Every finding on record at Kingsway Arms Nursing Center Inc

Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice. Specifically, (a.) opened medications had no open and/or expiration dates; (b.) personal items were stored in double locked cabinet with controlled substances for 4 out of 4 medication carts reviewed, and for 1 out of 2 medication storage rooms reviewed. This is evidenced by: The facility's Medication Storage Policy revised on 5/2024 documented, all medications would be stored in a clean and sanitary environment, in a locked cabinet, cart or medication room would be accessible only to authorized personnel, as defined by facility guideline. Bulk Medications or multi-use vials would be labeled with the date opened and date that would expire per manufacturer recommendations. These medications would be discarded according to manufacturer's expiration date. The facility's Medication Administration Policy: General revised 5/2024, documented PROCEDURE: 4 a: Read the Electronic Medication Administration Record. Carefully note the name, dose, amount of medication on hand, scheduled time, and expiration date. During an observation on 8/21/2024 at 11:35 AM, the refrigerator located in the pharmacy next to the [NAME] unit, contained an open bottle of Tuberculin Purified Protein Derivative with no open and or expiration date. During an observation on 8/21/2024 at 11:40 AM on [NAME] Unit, Cart #1 contained 1 Lispro and 1 Novolog open vials of insulin, opened 8/19/24 and 8/20/2024 respectively, with no expiration dates. Licensed Practical Nurse #3 stated they were not aware of pharmacy grid of medications with shortened expiration dates. During an observation on 8/21/2024 at 11:55 AM on Stockade Unit Medication Room, Narcotic Box side 2 contained 2 wallets and $3 cash in an envelope. Both belonging to residents. Medication cart # 2 contained open bottles of Timolol and Latanoprost eye drops with no expiration dates after opening. During an observation on 8/22/2024 at 8:50 AM on Stockade Unit, Cart #1 contained 1 open bottle of Artificial tears with no expiration date. During an observation on 8/22/2024 at 9:31 AM on Woodlawn unit, Cart #1 contained. 1 opened bottle of Systane eye drops with no open or expiration dates. During an observation on 8/22/2024 at 9:49 AM, Cart #2 contained 1 vial of Aspart insulin with no expiration date. Licensed Practical Nurse # 1 verbalized expiration was 28 days after opening insulin. During an interview on 8/21/2024 at 12:43 PM, Administrator #1 stated all residents have locked drawers in their room for personal items. Also, the facility had a safe located in their office to keep resident valuables. Families and leadership were made aware safe was available. During an interview on 8/22/2024 at 2:57 PM, Director of Nursing #1 stated the Medication Nurse was responsible for labeling open and expiration dates on multi vial dose medicine. Director of Nursing #1 and Assistant Director #1 stated they were aware of safe in administrator's office but did not know if other floor nursing staff were aware. During an interview on 8/26/2024 at 10:02 AM, Nurse Educator #1 stated nursing competencies included two days of orientation including Medication Administration. Medication administration audit was completed upon hire. Annual nurse competencies have been initiated beginning this year, 2024. The Medication Nurse was responsible for checking open and expiration dates prior to administering medication. The overnight Medication Nurse generally organized medication cart, checks for dates and cleanliness. Stock medications were labeled with open dates, and the expiration was preprinted on the stock medication bottle. 10 New York Codes, Rules, and Regulations 415.18(d)

Based on observation and interviews during the recertification survey, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the main kitchen and Grill Room (resident cafe). Specifically, equipment and food preparation area floors were not clean. This is evidenced by: During an observation in the main kitchen on 8/20/2024 at 9:42 AM, the cooking line shelving, ceiling fan, floor under and behind the cooking line equipment, floor in dry storage room, fire extinguishers, and kitchen fire suppression system canister and pull station were soiled with food particles or thick dust; additionally, the bulk container of liquid thickener was not labeled. During an observation in the Grill Room resident cafe on 8/20/2024 at 10:12 AM, the knife rack and floor under and behind the cooking line equipment were soiled with food particles. During an interview on 8/20/2024 at 10:56 AM, [NAME] #1 stated that they would have the soiled items, areas found in the kitchen and Grill Room would be cleaned and added to the cleaning list. During an interview on 8/20/2024 at 12:21 PM, Administrator #1 stated that they would discuss with the dietary and maintenance departments regarding the soiled areas found in the kitchen and Grill Room. 10 New York Codes, Rules, and Regulations 415.14(h) Chapter 1 State Sanitary Code Subpart 14

