Every finding on record at Kendal at Ithaca

Based on observations, record review, and interviews during the recertification survey conducted 12/16/2024-12/19/2024, the facility did not ensure the development and implementation of a comprehensive person-centered care plan for 2 of 2 residents (Resident #7 and #37) reviewed. Specifically, Resident #7 did not have a care plan for oxygen use, and Resident #37's fall prevention care planned interventions were not consistent with the care instructions and point of care tasks. The facility policy, Fall Prevention Program, revised 1/19/2016, documented after each resident fall, the interdisciplinary team would update the resident's fall care plan and the nurse doing the incident report would add any interventions immediately to the resident's fall care plan. The facility policy, Care planning/Interdisciplinary Team, revised 12/15/2019, documented the Interdisciplinary Team would provide person centered care plans for the residents. The care plan was available to all disciplines, was used to guide care, and contained a list of problems, goals, and approaches in use. The facility policy, Incidents/Accidents, revised 10/15/2021, documented if after a fall the nurse placed new interventions into the care plan, a care plan update alert would be sent to nursing staff, including nurses and certified nurse aides. 1) Resident # 7 had diagnoses including respiratory syncytial virus (RSV), asthma, and pneumonia. The 10/23/2024 admission Minimum Data Set assessment documented the resident had intact cognition, was independent for activities of daily living, and used oxygen. The 10/17/2024 Admission Assessment completed by Registered Nurse #25 documented the resident had rhonchi (coarse, low-pitched, bubbling sounds heard in the lungs during breathing) in all lung fields, had a productive cough, and did not use oxygen. Physician orders documented: - on 10/19/2024 oxygen 2 liters via nasal cannula as needed. - on 10/22/2024 oxygen 2-3 liters via nasal cannula as needed with a goal to keep oxygen saturations at 94% and above. - on 11/21/2024 oxygen 2-3 liters via nasal cannula, as needed with a goal to keep oxygen saturations at 92% and above. The Comprehensive Care Plan initiated 10/21/2024 documented the resident had shortness of breath related to asthma, pneumonia, and respiratory syncytial virus. Interventions included medications per physician orders, keep head of bed elevated as much as resident tolerated, assist with activities of daily living, maintain droplet precautions, and notify physician of any changes in condition. The Comprehensive Care Plan did not include oxygen therapy. The 11/1/2024 Care Plan Meeting documented the resident was diagnosed with respiratory syncytial virus during an emergency room visit on 10/14/2024 and admitted to the facility on [DATE]. The resident had been on supplemental oxygen via nasal cannula. On 10/31/2024 the resident's oxygen saturation (amount of oxygen in blood) dropped while on 2 liters of oxygen. The resident was sent to the emergency room and returned the same day with a diagnosis of pneumonia. During an interview on 12/19/2024 at 8:37 AM, Registered Nurse # 4 stated physician orders were either placed into the computer or given verbally and nursing was given discretion regarding treatment orders. Registered Nurse #4 stated the resident required oxygen and their physician order was oxygen as needed. Oxygen was not on the resident's care plan, and it should have been. They stated the Unit Manager was responsible for care plans. During an interview on 12/19/2024 at 10:31 AM, Registered Nurse Unit Manager #6 stated oxygen required a physician order and should be on the care plan. They were responsible for developing and updating the comprehensive care plans. Care plans were reviewed quarterly and more often if the situation warranted a review. Registered Nurse #6 stated the resident was on oxygen and should have been care planned for it. It was important to have oxygen care planned to ensure the resident was receiving the correct therapy. During an interview on 12/19/2024 at 11:12 AM, the Director of Nursing stated Registered Nurse Unit Manager #6 was responsible for monitoring and updating care plans. Care plans were reviewed and updated quarterly, during significant changes and as needed if there were a change with the resident. All information on the care plans, point of care, and resident care instructions should be consistent and match to ensure staff knew how to care for the resident. 2) Resident #37 had diagnoses including dementia and history of falls. The 10/10/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, required maximum assistance with most activities of daily living, had a motion sensor alarm, had two or more falls with no injuries and one fall with a non-major injury. Fall Incident Reports documented the following interventions: - on 8/31/2024 at 10:30 AM the resident would have a Dycem and a cushion in their wheelchair to prevent further sliding. - on 9/21/2024 at 7:31 AM the resident had a motion sensor. - on 10/14/2024 at 7:25 PM the resident had a motion detector. - on 11/9/2024 at 4:50 AM the resident had a motion detector for staff to use at their discretion. - on 12/8/2024 at 5:30 AM the resident had a low bed and floor mat. The Comprehensive Care Plan, revised 12/2/2024, documented the resident was at risk for falls. Interventions included Dycem (a non-slip pad) to be used in their chair. Interventions did not include a motion sensor alarm or a low bed with floor mattress when in bed. The certified nurse aide daily charting tasks documented the resident had a low bed with floor mattress when in bed. There was no documentation for use of Dycem or a motion detector. The 12/17/2024 resident care instructions (care card) documented Resident #37 had a motion detector. There was no documented evidence of a low bed, mattress on the floor, or use of Dycem. During an observation on 12/18/2024 at 9:21 AM, there was no motion detector in or outside the resident's room. During an observation on 12/18/2024 at 1:31 PM, the resident's wheelchair was in their bathroom. There was no Dycem on or underneath the chair cushion. During an interview on 12/18/2024 at 1:36 PM, Registered Nurse #4 stated the care cards were updated by Registered Nurse Manager #6 and had information regarding mobility, diet, and any safety interventions. The certified nurse aides were expected to take a copy of one each day to review. During an interview on 12/19/2024 at 8:53 AM, Certified Nurse Aide #5 stated the care cards included fall prevention interventions such as motion detectors and grips on the floor. Dycem, low beds, and floor mats would not be listed on the care card but would be listed as a daily documentation task. It was their responsibility to make sure those interventions were in place. Daily documentation of tasks was usually completed at the end of the day. It was possible something could be missed in the interim of the start of the shift and when charting was completed if interventions were not listed on the care card. Resident #37 fell frequently. They had a low bed, a mattress on the floor, and a motion detector. Only the motion detector was listed on the care card. They got the resident up that morning and thought the detector was on their mattress when they did so. After checking the resident's room, they stated they could not find the motion detector. They did not believe the resident was supposed to have Dycem in their chair as it was not in their chair that morning and they did not put one in the chair. After checking the resident's cushion, they confirmed there was no Dycem on or under the cushion. If something was on the care card it was important it was in place to make sure residents were safe and did not fall. During an interview on 12/19/2024 at 9:44 AM Registered Nurse Unit Manager #6 stated they updated the care plans. Unit Clerk #11 generated and updated the care cards based on alerts and communication they received from the interdisciplinary team members. There was not a process in place to check for accuracy. They expected specific fall prevention measures to be in the care plan, on the care card, and listed as a daily documentation task. The aides usually charted after lunch and if interventions were listed as a daily documentation task, but not on the care card then some interventions could be missed until later in the day when charting occurred. Resident #37 had multiple falls from both the bed and chair. Their current care plan interventions included Dycem to the chair. It did not include a motion detector, a low bed, or a floor mat. They thought a low bed and floor mattress had been put in place but was unsure as it was not listed on their care plan. The resident's care card listed a motion detector as the only safety precaution, but it had been discontinued due to a decline in mobility. It did not list a low bed, floor mattress, or Dycem. The only safety related daily documentation task was a low bed with floor mattress. The resident should not have a motion detector, a floor mattress, or low bed because it was not on their care plan. They should have Dycem because it was on their care plan. Consistent, accurate resident care information was important because the resident could fall, roll out of bed, and get injured. During an interview on 12/19/2024 at 11:12 AM the Director of Nurses stated the registered nurses were responsible for monitoring and updating the care plans. Care plans were reviewed/updated quarterly, with significant changes, and as needed. All information on the care plan, daily documentation tasks, and care card instructions should be consistent and match. This was important for resident safety, consistency, and so staff knew what they should be doing for the residents. 10NYCRR 415.11(c)(1) 50561

Based on record review and interviews during the recertification survey conducted 12/16/2024-12/19/2024, the facility did not ensure as needed orders for psychotropic drugs were limited to 14 days or had a prescribing provider order to extend beyond 14 days with documented rationale for 1 of 5 residents (Residents #26) reviewed. Specifically, Residents #26 had a physician order for lorazepam (a controlled antianxiety medication) as needed that was not re-evaluated for continued use after 14 days. Findings include: The facility policy, Psychotropic Medications, dated 12/16/2024, documented psychotropic medications would be used only when appropriate to treat a specific condition. Regular interdisciplinary reviews would be conducted to ensure the medication continued to be necessary, that the resident was receiving the appropriate dose, and that a gradual dose reduction was attempted when appropriate. The medications were also reviewed by the consultant pharmacists monthly for a possible reduction or other recommendations. Only medications in appropriate doses and duration which were clinically necessary to treat the residents' assessed condition or symptoms and maintain resident safety would be used. As needed orders for psychotropic medications would be limited to 14 days. Resident #26 had diagnoses including dementia with severe agitation. The 4/25/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, was short tempered and easily annoyed, had physical behavioral symptoms directed towards others (hitting, kicking, pushing), had verbal behavioral symptoms directed towards others (threatening, screaming, cursing), and received antianxiety medication. The Comprehensive Care Plan documented: -initiated on 4/23/2022, the resident had socially inappropriate/disruptive behavioral symptoms as evidenced by spitting, striking out, scratching staff with care and showering, wandering into other rooms, and was difficult to redirect. Interventions included maintain a calm, slow and understandable approach, assess whether the behaviors danger the resident or others, avoid over-stimulation, and to administer medications as ordered. -initiated on 1/24/2023, the resident received antianxiety medication related to dementia with behavioral disturbances. The resident received lorazepam (an antianxiety medication) routinely in the AM, at 6:30 PM, and had a weekly as needed dose for their shower. Interventions included pharmacy consultant review every quarter and as needed. The 1/22/2024 physician order documented lorazepam 0.5 milligram once per week as needed for unspecified dementia with behavioral disturbances. The November and December 2024 Medication Administration Records documented lorazepam 0.5 milligrams by mouth once per week as needed prior to showers for dementia with behavioral disturbances. The resident received 0.5 milligrams of lorazepam as needed: -on 11/4/2024 at 8:55 AM and 11/25/2024 at 9:16 AM. -on 12/2/2024 at 8:25 AM and 12/9/2024 at 7:50 AM. There was no documented evidence the use of the as needed lorazepam was re-assessed every 14 days. There was no documented evidence of a pharmacy review regarding need for re-assessment of use of medication. During an interview on 12/18/2024 at 1:20 PM, Registered Nurse #4 stated residents could only have an as needed order for antianxiety medications if they already had a routine order in place. The as needed order had to be reviewed and renewed by the physician every 60 days during their routine visits. Resident #26 had an as needed order for lorazepam for their shower and they did not always receive it. The most recent order was written on 1/22/2024 and since there was no end date it would just continue. During an interview on 12/18/2024 at 1:59 PM, Registered Nurse Manager #6 stated as needed antianxiety medication orders were only good for 14 days then the physician had to renew it. There was no formal process for a renewal, but they had an interdisciplinary team meeting every 14 days and the physician would attend and discuss the orders with the nurses. Resident #26 had a twice a day routine order for lorazepam and a once a week as needed order on their shower day. The original order was written on 1/22/2024, it did not appear to have been renewed, and it should have been renewed every 14 days. They stated it was important to review and renew a psychotropic medication because they needed to be monitored closely to make sure the medication was still appropriate, and the resident was not a fall risk as the medication could cause sedation. During an interview on 12/18/2024 at 2:34 PM, the Director of Nursing stated as needed medication orders were only good for 14 days. They had no process for tracking order renewals, but they did have a gradual dose reduction meeting with the pharmacist every quarter. Resident #26 had a weekly as needed order for lorazepam to be given before their shower. The most current lorazepam order was written on 1/22/2024 and it had not been renewed since then. It was important to renew the resident's order to avoid unnecessary medications and overmedicating which could lead to increased confusion and falls. 10 NYCRR 415.12(l)(2)

