kept at the nurses' station. She stated the Sanimaster wipes were not routinely used, and she had not seen them used. RN #1 stated staff were in-serviced regarding cleaning/disinfecting glucometers during annual training. In a follow up interview on 12/3/2013 at 1:45 PM, the Infection Control RN stated the glucometer policy included disinfecting with alcohol. The infection control committee made a decision to have the glucometer have an extra disinfection at night using a Sani-wipe. The Infection Control Nurse stated she was not aware of the difference between cleaning and disinfecting. The Infection Control Committee met quarterly and consisted of herself, the Director of Nursing, the Administrator, and Director of Facility Services. When interviewed on 12/3/2013 at 12:55 PM, the Medical Director stated he was not aware of the procedures or products to be utilized to clean or disinfect glucometers. When interviewed on 12/3/2013 at 2 PM, the Assistant Administrator stated she was not aware of the difference between cleaning a glucometer and disinfecting it, and the glucometers should be cleaned between residents and at night. She said the glucometer policy was written "a while ago." When interviewed on 12/3/2013 at 12:25 PM, the Director of Nursing (DON) stated she reviewed the glucometer manufacturer's recommendations for cleaning and disinfection prior to providing them to the survey team. She stated the direction was to clean the glucometer after resident use with an alcohol prep pad. When interviewed on 12/3/2013 at 1 PM, the Administrator stated the glucometer should be cleaned after each resident use, and she stated that an alcohol prep pad was used to disinfect the glucometer. In a follow up interview on 12/5/2013 at 9:50 AM, the Administrator stated she delegated the responsibility for ensuring the facility clinical policies were appropriate regarding clinical practice to the DON and the Assistant Administrator. --------------------------------------------------------------------------------------------- The Immediate Jeopardy was removed on 12/5/2013 based on the following corrective actions taken by the facility: - Policies and procedures for blood sugar testing were revised to include disinfection of shared glucometers between resident to resident use, and the disinfectant solution to be used. - The majority of facility staff were educated and trained on the revised policy and procedure regarding disinfection of shared glucometers, and a plan was in place to ensure education and training for the rest of the staff. - Quality assurance monitoring was initiated, by administrative staff, to ensure compliance with the new/revised policy and procedure. Isolation Precautions 4) Resident #10 had [DIAGNOSES REDACTED]. The resident's laboratory report, dated 11/19/2013, documented the resident had clostridium difficile (c-diff, a bacterial infection in the stool). A nursing note, dated 11/19/2013, documented the resident was positive for[DIAGNOSES REDACTED], the nurse practitioner was aware, and ordered [MEDICATION NAME] (an antibiotic) four times a day. The comprehensive care plan (CCP), dated 11/19/2013, documented the resident had a [DIAGNOSES REDACTED]." The resident's Resident Care Card (care instructions), dated 11/19/2013, documented the resident was on contact isolation precautions. Nursing notes, dated 11/20 and 11/21/2013, documented the resident continued on contact isolation precautions for[DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS) assessment, dated 11/22/2013, documented the resident had some difficulty with decision making, in new situations, and required extensive assistance of 1 to 2 staff for activities of daily living, including bed mobility, transferring, and personal hygiene. The MDS documented the resident was occasionally incontinent of urine and always continent of bowel. Nursing notes, dated 11/24, 11/28, and 11/30/2013, documented the resident continued on contact isolation precautions for[DIAGNOSES REDACTED]. When interviewed on 12/2/2013 at 10:30 AM, the registered nurse (RN) Unit Manager stated the resident was on contact isolation precautions for[DIAGNOSES REDACTED]. During an observation on 12/2/2013 between 3:45 PM and 4:15 PM, a sign posted outside of the resident's room documented "Attention All Visitors Contact Isolation Precautions Please Report to the Nurses Station Before Entering Room." Staff were observed entering, exiting, and providing care to the resident as follows: - At 3:45 PM, an occupational therapy staff member and a physical therapy staff member were in the resident's room, wearing no gloves or gowns. They moved the resident's wheelchair and pulled her privacy curtain closed. The staff transferred the resident into her bed, and exited the resident's room without washing their hands. Both staff used hand sanitizer as they walked down the hall. - Between 4 PM and 4:15 PM, the occupational staff member was in the unit kitchenette and stated to the surveyor she was getting the resident a drink. She stated she was going to work with the resident on hand strengthening now that the resident was in bed. She re-entered the resident's room without donning a gown or gloves, and moved items around on the resident's overbed table. During an interview on 12/4/2013 at 2:10 PM, the occupational staff member stated she was told by