Every finding on record at Kendal On Hudson

Based on interviews and record reviews conducted during a Recertification Survey from 04/30/2024 to 5/06/24, it was determined that for 2 of 16 residents (Residents #5 and #14), the facility did not ensure that preadmission screening for individuals identified with an intellectual disability (ID) was fully completed prior to admission, in order to receive care and services in the most integrated setting appropriate to their needs. Specifically, the Pre-Admission Screen Resident Review (PASRR) for Resident #5 and #14, dated 02/29/2024 and 02/23/24 respectively, lacked a screener identification number. Findings include: Resident #5 was admitted on [DATE] with a diagnosis of Alzheimer's/dementia and depression. The Minimum Data Set (a resident assessment and screening tool), dated 03/07/2024, documented the resident had moderately impaired cognition. Resident #14 was admitted to the facility on [DATE] with a diagnosis of Conversion Disorder with seizures, dementia, and delusional disorder. The Minimum Data Set, dated dated [DATE], documented the resident had severely impaired cognition. On 05/06/2024, Preadmission Screening and Resident Review forms were reviewed for 16 residents, revealing that 2 of them were missing the screener's identification number on item 38. The facility policy titled Pre-Admission Screen/Annual PASARR, with a revised date of 2023 documented that all residents must have PASARR screen prior to admission to the facility and thereafter when there is a significant change that has a bearing on the residents will be reviewed thoroughly prior to admission. During an interview on 05/06/2024 at 2:20 pm, the social worker acknowledged the issue concerning the two PASARRs lacking the required ten/twelve-digit ID. NYCRR 415.11 (e)

Based on record review, interview and observation during the recertification survey conducted from 4/30/24 through 5/6/24 the facility did not ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition for 1 of 2 residents (Resident #1) reviewed for activities of daily living. Specifically, Resident #1 who required staff assistance for eating was observed on 2 occasions being fed by a companion (no hands on care). The findings are: The policy and procedure titled Private Companion in the Health Center with a revision date of March 2023 documented the role of the companion included assisting at mealtimes with menu selection, setting up utensils, opening containers. No personal hands on care shall be provided by the companions without proper level of certification/licensure. Resident #1 was admitted with diagnoses including but not limited to osteoporosis, non alzheimer dementia, and anxiety. The 3/1/21 Certified Nurse Assistant Activity of Daily Living Tasks documented Resident #1 required assistance for eating. The 4/1/22 Certified Nurse Assistant/Companion Plan of Care Record documented certified nurse assistant/companion diet soft, encourage fluids/food was checked off daily and the certified nurse assistant section for eating did not give directives for feeding the resident/was not checked off daily. The 3/22/23 physician order documented may have meals in bed. The 5/26/23 physician order documented soft diet/bite sized. The 12/5/23 Quarterly Minimum Data Set and 3/4/24 Comprehensive Minimum Data Set documented Resident #1 had moderate cognitive impairment, was dependent with eating, and received a mechanically altered diet. The 3/12/24 care plan titled Risk for Weight Loss/Dementia documented mechanically altered diet. Interventions included team members to encourage completion of foods/fluids/supplements and to monitor meal intakes and offer alternatives. The 3/12/24 care plan titled Activities of Daily Living Self Care documented interventions including, resident will be assisted to perform eating swallowing with close supervision. Observe for decline in the activity of eating and the ability to feed self with no assistance. During observation on 4/30/24 at 12:09 PM Resident #1 was in bed with the head of the bed up. Staff #1 (Companion) was feeding Resident #1 their lunch meal which consisted of a shake, chocolate cake, pureed soup, mixed vegetables, chopped spaghetti and a protein. Facility staff were not present at the time of observation. During observation on 5/1/24 at 8:33 AM Resident #1 was in bed with the head of the bed up. Staff #1 was feeding Resident #1 their breakfast. Facility staff were not present at the time of observation. The 5/2/24 facility companion/certified nurse assistant list documented that Resident #1 had a companion. During an interview on 5/3/24 at 9:42 AM Staff #1 stated they were a companion. Staff #1 stated at times, after facility staff delivered the resident meals they fed Resident #1 because the resident liked that. Staff #1 stated that they reported resident meal intake to the facility registered nurses. Staff #1 stated they had not received training/in-service from the facility but did receive annual in-service through the home care agency. Staff #1 stated they should not feed Resident #1 but if the facility staff were busy and the resident was requesting their food, rather then having the food sit there, they fed the resident. During an interview on 5/3/24 at 11:02 Staff #2 (Registered Nurse Manager) stated Staff #1 was not supposed to feed Resident #1 because Staff #1 was a companion and not a certified nurse assistant. Staff #2 stated they and/or the certified nurse assistants were responsible for supervising Staff # 1. Staff #2 stated they were not aware that Staff #1 had been feeding Resident #1. During an interview on 5/3/24 at 12:23 PM the former Director of Nursing stated companions were to provide comfort/company and were not allowed to feed residents, as they were not trained. The former Director of Nursing stated that facility certified nurse assistants delivered meal trays to resident rooms, and the licensed practical nurse was responsible for oversight of lunchtime trays in resident rooms and ensuring appropriate staff were feeding the residents. The former Director of Nursing stated that registered nurses were responsible for oversight of the dining room and overseeing the licensed practical nurses. The former Director of Nursing stated there appeared to be a system problem in identifying the credentials of agency staff. 10 NYCRR 415.12