Based on observations, record review, and interviews during the recertification survey conducted 12/16/2024-12/19/2024, the facility did not to obtain informed consent (including risks and benefits) from the resident or the resident representative prior to the installation of bed rails (side rails) for 1 of 1 resident (Resident #6) reviewed. Specifically, there was no documented evidence informed consent was obtained for the placement of bilateral bed rails on Resident #6's bed. Findings include: The facility policy, Side Rails/Positioning Bars and Restraints, revised 12/5/2018, documented the use of side rails or positioning bars on beds would be permitted when the following conditions were met: -The resident was evaluated to be appropriate for side rail or positioning bar use as indicated on the side rail/positioning bar evaluation form and would be reviewed at least quarterly by the interdisciplinary care plan team. -The use of side rail or positioning bar would be included in the plan of care as a measure to enhance resident mobility, or for independent use of bed controls. -An order would be obtained from the physician. -Side rails or positioning bars could be used at any time with staff present but returned to the original down position prior to leaving the room. The policy did not document obtaining informed consent prior to the installation of side rails. Resident #6 had diagnoses including difficulty in walking, age related osteoporosis (bones become weak and brittle), and muscle wasting and atrophy (shrinkage and loss of function). The 11/15/2024 Minimum Data Set assessment documented the resident had severe cognitive impairment, required substantial/maximal assistance with bed mobility and transfers, and did not use bed rails. The Comprehensive Care Plan initiated 5/15/2023, documented the resident had impaired functional status on admission to the facility. Interventions included bilateral bedside positioning bars for bed mobility. The 8/10/2023 Physician order documented positioning bars to bilateral sides of the bed for assistance with self-positioning. The was no documented evidence informed consent for the use of bed rails was obtained or the risks and benefits were reviewed with the resident or resident representative prior to their placement. The 11/15/2024 positioning bar assessment completed by Registered Nurse Manager #6 and Director of Rehabilitation #16 documented bedside enabler bar (grab bar) usage was requested in order to facilitate positioning in bed. During an observation on 11/16/2024 at 11:43 AM, Resident #6 had bilateral white enabler bars on their bed. During an interview on 12/18/2024 at 3:56 PM, the Administrator stated they had never completed informed consents for enabler bars since they had worked at the facility. They had questioned it when they started but were told enabler bars were not technically side rails, so they did not need to obtain consents from resident or resident representative to use them. During an interview on 12/19/2024 at 9:39 AM, Licensed Practical Nurse #15 stated bed rails required a physician order and assessments were done monthly by a registered nurse and the Director of Therapy to determine if the resident qualified for their use. They were unsure if consents were obtained from the resident or resident representative but thought it was important to get consent to make sure they knew the risks of using them. During an interview on 12/18/2024 at 10:14 AM, Director of Rehabilitation #16 stated bed rails required a physician order and they completed quarterly bed rail assessments with Registered Nurse Manager #6. They educated the resident or resident representative while they were doing the bed rail assessment, and they would verbally agree to use them, but they did not obtain a signed consent. They stated it was important to obtain a signed consent to acknowledge the risks of using bed rails. During an interview on 12/19/2024 at 10:48 AM, Registered Nurse Manager #6 stated they completed bed rail assessments quarterly with therapy to ensure residents were appropriately using them. Resident #6 had bilateral bed rails for positioning, and they had a physician order. They thought it was important to obtain signed consent forms from the resident or their family to show they knew the risks involved with bed rails and agreed with their use. During an interview on 12/19/2024 at 11:08 AM, the Director of Nursing stated bed rails required a physician order and quarterly assessments were completed by nursing and therapy to ensure the resident was appropriate to use them. It was important to obtain a consent, so the resident knew the potential risks of using bed rails. 10NYCRR 415.12(h)(1)(2)

Based on observations, record review, and interviews during the recertification survey conducted 12/16/2024-12/19/2024, the facility did not ensure residents received adequate supervision to prevent accidents for 1 of 6 residents (Resident #146) reviewed. Specifically, Resident #146 had a stroke, was on comfort care measures, could not swallow, did not have a clear diet consistency order, and was assisted with eating food before a swallowing evaluation was performed to determine the appropriate diet consistency. Findings include: The facility policy, Diet Order Procedures, dated 5/2015, documented the following diets had been approved for use in the facility and approved by the Medical Director and Dietitian as defined in the diet manual for long-term care residents: house diet, no added salt, limited concentrated sweets, full liquid, clear liquid, regular or normal consistency, mechanical soft and pureed. The facility policy, Consistency of Foods, revised 4/2018, documented upon admission the resident would have a diet as ordered by the physician and a consistency best tolerated by the resident. This would be dependent on the resident's ability to chew and swallow. The undated facility policy, Comfort Care Protocol Orders, documented diet and activity as tolerated. If unable to swallow, make nothing by mouth and discontinue all by mouth medications. The undated Pleasure Feeding Guidelines documented a physician order would be required for pleasure feeding and a resident assessment would be completed by a physician, licensed nurse, or dietitian to assess the suitability for pleasure feeding. Factors considered would be swallowing, dental status, cognition, and medical conditions. Staff would follow safe feeding practices including positioning the resident upright, giving small amounts of food or fluids, and monitoring for signs/symptoms of choking or aspiration (inhaling food into the lungs). Resident #146 had diagnoses including cerebral infarct (stroke) The Minimum Data Set admission assessment had not yet been completed. The 12/13/2024 Admission Assessment completed by Registered Nurse #18 documented the resident was dependent for all activities of daily living; was rarely/never understood; and was not oriented to person, place, or time. The 12/13/2024 Comprehensive Care Plan documented: - the resident had impaired functional status related to stroke and was on comfort care. A decline in functional status was anticipated. Interventions included extensive assistance of 1 for eating and diet as tolerated. - the resident was at risk for weight loss due to swallowing and chewing problems related to stroke. Interventions included the resident would be provided with foods that brought them comfort or pleasure as long as they could safely tolerate them; the resident was fed by the nursing staff; and the resident would be provided with a physician diet order and consistency as tolerated. The undated resident care instructions documented Resident #146's dietary needs were a normal consistency, thin liquid, house diet. The 12/13/2023 Physician #23 order documented nothing by mouth. That order was discontinued on 12/14/2024. A 12/13/2024 at 6:58 PM Registered Nurse #6 progress note documented the resident arrived via stretcher for admission, had a stroke with right sided facial droop and weakness, had a nothing by mouth diet order, and all by mouth medications were discontinued. Comfort measures were put in place with opioid pain medications (Morphine) and anti-anxiety medications (Lorazepam). The 12/14/2024 Physician #23 order documented diet as tolerated with a stop date of 12/18/2024. A 12/14/2024 at 2:45 PM Licensed Practical Nurse #20 progress note documented the resident's diet order was changed to as tolerated. Resident #146 was given mashed potatoes, pudding, and honey thickened juice. The feeding was discontinued due to the resident pocketing food and their inability to swallow. A 12/15/2024 at 11:12 AM Registered Nurse #4 progress note documented Physician #23 met with the resident's family. The resident's medical conditions were discussed with the family. Recommendation was made for thickened water due to the resident pocketing food, and a trial feeding pending a speech evaluation scheduled for Tuesday (12/17/2024). The family agreed to pleasure feedings with attempts to give thickened water until the speech evaluation was completed. A 12/16/2024 at 2:53 PM Registered Nurse Unit Manger #6 progress note documented they received a phone call from Physician #23 regarding the resident's nothing by mouth diet order. A new order for a speech evaluation was received. A 12/16/2024 at 11:47 PM Registered Nurse #25 progress note documented the resident had honey thickened tomato soup, a Magic Cup (a protein rich ice cream), and honey thickened juice for dinner. The resident appeared to work hard to swallow. A 12/17/2024 at 1:17 PM Registered Dietitian #10 progress note documented the resident was fed mashed potatoes and honey thickened liquids for lunch. The resident held food in their mouth and then swallowed. A speech evaluation was scheduled for 12/19/2024. A 12/17/2024 at 3:50 PM Speech Language Pathologist #22's swallowing evaluation documented Resident #146 was seen for acute onset of dysphagia (difficulty swallowing) related to a stroke. The resident's current dietary intake was moderately thick (honey thick) and pureed consistencies. The resident's positioning was inadequate and led to decreased safety. The resident's overall assessment was moderately severe oropharyngeal dysphagia (impaired ability to swallow), and their risk was exacerbated due to poor clearance of materials via cough. Recommendations were to continue comfort care measures with continued attention to oral hygiene and frequent positioning and to allow oral intake for pleasure as awake status permits. A further decline in status was expected. A 12/18/2024 at 1:40 PM Registered Dietitian #10 progress note documented they approached the resident's family representative regarding food allergies. The family representative expressed Resident #146 was not going to eat food and further discussion was not necessary. The following observations of Resident #146 were made: - on 12/16/2024 at 12:45 PM, Registered Nurse #6 was feeding the resident an undetermined soup and mashed potatoes. - on 12/17/2024 at 12:17 PM, the resident was served a bowl of soup. - on 12/17/2024 at 12:24 PM, Certified nurse aide #21 was assisting the resident at lunch and feeding them soup. The head of the resident's wheelchair was positioned at approximately 30 degrees. During an interview on 12/17/2024 at 12:19 PM, Health Care Dining Attendant #19 stated they did not have a meal ticket for the resident and did not know what kind of diet the resident received. During an interview on 12/17/2024 at 12:21 PM Licensed Practical Nurse #20 stated the resident came into the facility with a nothing by mouth diet order and the next day Physician #23 changed the diet to as tolerated. They stated the resident had not had a speech or swallowing evaluation. They did not know if the resident should be fed prior to the evaluation and was just following their supervisor's orders. They stated the family had initiated comfort care measures per the resident's Medical Orders for Life Sustaining Treatment form. During an interview on 12/17/2024 at 12:27 PM Certified Nurse Aide #21 stated the resident was receiving a honey-thickened diet, it was not documented, and they knew how to feed a resident with a stroke based on their care instructions. They stated Resident #146's care instructions documented a house, regular consistency, thin liquid diet and that was not correct. The risk of a resident receiving an incorrect diet order could be pocketing the food and not swallowing it. During an interview on 12/19/2024 at 8:50 AM, Registered Nurse #4 stated all residents required a physician order for their diets. An as tolerated diet was not sufficient, it did not specify what was allowed on the diet. They stated Resident #146 had not done well on their swallowing evaluation in the hospital and the family stated if the resident could not feed themself, they did not want staff to feed them. If staff were unsure how to feed the resident, they should not have fed them and should have called the physician for clarification. The resident should have remained on a nothing by mouth diet order until a swallowing evaluation was conducted. The resident was at risk for choking and aspiration without a proper diet consistency order. During an interview on 12/19/2024 at 9:32 AM, Registered Dietitian #10 stated residents' diet orders would be on the hospital discharge summary. They relied on nursing to advise them what consistency food the resident could tolerate. Resident #146 had an as tolerated diet, and they did not know what that meant. Registered Dietitian #10 stated the resident had a severe stroke, could not make their needs known, and had been fed prior to a speech and swallowing evaluation. They stated they watched the resident eat and they held food in their mouth for a very long time. A house diet with regular consistency and thin liquids would not be appropriate for the resident. During an interview on 12/19/2024 at 10:17 AM, Registered Nurse Unit Manager #6 stated the resident came to the facility with a nothing by mouth diet order and it was changed to as tolerated. Feeding instructions for staff were not documented in the resident's electronic medical record. All residents should have a proper diet consistency order to prevent choking or aspiration. The resident's care instructions documented a house diet with regular consistency and thin liquids and that was not correct. During an interview on 12/19/2024 at 10:50 AM, the Director of Nursing stated Resident #146 came to the facility with a nothing by mouth diet order and Physician #23 changed it to as tolerated. The diet order should have been more specific. A registered nurse could do an assessment for eating but they did not think a licensed practical nurse trialed the resident with food. They stated Licensed Practical Nurse #20 had fed the resident mashed potatoes and pudding but was unsure if it was a trial for feeding. During an interview on 12/19/2024 at 11:47 AM, Speech Language Pathologist #22 they received Resident #146's order for an evaluation on 12/17/2024 and completed the evaluation. The resident had right sided weakness with facial droop and had failed the speech and swallowing evaluation due to severe weakness and inability to swallow. An as tolerated diet should have a consistency ordered and it was unsafe for staff to assist the resident with eating with their head at a 30-degree angle as it could increase their risk for choking and aspiration. They stated the resident's care instructions were incorrect in listing the resident's diet as a house diet, regular consistency, thin liquids. This could cause confusion as to how to assist the resident with eating. During an interview on 12/19/2024 at 12:20 PM Physician #23, stated they visited Resident #146 on 12/14/2024 and the resident was alert. They changed the diet order from nothing by mouth to as tolerated. Nursing staff would know how to feed the resident from experience of feeding residents with dysphagia. They stated they did not think an as tolerated diet would need a consistency order as it was trial and error. Family agreed to pleasure feedings. Physician #23 did not think pleasure feedings required an order and nursing could trial the resident before a speech evaluation. They stated Speech Language Pathologist #22 was not available on the weekends and the resident would have been required to return to the hospital for a formal swallowing evaluation and the family opted out of sending them. 10NYCRR 415.12 (h)