Based on observation and interviews during the recertification survey, the facility did not dispose of refuse properly for the outdoor grease collection bin. Specifically, the exterior of outdoor grease collection bin was heavily soiled with a black build-up. This is evidenced by: During an observations on 8/20/2024 at 9:49 AM, the exterior of the grease recycling bin (located in the garbage compactor area) was heavily coated with a black build-up of spilled over grease; flies were hovering around the bin. During an interview on 8/20/2024 at 10:56 AM, [NAME] #1 stated that they would have the grease bin cleaned. During an interview on 8/20/2024 at 12:19 PM, Administrator #1 stated that they would discuss with the dietary and maintenance departments on how the grease bin should be properly filled and kept clean. 10 New York Codes, Rules, and Regulations 415.14(h)

Based on record review and interviews during an abbreviated survey (Case #NY 932), the facility did not ensure that advanced directives were implemented, based on its written policies to implement advance directives for 1 (Resident #1) of 3 residents reviewed. Specifically, for Resident #1, whose Medical Orders for Life-Sustaining Treatment (MOLST) form, documented a DNR Order: Do not attempt Resuscitation (allow natural death), the facility did not ensure Resident #1's preferences regarding advance directives were honored and facility policies for Advanced Directives followed when on [DATE], Resident #1was found without a pulse and without respirations and facility staff performed CPR. This is evidenced by: Resident #1: Resident #1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment tool) dated [DATE], documented the resident's cognitive skills for daily decision making were moderately impaired. The MOLST form, last reviewed/renewed on [DATE], documented a DNR Order. The Policy and Procedure (P&P) titled Advance Directives - General revised ,d+[DATE], documented that the purpose of the policy was to provide an atmosphere of dignity and respect which would ensure that each resident's ability and right to participate in medical decision-making was maximized and to ensure compliance with State and Federal laws and regulations. Residents would be encouraged to communicate their preferences regarding advance directives to their health care agents in the event the resident became incapacitated, rendering them unable to make decisions. As part of the admission process, the resident/health care agent would be provided with access to information including assistance with the development of a MOLST (Medical Orders for Life Sustaining Treatment). Documentation would be made in the EMR (electronic medical record) regarding discussion of advance directives as well as the health care decisions made by the resident and/or health care agent. The P&P titled Advance Directives: MOLST revised ,d+[DATE], documented that the purpose of the policy was to define a process to follow when a resident was admitted with a MOLST. The P&P documented that the policy also outlines procedures regarding the completion of a MOLST by a resident of health care agent and the steps necessary when implementing, reviewing, or revising a MOLST form. The goal of the facility was to honor the wishes of residents and assist them in directing their own care. The P&P documented that a completed MOLST was a valid medical order and was immediately actionable. A Comprehensive Care Plan (CCP) for Advance Directives documented the resident was a DNR. The Incident Note dated [DATE] at 7:00 PM, written by the Director of Nursing (DON), documented that at approximately 5:00 PM, the aide went into Resident #1's room to deliver the meal tray and found the resident on the floor unresponsive. The nurse checked for pulse and respirations, and both were absent. CPR was initiated until the code status was verified that the resident was DNR status per the medical chart. The time of death was 5:35 PM. Review of the Facility's Preliminary Investigation Findings as of [DATE] at 5:00 PM, documented that on [DATE] at approximately 5:00 PM, the Certified Nurse Aide (CNA) entered the resident's room to deliver the meal tray and found the resident on the floor unresponsive. The CNA called out for help and the Licensed Practical Nurse (LPN) determined that the resident had no pulse or respirations. The General Practice Nurse (GPN) and Registered Nurse (RN) responded. The