Based on observations, record review and interviews conducted during the Recertification Survey from 4/30/24-5/6/24, the facility did not ensure 1 of 2 residents (Resident #19), reviewed for positioning, received treatment and care in accordance with professional standards of practice. Specifically, Resident #19 was observed on multiple occasions sitting in their wheelchair without footrests, legs were dangling, and feet were not touching the floor. The findings are: The facility policy titled Wheelchair Positioning dated 12/2004 and updated in 2023 documented it is the policy of the Rehabilitation Department to provide functional, safe, and comfortable wheelchair positioning to all residents at the time of admission or as identified at any time the need for a new evaluation. Resident #19 was admitted to facility on 04/04/24 with diagnoses including but not limited to Alzheimer's disease, anxiety disorder, hypothyroidism, and muscle weakness. The Comprehensive Minimum Data Set, an assessment tool, dated 4/10/24 documented the resident had severely impaired cognition, required total assistance with eating and toileting and extensive assist with bed mobility and transfers. Furthermore, the Minimum Data Set documented that Resident #19 required a wheelchair. The Adaptive/Safety Equipment/Repositioning Care Plan dated 4/23/24 documented the resident will utilize assistive devices properly with teaching and appropriate selection of equipment. Interventions included that resident is currently using a reclining wheelchair. On 04/30/24 at 10:52 AM, Resident #19 was observed sitting in high back wheelchair in the dayroom asleep at the table. There were no footrests in place and feet were dangling. On 04/30/24 at 12:25 PM, Resident #19 was observed in the dining sitting in their wheelchair with both legs elevated and dangling above the ground. There were no leg/footrests in place. On 04/30/24 at 12:45 PM, Resident #19 was observed being wheeled in their wheelchair to the dayroom with both legs elevated and dangling above the ground. There were no leg/footrests in place. On 05/03/24 at 9:05 AM, Resident #19 was observed sitting at the table eating breakfast and legs were dangling and footrests were not in place. On 05/03/24 at 09:25 PM, Resident #19 footrests were observed in their bathroom underneath the sink and the resident was in the dayroom. During an interview on 05/03/24 at 9:27 AM, Staff #6 (certified nurse aide) stated that they were aware that Resident #19 was supposed to have footrests on their wheelchair and that they were rushing and unable to put them on. During an interview on 05/03/24 at 09:27 AM, Staff #7 stated that Resident #19 was supposed to have footrests on the wheelchair for safety and comfort and was not sure as to why the certified nurse aide did not put them on. During an interview on 05/03/24 at 01:40 PM, Staff #2 (registered nurse unit manager) stated that Resident #19 should have footrests on their wheelchair and that their legs should not be dangling. During an interview on 05/03/24 at 03:13 PM, Staff #8 (occupational therapist) stated that on admission the resident was received in the chair with footrests and that all wheelchairs had leg rests. They stated the leg/footrests should be used unless an evaluation was done and it was determined that there was no need for the use of footrests. During an interview on 05/03/24 at 03:56 PM, the Director of Rehabilitation stated that it was expected that any changes with resident's activities of a daily living, the therapy department should be documenting and communicating with nursing. 10NYCRR 415.12