Based on observations and interviews during the recertification survey conducted 12/16/2024-12/19/2024, the facility did not ensure each resident received food and drink that was palatable, attractive, and at a safe and appetizing temperature for 1 of 2 meal trays (the 12/18/2024 [NAME] Unit lunch) reviewed. Specifically, the grilled salmon grain bowl and French fries were not served at palatable temperatures and lacked taste. Findings include: During an anonymous Resident Council meeting on 12/16/2024 at 2:03 PM, one resident stated the food was cold. During an interview on 12/16/2024 at 10:58 AM, Resident #18 stated the food temperatures were cold and the food did not taste good. During an observation on 12/18/2024 at 12:07 PM on the [NAME] Unit, Resident #7's lunch tray was served, and a replacement was given. The main entree was a grilled salmon grain bowl (cold plate). Temperatures were measured on the original lunch tray as follows, the salmon was 52 degrees Fahrenheit and was dry and overcooked, the rice medley was 60 degrees Fahrenheit, and the French fries were 65 degrees Fahrenheit. The food was not seasoned and was not palatable. During an interview on 12/18/2024 at 12:12 PM, Health Care Dining Attendant #17 stated upon hire they received education regarding proper food temperatures and how to take them. They stated when Resident #7's food arrived from the kitchen, they took the temperature, and it was 42 degrees Fahrenheit. Cold plate food should be below 40 degrees Fahrenheit. They did not know if Resident #7s plate had sat out. They stated they made up the room trays when needed and did not let them sit for long periods of time. During an interview on 12/19/2024 at 9:44 AM, the Director of Dining and Nutritional Services stated lunch tray items were prepared in the main kitchen and brought up to the units via a hot box. Cold food plates were prepared in the main kitchen at 10:00 AM and they assumed they were brought up to the Units by 11:00 AM. They stated warm food items such as French fries should be 140 degrees Fahrenheit or higher and placed on a separate plate from the cold plate. The salmon and rice should have been below 40 degrees Fahrenheit. It was important to maintain proper food temperatures to prevent food borne illnesses. 10NYCRR 415.14(d)(1)(2) 50561

Based on observations, record review, and interviews during the recertification survey conducted 12/16/2024-12/19/2024, the facility did not ensure each resident received and the facility provided food that accommodated resident allergies, intolerances, and preferences for 3 of 7 residents (Residents #8, #25, and #37) reviewed. Specifically, Resident #8 did not receive yogurt and a banana for lunch as specified on their menu and Residents #25 and #37 were not offered desserts as specified on their menus. Findings include: The facility policy, Meal Round Policy, dated 2/1/2023, documented the facility ensured all residents had access to nutritious, high-quality meals that met their individual dietary needs and preferences. Residents were encouraged to inform the dining team of any specific needs or preferences that may affect their meal choices. The facility policy, Meal Attendance, Nutritional Preferences and Nutritional Intake, dated 9/11/2024, documented as part of the admission process, social work, dining, and nursing staff would gather and document resident food preferences and dietary restrictions or therapeutic diets or ethnic and religious food preferences in the individualized service plan and physician orders. Dining staff would ensure staff were aware of any special accommodations. 1) Resident #8 had diagnoses including dementia. The 3/13/2024 Minimum Data Set assessment documented the resident was cognitively intact and was independent with eating. The 3/15/2021 physician order documented a house diet, normal consistency, and thin liquids. During an observation and interview on 12/16/2024 at 1:09 PM, Resident #8's lunch meal ticket documented yogurt and a banana at breakfast and lunch. The resident did not have either item on their tray. The resident stated they only received the yogurt and banana during the breakfast meal. During an observation and interview on 12/17/2024 at 12:35 PM, Resident #8's lunch meal did not include yogurt, or a banana as documented on their meal ticket. The resident stated they would have eaten them if they had received them. During an observation on 12/18/24 at 12:11 PM, Resident #8's lunch meal did not include yogurt, or a banana as documented on their meal ticket. 2) Resident #25 had diagnoses including mitral valve insufficiency (a disorder of a heart valve) and disorder of the kidney and ureter (tube that goes from the kidney to the bladder). The 11/14/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition and was independent with eating. During an observation on 12/16/2024 at 12:15 PM, the resident's lunch meal menu documented tomato basil soup, grilled cheese sandwich, two cups of orange juice, and fresh fruit for dessert. The fresh fruit was missing from the resident's tray and was not offered prior to them leaving the dining area. During an observation on 12/18/2024 at 12:42 PM, the resident left the dining room and was not offered a dessert. During an interview on 12/18/2024 at 12:44 PM, Health Care Dining Attendant # 8 stated Resident #25 did not get their fruit for dessert at lunch that day and often left the dining area before they received their dessert. 3) Resident #37 had diagnoses including fracture of the left forearm and essential hypertension (high blood pressure). The 7/10/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition and was independent with eating after set-up assistance. The 8/7/2024 physician order documented a house diet, regular consistency, and thin liquids. During an observation on 12/17/2024 at 12:26 PM, Resident #37's lunch meal ticket documented a salted peanut butter bar. The resident was removed from the dining area and was not offered a salted peanut butter bar. During an observation on 12/18/2024 at 12:58 PM, Resident #37's lunch meal ticket documented carrot cake. The resident was removed from the dining area and did not receive their dessert. During an interview on 12/16/2024 at 12:56 PM Health Care Dining Attendant #14 stated residents filled out menus the day before the meal was served. The resident menus were looked at and plates were made based on the menu choices. Desserts were served when residents were finished eating. Some residents had their dessert choices circled, and the dining staff chose dessert for other residents who were unable to choose. Menus Health Care Dining Attendant #14 stated it was their responsibility to serve everyone dessert and they were not aware of any residents who refused dessert. If dessert was on the menu, it should be offered. Resident #25 circled fresh fruit on their menu, and it was not offered. They stated it was important residents received foods they liked. During an interview on 12/18/2024 at 12:21 PM, Health Care Dining Attendant #8 stated they checked the menus to make sure items selected match what was served. Stickers on the bottom of the menus guided how big the portions were listed allergies. They were generated by the dietitian. Extra food or preferences would be placed on the trays. Health Care Dining Attendant #8 stated it was their responsibility to check the tickets to ensure residents received foods per their preference. They were not aware Resident #8 had a banana and yogurt for the lunch meal. They stated whoever delivered their tray should check to make sure all food items were on the tray. At 12:44 PM, Health Care Dining Attendant # 8 stated residents were asked and offered desserts that were available. There were a variety of desserts such as ice cream, puddings, applesauce, and fresh fruit. It was their responsibility to ensure residents received the dessert they requested. Desserts were not served until the resident's plates were cleared. They were asked by their supervisor not to place desserts out early due to the restaurant style dining experience. It was important for residents to receive what they asked for and if there were multiple missed desserts, they should notify management. During an interview on 12/18/2024 at 12:35 PM, Certified Nurse Aide #9 stated when they delivered food, they read the meal ticket and ensured what was served to the resident matched the ticket. They were familiar with the stickers at the bottom of the meal ticket and stated they reviewed them. They stated Resident #8's meal ticket listed a yogurt and banana for the lunch meal and was missed. It was important for residents to receive their food items because they were part of their nutritional plan. During an interview on 12/18/2024 at 2:13 PM, Registered Nurse Unit Manager #6 stated they expected all food items on the meal ticket to match the actual foods served. Staff should check the meal tickets for accuracy and special instructions. Desserts were a joint effort between dietary and nursing staff. The dietary staff-initiated desserts, but nursing should catch errors. If a resident was not receiving dessert before they left the dining area staff should have been aware and offered it sooner. During an interview on 12/19/2024 at 10:56 AM, the Director of Dining and Nutritional Services stated dining attendants were responsible for all items on the meal tickets including desserts. Residents should be offered dessert even if it was not circled. Staff were familiar with residents and knew their preferences. Residents filled out their dessert menus and put thought into their choice. Desserts could be offered at any time and dining staff were responsible to ensure residents received them. If the items were on the resident's meal ticket, they should receive them. 10NYCRR 415.4(d)(4)

Based on observations, record review, and interviews during the recertification survey conducted 12/16/2024-12/19/2024, the facility did not ensure residents received respiratory care consistent with professional standards of practice for 1 of 1 resident (Resident #7) reviewed. Specifically, Resident #7 had a physician order for oxygen at 2-3 liters per minute via nasal cannula to keep oxygen saturations (amount of oxygen in the blood stream) above 92%, the resident received continuous oxygen, oxygen saturation readings were consistently above 92% and taken while the resident was on oxygen. Findings include: The facility policy, Storage, Transportation and Administration of Oxygen, revised 8/2023, documented the administration of oxygen required a physician, physician assistant or nurse practitioner order. Such orders should contain the following: delivery method (nasal cannula, oxygen mask, variable flow mask, nonrebreather mask), liter flow or oxygen percentage, continuous, as needed, or use titrated to pulse oximetry. In cases where an order is given to titrate the liter flow based on pulse oximetry readings, the order must also include a maximum liter flow. Delivery method would not be changed without a physician order. Resident # 7 had diagnoses of respiratory syncytial virus (RSV, a respiratory virus), asthma, and pneumonia. The 10/23/2024 admission Minimum Data Set assessment documented the resident had intact cognition, was independent for their activities of daily living, and used oxygen. The Comprehensive Care Plan initiated 10/21/2024 documented the resident had shortness of breath related to asthma, pneumonia, and respiratory syncytial virus. Interventions included medications per physician orders, keep head of bed elevated as much as resident tolerated, assist with activities of daily living, maintain droplet precautions, and notify physician of any changes in condition. Oxygen therapy was not included on the Comprehensive Care Plan. The 11/21/2024 Physician #12 order documented oxygen 2-3 liters per minute via nasal cannula as needed with goal oxygen saturation levels at or above 92%. The resident was observed receiving oxygen by an oxygen concentrator at 2 liters per minute via a nasal cannula on 12/16/2024 at 10:44 AM, 12/17/2024 at 9:13 AM, 12/18/2024 at 8:35 AM, and 12/19/2024 at 8:35 AM. Resident #7's oxygen saturation levels were documented as 92%-98% from 12/1/2024-12/19/2024. During an interview on 12/19/2024 at 8:13 AM Certified Nurse Aide #13 stated the resident was admitted 3 months ago, had a respiratory virus, and was on oxygen. The resident had been off oxygen for a short period of time when they were first admitted but now used it all the time. During an interview on 12/19/2024 at 8:37 AM, Registered Nurse # 4 stated Resident #7's oxygen order was as needed and their oxygen saturation levels were between 92% and 96%. They stated the oxygen saturation levels were taken while the resident was on oxygen, they wore it continuously, and did not think the resident had ever been trialed off oxygen. If a resident required oxygen continuously, the physician order should have been changed. During an interview on 12/19/2024 at 10:31 AM, Registered Nurse Unit Manager #6 stated Resident #7 required oxygen and their physician order documented oxygen 2-3 liters per minute via nasal cannula as needed with goals to keep oxygen saturations above 92%. If a resident required continuous oxygen, the order should be changed. It was important for the resident to have the correct oxygen order, so they did not retain too much carbon dioxide. During an interview on 12/19/2024 at 10:40 AM, the Director of Nursing stated a resident receiving oxygen required a physician order and should not be on oxygen continuously if the order documented as needed. Resident #7's order documented oxygen was as needed to keep their oxygen saturations above 92%. If they required it continuously, nursing should have called the physician to have the order changed. The risk of a Resident #7 receiving oxygen on a continuous basis with an as needed order could result in unnecessary use of the oxygen. 10 NYCRR 415.12(k)(6)