RN then asked the CNA to check the code status. The CNA yelled back that the resident was not a DNR. It documented unfortunately, the CNA was incorrect. The code status of the resident was DNR. The RN initiated CPR based on the CNA's verbal answer and failed to validate the resident's code status with the medical chart, which was readily available per facility policy. EMS personnel arrived and took control of the resuscitation effort. Shortly thereafter, the RN building supervisor retrieved the medical chart, validated the correct code status, and in consultation with EMS personnel, CPR efforts were discontinued. It documented that all staff were being provided with general education regarding Code Status Verification and would be completed for all active staff by [DATE]. Based on a review of the circumstances, the attending physician (MD) has made a preliminary determination that the resident passed from a sudden cardiac event. Review of CNA #1's undated investigation statement documented that they were delivering Resident #1's dinner tray and saw the resident on the floor. CNA #1 ran to tell another CNA and then that CNA ran to tell RN #2, while CNA #1 ran to tell the GPN. The GPN checked for a pulse and then RN #2 arrived and asked if the resident was a DNR and for the supervisor to be called. CNA #1 went and checked the board in the breakroom and saw that the resident's name was not there, so they yelled that the resident wasn't a DNR. Review of RN #2's undated investigation statement documented that on [DATE], CNA #1 screamed their name, they stopped what they were doing, and another aide told them that a resident was on the floor. RN #2 stated that they found Resident #1 on the floor with no respirations and no pulse. RN #2 called out for the code status; someone yelled that the resident was a full code; and they initiated CPR. When EMS arrived, the code status was verified by the medical chart, and it was determined the resident was DNR status. During an interview on [DATE] at 1:24 PM, CNA #1 stated that they were supposed to check the patient's chart for the code status and look for the MOLST, that was usually on the first page. CNA #1 stated that RN #2 asked for someone to see if the resident was a DNR. CNA #1 stated that there was a board in the breakroom that would have information about the resident, instead of having to go to the chart. CNA #1 stated that the resident's name was not written on the full code section of the board. CNA #1 went back to RN #2 and told them that their name was not there for DNR. CNA #1 stated that RN #2 did not ask for the chart. CNA #1 did not know who updated the board and said that everyone looked at the board. CNA #1 stated that the board was taken out. CNA #1 stated that afterwards, they were told to give the chart to the nurse and the nurse would tell them what to do. CNA #1 stated that every unit had a board, and all the boards were gone. During an interview on [DATE] at 2:37 PM, RN #2 stated that they knew about the policy and procedure for checking code status. RN #2 checked the resident, and they were unresponsive and had no pulse or respiration. RN #2 screamed out that they needed to know her code status and someone screamed that they were a full code. RN #2 stated that they did not get the resident's chart and RN #2 proceeded with CPR. RN #2 stated that they did not know where they got the resident's code status from and did not think they looked at the MOLST. RN #2 stated that they thought the aide ran into the break room where there was a board that had the code status. RN #2 stated that only the full codes were written on it, not the residents who were DNR status. RN #2 stated that CPR was yelled out. RN #2 stated that resident's unit was not their regular unit and they were floating to different units. RN #2 stated that their emotions were running high, they heard CPR and initiated CPR. RN #2 stated that they knew the policy was to look at the chart, not the board. During an interview on [DATE] at 1:41 PM, the Director of Nursing (DON) stated that they identified the problem with the board the evening of [DATE]. The DON stated that the board had a full code status section that looked accurate. The DON stated that other wings were checked for boards and the A wing was the only unit to have a board and the only one with a break room. The DON did not know how long the board was being used or who was updating it. The DON stated that the Unit Manager was not aware it was still being used. During an interview on [DATE] at 1:01 PM, RN Manager (RNM) #3 stated they were the Manager for about a year and a half, and the board was there when they first started. RNM #3 stated that they never really looked at it and did not