nursing staff the resident had an infection in her urine, and staff needed to wear gloves. During an interview on 12/4/2013 at 2:40 PM, the physical therapy staff member stated she knew the resident had[DIAGNOSES REDACTED] in her feces, and she would wear a gown and gloves if there was a chance she would get the resident's stool on her. She stated the the resident used the bedpan or the commode. She stated she did not think she needed to wear a gown, and gloves when she transferred the resident into bed. During an observation on 12/2/2013 at 5:15 PM, the medication licensed practical nurse (LPN) #6 donned gloves and no gown and entered the resident's room to administer medications. She brushed up against both sides of the resident's bed, and the privacy curtain, as she pulled it closed. LPN #6 exited the resident's room without washing her hands, and used the hand sanitizer that was on the medication cart. During an interview on 12/4/2013 at 2:50 PM, the LPN #6 stated she did not need to wear a gown to administer the resident's medications when the resident was in bed because she did not come in contact with the bed. During an observation on 12/3/2013 between 8:05 AM and 8:10 AM, the medication RN wore gloves and no gown as she leaned over the resident's bed talking to the resident. There was a brown substance visible on the resident's toilet seat. During an observation on 12/3/2013 at 9 AM, there was a brown substance visible on the toilet seat. During an observation on 12/4/2013 between 10:15 AM and 10:30 AM, the unit housekeeper entered the resident's room wearing gloves and no gown. The housekeeper emptied the bathroom trash. A dark brown substance was visible on the inside of the toilet bowl. The housekeeper exited the room wearing the same gloves, touched her face, retrieved a wet cloth from her cart, and re-entered the resident's bathroom. She squatted in front of the toilet as she cleaned and flushed it. The housekeeper returned to her cart and took a bottle of cleaning solution into the resident's bathroom and cleaned the toilet a second time. During an interview on 12/4/2013 at 2:20 PM, the unit housekeeper stated she knew a resident was on contact isolation precautions by the sign posted outside of the room. She said did not remember being told she should wear personal protective equipment, other than gloves, when entering the resident's room to clean it. During an interview 12/4/2013 at 2:25 PM, the Director of Facility Services stated staff should ask what precautions need to be taken and what type of protective equipment needed to be used when entering a contact isolation precautions room. He stated nursing staff should give this information to the housekeepers. During an interview on 12/4/2013 at 2:55 PM, the RN Unit Manager stated staff needed to wear a gown and gloves when providing care to the resident. She said staff should "definitely" wash their hands before exiting the resident's room. The Manager stated medication nurses should wear a gown and gloves, as there might be contaminated items on the bed. The Manager stated she notified the Director of Facility Services, regarding contact isolation precautions rooms, electronically or verbally. She said neither she nor the Infection Control Nurse notified the Director of Facility Services, in writing, regarding the resident's isolation needs. The Manager stated she could not remember which housekeeping staff she told as there were several on her unit. During an interview on 12/4/2013 at 3:50 PM, the Infection Control RN stated[DIAGNOSES REDACTED] precautions were contact precautions with "extra special precautions." The RN stated housekeeping was notified verbally regarding resident rooms with contact isolation precautions. Staff need to utilize handwashing for hand hygiene, and should not use hand sanitizers. The RN stated staff should wear a gown if there was "a chance" of contamination. She stated she did not know this resident. She stated housekeeping should wear a gown and not squat in front of the toilet, when cleaning it. During an interview on 12/4/2013 at 4:10 PM with the Assistant Administrator and the Director of Nursing, they both stated that when a resident was on precautions for[DIAGNOSES REDACTED], handwashing, not the use of hand sanitizers, should be employed after working with the resident. They stated the facility policy regarding personal protective equipment should be followed by staff, which was dependent on the task performed. In a follow up interview on 12/5/2013 at 10:40 AM, the physical therapy staff member stated she had thought that the use of hand sanitizers, and every few times employing handwashing, was correct when working with this resident on contact precautions. In a follow up interview on 12/5/2013 at 11:35 AM, the occupational therapy staff member stated she had thought hand hygiene using the hand sanitizers was correct after working with this resident on contact precautions. 10NYCRR415.19 (a)(1-2)(b)(2)