Based on observation, interview, and record review during the recertification survey conducted 5/1/23-5/4/23, the facility failed to store all drugs and biologicals in locked compartments for 1 of 3 treatment carts (Owasco unit) observed. Specifically, the Owasco treatment cart was unsupervised, unlocked and in a resident hallway and contained scissors and treatment supplies which could potentially cause adverse consequences if accessed by residents. Findings include: The facility policy Storage of Medications dated 5/2018 documented the medication rooms, carts, and supplies were locked when not attended by persons with authorized access. On 5/1/23 the Owasco unit treatment cart was observed: - at 10:37 AM, in the front of an alcove across from resident room [ROOM NUMBER], next to the chain that tethered the cart to the wall. The cart was unsupervised, unlocked, untethered, and the top drawer contained 3 pairs of scissors (1 pair of bandage scissors and 2 pairs of sharp surgical scissors), various bandages, multiple single use packets of Bacitracin (topical antibiotic ointment), alcohol prep pads, antifungal powder, skin prep (protective skin barrier wipes), iodine swabs, petroleum packets, calmoseptine ointment (skin protectant) single use packs, multiple lubricating jelly single use packs, and nail clippers. - At 12:40 PM, in the alcove across from resident room [ROOM NUMBER]. The cart was unsupervised, unlocked, and untethered and the top drawer contained 3 pairs of scissors (1 pair of bandage scissors and 2 pairs of sharp surgical scissors), various bandages, multiple single use packets of Bacitracin (topical antibiotic ointment), alcohol prep pads, antifungal powder, skin prep (protective skin barrier wipes), iodine swabs, petroleum packets, calmoseptine ointment (skin protectant) single use packs, multiple lubricating jelly single use packs, and nail clippers. On 5/2/23 the Owasco treatment cart was observed: - at 8:50 AM, toward the back of the alcove across from resident room [ROOM NUMBER], unsupervised, unlocked, and untethered, and the top drawer contained 3 pairs of scissors (1 pair of bandage scissors and 2 pairs of sharp surgical scissors), various bandages, multiple single use packets of Bacitracin (topical antibiotic ointment), alcohol prep pads, antifungal powder, skin prep (protective skin barrier wipes), iodine swabs, petroleum packets, calmoseptine ointment (skin protectant) single use packs, multiple lubricating jelly single use packs, and nail clippers. - at 12:01 PM, in the alcove across from resident room [ROOM NUMBER], unsupervised, unlocked, untethered and the top drawer contained 3 pair of scissors (1 pair of bandage scissors and 2 pairs of sharp surgical scissors), various bandages, multiple single use packets of Bacitracin (topical antibiotic ointment), alcohol prep pads, antifungal powder, skin prep (protective skin barrier wipes), iodine swabs, petroleum packets, calmoseptine ointment (skin protectant) single use packs, multiple lubricating jelly single use packs, and nail clippers. - at 1:12 PM, in the alcove across from room [ROOM NUMBER], unsupervised, untethered, and unlocked and the top drawer contained 3 pairs of scissors (1 pair of bandage scissors and 2 pairs of sharp surgical scissors), various bandages, multiple single use packets of Bacitracin (topical antibiotic ointment), alcohol prep pads, antifungal powder, skin prep (protective skin barrier wipes), iodine swabs, petroleum packets, calmoseptine ointment (skin protectant) single use packs, multiple lubricating jelly single use packs, and nail clippers. During an interview on 5/2/23 at 2:13 PM, licensed practical nurse (LPN) #1 stated the treatment cart did not need to be tethered to the wall, it was tucked away in the corner. LPN #1 stated they did a treatment earlier in the day and it was not locked at that time, and it should have been. They stated the carts had Bacitracin ointments and other dressing supplies. They stated they did not think there was anything in the treatment cart that could harm the residents. During an interview on 5/3/23 at 3:33 PM, registered nurse (RN) Unit Manager #4 stated the treatment cart should be stored in the cubicle near the resident lift equipment and should be locked when not in use. They stated that the cart contained cream medications that could be eaten by residents and possibly cause harm. They stated scissors should be in the drawers and drawers should be locked. During an interview on 5/4/23 at 9:59 AM, the Director of Nursing (DON) stated treatment carts were used throughout the day and should be locked when not in use. The DON stated the treatment carts contained bandage supplies, single dose ointment packets, and other various bandage supplies. They stated the resident in room [ROOM NUMBER], one room down from the alcove, frequently wandered around the unit. The DON stated they did not think that resident would get into the treatment cart. The DON stated there should not be any pointy scissors in the treatment cart, only bandage scissors. They stated there was potential for harm if a resident was able to remove the scissors but did not think the residents could open the ointments. The DON stated the best practice was to always lock the treatment cart when not in use. 10 NYCRR 415.18 (d)

Based on observation, interview, and record review during the recertification survey conducted 5/1/23 -5/4/23, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 2 of 8 residents (Resident #6 and #13) reviewed. Specifically, during a medication administration observation, licensed practical nurse (LPN) #1 did not perform hand hygiene prior to medication administration and in between residents. Findings include: The facility policy Handwashing revised 12/2022 documented handwashing was the single most important element in the spread of infection in a health care facility. Staff would perform hand hygiene by using either alcohol- based hand rub or washing hands with soap and water. Appropriate hand hygiene must be performed before handling or preparing medications, and after contact with blood, body fluids, excretions, secretions, and mucous membranes or non-intact skin. During a medication administration observation on 5/2/23 from 8:31 AM-8:45 AM LPN #1 was standing at the medication cart writing on a piece of paper. There was green commuter mug on top of the medication cart. The LPN stated it was theirs and placed it on the handrail near the medication cart. LPN #1 stated they were going to administer medications to Resident #6. They opened the medication cart drawer and unrolled the prepackaged day shift medications for Resident #6. LPN #1 logged into the medication cart computer using the keyboard and mouse, checked each medication with the electronic record, and used a pink highlighter marker on the plastic label to review each medication for accuracy. LPN #1 did not perform hand hygiene. LPN #1 then opened the plastic sleeve and put Resident #6's pills in a cup to crush. LPN #1 administered the medications to Resident #6 who was sitting alone in the private dining room eating their breakfast. LPN #1 placed their ungloved hand on the resident's shoulder and administered the nasal spray. LPN #1 left the dining room and began to prepare Resident #13's medications without performing hand hygiene. LPN #1 opened the medication cart drawer and unrolled the prepackaged day shift medications for Resident #13. They logged back into the medication cart computer using the keyboard and mouse, checked each medication for accuracy, highlighted the medication package after each check, and crushed the medications. LPN #1 administered Resident #13's medications in the dining room. The resident was not able to swallow the pills and LPN #1 lifted the resident's orange juice to provide an additional drink. LPN #1 returned to the medication cart and did not perform hand hygiene. During an interview on 5/2/23 at 8:45 AM, LPN #1 stated they were supposed to complete hand hygiene in between every 2 or 3 residents or when they administered eye drops. They stated it was important to complete hand hygiene to prevent the spread of infection and germs from resident to resident. Hand hygiene should be completed with antiseptic or soap and water. During the interview a hand sanitizer dispenser was observed on the wall near the medication cart. During an interview on 5/4/23 at 10:17 AM, the Director of Nursing (DON) stated hand washing between residents and during medication administration was standard nursing practice. LPN #1 had completed their annual facility medication training online in June of 2022. The training included hand hygiene. During an interview on 5/4/23 at 10:30 AM, registered nurse (RN) Infection Preventionist/Staff Educator stated infection control education was completed in the first quarter for all staff and included a review of all infection control policies. This training also included hand washing/hygiene. They expected nursing staff to wash their hands or sanitize between each resident during medication administration. If using the hand sanitizer, hands should be washed with soap when a resident was on contact precautions or when hands were visibly soiled. There were alcohol hand sanitizer dispensers outside of each resident room. LPN #1 received hand hygiene education on 3/28/23 and there were no issues noted from previous competencies. The purpose of hand washing, or hand hygiene was to reduce the chance of getting or passing an infection to others. If hand hygiene was not completed as required infection could be spread to residents and staff. 10NYCRR 415.19(b)(4)

Based on record review and interview during the abbreviated survey (NY 858) the facility did not ensure each resident received adequate supervision to prevent accidents. Specifically, Resident #1 was observed by staff exiting the unit, was not followed, left the building, and walked to the local police department. Additionally, the facility did not contact local police timely to report a missing resident. Findings include: The Missing Resident Code White policy updated 3/2015 documents: - Alert all staff on the unit via pagers, cell phones, and face to face. - Conduct a quick but thorough search of the unit and logical places where the resident may have gone. - If the resident is not found during this rapid but thorough search, the charge nurse will notify the Nurse Manager, Director of Nursing (DON), Administrator, Executive Director and/or Administrator on call at the time the resident was not found, and call a Code White, send out a page. - For Health Center (skilled facility) residents, 30 minutes should be considered the maximum length of time allowed to elapse from the time the resident was determined missing to the time the outside authorities are notified. The 3/2015 Missing Resident Code White flow chart documents if a resident is observed in an unusual place, bring the resident to nursing. If the resident refuses, stay with them and send for help. Resident #1 had [DIAGNOSES REDACTED]. The 4/12/19 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment and signs and symptoms of [MEDICAL CONDITION] including inattention and disorganized thinking. The resident required limited assistance of one person for walking on and off the unit and utilized a walker. The 4/5/19 Resident Admission Assessment documented the resident required assistance for transfers and ambulation, had a wheelchair/scooter and a walker/cane. The resident had impaired vision, was disoriented to person, place, or time, and had an unsteady gait. On admission, 4/5/19, the resident was assessed for elopement risk and was not at risk related to the inability to ambulate or wheel independently, no history of wandering, no rejection of placement, and the resident did not desire to leave. The comprehensive care plan (CCP) dated 4/5/19 documented the resident had adjustment difficulty related to being admitted to the skilled nursing facility. The CCP did not document the resident was at risk for elopement. The 4/7/20 Registered Nurse Supervisor (RNS) #4's progress note documented the resident was assessed at 6:30 AM, following being returned by the local police department. The resident had no injuries, asked for coffee, and was given a blanket to warm up. The Investigative Summary signed by DON #1 on 4/8/19 documented: - On 4/7/19 at approximately 4:00 AM, certified nurse aide (CNA) #2 and licensed practical nurse (LPN) #3 assisted the resident in the bathroom and left at approximately 4:10 AM. - LPN #3 took a restroom break and CNA #2 attended to another resident. Upon return, LPN #3 noted Resident #1's call light on, and when she checked, the resident was not in their room. - LPN #3 heard the door to the unit close and thought it was CNA #2, and then saw the resident exiting the unit and the door closing behind them. - LPN #3 ran back to the desk to get the registered nurse (RN) from the next neighborhood (Cayuga) to intercept the resident, but when she called the other neighborhood, no one answered the phone. LPN #3 ran down the hall, went first to the adjacent Enhanced Assisted Living facility to see if the resident was there and when the resident was not found, LPN #3 went to the Cayuga neighborhood. - The RN Supervisor (RNS) and maintenance were notified to begin a search. Staff searched the area, suspecting the resident may have gone back to the independent unit (where they were admitted from and where their spouse resided). - The resident's spouse was called and when staff were about to contact the police, the police arrived with the resident at the facility. - The resident left the building sometime between 4:20 AM and 4:25 AM. - Police reported the resident arrived at the police station at 5:03 AM. - The police station was approximately 0.5 miles from the facility (from the facility's main address; the actual distance from the Heath Center is 0.8 to 1.2 miles to the police station, as the resident had to walk down the campus road before getting to the road of the primary address). The 4/7/19 Police Report documented at 5:03 AM: - The resident arrived at the police station stating they needed help, was freezing, and wanted to report a break-in at their former address. - The resident was wearing a T-shirt, sweatpants, and blue foot socks and stated the staff stole their belongings, so they walked to the police station. - The temperature outside was approximately 41 degrees Fahrenheit (F). - The resident was returned to the facility at 5:08 AM and no further action was taken. Based on the police report and time the resident was suspected to have exited the building (4:20-4:25 AM), the resident had been missing for 43-48 minutes and the facility did not contact the police during that time. The 4/10/19 statement from RNS #4, signed by RNS #4 and DON #1, documented: - RNS #4 was on the Cayuga neighborhood and heard the phone ring at approximately 4:25 AM. She was not able to reach it in time and called the other two neighborhoods to see what was needed. - CNA #2 reported Resident #1 left and LPN #3 went to look for the resident. - RNS #4 went to the hall and met LPN #3, who stated she already looked on the Assisted Living side, she then alerted the nurse on the other unit and the maintenance worker. - The campus search began, the maintenance worker checked the spouse's cottage, the front door and parking lot were checked, and other areas they thought the resident may have gone. - RNS #4 returned to the unit and was going to call the police and at the same time, the phone rang, and it was the police notifying her the resident was with them. - The Director of Nursing (DON) advised RNS #4 if a resident was ever missing on the night shift, 911 should be called immediately after a search of the immediate area was conducted. An undated written statement by LPN #3, included with the investigation documented: - She saw the resident going through the door and the door closed behind the resident. - She ran back to the desk to call the RNS on the next unit to have her cut (the resident) off at the pass but no one answered the phone. - She ran down the hall to get the resident, went over to the Assisted Living side, and asked if the resident was seen, went back to see if the resident had gone to the Cayuga unit, and saw RNS #4 coming down the hall. - Maintenance was on the phone, searched the hallways down by the apartments, the fitness room, no one saw the resident, went back to the unit and called the RNS on Cayuga. On 10/23/20 at 10:15 AM, 10:56 AM, and 1:39 PM, the resident was observed seated in their room, with a roam alert bracelet on their ankle. During an interview with the Administrator on 10/23/20 at 3:15 PM, he stated he was not the Administrator at the time of the incident, but his expectation would be to contact the police immediately upon discovering a resident was missing and if a resident was observed leaving the unit, he would expect staff to stay with the resident. During a telephone interview with LPN #3 on 10/26/20 at 1:01 PM, she stated on the date of the incident, she observed the resident exiting the unit and the door closed behind them. She did not follow the resident because she was closer to the desk than she was to the resident and she was physically limited in her ability to run after the resident. She called the RNS on the next unit thinking the resident went in that direction (to the left of the unit doors) but could not recall if she saw the resident turn in that direction. No one answered the phone on the next unit, and she called again, and then began to look for the resident. She was unable to recall the facility's protocol to implement when a resident was observed leaving the unit and she was not responsible for calling the police. She stated she contacted the RNS and they looked for the resident until the police returned with the resident. During a telephone interview with CNA #2 on 10/26/20 at 2:30 PM, she stated she was working the night the resident left the building. She did not see the resident leave as she was caring for another resident. When she exited the other resident's room, LPN #3 told her Resident #1 left the unit, called the Supervisor and CNA #2 went to look for the resident off the unit. She did not know how long the resident had been gone before LPN #3 told her. If she observed any resident leaving the unit, she would follow them and stay with them, especially that time of night/morning. During a telephone interview with DON #1 on 10/26/20 at 2:40 PM, she stated she completed the investigation into the incident when Resident #1 left the building but was not present when it occurred. Prior to the incident, the resident was not identified as a wander risk and did not have a roam alert bracelet (wandering bracelet) on. DON #1 stated there may have been reasons why LPN #3 did not stay with the resident when she saw the resident exiting and she wished LPN #3 had a radio or called for assistance instead of going back to the desk to call for help. In hindsight, LPN #3 should have stayed with the resident. The time to notify the police was not typically over 40 minutes, she thought the policy was 30 minutes, depending on risk factors like weather and time of day. The resident was at risk for falls, had a walker, and walking at that hour alone posed a risk. Given the early morning hours and limited staff, the staff should have called the police sooner. Everyone underestimated how fast the resident left and they all looked thinking the resident would be found on campus or in an adjoining building. The DON advised the RNS that in the future, 911 should be called immediately if a resident left on the overnight shift. 10 NYCRR 415.12(h)(2)