write on it. RNM #3 stated that it was in the break room on the right side of the wall. RNM #3 stated that they were not aware that staff were utilizing the board and was absolutely surprised that staff were using it. RNM #3 stated that staff were supposed to go to the medical chart for code status because it was a legal binding document. RNM #3 stated that when they did their practice drills, they told staff to go to the chart for code status. RNM #3 stated that the CNA would have had to walk past the charts to get to the board in the breakroom. During an interview on [DATE] at 3:55 PM, the Administrator stated they were made aware that there was a white board in the break room. The Administrator stated that it seemed like someone tried to put together a quick access list. The Administrator stated that no other units had a board like that. The Administrator stated that the education given to staff was for residents to wear wrist bands and check the chart for the code status. 10 NYCRR 400.21

Based on observation and staff interview during the recertification survey, the environment was not free from accident hazards over which the facility has control. Specifically, resident room wardrobes were not secured and could topple over on three (3) of four (4) resident units. This is evidenced as follows. During observations on 02/18/2022 from 1:00 PM to 3:30 PM, the wardrobes in resident room numbers 101, 105, 117, 111, 119, 121, C-3, C-4, 201, 203, 204, 205, 207, 209, 211, 217, 218, 221, 233, 310, and 329, were not attached to the wall and could easily topple. During an interview on 02/18/2022 at 3:10 PM, the Director of Maintenance stated that while unaware wardrobes were not attached, perhaps at times, to help residents, staff or family members will try to move wardrobes by pulling on a wardrobe and dislodging the screws attaching it to the wall. During an interview on 02/18/2022 at 5:24 PM, the Administrator and Director of Nursing stated that they were unaware that wardrobes were not secured, all wardrobes are now being secured, and at present the facility does not have problematic residents that wander in and out of rooms. 10 NYCRR 415.12(h)(1)

Based on observation, record review and interview during a recertification survey the facility did not ensure comprehensive person-centered care plans were developed and implemented for each resident that included measurable observations and time frames to meet a resident's medical, nursing, mental and psychosocial needs for (2) (Resident #'s 12 and #76, of two (2) resident's care plans reviewed for an ambulation program. Specifically for Resident #'s 12 & #76, the facility did not ensure the comprehensive care plan (CCP) for the resident's ambulation program was consistently implemented. This is evidenced by: The facility Policy and Procedure P&P titled, Care Plan: Development and Management last reviewed 3/2021, documented the purpose of the policy was to create and develop comprehensive care plans to provide effective person-centered care. The facility was unable to provide a P&P for the Nursing Unit Ambulation Program. The facility P&P titled, ADL documentation, CNA (Certified Nurse Assistant) reviewed 2/2021 documented the CNA who has completed the resident care will be responsible for documenting the level of care the resident received during their shift. It documented the CNA would notify the nurse of any concerns regarding refusals or change in ability. Nurses would evaluate the resident and determine appropriate interventions during each instance of refusal of when goals were not met and nurses notes would include the identified issue and interventions tried. Resident #12: Resident #12 was admitted to the facility with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment tool) dated 11/19/2021 documented the resident was without cognitive impairment. The resident was alert and oriented. It documented the resident required one-person physical assistance with ambulation. The CCP for Activities of Daily Living (ADL) Performance Deficit, revised 11/5/2021 documented an intervention for the resident to be walked in the corridor with limited assistance of one person for up to forty feet twice daily. Additionally, an intervention documented the resident would be provided with the nursing unit ambulation program as scheduled. The Follow Up Question Report (used by staff to document care provided) for Resident #12 dated 1/17/2022 through 2/17/2022 documented: Walk in Corridor with limited assistance of one staff for up to forty feet twice daily: A response of Not Applicable was documented on 1 day shift out of 32 opportunities and 10 evening shifts out of 32 opportunities. A distance of greater than 40 feet was documented for 14 