Based on observations, record review, and interviews conducted during the recertification and abbreviated surveys (NY00321462) from 4/30/24 to 5/06/24, the facility did not ensure adequate supervision was provided and that the residents environment remained as free of accidents hazards as possible for 2 of 4 residents (Residents #18 and #74) reviewed for accidents. Specifically, (1) Resident #18 whom has a history of falls with major injuries, was observed on multiple occasions without their floor mats in place to the sides of their bed. (2) Resident #74 who had exit seeking behavior, was not provided adequate supervision and was able to exit the facility undetected by staff. Resident #74 followed visitors out of the facility and was found in the hospital parking lot by hospital staff. The findings are: 1. Resident #18 was admitted to the facility with diagnoses including but not limited to a right hip fracture, intertrochanteric fracture of the right femur, and rhabdomyolysis. The 04/24/2024 Quarterly Minimum Data Set (assessment tool) documented that Resident #18 had severely impaired cognition, and required total assistance with toileting and, extensive assistance with bed mobility, set up with eating, and transfers did not happen. Furthermore, the 04/24/2024 Quarterly Minimum Data Set Documented Resident #18 had recent surgery due to fracture requiring a skilled nursing facility. The facility policy titled Floor Mats/Safety dated 2017 documented facility will utilize a floor mat/s to prevent injury to a resident from fall out of bed onto the floor. Care plan will reflect the need for Floor mat/s based on the resident's cognitive ability and assessed by the interdisciplinary team for use. Resident who has a history of attempting to exit the bed without assist may be a candidate. The At risk for accidents/falls/injury Care Plan dated 1/30/24 documented diagnosis of left hip fracture status post left hip fixation on 10/15/23. Goals included Resident #18 will have safety measures maintained to lessen any injury from a fall. Interventions included floor mats is to be on both sides of the bed. On 04/30/24 at 11:04 AM, Resident #18 was observed in their room lying in bed. There were no floor mats in place to either side of the bed. The floor mats were observed folded up behind a chair. On 05/01/24 at 11:50 AM, Resident #18 was observed awake lying in bed. There were no floor mats in place to either side of the bed. Floor mats were folded up behind a chair. On 05/03/24 at 09:15 AM and 10:17 AM, Resident #18 was observed lying in bed. The bed was in highest position and the right floor mat was observed on the wall, and not in place on the side of the bed. During an interview on 05/03/24 at 10:18 AM, Staff #2 (registered nurse unit manager) and Staff #9 (registered nurse) stated the resident should have had floor mats on both sides of the bed and the bed should have been in the lowest position. During an interview on 05/03/24 at 10:20 AM, Resident #18's son stated that six weeks after admission for a left hip fracture, the resident fell out of bed resulting in a fracture of the right hip and stated the resident should have their floor mats in place. During an interview on 05/03/24 at 10:41 AM, Staff #10(certified nurse aide) stated that they were aware Resident #18 was supposed to have floor mats on both sides of the bed for safety due to history of falls. 48850 2. Resident #74 had diagnoses of dementia, depression, and delusional disorder. The Minimum Data Set (a resident assessment and screening tool) dated 07/14/2023 revealed the resident was severely cognitively impaired. The MDS documented the resident needed limited assistance on transfer, walk in room, walk in corridor with which occurred once or twice with one person. A wander alarm to be used daily. The undated facility policy titled Elopement Prevention documented that residents who were identified at risk for elopement would have individualized interventions implemented to decrease the risk of elopement and to keep the resident safe. The comprehensive care plan, titled Potential for Wandering/Elopement, initiated on 06/21/2023, outlined interventions to assess Resident #74 for wandering/elopement tendencies. It included the initiation of a wander guard system and ongoing evaluation of its necessity based on the resident's pattern of wandering. The plan specified ensuring the resident wears an ID band and that the wander guard is properly placed on the left ankle and checked for functionality during every shift. Staff were instructed to monitor the resident for any attempts to exit the building, document circumstances, employ redirection interventions, and record outcomes. Additionally, caregivers were tasked with providing structured and supervised walking activities, reorientation, scheduled opportunities, and pleasant diversions to distract the resident from wandering, such as engaging in activities of interest, watching television, or reading. The care plan updated 07/26/2023, documented Resident #74 continued to benefit from the wander guard on their ankle. The resident was exit seeking and looked for their spouse. The care plan goal was the resident would not be exit seeking or leave the facility unattended. The nursing progress note by Staff #15 (licensed practical nurse) dated 08/02/2024 at 5:59 PM documented Resident #74 was redirected throughout the day, with frequent monitoring for safety due to frequent attempts to leave the unit. The wander guard (electronic monitoring device) was in place and functioning. Resident #74 continued to be pleasantly upset as they were unable to leave the unit. The resident was observed wandering on the unit in a wheelchair throughout the day, self-propelling and transferring independently. The nursing progress note by Staff #15 dated 8/3/2024 at 4:19 PM documented at 2:15 PM the resident was self-propelling their wheel chair with their feet on the unit. At 2:30 they were unable to locate the resident and at 2:45 PM the resident was located and assisted back to the unit. The accident/incident report dated 08/03/2023 at 2:30 PM, documented the resident was not found during medication pass, prompting notification of the family, who denied having taken the resident with them from the unit. Between 2:35 and 2:40 PM, the Director of Nursing and Director of Social Work initiated a search for the resident, activating a missing resident (code Green). The Director of Resident Services reported that they saw the resident on the unit between 2:10 and 2:15 PM. At 2:43 PM, a former employee, now working at the hospital, called the Director of Resident Services to inform them that the resident was in the hospital parking lot. Resident #74 was then escorted back to the facility and physically returned to the facility at 2:45 PM. The report documented that the wander guard bracelet placed on the resident's ankle was tested , and its proper function was verified. During an interview on 05/03/2024 at 11:00 AM, the Director of Nursing stated that the resident followed two visitors who were exiting the building. The Director of Nursing stated the resident was on 15-minute checks before the incident occurred, and although the wander guard was functional, it did not have an alarm activated at the time. During an interview on 5/6/2023 at 4:30 PM, Staff #15 stated that on the day of the elopement, they had seen Resident #74 around 2:15 PM. Staff #15 stated that the resident was on 15-minute checks prior to the elopement incident on 08/03/2023 and the Certified Nurse Aides were responsible for completing the forms but did not know where the forms were. Staff #15 stated they could not recall when the 15-minute checks were implemented and had seen the resident wandering throughout the day. Further review of the written statements dated 8/3/24, by Staff #13, Staff #16 and Staff #17 (all Certified Nurse Aides) documented the last time any of them saw the resident was at 1:40 PM. During an interview on 5/6/2024 at 5:17 PM, Staff #13 stated that on 08/03/2023, Resident #74 was not on their assignment. Staff #13 remembered seeing the resident outside room [ROOM NUMBER] and instructed them to return to their room. However, when returning from assisting another resident, Resident #74 was no longer present. Staff #13 stated they had not been informed of any increase in exit-seeking behavior exhibited by Resident #74 that day. 10NYCRR 415.12(h)(1)