Based on record review, interview and observation conducted during the recertification survey, it was determined the facility did not promote care for 4 of 11 residents (Residents #1, 2, 8, and 9) and 1 additional resident (Resident #13) in a manner and an environment that maintained or enhanced each resident's dignity. Specifically, Residents #1, 2, 8, 9, and 13 were not provided a leisurely dining experience due to multiple staff interruptions to meet the feeding needs of other residents. Findings include: 1) Resident #8 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident's cognition was severely impaired and she required total assistance by staff for all activities of daily living (ADL) including eating. The comprehensive care plan (CCP), dated 10/24/2017, documented the resident required total assistance with meals and fluids. She was on a regular diet with pureed solids and honey thick liquids. The current physician's orders [REDACTED]. - pureed diet with honey thick liquids; - watch for each swallow and discontinue feeding if swallow is not noted; and - recommend alternating tastes and temperatures to increase attention and awareness while eating. During a supper meal observation on 11/1/2017: - At 5:16 PM the resident received her meal, licensed practical nurse (LPN) #2 sat and fed her while certified nurse aide (CNA) #4 fed Resident #9 who was sitting next to the resident. - At 5:20 PM, LPN #2 asked the resident sitting across the table if she needed help and got up and went over to Resident #1 and assisted her with a bite. - From 5:22 PM to 5:36 PM, LPN #2 was the only staff member in the dining room and walked around the resident's table assisting the other residents (Residents #1, 3, 9, and 13). She stood to feed the residents during this time quickly moving from resident to resident. - At 5:36 PM, CNA #3 arrived at the dining room. - From 5:36 PM to 6:14 PM, CNA #3 and LPN #2 rotated around the table encouraging, assisting, and feeding the 5 residents. CNA #3 sat down and got up 7 times while feeding the resident to assist other residents. LPN #2 sat and fed the resident 3 times during this period. - At 6:14 PM, CNA #3 took the resident back to her room. When interviewed on 11/2/2017 at 3:30 PM, LPN #2 stated they had 2 staff in the dining room at supper to assist the residents. She said 1 CNA went on break from 5:00 PM to 5:30 PM and the other from 5:30 PM to 6:00 PM. She said if a resident that ate in their room needed assistance or if someone in the dining room needed to go to the bathroom, that left her alone to feed. She stated it was not ideal to jump from resident to resident; dinner should be quiet and enjoyable. She said it was a disturbance to the resident's meal when staff were up and down, and the resident might think they were leaving. When interviewed on 11/3/2017 at 9:45 AM, the registered nurse (RN) Manager stated due to the number of residents that required cueing in the dining room, staff had to rotate around. She stated staff should not get up too frequently and she expected one person to sit between Resident #8 and #9 and feed both of them. She stated she would expect the staff member to sit at least 15 minutes before getting up. 2) Resident #9 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Sheet (MDS) assessment dated [DATE] documented the resident having severe cognitive impairment and was totally dependent on staff for eating. The comprehensive care plan (CCP), dated 10/24/17, documented the resident required assistance with feeding and was on a pureed diet with honey thickened liquids. During a supper meal observation on 11/1/2017 the following was observed: - From 5:15 PM to 5:22 PM, the resident was being fed by CNA #4 until the CNA got up to take another resident to the bathroom. - At 5:25 PM, CNA #4 brought the resident she had taken out of the dining room back in and left the dining room. CNA #4 was not seen again during the supper meal. - LPN #2 was the only staff in the dining room until CNA #3 arrived. During this time LPN #2 circled the table feeding the resident a bite while standing and then moving on to the next resident. - At 5:36 PM, CNA #3 arrived at the dining room. - From 5:36 PM to 6:02 PM, CNA #3 and LPN #2 rotated around the table encouraging, assisting, and feeding the 5 residents. The resident was fed by CNA #3 four times during this period and he stood to feed her every time giving a few bites and moving on to the next resident. LPN # 6 fed the resident 6 times and stood while feeding 3 of the times. - At 6:02 PM, the resident had finished eating and LPN #2 wiped her mouth and took the clothing protector off. When interviewed on 11/2/2017 at 3:30 PM, LPN #2 stated they had 2 staff in the dining room at supper to assist the residents. She said 1 CNA went on break from 5:00 PM to 5:30 PM and the other from 5:30 PM to 6:00 PM. She said if a resident that ate in their room needed assistance or if someone in the dining room needed to go to the bathroom, that left her alone to feed. She stated it was not ideal to jump from resident to resident, dinner should be quiet and enjoyable. She said it was a disturbance to the resident's meal when staff were up and down, and the resident might think they were leaving. When interviewed on 11/3/2017 at 9:45 AM, the registered nurse (RN) Manager stated due to the number of residents that required cueing in the dining room, staff had to rotate around. She stated staff should not get up to frequently and she expected one person to sit between Resident #8 and #9 and feed both of them. She stated she would expect the staff member to sit at least 15 minutes before getting up. 3) Resident #2 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment and required extensive assistance for activities of daily living (ADL's). The comprehensive care plan (CCP) updated 10/25/2017 documented the resident required assistance and supervision with his ADL's. Interventions included intermittent supervision during meals as he may get up from the dining room, may need to redirect to complete meal, and to assist with meals as needed. During a supper meal on 11/1/2017:from 5:16 PM to 6:20 PM the resident was observed: - At 5:20 PM certified nurse aide (CNA) #4 assisted resident with a bite of his meal then walked away. - Licensed Practical Nurse (LPN) #2 called out from across the table for the resident to swallow food in your mouth. - At 5:30 PM, LPN #2 was circling the table and put food on the resident's fork and instructed him to swallow. - At 5:36 PM, CNA #3 walked around table feeding other residents, stopped at Resident #2, stood over resident and told resident to swallow food and handed resident a sandwich. - From 5:40 PM to 6:20 PM, LPN #2 circled the table on a rolling stool occasionally stopping to encourage the resident. CNA #3 stood when assisting the resident and was observed putting a fork with a carrot in his mouth and while the resident chewed the CNA put another carrot on the fork, put it in the resident's hand, said there's your next bite and walked away. Another time the CNA came over put a french fry on the fork, did not say anything, and walked away. When interviewed on 11/2/2017 at 3:30 PM, LPN #2 stated they had 2 staff in the dining room at supper to assist the residents. She said 1 CNA went on break from 5:00 PM to 5:30 PM and the other from 5:30 PM to 6:00 PM. She said if a resident that ate in their room needed assistance or if someone in the dining room needed to go to the bathroom, that left her alone to feed. She stated it was not ideal to jump from resident to resident, dinner should be quiet and enjoyable. She said it was a disturbance to the resident's meal when staff were up and down, and the resident might think they were leaving. When interviewed on 11/3/2017 at 9:45 AM, the registered nurse (RN) Manager stated due to the number of residents that required cueing in the dining room, staff had to rotate around. She stated staff should not get up to frequently and she expected one person to sit between Resident #8 and #9 and feed both of them. She stated she would expect the staff member to sit at least 15 minutes before getting up. She also stated it was alright to stand if they were handing the person a drink and if they were feeding they should sit. 10NYCRR 415.5(a)

Based on record review, observation, and interview conducted during the recertification survey, it was determined the facility did not ensure the resident environment was free of accident hazards as is possible due to the hot water in the facility being too hot on 1 of 3 days of the survey (July 12, 2016). Specifically, the hot water temperature was determined to be over 120 degrees Fahrenheit (F) on July 12, 2016. Findings include: Hot Water Return Status forms (hot water temperature logs, form dated 9/22/2009) documented the hot water temperature was checked 2 or 3 times daily in July 2016 in the skilled nursing facility (Owasco and Cayuga Units). The hot water temperature was close to the maximum temperature allowed at times: - on 7/2/2016, it was 118 degrees F at midnight in room 5117 (Owasco Unit); - on 7/4/2016, it was 118 degrees F at 10:00 PM in room 5115 (Owasco Unit); and - on 7/8/2016, it was 119.5 degrees F at 8:00 AM in room 5117 (Owasco Unit). The Hot Water Return Status forms documented the hot water temperature on 7/9/2016 at midnight was 122 degrees F in room 5222 (Cayuga Unit), and 125 to 130 degrees F in room 5122 (Owasco Unit). The form did not document any action taken after the hot water that was found to be too hot. There was no documented evidence elsewhere that any action was taken to reduce the hot water temperature after it was determined to be too hot on rounds on 7/9/2016. The Hot Water Return Status form documented the hot water temperature in the Cayuga unit spa (bathing room) was 118 degrees F at 12:00 PM on 7/10/2016. A surveyor determined facility hot water temperatures on 7/12/2016 between 2:43 and 2:55 PM, as follows: - in resident room 5222 (Cayuga Unit), hot water in the toilet room sink was 122 degrees F; - in resident room 5101 (Owasco Unit), hot water in the toilet room sink was 122 degrees F. The surveyor retested hot water temperatures with the Facility Services Director on 7/12/2016 between 3:17 and 3:30 PM, as follows: - in the room 5217 (Cayuga Unit) spa/bathing room sink, the hot water temperature had risen to 124 degrees F, dropped to 122 degrees F, then dropped to 119 degrees F; - in room 5101 (Owasco Unit), hot water in the toilet room sink was 121 degrees F. During an interview with the Facility Services Director on 7/12/2016 at 4:55 PM, he stated there were 2 mixing valves in the water treatment room. The surveyor observed the 2 mixing valves at 4:55 PM. The Facility Services Director stated the facility reduced the outgoing hot water temperature after finding the hot water too hot earlier in the day. One of the mixing valves was showing an outgoing hot water temperature that was too hot at 4:55 PM, and staff turned off that hot water feed at that time. During an interview with the Facility Services Director on 7/13/2016 at 9:30 AM, he stated: - maintenance staff checked the hot water temperature during rounds on every shift, which was 3 times a day weekdays, and 2 times a day on weekends; - staff normally checked a few rooms in the skilled nursing facility; - the maintenance staff person doing rounds on the night shift on 7/9/2016 (who found the hot water temperature too hot) did not call facility services staff; - the maintenance staff person on night shift rounds on 7/9/2016 would not have adjusted the hot water temperature; - the Facility Services Director and the Maintenance Manager are always on call; - facility protocol is that in the event staff determined the hot water temperature was too hot, staff should have called facility services staff; - showers and sinks in the skilled nursing facility have additional anti-scald/mixing valves; and - he was considering reducing the outgoing hot water temperature. The facility Rounds Procedure updated 5/9/2016 documented on night shift rounds, maintenance staff should check the hot water temperature in the water treatment room in the Cayuga Unit, which should be going out below 125 degrees F. The facility policy Domestic Hot Water Temperature dated 1/3/1996 documented maintenance staff were to check the hot water temperature in the boiler room on each shift, and at a faucet in the skilled nursing facility (Taughannock House). The temperature should be no greater than 120 degrees (F). If the hot water temperature was over 120 degrees F, staff was to notify the Charge Nurse, Maintenance Coordinator, and the Facility Services Director. 10NYCRR 415.12(h)