Based on observation, interview and record review conducted during the standard survey, it was determined for 4 of 4 licensed practical nurses (LPNs #1, 4, 5, and 7), the facility failed to ensure Administrative staff administered the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain or maintain the highest practicable physical well-being of each resident. Specifically, the Administrative staff failed to develop a policy and procedure to include proper disinfection of shared glucometers (a device that measures blood sugar levels)between resident to resident use. Refer to F441. This resulted in no actual harm that was Immediate Jeopardy to the health and safety of 34 residents (Residents #1, 2, 11, 15, 16, 19, 25 - 29, and 31 - 53), who required routine testing of blood sugar levels. The Immediate Jeopardy was removed on 12/5/2013, prior to the survey exit. Findings include: When interviewed on 12/3/2013 at 12:15 PM, the facility Infection Control RN stated the glucometer needed to be cleaned with an alcohol prep pad after each resident use, and they were disinfected daily on the 11 PM to 7 AM shift with a germicidal wipe. She stated the facility followed the manufacturer's recommendations, and had been following this procedure for "a couple of years." In a follow up interview on 12/3/2013 at 1:45 PM, the facility Infection Control RN stated the glucometer policy included disinfecting with alcohol. she stated the Infection Control Committee decided glucometers would have an extra disinfection at night using a Sani-wipe. She said the committee met quarterly and consisted of herself, the Director of Nursing (DON), the Administrator, and the Director of Facility Services. The Infection Control Nurse stated she was not aware of the difference between cleaning and disinfecting glucometers. When interviewed on 12/3/2013 at 12:55 PM, the Medical Director stated he did not know the procedure or products to be used for cleaning or disinfecting glucometers. He stated he did not know if disinfecting of glucometers was routinely performed. When interviewed on 12/3/2013 at 2 PM, the Assistant Administrator stated she did not know the difference between cleaning and disinfecting glucometers. She stated glucometers should be cleaned between residents and on the night shift. The glucometer policy was written "a while ago." When interviewed on 12/3/2013 at 12:25 PM, the DON stated she reviewed the glucometer manufacturer's recommendations for cleaning and disinfection. She stated the direction was to clean the glucometer after resident use with an alcohol prep pad. When interviewed on 12/3/2013 at 1 PM, the facility Administrator stated the glucometer should be cleaned after each resident use, and an alcohol prep pad was used to disinfect the glucometer. In a follow up interview on 12/5/2013 at 9:50 AM, the facility Administrator stated she delegated the responsibility for ensuring the facility clinical policies were appropriate, regarding clinical practice, to the DON and the facility Assistant Administrator. --------------------------------------------------------------------------------------------- The Immediate Jeopardy was removed on 12/5/2013 based on the following corrective actions taken by the facility: - Policies and procedures for blood sugar testing were revised to include disinfection of shared glucometers between resident to resident use, and the disinfectant solution to be used. - The majority of facility staff were educated and trained on the revised policy and procedure regarding disinfection of shared glucometers, and a plan was in place to ensure education and training for the rest of the staff. - Quality assurance monitoring was initiated, by administrative staff, to ensure compliance with the new/revised policy and procedure. 10NYCRR 415.26(a)

Based on observation, interview and record review conducted during the standard survey, it was determined for 4 of 4 licensed practical nurses (LPNs #1, 4, 5, and 7), the facility failed to ensure the Medical Director oversaw the implementation of policies, procedures and coordination of medical care. Specifically, the Medical Director failed to ensure shared glucometers were disinfected between resident to resident use. Refer to F441. This resulted in no actual harm that is Immediate Jeopardy to the health and safety of 34 residents (Residents #1, 2, 11, 15, 16, 19, 25 - 29, and 31 - 53), who required routine blood sugar testing. The Immediate Jeopardy was removed on 12/5/2013, prior to the survey exit. Findings include: During an interview on 12/2/2013 at 12:55 PM, the Medical Director stated he was not aware of the procedures or products to be utilized to clean or disinfect glucometers, or if this was routinely done at the facility. In summary, the facility failed to ensure the Medical Director oversaw the implementation of policies and procedures and the coordination of medical care in the facility in regards to infection control/glucometers. -------------------------------------------------------------------------------------------- The Immediate Jeopardy was removed on 12/5/2013 based on the following corrective actions taken by the facility: - Policies and procedures for blood sugar testing were revised to include disinfection of shared glucometers between resident to resident use, and the disinfectant solution to be used. - The majority of facility staff were educated and trained on the revised policy and procedure regarding disinfection of shared glucometers, and a plan was in place to ensure education and training for the rest of the staff. - Quality assurance monitoring was initiated, by administrative staff, to ensure compliance with the new/revised policy and procedure. 10NYCRR 415.15(a)