Based on observations, interviews, and record review conducted during the recertification survey, 4/30/2024-5/6/32024 the facility did not ensure that special eating equipment and utensils for a resident who need them was provided for 1 of 1 resident (Resident #9) reviewed for adaptive equipment. Specifically, built up (red foam) utensils were not provided for Resident #9 as per physician order. The findings are: A policy and procedure titled Adaptive Devices dated June 2005 last revised 2023 documented the purpose was to provide residents with device/s to ensure eating independence. Resident #9 had diagnoses including chronic obstructive pulmonary disease, lymphedema, and unspecified hearing loss. The physician order dated 11/13/2023 documented a 3-compartment plate, a regular diet, and (red foam) built up utensils with all meals. The Quarterly Minimum Data Set (an assessment tool) dated 3/9/2024 documented the resident's cognition was moderately impaired. The resident required set up assistance, for eating and all other activities of daily living required substantial to maximal assistance. During observations on 04/30/24 and 5/1/2024, lunch was served in the resident's room, no built-up utensils were noted on the tray. During an observation on 05/01/24 at 09:38 AM breakfast was served while the resident was in bed. The resident's tray was noted to have a 3-section plate, and no built-up utensils had been provided. During an observation on 05/02/24 at 12:18 PM during lunch there were no built-up utensils on the tray. The resident had difficulty holding the fork and spilled food down the front of their clothes when attempting to eat coleslaw. During an observation on 05/03/24 at 09:12 AM the resident was in bed with breakfast tray. Built-up (red Foam) utensils were present on the tray and the resident was using them. The resident ate 100% of her meal. During an interview on 5/2/24 at 1:32 PM Staff #3 (Certified Nurse Aide) stated the resident received set up assistance with meals, they gave the resident finger food, and the resident had built up utensils in the past, but not recently. They thought the utensils should come from the kitchen. During an interview on 5/2/24 at 1:32 PM Staff #4 (Certified Occupational Therapy Assistant) stated they had recommended a 3-section plate and built-up utensils. Therapy provided them to the kitchen for Resident #9 and they had even left one in the resident's room for the resident to use. Staff #4 stated they did not know what happened to the utensils. During an interview on 5/2/24 at 2:22 PM the Director of Nursing stated they communicated with the Interdisciplinary Team, when a physician wrote an order, to ensure all orders were carried out. The built- up utensils would come from the kitchen and should be listed on the resident's menu. During an interview on 5/2/24 at 2:33 PM Staff #5 (Certified Dietary Manager) stated they did not receive the order for the built-up utensils. The process would be for therapy to make a recommendation, an order placed by the physician, and the nurse would provide the dietitian with a slip indicating the changes. The dietitian would care plan and update the roster to include the changes, and adaptive equipment would be listed on the resident's menu. During an interview on 05/03/24 at 09:14 AM, Resident #9 stated the special utensils did help them a little to eat. Resident #9 stated they would use them if they were available. 10 NYCRR 415.14 (g)

Based on observation and interview conducted during a recertification survey from [DATE] to [DATE], the facility did not ensure that food was stored in accordance with professional standards for food safety practice, Specifically, multiple food items were found with expired dates, leftover foods were unlabeled, and dented cans were found. The findings include: Observation and interviews from the kitchen initial tour conducted on [DATE] at 9:45AM with the sous-chef revealed: - a half used country mustard with an expiration date of [DATE]; - a dill weed container with the expiration date of [DATE]; - a white pepper container half used without the opened date and expiration date; - 2 unopened Coleman's mustard containers had expiration dates of [DATE] and [DATE]; - 2 dented cans of black beans; - arrowroot used approximately 80% without an opened date or expiration date; - sliced cake in the freezer without proper label, labeled ,d+[DATE] - ,d+[DATE]; and - a dirty smoke liquid bottle with date barely visible. During an interview on [DATE] at 9:50 AM, the sous-chef stated all of the expired goods should have been not been left in stock and should have been thrown out. They stated the sliced cake in the freezer could be kept for a week and that it was incorrectly labeled. During an interview on [DATE] at 10:05 AM, the Dining Service Director stated the expired dill weed, white pepper, and other expired products should have been removed from circulation. They also stated the dented cans should have been removed from inventory to ensure food safety. 10NYCRR 415.14 (h)