Based on observation, interview, and record review conducted during the recertification survey, it was determined the facility did not ensure food was stored and prepared under sanitary conditions in 2 of 4 kitchens in the facility (temporary main kitchen and cafeteria kitchen). Specifically, spoiled and outdated foods were stored in the cafeteria walk-in refrigerator (ham and pastrami), and a food service worker in the main kitchen tested the sanitizer concentration in the potwash/3 compartment sanitizer sink by an unapproved method. Findings include: 1) A surveyor observed the cafeteria walk-in refrigerator on 7/12/2016 between 10:50 and 11:15 AM. Outdated food in the walk-in refrigerator included a small piece of ham dated 5/27 and unsliced pastrami dated 6/29. During the initial tour on 7/12/2016 between 10:30 and 11:30 AM, the Dining Services Director stated food for the skilled nursing facility was prepared in a combination of locations: the main kitchen, the cafeteria kitchen, and the unit kitchens. During a second observation in the cafeteria walk-in refrigerator on 7/13/2016 at 3:30 PM, the surveyor observed the ham dated 5/27, covered in plastic wrap, had at least half the surface covered in mold. The pastrami dated 6/29 remained in the refrigerator. During an interview with the Dining Services Director on 7/13/2016 at 3:40 PM, he stated the facilty policy was to use an expiration date 3 days after preparation. The Chef Manager and Cooks were responsible to discard outdated food. Cured meat, like pastrami, would last longer than other food items. The Dining Services Director stated on 7/13/2016 at 4:15 PM that the facility applied the 3 day expiration date to nearly all food items. The facility policy Food Safety revised 3/2010 did not document how long the facility could store potentially hazardous foods under refrigeration prior to discarding them. 2) A surveyor observed Employee #2 washing pots in the temporary main kitchen potwash/3 compartment sink on 7/12/2016 at 10:30 AM. At the surveyor's request, Employee #2 tested the sanitizer concentration in the 3 compartment sanitizer sink with the facility's test strips. Employee #2 performed the test by dipping a test strip in the sanitizer solution for 5 seconds; the test strip showed little to no color change after the test, indicating the sanitizer concentration was too low. When the surveyor read the instructions for testing the sanitizer concentration on the vial with the facilty's test strips, the instructions were to have 90 seconds of contact time to check the sanitizer concentration. During an interview with Employee #2 on 7/12/2016 at 10:40 AM, she stated she did various jobs in dietary, including washing pots part of the time. 10NYCRR 415.14(h), 14-1.1.31, 14-1.112

Based on record review, interview and observation conducted during the recertification survey, it was determined for 1 of 2 residents (Resident #1) reviewed for skin breakdown, the facility did not ensure necessary treatment and services were provided to promote healing and prevent new pressure ulcers from developing. Specifically, Resident #1 was inadequately assessed as low risk for developing skin breakdown, and the facility did not develop and implement timely preventative skin measures. Finding include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A skin evaluation form dated 6/2/2016 documented the resident had an area of small dark bruising to the right sacrum and buttock, measuring 5.0 centimeters (cm) x 2.0 cm. On the right inner buttock near the rectum he had a skin tear 1.0 cm in length, described as closed and slightly fragile. The plan was to initiate a turn and position schedule and apply a protective cream to buttocks and sacrum at bedtime. An admission skin breakdown risk screening form dated 6/2/2016 documented the resident required assistance with bed mobility and was continent of bowel and bladder. The resident was at low risk for skin breakdown and was not followed weekly by the skin team. The comprehensive care plan (CCP) initiated 6/2/2016 documented the resident was at low risk of developing pressure ulcers related to subdural hematoma and deconditioning. Interventions included to provide toileting assistance as needed and turn and positioning schedule as needed for mobility. The certified nurse aide (CNA) activity of daily living (ADL) care plan dated 6/2/2016 documented to turn and position the resident per the individualized plan of care. There was no documented evidence the resident had a turning and positioning schedule in place. The CNA monthly charting for June 2016 documented to turn and position the resident per the individualized plan of care. There was no documented evidence the resident was on an individualized turning and positioning schedule. The CNA monthly documentation included the resident was turned and repositioned once per shift on the day, evening, and night shifts. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was intact. He required extensive assist with bed mobility and transfers, and was occasionally incontinent of bladder. The MDS documented the resident did not have any unhealed pressure ulcers and was at risk for developing pressure ulcers. He required skin and ulcer treatment of [REDACTED]. The CCP was reviewed on 6/10/2016 and documented the resident triggered as low risk on the Braden Scale (risk for pressure ulcer scale), did not have any pressure ulcers on admission, and follow care plan. A wound care nurse (registered nurse/RN) progress note dated 6/12/2016 documented the bruising to the resident's right sacrum and buttocks was nearly resolved, and the skin tear to the right inner buttock was healed. A wound care progress note dated 6/21/2016 documented the bruising on the sacrum and buttocks had resolved and the right inner buttock remained closed. Tissue pink and supple. The progress note documented the resident was slowly getting stronger. The CNA monthly charting from 7/1/2016 - 7/10/2016 documented to turn and position the resident per the individualized plan of care. There was no documented evidence the resident was on an individualized turning and positioning schedule. The CNA monthly documentation included the resident was turned and repositioned once per shift on the day, evening, and night shifts. An RN progress note dated 7/11/2016 documented the resident was observed with pressure areas on both buttocks that were red, purple, and blue in color. The physician was notified and an order was obtained for [MEDICATION NAME] (protective dressing) to the affected area, to be changed every 3 days and as needed. A turning and positioning schedule would be put on the resident's plan of care, and the resident was to be back to bed after breakfast and lunch to keep him off his buttocks. The resident had a cushion in the wheelchair and the cushion type (was) subject to change. The CNA monthly charting initiated 7/11/2016 included an individualized plan of care including to turn and position the resident from his left side to his back; and when on his back, place pillows on both his sides to keep pressure off his buttocks. The CNA care plan also included to place the resident back to bed after breakfast and lunch to keep him off his buttocks. A wound care nurse progress note dated 7/12/2016 documented the resident's buttocks were assessed and the color was dark pink with a slight purple hue. Most of the discoloration is due to previous healed trauma from fall before admission. This may be permanent for sometime. The [MEDICATION NAME] dressing was discontinued and the treatment was changed to Duoderm (adherent dressing) as needed when tissue was fragile. The resident's wheelchair cushion was upgraded to a ROHO cushion and he was encouraged to shift his weight in the wheelchair every 15 minutes. During an interview with the RN Unit Manager on 7/12/2016 at 10:20 AM, she stated the resident had something on his buttocks, discovered the day before and the area had not been staged yet. The RN provided the surveyor with a CNA assignment sheet (care instructions). The undated CNA assignment sheet documented the resident transferred with a one assist. The assignment sheet did not contain any documentation regarding turning and repositioning the resident, or placing the resident back to bed after breakfast and lunch. The resident was observed 7/12/2016 at 10:45 AM in his room in his wheelchair. At 12:46 PM, he was sitting in the dining room in a regular dining room chair without a cushion. The CCP was updated on 7/13/2016 to include a ROHO cushion for his wheelchair and the CNA care plan was updated to include to turn and position the resident per individualized plan of care. The individualized plan of care documented to turn and position the resident from his left side to his back; when on his back, place pillows on both his sides to keep pressure off his buttocks. The CNA care plan included to place the resident back to bed after breakfast and lunch to keep him off his buttocks. The CCP dated 7/13/2016 documented the resident's skin integrity was impaired related to trauma on the buttocks. Interventions included wheelchair cushion at all times, and educate the resident on the importance of shifting his weight when in his wheelchair. There was no documented evidence this was added to the CNA care plan. During an interview with CNA #2 on 7/13/2016 at 8:15 AM, she stated she would know if and when to turn and position a resident by looking at her assignment sheet. The resident was observed on 7/13/2016 at 8:30 AM, sitting in a chair at the dining room table without a cushion. At 9:30 AM, 9:45 AM, 10:20 AM, 10:50 AM, 11:30 AM and again at 12:00 PM, the resident was in his room in a wheelchair watching television. During a treatment observation on 7/13/2016 at 3:30 PM with the RN wound nurse, the resident had a Duoderm on his left buttock. The RN slowly removed the Duoderm and the resident's top layer of skin was removed with the dressing, exposing a bleeding and red wound bed measuring approximately 4 cm x 4 cm. The intact skin to the upper aspect of the wound was a dark purplish color. The RN stated the resident did not like to move around much and he needed to be educated on the importance of changing positions. She stated the area to the resident's buttocks was open upon his admission to the facility, and the area was bruising as a result of his fall at home, resulting in the skin being fragile in that area of trauma. She stated she placed the resident at low risk for developing pressure ulcers as he had good nutrition and did not have any red flags. She thought he was going to get more mobile and we could get him to move off his buttocks. During an interview with licensed practical nurse (LPN) #3 on 7/14/2015, she stated she was responsible for the resident's direct care that day, and he was occasionally incontinent of bladder. She stated an individualized turn and positioning schedule would direct staff when and how he needed to be repositioned and that information would be included in his plan of care. The LPN reviewed the resident's CNA documentation and stated an individualized turn and reposition schedule was not initiated until 7/11/2016. The RN wound care nurse was interviewed a second time on 7/14/2016 at 1:10 PM. She stated she did not think the area was pressure related or was a deep tissue injury, as the resident came in with the bruising on his buttocks and the discoloration went away. She stated the skin tear on the right buttock was from friction and shearing and had since resolved. She stated the resident did have fragile skin to his buttocks from the trauma. She stated she initially put the resident at low risk of developing pressure ulcers as she figured they could get it healed up. She stated the turning and positioning per individualized plan meant not bothering him during the night, and rather than turn and position every 2 hours; staff would monitor his mobility needs. 10NYCRR 415.12