out of 32 day shift opportunities and 7 out of 32 evening shift opportunities. Nursing Progress Notes dated 1/17/2022 through 2/17/2022 did not include documentation of resident refusal or inability to ambulate per CCP. During an interview on 2/18/2022 at 1:18 PM, Resident #12 stated they are not consistently ambulated on the evening shift. Resident #12 stated they were ambulated on the day shift only yesterday. Resident #76: Resident #76 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-an assessment tool) dated 1/7/2022, documented the resident was cognitively intact, and required extensive assistance of one-person assistance with ambulation. During an interview on 2/17/2022 at 10:15 AM, Resident #76 stated they were not consistently ambulated twice daily. Resident #76 stated the staff told them they did not have time to ambulate them twice a day, mostly on the evening shift. The CCP for ADL/ Mobility last revised on 7/23/21 documented an intervention for the resident to be walked in the corridor with extensive assistance and one person for sixty feet. Additionally, an intervention documented the resident would be provided the nursing unit ambulation program as scheduled. The Follow Up Question Report (used by staff to document care provided) for Resident #76 dated 1/17/22 through 2/17/22 documented for: Walk in Corridor with extensive assistance of one staff sixty feet twice daily: A response of Not Applicable on 17 out of 32 opportunities evening shift opportunities. A distance of thirty feet or less was documented for 9 out of 32 [NAME] shift opportunities and 8 out of 32 evening shift opportunities. Nursing Progress Notes dated 1/17/22 through 2/17/22 did not include documentation of resident refusal or inability to ambulate per CCP. Interviews During an interview on 2/23/22 at 10:37 AM, Licensed Practical Nurse (LPN) #1 stated residents should be ambulated by Certified Nurse Assistants (CNA) once or twice daily as scheduled on the CNA tasks. LPN #1 stated if the task could not be performed or the resident refused the CNA should let the nurse know, the resident reapproached, and a nursing note would be written. During an interview on 2/3/22 at 11:08 AM, CNA #2 stated they regularly cared for Resident #12 and Resident #76, and they did not refuse ambulation. CNA #2 stated she did not know why a CNA would document NA for ambulating a resident. During an interview on 2/23/22 at 11:23 AM, Registered Nurse Unit Manager (RNUM) #1 stated the resident should be ambulated as scheduled usually once or twice per day. RNUM #1 stated the CNA tasks were assigned in the electronic record and when a resident was tasked for ambulation on the day and evening shift then the CNA would know to ambulate the resident that frequency. RNUM #1 stated a CNA would be expected to tell the nurse when a resident refused, or an ambulation program scheduled was not completed. The RNUM #1 stated they were not aware CNAs were documenting Not Applicable for ambulation on Resident #12 and #76. During an interview on 2/23/22 at 11:38 AM, the Director of Nursing (DON) stated staff should provide ambulation per the resident's CCP. The DON stated a facility report was run daily and included the level of assistance needed, how far a resident was to be ambulated and the frequency the ambulation should occur. The DON stated they would expect the care plan would be implemented and staff would not document Not Applicable for a resident with a care planned ambulation program. 10NYCRR415.4(b)(1)(i)

Based on observation, record review and interview during the COVID-19 Focused Infection Control Survey (NY 569) conducted on 09/23/20, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent and/or contain transmission of COVID-19. Specifically, facility staff did not use proper personal protective equipment (PPE) for Residents on droplet contact precautions for 2 of 4 units reviewed. Additionally, the facility did not ensure that staff performed hand hygiene on one of 4 units. The findings are: Review of the facility policy titled Infection Control Droplet Precautions revision date of September 2019, directed all persons having direct contact with residents or contaminated environment must wear clean gloves, gowns, mask and goggles. On 9/23/20, the Hospital Electronic Response Data System (HERDS) report listed the following information: Facility census- 153, 1 COVID-19 positive resident; 0 COVID-19 related deaths, and 49 residents on isolation. Interview on 9/23/20 at 9:20 AM, the Director of Nursing stated 49 residents were on Droplet Contact Isolation Precautions. Staff are expected to wear surgical face masks, goggles, gown, and gloves while in isolation rooms. Findings #1 Observation on 9/23/20 at 10:00 AM on