Based on observations, interviews and record review conducted during a recertification survey, the facility did not ensure that the advance directives formulated for 3 of 3 residents (#5, #7, and #17) regarding Do Not Resuscitate (DNR) would be honored. Specifically, the facility did not effectively implement a system to carry out Do not Resuscitate (DNR) orders for residents who have been identified to have written consents for DNR (Do Not Resuscitate) that they would not be resuscitated when indicated. The facility's policy dated [DATE] last revised documents the policy's purpose is to assure the resident and/or family the opportunity to choose his/her own course of treatment with his/her attending physician.residents of [NAME] on Hudson have the right to consent or refuse to consent to cardiopulmonary resuscitation (CPR) measures in the event of respiratory or [CONDITION(S)]. MD order must be obtained prior to the DNR being in effect. Nursing staff is to notify Social Services once MD order is written. The findings are: 1.Resident # 5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] Quarterly Minimum Data Set (MDS) documented the resident had a Brief Interview of Mental Status (BIMS) of 8 (moderately cognitively impaired) Review of the Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #5's DNR status since the resident was admitted to the facility on [DATE]. Review of the Electronic Medical Record (EMR) documented Resident #5 had a written consent for DNR in place dating back to [DATE]. 2.Resident #7 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Quarterly MDS dated [DATE] documented the resident had a BIMS of 15 (cognitively intact). Review of the Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The [DATE] Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Electronic Medical Record (EMR) documented Resident #7 had a written consent for DNR in place dating back to [DATE]. 3. Resident # 17 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The [DATE] Quarterly Minimum Data Set (MDS) documented the resident had a Brief Interview of Mental Status (BIMS) of 12 (cognitively intact) Review of the Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #17's DNR status since the resident was admitted to the facility on [DATE] The Director of Nursing (DON) was interviewed on [DATE] at 04:11 PM and DON stated the RN who is assigned to do the admission to facility writes out on paper a list of orders then they call the doctor and run it by the doctor and if the doctor wants a change, they can easily write it on the paper. Once orders are clarified then the order is entered in the EMR. DON stated LPN #3 was responsible for reviewing monthly order renewals and updating the Medical Doctor when a change is needed. The Licensed Practical Nurse (LPN #3) was interviewed on [DATE] at 04:22 PM and LPN #3 stated one of her responsibilities is to go in the EMR and review orders on a monthly basis. LPN #3 stated they review the Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN #3 stated they must have overlooked the DNR orders and stated because the residents' charts were all flagged as DNR it just didn't register with them. The Medical Director (MD) was interviewed on [DATE] at 4:48 PM and the MD stated that when they are given the monthly review they usually focus on the medications and not other orders, such as a DNR from admission. MD stated they are surprised the residents did not have DNR orders as they are not newly admitted and it was believed the residents had DNR orders in place on admission. 483.10(c)(6), (c)(8), (g)(12)

Based on observation, record review and interview conducted during the recent recertification survey, the facility did not ensure that medications held in the emergency box had been removed when they reached the manufacturer's expiration date. The findings are: The medication storage room was observed on [DATE] at approximately 11:00 AM. The [ENTITY] medication dispensing system for emergency medications was observed and attached to it was a list of medications contained within the box. Review of the list indicated multiple expiration dates that had passed (e.g. [MEDICATION NAME] exp. 4/30/19). The Licensed Practical Nurse (LPN) present at the time of the review stated that the list was an old one and the pharmacy account manager was there recently replacing medications. In an interview with the Director of Nursing at that time regarding the expired medication list, she stated she would call the [ENTITY] account manager to obtain a more current list. Review of the updated [ENTITY] medication list indicated there were medications on the list with expiration dates of 11/30/19. In an interview with the Pharmacy Account Manager on 1[DATE] at 10:30 AM she stated the 11/30/19 expiration dates on the list were predated by one month. The manufacturer's expiration date on the medications was 12/30/19. She stated she predates the expiration dates on the list in the event that she cannot get to the facility in time to remove the expired medications. The [ENTITY] dispensing system was opened by the Account Manager at 10:45 AM. The 16 medications with expiration dates of 11/30/19 that appeared on the list were all checked. 14 of the 16 medications had expiration dates of 12/11/19. The Account Manager stated at that time she would discard all those medications and replace with new ones. She could not explain what caused the problem. The following is a list of medications that had expired on 12/11/19. 1. [MEDICATION NAME] 200 mg - anticonvulsant 2. Cefpoxodine 100 mg - antibiotic 3. [MEDICATION NAME] 250 mg - antibiotic 3. [MEDICATION NAME] 250 mg - antibiotic 4. [MEDICATION NAME] [AGE] mg - antiplatelet/blood thinner 5. [MEDICATION NAME] - antiarrhythmic (for treatment of [REDACTED].>6. [MEDICATION NAME] 100 mg - nerve pain medication/anticonvulsant 7. [MEDICATION NAME] 25 mg - diuretic/antihypertensive 8. L[MED] 250 mg - anticonvulsant 9. [MEDICATION NAME] 250 mg - antibiotic 10. [MEDICATION NAME] 4 mg - antiemetic (for nausea) 11. [MEDICATION NAME] 100 mg - [MEDICATION NAME] pain reliever (urinary pain) 12. [MEDICATION NAME] 1mg - anticoagulant/blood thinner 13. [MED] 10mg - anticoagulant/blood thinner 14. [MEDICATION NAME] 5 mg - steroid 415.18(e)(1-4)