Based on record review, interview, and observation conducted during the recertification survey, it was determined the facility did not ensure resident drug regimens for 2 of 2 residents (Residents #2 and 6) reviewed for psychoactive medications were free from unnecessary medications. Specifically, Resident #2 was started on a routine antipsychotic medication without documentation of a supportive diagnosis, and the dosage of Resident #6's antipsychotic medication was increased without adequate indication. Findings include: 1) Resident #6 had [DIAGNOSES REDACTED]. A Physician Visit Form (Out of Office) dated 5/4/2016, completed by a psychiatrist, documented a recommendation to start low dose [MEDICATION NAME] (antipsychotic) 12.5 mg (milligrams) to help with disruptive behavior and agitation. The Food and Drug Administration (FDA) warning of increased mortality risk was discussed with the resident. An Informed Consent for Atypical Antipsychotic Drug Use in Dementia Residents, dated 5/8/2016 and signed by the attending physician and the resident's health care agent, documented atypical antipsychotics are not approved for the treatment of [REDACTED]. If staff were unable to treat the behaviors with the approaches listed, antipsychotic medications may be indicated. Justification for an antipsychotic included the resident presenting a danger to himself or others, inconsolable or persistent distress, substantial difficulty in receiving necessary physical care, and a significant decline in function. The resident was admitted to the skilled nursing unit on 5/12/2016 from the Adult Home. A nursing note dated 5/12/2016 at 12:46 PM documented the resident was discharged to skilled nursing. The attending physician reported the [MEDICATION NAME] would remain at 12.5 mg until the psychiatrist returned call regarding any recommendations to change med or increase medication. A physician order [REDACTED]. A nursing progress note dated 5/15/2016 at 12:44 PM documented the resident had adjusted well and was easily redirected and cooperative. A nursing home admission form dated 5/17/2016 documented the resident was transferred from assisted living due to agitation. The resident was seen by a specialist who recommended [MEDICATION NAME] 12.5 mg every day. Initially it did not help, but now better. Will leave dose as is. The plan was to reassess in another month or sooner and if behaviors improved, stopping the [MEDICATION NAME] would be considered at the next visit. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severe cognitive impairment, did not have potential indicators for [MEDICAL CONDITION], and did not have behavioral symptoms that impacted the resident or others. The resident required supervision for most activities of daily living (ADLs), and was occasionally incontinent of urine and frequently incontinent of bowel. The comprehensive care plan (CCP) dated 5/26/2016 documented the resident was receiving an antipsychotic drug for dementia, which would have desired results without adverse side effects such as drowsiness, headache, agitation, dizziness, and dry mouth. There was no documentation of what the desired results were. A physician progress notes [REDACTED]. Discontinuation of [MEDICATION NAME] would not be attempted until the resident was seen by the specialist later that month. A nursing note dated 6/12/2016 at 11:04 AM documented the resident was adjusting to his recent transfer and remained pleasant and cooperative. A nursing note dated 6/21/2016 at 3:03 PM documented the resident was pleasant and cooperative throughout the day. The resident wandered and was easily directed. The resident did have slight agitation at times which tends to happen when he has went several days without a BM (bowel movement). A Physician Visit Form (Out of Office) dated 6/27/2016, completed by a psychiatrist, documented the resident had clinical improvement, was much calmer and more redirectable. No paranoia, agitation or aggression was seen. The resident's sleep was still limited. A new treatment order included to increase [MEDICATION NAME] to 25 mg for 6 months, considering remarkable clinical improvement with such a low dose. A nursing progress note dated 6/27/2016 at 5:26 PM documented the resident's psychiatrist called stating he had seen the resident that day and was recommending the [MEDICATION NAME] be increased to 25 mg due to the resident being wakeful at night. He stated he had read the attending physician note, regarding the attending physician wishing to discontinue the [MEDICATION NAME] due to improvement noted. However, due to the lack of sleeping, the psychiatrist was recommending an increase. The nurse had asked if he had any other medication suggestions other than [MEDICATION NAME], and he stated to her no that the [MEDICATION NAME] was effective and increasing it would address sleep pattern. A nursing note dated 6/27/2016 at 9:54 PM documented the psychiatrist had recommended the resident's [MEDICATION NAME] be increased due to wakefulness at night. Nursing documentation was reviewed and there were few notes or change of shift reporting the resident has been wandering or wakeful during the night; it is documented that resident does get up a couple of times during the night to go to the bathroom, and returns to bed and has no problems falling back to sleep. Physician orders [REDACTED]. A nursing note dated 6/28/2016 at 1:30 PM documented the resident was seen by the psychiatrist and he recommended increasing the [MEDICATION NAME] because his sleep is still limited. The nurse was unsure where the physician got that information. The resident's wife told the nurse she spoke to the physician about the resident's untreated sleep apnea. The certified nurse aide (CNA) who had accompanied the resident on the appointment told the physician the resident got up a couple of times a night. The nurse spoke with night staff, who stated the resident got up 2-3 times per night to use the bathroom and would go right back to sleep. The nurse discussed the information with the attending physician, who stated he would like to increase the resident's [MEDICATION NAME] as recommended by the psychiatrist. A nursing note dated 6/29/2016 documented the resident had no change in his behavior with the increase in [MEDICATION NAME] from 12.5 mg to 25 mg. A physician progress notes [REDACTED]. During an interview with licensed practical nurse (LPN) #4 on 7/14/2016 at 9:00 AM, she stated she had received a report from Assisted Living that the resident had urinated in his garbage can, played in his feces, and became agitated and combative while there. She stated since he was in the skilled section he had not been combative and had shown no real agitation. She had noticed when he had not had a bowel movement he would become a bit agitated, but once he was able to move his bowels he was easily redirected. She stated he was known to get up at night to use the bathroom, and once he did he went back to sleep. She stated the attending physician wanted to keep the [MEDICATION NAME] at the 25 mg dosage because it was recommended by the psychiatrist. The attending physician was interviewed on 7/14/2016 at 9:45 AM. He stated the staff reported to him the resident had variable instances of behaviors. He stated the current dose of [MEDICATION NAME] was low and he followed the resident frequently. The resident was sent to a physician who specialized in dementia. He stated when a resident was sent to a specialist, there was a reason. He felt he should follow the recommendations made by an expert consultant, as that was why the resident was sent in the first place. He stated the resident had made improvements with his behaviors, and it was difficult to determine if the improvement was related to the move or the medication. He was willing to review the dose again. 2) Resident #2 had [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) dated 10/16/2015 documented the resident could become overwhelmed by fast and loud communication. Interventions included to speak slowly and quietly. She enjoyed the beauty salon, and generally responded well to attention and stimulation. The resident's Medication Administration Record [REDACTED]. A physician progress notes [REDACTED]. The monthly note documented agitation was still a problem at times. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident's cognition was impaired, and she required extensive assistance with most activities of daily living (ADLs). The resident received an antipsychotic medication daily. The MDS did not document an associated [DIAGNOSES REDACTED]. A social work progress note dated 4/5/2016 documented the resident continued on the [MEDICATION NAME] for delusional disorder and the resident was not seen by a psychologist. A social work progress note dated 4/12/2016 documented the resident had no mood indicators, and staff observed some increase in anxiety in the evening though not recently. The progress note documented there had been no recent gradual dose reductions (GDRs) of the antipsychotic medication, and the family consented to the continued use of the medication, as they had observed a significant increase in the resident's quality of life. A social work progress note dated 4/22/2016 documented the resident's daughter was educated on the side effects and consented to the continued use of the antipsychotic medication. A nursing progress note dated 5/6/2016 documented a note was left for the physician to change the evening time of the [MEDICATION NAME] to 5:30 PM, as the resident had an increase in behaviors and anxiety, such as yelling out during dinner and bedtime care. The May 2016 MAR indicated [REDACTED]. A nursing progress note dated 5/10/2016 documented the resident was found in bed hugging a stuffed animal, and she started screaming out and told the nurse she did not trust her. The resident stated, People do disgusting things. I guess I'll report this when I get home. After about 10 minutes, the resident was quiet and fell asleep. A physician progress notes [REDACTED]. The resident continued to become easily agitated, and reducing other [MEDICAL CONDITION] would likely cause an exacerbation of her agitation. A social work progress note dated 7/12/2016 documented a care plan meeting was held on that day. The resident had no mood indicators and staff observation concurs. The CCP reviewed on 7/12/2016 documented the resident could become overwhelmed by fast and loud communication. Interventions included to speak slowly and quietly. She enjoyed the beauty salon, and generally responded well to attention and stimulation. The resident was observed on 7/12/2016 sitting in the dining room eating her lunch. At 4:00 PM, the resident was observed being encouraged by staff to participate in an activity. During an interview with licensed practical nurse (LPN) #3 on 7/14/2016 at 9:15 AM, she stated she was responsible for the resident's direct care that day and knew the resident well. She stated the resident became anxious in large group settings and at time would become weepy. She stated a lot of times when the resident became anxious or weepy, she would lie down for a nap and wake up in a better mood. During an interview with the physician on 7/14/2016 at 9:15 AM, he stated he reviewed a GDR at the time of each resident visit/review, and documented why or why not in his progress note. He stated he thought the resident had a GDR of the [MEDICATION NAME] in the past. He would initiate a GDR if the resident's behaviors were stable. 10NYCRR 415.12(l)(1)

Based on record review and interview conducted during the standard survey, it was determined for 6 of 10 residents (Residents #2, 3, 4, 5, 9, and 10) reviewed for abuse/neglect, the facility did not ensure all alleged violations involving mistreatment, neglect, or abuse were thoroughly investigated. Specifically: - for Residents #2 and 5, thorough and complete investigations were not completed to determine if abuse/neglect occurred after they sustained falls; - for Residents #3, 4, 9 and 10, thorough and complete investigations were not completed to determine if abuse/neglect occurred after they sustained injuries of unknown origin; - for Resident #2, thorough and complete investigations were not completed to determine if abuse/neglect occurred after having difficulty chewing and swallowing during a meal; and - for Resident #10, thorough and complete investigations were not completed to determine if abuse/neglect occurred after a choking episode. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: The facility's Abuse Identification and Prevention Program policy, dated 3/2013, documented the investigation process included: - Interview the complainant, who observed the victim, all caregivers involved with the resident on all shifts for the 24 hours preceding the event to 24 hours after the event, and supervisors for that unit; - obtain signed statements from each person interviewed; and - conduct a full investigation using the Abuse and Neglect Investigative Summary. 1) Resident #5 had [DIAGNOSES REDACTED]. The comprehensive care plan (CCP), dated 6/2/2015, documented the resident was at high risk for falls. The Minimum Data Set (MDS) assessment, dated 6/9/2015, documented the resident was moderately cognitively impaired, required extensive assistance for transferring and bed mobility, and she had a fall with a fracture prior to admission. A physician note dated 6/17/2015 documented the resident was the office for a follow up of a right humerus (upper arm bone) dislocation. The physician documented an x-ray showed some callus (woven bone) was forming. An incident investigation, dated 6/30/2015 at 3:05 PM, documented the resident fell when staff were assisting her with transferring into bed. The investigation documented the resident lost her balance, fell face first onto the bed with her head turned to the right, and both arms extended at her side. The investigation did not document statements by direct care staff; whether the care plan had been followed; and a determination whether abuse/neglect, had occurred. The fall quality assurance worksheet, dated 6/30/2015 at 3:05 PM, by the registered nurse (RN) Manager, documented the resident was transferring into bed and lost her balance. A nursing progress note, dated 6/30/2015 at 4:04 PM, documented the resident lost her balance during a transfer with staff assistance, and fell face first on the bed. The note documented the resident was repositioned in the bed and ice was applied to her right arm. A nursing progress note, dated 6/30/2015 at 4:10 PM, documented the resident was given [MEDICATION NAME] for right arm discomfort. A nursing progress note, dated 7/1/2015 at 12:35 AM, documented an ice pack was provided for the residents' right arm discomfort. A nursing progress note, dated 7/1/2015 at 3:07 AM, documented the resident was given [MEDICATION NAME] for right shoulder discomfort. A nursing progress note, dated 7/1/2015 at 3:22 PM, documented the resident saw the orthopedic surgeon, her right elbow was displaced, and was re-reduced (put back into alignment) by the surgeon. The CCP, updated on 7/1/2015, documented the resident seemed to pitch forward' while being transferred and fell on to the bed. The CCP documented the resident had stated a gait belt was being used and she had felt it was on looser than normal; the wheelchair was in the way; and the certified nurse aide (CNA) that was assisting her did not normally provide her care. She stated she got her feet tangled causing her to fall. The CCP documented the CNA was counseled verbally on the need to have the gait belt tight and to remove obstacles out of the way. The CCP documented when ambulating/transferring the resident make sure the area was free of obstacles, and use a gait belt firmly fastened around the resident's waist. The orthopedic consult, dated 7/1/2015, documented the resident fell four weeks and sustained a [MEDICAL CONDITION] and elbow. She had been doing well, and unfortunately sustained another fall. The resident reported it was difficult to get the splint on as things seemed to have moved a little bit and she was sore following the most recent fall. The surgeon documented upon exam a deformity of the right arm was noted. The consult documented two sets of x-rays were taken, one set prior to the reduction and a second afterwards. The first x-ray documented the fracture was widely displaced and the second x-ray documented after the reduction the bones were better aligned. The x-ray report documented a comparison of 6/17 and 7/1/2014 x-rays and showed a [MEDICAL CONDITION] and wrist. The x-ray report documented there had been increasing displacement to the elbow fracture. When interviewed, on 7/9/2015 at 7:30 AM, registered nurse (RN) #7 stated on 6/30/2015 she heard CNA #6 yell for help. She stated upon entering the resident's room she observed the resident face down on the bed with her right arm down and away from her body. She assessed the resident, and assisted her to a sitting position. The resident stated she had increased pain, and wanted to lie down. RN #7 stated they assisted her to lay in the bed, gave her [MEDICATION NAME] for the pain, and applied an ice pack to the right elbow. She stated she did not provide a written statement of the incident. The orthopedic physician was unavailable for interview upon request. When interviewed on 7/9/2015 at 9:45 AM, the resident's primary physician stated he was informed of the resident's fall on 6/30/2015, and the resident was seen by the orthopedic surgeon the next day. The physician stated he knew x-rays were taken and that the resident's elbow had to be re-reduced. When interviewed on 7/9/2015 at 10:20 AM, the resident stated on 6/30/2015 while being transferred from the wheelchair into the bed, her feet got tangled up and she pitched forward face down on the bed. She stated CNA #6 put a gait belt around my waist but it was too loose and did not work right when she had started to fall. She stated she started to have increased pain right after the fall and went to the orthopedic surgeon the following day. She stated while at his office he unwrapped my arm and said a x-ray was needed. She stated after the x-ray she was told he had to move the bones back into place. She stated it was painful and as soon as it was back in place, the pain immediately felt better. CNA #6 was not available for interview upon request. When interviewed on 7/9/2015 at 10:44 AM, the Director of Nursing (DON) stated she interviewed staff the day of the incident and did not document their statements. She stated the resident was interviewed the next day and the resident did not think the gait belt was tight enough. She spoke to the staff regarding the tightness of the gait belt. The DON stated there was no documentation to determine how she ruled out abuse/neglect. The DON stated her interviewing staff about the incident was a complete investigation, and she should have talked to the CNA about proper placement of the gait belt. 2) Resident #10 had [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS) assessment dated [DATE] documented he was severely cognitively impaired and was totally dependent on staff for eating. The resident's comprehensive care plan (CCP), dated 2/3/2015, documented he was having increased difficulty chewing and swallowing and was at risk for aspiration. Interventions included a mechanical soft diet consistency with extra sauce/gravy, nectar thick liquids, alternate solids/liquids every 3 bites, be upright for all meals and for 20 - 30 minutes after meals. The resident required total assistance with meals and fluids, and was to be monitored for choking/aspiration. A 3/22/2015 at 1 PM, an incident report documented the resident had a choking incident while eating his meal. The registered nurse (RN) was assisting the resident, he began coughing, holding his breath and his lips were pursed shut. The resident was removed from the dining room and brought back to the unit. The resident had wheezes throughout the left lung. The report did not document statements by staff involved or the resident's family member who was present at the time of the event, to determine if the resident's plan of care was followed. The report did not document how it was determined there was no evidence of abuse/neglect and mistreatment. A nursing progress note, dated 3/22/2015 at 11:37 PM, documented the resident had wheezes throughout his lungs and more so through the left lung. A nursing progress note, dated 3/23/2015 at 2:32 PM, documented the resident had wheezes with a grunting sound throughout his lungs and was using his accessory muscles for breathing. The note documented the nurse practitioner (NP) was notified and an appointment was made for the resident to be seen at 4 PM. A NP progress note, dated 3/23/2015 at 4 PM, documented she was asked to see the resident as he had been wheezing since his choking episode on 3/22/2015. Upon exam the resident had upper respiratory wheezing, a loose non productive cough, and a hoarse voice. A swallowing evaluation was requested and hospice care was recommended. When interviewed on 7/9/2015 at 10:44 AM, the Director of Nursing stated when she spoke to staff regarding the incident, she did not document their statements, and there was no documentation to determine how she ruled out abuse/neglect. She stated she was unable to recall if the resident's care plan for feeding was followed. When interviewed on 7/9/2015 at 2:15 PM, RN #8, who was feeding the resident when he had the choking episode, stated when the resident started to choke she stopped feeding, and removed him from the dining room. She stated he was wheezing and coughing a lot. She stated she faxed the primary physician to notify him of the incident. She stated she could not remember what the resident's plan for eating was at that time, or how she assisted him to eat. 3) Resident #3 had [DIAGNOSES REDACTED]. Incident reports for the resident documented the following: - On 12/1/2014 the resident was found with an abrasion of unknown origin on the left knee. The investigation documented the Director of Nursing (DON) spoke with the day shift about the injury and believed the abrasion was the result of the resident inadvertently bumping his knee on the edge of the table. The resident used in a tilt back wheel chair. Staff were reminded to make sure the wheel chair was tilted down when he was brought to the table. - On 1/8/2015 the resident was found with an abrasion of unknown origin below the right knee. The investigation by the DON documented the area was examined and there were no signs this was from rough handling. The injury was consistent with the resident inadvertently bumping his leg on a chair or other hard object. - On 1/14/2015 the resident was found with a skin tear of unknown origin on the left elbow. The investigation report documented there were no signs of rough handling and this appeared to be an accidental injury from rubbing his arm on the wheel chair or other rough object or from accidentally hitting his arm on table edge. - On 2/13/2015 the resident was found with an abrasion of unknown origin on the left knee. A registered nurse (RN) follow-up documented the injury was most likely the result of the resident inadvertently bumping his knee on the table at meal time and there was no evidence of staff abuse or neglect. The investigations did not include direct care staff statements to determine the cause of the injuries. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had severely impaired cognition, was rarely/never understood, and was totally dependent for activities of daily living (ADL). The comprehensive care plan (CCP) dated 4/7/2015 documented the resident had cognitive losses related to dementia and needed daily decisions made for him. Interventions included to provide total assistance with all ADLs, transport to meals, and decisions made for him. There was no documentation the resident used a tilt back wheel chair that should be upright when brought to the table for meals. Incident reports documented the following: - On 6/10/2015 the resident was found with an irregular shaped, dark purple bruise of unknown origin on the inner corner of the right eye. The bruise was likely caused by either the residents eyeglasses or was self inflicted as the resident often sat holding his hand against his face. - On 6/28/2015 the resident was found with a small blue/purple bruise of unknown origin at the base of the right pointer finger. There was no other injury that would suggest rough handling and the injury was consistent with the resident inadvertently bumping his hand on table or other hard object. The investigations did not include direct care staff statements to determine the cause of the resident's injuries. When interviewed on 7/9/2015 at 10:44 AM, the DON stated when investigating injuries of unknown origin she looked at activities the resident participated in, she observed the resident for any unusual behavior such as rubbing on a chair or moving eyeglasses while on, and observed the resident for complaints of pain. She stated she looked at equipment used for the resident. The DON stated when she spoke to staff, she did not document their statements, and there was no documentation to determine how she ruled out abuse/neglect. 10NYCRR 415.4(b)(3)