Based on observation, interview and record review the facility did not ensure that food was prepared and stored according to professional standards for food safety. Specifically, 1) cooling temperatures and timeframes were not recorded for food that had been cooked and cooled to be used at a later time and 2) hot food was not held at a safe holding temperature, prior to service, to prevent bacterial contamination. The findings are: 1) During the initial tour of the kitchen on [DATE] at 9:30 AM a pan of cooked ground beef was observed in the walk-in refrigerator. The Executive Chef who was present at the time stated the ground beef will be used for empanadas the next day. When asked if cooling logs had been completed, he stated they had. Review of the cooling log for the ground beef revealed no time frames with corresponding temperature recordings to ensure cooling of the ground beef was done according to professional standards for food safety. The Executive Chef was interviewed on 1[DATE] at 2:10 PM and was able to verbalize the proper cooling procedures. 2) Temperatures were checked for hot food lunch items on [DATE] at 12:00 PM. Two of the three items were being held at a safe temperature (above 135 degrees F.) The third item was chicken quesadillas and the holding temperature was 114 degrees F. The Food Service Worker stated he would put the quesadillas back in the oven. A second temperature check at 12:20 PM revealed the temperature had reached 126 degrees. The Executive Chef was interviewed on [DATE] at 12:13 PM. When asked what the procedure was for making and holding the temperature of the quesadilla, he stated the chicken is cooked and cooled. Once it cools down completely the chicken is placed on the flat top grill with the tortilla where the quesadilla is assembled. It is then further grilled in a panini press. Once made it is placed in the hot box for transport down to the unit kitchen where it is kept warm until service. He was unaware that the quesadilla holding temperature was not adequate. He also stated he did not have cooling logs for the chicken to ensure safe cooling procedures. 415.14(h)

Based on observation, interview and record review conducted during a recertification survey, the facility did not ensure that dishwasher equipment in the kitchen was maintained in a sanitary condition. This resulted in pattern for potential of more than minimal harm that is not immediate jeopardy. The findings are: On 10/2/14 at approximately 9:00 AM, the nursing home kitchen, known as "the pantry," was toured. The dishwasher rinse temperature was observed to reach 136 degrees Fahrenheit (F) and 154 degrees F on two separate run-through's of dishware. A maintenance report of 10/2/14 completed by an outside contractor was then reviewed. The report indicated that the rinse cycle included 0 ppm (parts per million) of sanitizer, rather than the required 50 ppm in circumstances where the rinse temperature does not reach 180 degrees F. This maintenance report indicated that the sanitizer probe had not been properly positioned, resulting in no use of sanitizer during the rinse cycle. Part 14 of the State Sanitary Code requires that if a temperature of 180 degrees is not obtained during the rinse cycle, a sanitizer equal to at least 50 ppm is necessary to ensure absence of any bacterial contamination of dishware. A review of the temperature logs for a six month period, from April 2014 through September 2014, revealed that the documented temperatures of the rinse cycle reached 180 degrees, only 14% of the time (62 of 450 opportunities). During interviews with the Director of Operations on 10/02/14 and 10/03/14, he stated that the facility was waiting for a "part" to repair the dishwasher rinse temperature cycle and that he was unaware that the sanitizer dispenser was inoperable and for how long it had been inoperable. 414.14(h)

Based on record review and interviews conducted during the most recent re-certification survey, the facility did not ensure that the nutrition care plan was updated to address weight loss for 1 of 3 residents reviewed for nutrition (Resident #3) and resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The findings are: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS (Minimum Data Set; a resident assessment tool) dated 1/5/14 revealed that the resident was 69 inches tall and weighed 144 lbs. at the time of the assessment. The resident had no/unknown weight loss or gain in the past six months and was not receiving a therapeutic diet. The 7/4/14 MDS quarterly assessment revealed that the resident's weight was 139 lbs. at the time of the assessment and the 10/2/14 MDS quarterly assessment revealed that the resident weighed 135 at the time of the assessment. This weight loss was not documented as significant. The Nutrition assessment dated [DATE] indicated that the resident's weight was 144 lbs.; Usual Body Weight (UBW) = 145 lbs.; Ideal Body Weight (IBW) = 160 lbs.; required total assist in eating; and Food/Nutrition History indicated that the resident likes most food/fluids, specifically yogurt, stewed prunes, wheat bread and green tea. Appetite was documented as 75-100% for all three meals and snacks would be provided as desired. The summary of Nutritional Findings indicated that the resident was at 99% of UBW (145 lbs.) and had a Body Mass Index (BMI) of 22 indicating normal weight status. The Nutrition assessment dated [DATE] indicated that the resident's weight was 139.6 lbs., UBW = 135 lbs. and IBW = 160 lbs. The summary of Nutritional Findings indicated that the resident was at 103% of his UBW (135 lbs.) and his BMI was 20. There was no documentation regarding the 4-5 lb. weight loss the resident experienced between the two assessments (24 days). The Weight Tracking record revealed the following weight changes: 1/6/14 - 144 lbs. 2/12/14 - 139.2 lbs. 3/4/14 - 142 lbs. 6/2/14 - 139.4 lbs. 7/16/14 - 137.2 lbs. 9/15/14 - 135.4 lbs. These weights represented a downward trend with a total weight loss of 8.6 lbs. since January. The resident's BMI dropped from 22 at the time of admission to 19 when the last weight was recorded in September 2014. The October weight was not available. The care plan for Nutrition revealed an entry dated 10/6/14 which indicated that the resident's weight was 135.4 lbs., 94% of IBW (144-176 lbs.) and 100% of UBW (135 lbs.). Entries in the care plan dated 1/8/14 and 4/7/14 revealed that the UBW was identified as 145 lbs. On subsequent updates to the care plan, the UBW was documented as 135 lbs. In addition, there was no indication as to why the UBW was changed from 145 lbs. to 135 lbs. There was no documented evidence in the care plan identifying the resident's downward trend in weight since admission and the steady trending down of weight since March 2014. In an interview with the Registered Dietitian (RD) on 10/6/14 at 2:45 PM, she stated that she did not document the weight loss of the resident because it is not considered significant according to MDS guidelines and that the resident was still at his usual body weight. When asked why his usual body weight was changed from 145 lbs. to 135 lbs. she stated that it might have been a mistake. When asked how she thought he lost close to 9 lbs., the dietitian stated that maybe he doesn't eat snacks as much as he did before. Review of the meal intake records for October 2014 revealed that the resident consumed between 75-100% at meals. He received a 10 AM, a 2 PM and an 8 PM snack daily and that he ate between 0 and 100%. In an interview with the Director of Nursing on 10/6/14 at 3:15 PM she stated she thought that the reason for the weight loss was due to an increase in the resident's tremors that he experiences as a result of his [MEDICAL CONDITION] and that medication changes were also made which may have contributed to the weight loss. The DON was not aware of why the RD had no knowledge of this information. 415.11(c)(2)(i-iii)