Based on record review and interviews conducted during the standard survey, it was determined for 1 of 6 residents (Resident #2), reviewed for accidents, the facility did not consistently provide an environment free of hazards, and supervision/assistance to prevent accidents. Specifically, Resident #2 had a decline in cognitive and physical abilities, exited the facility, and there was no change to the plan of care to ensure safety. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: Resident #2 had [DIAGNOSES REDACTED]. The resident's 4/6/2015 Minimum Data Set (MDS) assessment documented the resident was severely cognitively impaired, it was very important for the resident to go outside, and the resident required extensive assistance of one person for locomotion off the unit. A 4/7/2015 wander risk assessment documented the resident ambulated or wheeled independently, was disoriented to person, place or time, and to consider a wander device. The portion documenting additional/alternative interventions and additional comments was left blank. There was no further documentation related to the determination/wander assessment in the resident's record. The resident's comprehensive care plan (CCP), updated 4/7/2015, documented the resident needed assistance with many activities of daily living (ADL) due to dementia. The CCP documented the resident was no longer independent with transferring, was able to self propel the wheel chair, and may not always use good judgment or remember that she could not walk. The resident may sundown (a change in behaviors) during the evening and night, the resident's cognitive status may decline later in the the day, and a motion detector was to be in place when she was alone in her room related to falls and self transferring. Staff were to anticipate the resident's needs, re-orient, give more direction, and assist the resident in the wheel chair when she tired. The CCP documented It was important for the resident to spend time outside. Nursing progress notes documented on 5/12, 5/24, 6/1, and 7/3/2015, the resident's motion alarm sounded when the resident attempted to self transfer. A registered nurse (RN) progress note dated 7/3/2015 documented she was alerted by staff the resident was self propelling outside of the facility after activities ended and dinner had begun. There was no further documentation in the nursing progress notes regarding the resident exiting the building undetected. There was no documented update to the CCP regarding the resident being found self propelling outside near the parking lot; no documented evidence planned interventions were evaluated for effectiveness and no documented changes to ensure the resident was able to be outside safely. During an interview with RN Manager #4 on 7/7/2015 at 10 AM, she stated the resident was no longer a wander risk as she was not as ambulatory as she once was. During an interview with RN #2 on 7/8/2015 at 3 PM, she stated: - she documented in the nursing notes on 7/3/2015 after the resident was found outside near the parking lot in her wheel chair; - the resident was a complicated case as her physical and cognitive abilities fluctuated, and sometimes it was okay for her to be outside on her own and sometimes it was not; - it did not seem safe for the resident to be near the parking lot on any day; and - the resident enjoyed being outside and she used to be more ambulatory and independent. During an interview with the Director of Activities on 7/9/2015 at 11:55 AM, she stated the resident liked to go outside, required 1:1 assistance to go outside with activities, she had a decline in cognition and physical status recently, and needed more assistance with the wheel chair. During an interview with RN Manager #4 on 7/9/2015 at 12 PM, she stated - the resident used to be independent with ambulation and go outside with her walker; - the resident still enjoyed sitting outside; - staff were able to keep track of her as she moved slowly through the building; - the resident had declined and had become more slow and demented over the last couple months; - she was not aware the resident was outside of the building on 7/3/2015; - it should have been brought up in morning report and discussed by the interdisciplinary team; and - there was no change made to the CCP following that date to address the resident's decline or safety concerns. 10NYCRR 415.12(h)(1,2)

Based on observation and interview conducted during the Standard survey completed on 6/7/13, the facility did not store, prepare and distribute food under sanitary conditions. Two (Main Kitchen, Health Center Kitchen) of two kitchens observed for sanitary conditions had an issue involving non-stick coated pans that had surfaces that were not intact. In addition, there were issues with improper sanitization of non-food contact surfaces in food preparation and dish washing areas in the Main Kitchen. This was a pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy. The findings are: 1. On 6/6/13 at approximately 11:20 AM, during a follow-up visit to the Main Kitchen in the presence of the Food Service Director (FSD), a thick layer of dust was observed covering the stove hood filters and the light bulb covers under the stove hood. The observation revealed two large, uncovered pots containing water and milk were heating up on the stove and the Cook was cutting up fresh vegetables on a work surface that was under the stove hood. There was a large pot under the stove hood that the Cook said had just been used to make strawberry pie filling. During an interview at the time of the observation, the FSD stated that the stove hood and bulb covers are supposed to be cleaned once a month, but they do not keep a documented record of this. The FSD said they need to have a more frequent cleaning schedule and a record of the cleaning. On 6/6/13 at 11:30 AM, four non-stick coated saute pans were observed to have cooking surfaces where the non-stick coating was coming off in areas where the pans were scratched and worn. At this time, the FSD threw the pans out and said the pans are used to cook omelets. The FSD stated that they need to make sure that any pans with damaged cooking surfaces are taken out of use. On 6/6/13 at 11:40 AM, two large wall fans in the dish room had a thick accumulation of dust on the fan blades and fan cage. Both fans were on and blowing directly on clean dishes. At this time, the FSD stated there was no cleaning schedule for the fans and he did not know when they were last cleaned. 2. Observation of the Health Center Kitchen on 6/6/13 at approximately 11:45 AM revealed two non-stick coated saute pans had cooking surfaces where the non-stick coating was not intact. At this time, the FSD was observed to throw the pans out. 415.14(h) 14-1.90 14-1.91(a) 14-1.110(d)

Based on record review and staff interview conducted during the standard survey it was determined for 1 of 5 new employees in the sample, (Employee #1), the facility did not ensure licensure/certification status was determined prior to employment. Specifically, the licensure status for Employee #1, an LPN (licensed practical nurse), was checked two weeks after the employee's hire date. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: The Status/Payroll form signed by the Director of Nursing on January 24, 2012 documented Employee #1 was an LPN (licensed practical nurse) hired on January 24, 2012. The undated Plan of Correction - Checklist form in the employee's personnel file was reviewed on April 4, 2012. Next to multiple documents related to the hiring process (for example references, employment application, payroll status change form) was a check mark. There was no check next to license or certificate. There was no documented check of the employee's license status on, or prior to, the hire date of January 24, 2012. The New York State Office of the Professions Verification Search dated February 7, 2012 documented the employee was an LPN. The Human Resources Director was interviewed on April 4, 2012 at 4:20 PM. She stated the individual department director was responsible to check the license of a licensed new employee. The Human Resources Director stated to the surveyor after the interview at 4:45 PM on April 4, 2012 that the Director of Nursing told her the LPN's license had been checked on the State Education Department website but no record had been printed. The facility policy titled "Background Check" dated September 2008 documented the licensing board would be contacted to determine whether there were any sanctions against a licensed health care professional's license. In summary, there was no documented evidence the facility checked Employee #1's licensure status at the time of, or prior to the hire date. 10NYCRR 415.4(b)

Based on observations, staff interviews and review of facility menus conducted during the standard survey, it was determined the facility did not ensure menus met the nutritional needs in accordance with the recommended dietary allowances and did not ensure recipes were followed as planned for 10 of 10 residents on pureed diets, including Residents #2, 8 and 10. Specifically, significant alterations to pureed food, served to the residents on pureed diets including Residents #2, 28, and 10, were made without the knowledge and approval of the registered dietitian (RD). This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: A review of the list of resident diets dated March 29, 2011, revealed 10 of the facility's 35 residents were on pureed diets, including Residents #2, 8, and 10. The Food Service Director was interviewed on March 30, 2011 at 11:45 AM, and stated the RD and the Health Center Dining Manager (on vacation at the time of survey) randomly did test trays of the pureed food items. The Dining Room Coordinator of the Health Center was interviewed on March 30, 2011 at 11:48 AM. She stated she and other dietary staff observed and tasted the pureed lunch and supper meals prior to serving. She said she specifically looked for thickness to be "more like pudding". If the product was too thin, they "use bread", approximately 4 pieces for 18 portions. The RD was interviewed on March 30, 2011 at 12:15 PM. She stated she randomly observed the food at mealtime on the 2 days of the week she was at the facility to see if it was "too runny." She did not taste the food. If it was "too runny", it was considered unacceptable and she would inform the cook. She stated the cook had guidelines to correct the pureed items. She did not know the specific guidelines. When asked about adding bread to the product, the RD stated if too much was added, it would change the nutrient value. She stated she was not aware 4 slices of bread were added to 18 portions and said it was too much bread. At 12:30 PM on March 30, 2011, the Dining Room Coordinator was interviewed in the presence of the RD. She stated the pureed cranberry chutney and ham panini were runny at the noon meal and she added 4 pieces of bread to the cranberry chutney and the ham panini. The Dining Room Coordinator stated when she made any changes to the consistency, she did not inform the Food Production Manager or anyone in the main kitchen. She said the vegetable was the most common product that was "runny" and at times, she needed to add bread. The surveyors and the RD sampled a test tray for the lunch meal on March 30, 2011 at 12:30 PM and tasted the pureed cranberry chutney and the regular cranberry chutney. When tasted, the tart flavor of the regular consistency cranberry chutney was not evident in the pureed product. The facility's recipe for pureed cranberry chutney documented the cranberry chutney was pureed "til smooth". The ingredients for the ham panini identified the use of panini bread. Neither recipe included adding additional bread to the products. In summary, the facility did not ensure the menus met the nutritional needs of the 10 residents on pureed diets, including Residents #2, 8 and 10, as the recipe for pureed foods, including the ham panini and cranberry chutney, served on March 30, 2011, were not reviewed, assessed, and approved by the qualified dietitian, prior to serving the residents. 10 NYCRR 415.14(c)(1-3)