Based on observation, interview and record review, positioning devices were not in place according to the care plan for Resident #37. This was evident for one of one residents reviewed for positioning and had the potential for more than minimal harm that is not immediate jeopardy. The findings are: Resident #37 is a [AGE] year old with [DIAGNOSES REDACTED]. The resident's most recent 8/16/13 physician's orders [REDACTED]. The resident's care plan identified goals to ensure the most erect posture in seating, to maintain the best cardiovascular health and to prevent trunk contractures. A seating posture evaluation was completed and care plan interventions were initiated on 5/5/12 that included to provide the resident with a high back wheelchair, drop stop to prevent leg injury, pummel cushion for proper pelvic positioning and lateral support for proper positioning. The resident was observed out of bed seated in a straight back wheelchair without the positioning devices in place on the morning of 9/6/13 and again at lunchtime in the dining room on 9/6/13. Further observation on the same day at 12:30 PM also revealed that the the lumbar support cushion and the drop stop were not in evidence in the resident's wheelchair. The Director of Nurses (DON) was interviewed on 9/6/13 at 12:35 PM and stated that the lateral support cushion and the foot drop had been removed from the resident's wheelchair on the night of 9/3/13 for cleaning and had not been replaced as of 9/6/13. The Certified Nurse Aide (CNA) was interviewed on 9/6/13 at 12:45 PM and stated that he knew that the resident should have been provided with the lateral support cushion and drop stop. The CNA stated that he forgot to put them on the wheelchair. There was no evidence of instructions for use of the positioning devices in the resident care guide used by the Certified Nurse Aides. The Registered Nurse Unit Manager stated on 9/6/13 at 2:15 PM that the information on the resident care guide is how CNAs would determine the care needs of the resident and that the positioning devices should have been noted on the resident care guide. 415.11 (c)(3)(ii)

Based on observation, interview and record review, care to promote optimal well-being was not provided for a dependent resident. Specifically, positioning devices were not in place according to the care plan for Resident #37. This was evident for one of one residents reviewed for positioning and had the potential for more than minimal harm that is not immediate jeopardy. The findings are: Resident #37 is a [AGE] year old with [DIAGNOSES REDACTED]. The resident's most recent 8/16/13 physician's orders [REDACTED]. The resident's care plan identified goals to ensure the most erect posture in seating, to maintain the best cardiovascular health and to prevent trunk contractures. A seating posture evaluation was completed and care plan interventions were initiated on 5/5/12 that included to provide the resident with a high back wheelchair, drop stop to prevent leg injury, pummel cushion for proper pelvic positioning and lateral support for proper positioning. The resident was observed out of bed seated in a straight back wheelchair without the positioning devices in place on the morning of 9/6/13 and again at lunchtime in the dining room on 9/6/13. Further observation on the same day at 12:30 PM also revealed that the the lumbar support cushion and the drop stop were not in evidence in the resident's wheelchair. The Director of Nurses (DON) was interviewed on 9/6/13 at 12:35 PM and stated that the lateral support cushion and the foot drop had been removed from the resident's wheelchair on the night of 9/3/13 for cleaning and had not been replaced as of 9/6/13. The Certified Nurse Aide (CNA) was interviewed on 9/6/13 at 12:45 PM and stated that he knew that the resident should have been provided with the lateral support cushion and drop stop. The CNA stated that he forgot to put them on the wheelchair. There was no evidence of instructions for use of the positioning devices in the resident care guide used by the Certified Nurse Aides. The Registered Nurse Unit Manager stated on 9/6/13 at 2:15 PM that the information on the resident care guide is how CNAs would determine the care needs of the resident and that the positioning devices should have been noted on the resident care guide. 415.12

Based on interview and record review, rehabilitation screening was not performed for a resident following a fall incident, according to the recommended measure identified in the investigation of the incident, to prevent potential accidents . The was evident for one of three residents reviewed for accidents (Resident #11) and resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The findings are: Resident #11 is a [AGE] year old with [DIAGNOSES REDACTED]. According to the resident's annual Minimum Data Set assessment, she required the extensive assistance of another person to perform most aspects of her activities of daily living. An Accident/Incident Report completed for the resident revealed that a Certified Nurse Aide (CNA) observed the resident lying on the dayroom floor on 8/9/13 at approximately 1:30 PM. The Accident/Incident Report also stated that a CNA observed another resident trying to pull Resident #11 up by the hand to help her walk to the bathroom. The report further stated that the resident's chair alarm sounded, the CNA responded immediately and the resident was lowered to the floor without injury. The above incident was investigated by the Director of Nursing (DON)on 8/9/13. Documented remedial measures included rehabilitation (rehab) screening. Rehabilitation Notes, the resident's comprehensive care plan, assessments, and Interdisciplinary Progress Notes were reviewed and revealed no documented evidence that rehab screening was conducted following the above incident. The Director of Rehab, who was responsible for conducting rehab screens, was interviewed on 9/6/13 at 8:40 AM and 9:00 AM and stated that screening following an incident would be conducted to assess whether the resident experienced changes in functional status and might benefit from assistive or adaptive devices. The Director of Rehab stated that he did not recall conducting any rehab screens as a result of the incident on 8/9/13. The Director of Rehab further stated that he did not receive any request from nursing to conduct rehab screening for this resident. The DON was interviewed on 9/6/13 at 10:55 AM and stated that a request for rehab screen would have been given to the rehab director during morning report following the incident. The DON stated that she had not received any report from the Rehab Department. 415.12 (h)(l)

Based on record review and interviews, the facility did not ensure that a specific intervention to minimize the resident's risk for further accidents was consistently put into place. Specifically, a chair alarm to alert the staff of the resident's unsafe transfer was not consistently applied to prevent falls and injuries. This was evident for 1 of 8 residents reviewed for falls and fractures in a total sample of 10 residents (Resident #6). This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. Finding is: Resident #6 is a [AGE] year old male with [DIAGNOSES REDACTED]. A review of the Accident / Incident Reports revealed that the resident sustained [REDACTED]. - 7/29/12, the resident was found on the floor after losing his balance while walking to the bathroom but did not sustain any serious injuries; - 8/19/12, the assigned Certified Nursing Aide found the resident sitting on the floor. The resident stated that he slid and fell while reaching for the telephone and sustained pain to the right hand and right wrist without fractures; and - 8/21/12, the resident slid to the floor while talking on the telephone but did not sustain any serious injuries. The current care plan for "At Risk for Accidents/Falls/Injury" was revised on 8/19/12 and 8/20/12 with interventions including placing the telephone on the night stand and wheeling the nightstand to the floor mat closer to the resident, Occupational Therapy evaluation and applying tab alarm while in bed and while in a wheelchair. The above interventions were confirmed with MDS (Minimum Data Set) assessment coordinator during an interview on 8/29/12 at 10:45 AM. At this time, the MDS Coordinator and the stated surveyor proceeded to the resident's room. The resident was observed to be sitting alone in his room on a regular chair without a tab alarm in place. The MDS coordinator stated that the resident must have a chair alarm in place to monitor his unsafe transfer. The tab alarm was found to be hanging on the side rail of the bed and was not attached to the resident. During an interview with the assigned Certified Nursing Assistant on 8/29/12 at 11:20 AM, she stated that the resident needed a tab alarm and that she checked the resident earlier and that the Physical Therapist took the resident to the Rehabilitation Department. When asked as to why the tab alarm was not applied, she stated that she did not know that the resident had returned to his room. During further interview with the MDS Coordinator on 8/29/12 at 11:45 AM, she stated that the Physical therapist who wheeled the resident back to his room did not know that the resident needed a tab alarm. The MDS Coordinator agreed that the lack of communication between the interdisciplinary team members had placed the resident at risk due to the inconsistent implementation of preventive measures to prevent further falls and injuries. 415.12(h)(1)

Based on observation and staff interview, the facility did not ensure proper disposition of a medication beyond its expiration date. Specifically, a bottle containing expired tablets of nitroglycerin (used to relieve chest pain in anginal attacks) which is an active part of the resident's medication regimen was found to be stored in the medication cart. This was evident in 1 of 2 facility unit medication carts (Sunnyside) and for 1 resident (#15). This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. Finding is: During initial tour of the facility on 8/28/12 at 8:30 AM, an inspection of the Sunnyside unit's medication room and medication cart was conducted. It was revealed that a bottle containing 25 tablets of nitroglycerin expired on 7/20/12. When the unit medication Registered Nurse (RN) was interviewed at this time, it was revealed that this medication is currently on Resident #15's medication regimen for chest pain. The RN stated there is also another bottle of unexpired nitroglycerin tablets the resident may use. However, she had no explanation as to the reason why the expired nitroglycerin tablets were still being stored in the medication cart. She further stated that it is the responsibility of the pharmacist to ensure that medications were removed before their expiration dates. Resident #15 is a [AGE] year old female with [DIAGNOSES REDACTED]. A review of the Medication Record for 08/2012 revealed an order for [REDACTED]. During an interview with the consultant pharmacist on 8/30/12 at 11:00 AM, she stated that the nitroglycerin tablets should have been removed before its expiration date. She further stated that if her consulting company was in the facility during its monthly inspection on July 2012, the expired medication would have been removed. When the Director of Nursing was interviewed on 8/30/12 at 1:00 PM, she stated that the consultant pharmacist's representative was in the facility on 8/7/12 and she stated that the expired nitroglycerin tablets were missed. 415.18 (a)