Unit A, Licensed Practical Nurse (LPN) #1 was wearing a surgical mask, goggles, and gloves while providing care to a Resident in room [ROOM NUMBER]. Signage on the door of room [ROOM NUMBER] read All staff must wear gloves, gown, mask and eye protection to enter the room. LPN #1 was not wearing a gown. Interview on 9/23/20 at 10:03 AM, LPN #1 stated she forgot to put on a gown before entering the room to provide resident care. LPN #1 confirmed the resident was on droplet precautions. Findings #2 Observation on 9/23/20 at 10:04 AM on Unit D, room [ROOM NUMBER]'s door had signage that read Droplet and Contact Precautions. At 10:09 AM, Certified Nursing Assistant (CNA) #2 was observed in room [ROOM NUMBER] wearing goggles, surgical face mask and gloves. CNA #2 was not wearing a gown. CNA #2 removed her gloves, exited the room and proceeded up the hallway pushing a dirty linen cart. She did not perform hand hygiene. She stopped in the hallway, used a wall hand sanitizer and continued pushing the dirty laundry cart. CNA #2 parked the dirty laundry cart next to a clean linen cart and proceeded to handle towels and washcloths from the clean linen cart. Interview on 9/23/20 at 10:13 AM, CNA #2 stated she was supposed to wear a face mask, goggles, gown, and gloves when in isolation rooms. CNA #2 stated she did not wear a gown while cleaning the room because the resident was not in the room. CNA #2 stated that she should have washed her hands between touching the dirty and clean laundry cart and once she touched the dirty linen, she should have washed her hands. Interview on 9/23/20 at 10:20 AM, the Unit Manager stated that all staff members providing care to residents on droplet precautions are expected to wear face mask, goggles, gowns and gloves. The Unit Manager stated that the CNA #2 needed to wear a gown since [MEDICAL CONDITION] is airborne and it could attach to her clothing. The CNA #2 should have performed hand hygiene after touching the dirty laundry cart. Interview on 9/23/20 at 11:45 AM, the Infection Control Preventionist (ICP) stated that she and other staff members make impromptu rounds to ensure staff's compliance. If a problem is identified, that staff member receives immediate re-training and is monitored closely for adherence. 10NYCRR415.19 (a) (1-3) 10NYCRR415.19 (c)

Based on observation and staff interview during the recertification survey, the facility did not store, prepare, distribute or serve food in accordance with professional standards for food service safety. Specifically, food contact and non-food contact equipment in the main kitchen were not clean, and beverages and plastic serving utensils were stored under sink waste lines. This is evidenced as follows. The food preparation areas were inspected on 09/24/2019 at 8:49 AM. Ten cutting boards on the storage rack in the main dining were covered in food debris, the exhaust fan guards in the walk-in cooler were covered in dust, exhaust fan guards over the grill line covered were covered with grease, and the floor under the grill line was covered in grease. Soda cans and plastic serving wares were stored under the sink waste line in C-wing resident unit kitchen. The Director of Dining Services stated in an interview on 09/24/2019 at 9:28 AM, that staff can do a better job of cleaning the cutting boards, exhaust fans, and wall behind the grill line. Additionally, he will follow up with the nursing staff to ensure that food and plastic utensils are not stored under waste lines in the nourishment kitchens. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.90, 14-1.110, 14-1.170

Based on record review and staff interview during the recertification survey, the facility did not ensure their policy regarding foods brought to residents by family and other visitors included information on the safe and sanitary storage, handling and consumption of food. Specifically, the facility policy does not provide information on safe reheating of food and a procedure to ensure facility staff assisted dependent residents in accessing and consuming the food. This is evidenced is as follows. Record review of the facility policy for food brought in by visitors was reviewed on 09/25/2019. The policy did not include information regarding holding temperatures and reheating procedures for foods and did not include a procedure to ensure staff-dependent residents in accessing and consuming the food. The Director of Dining Services stated in an interview on 09/25/2019 at 2:15 PM, that the policy for food brought to residents does not include procedures for reheating and storing food at proper temperatures and does not include guidelines on how residents will access food brought to them.

Based on observation and staff interview during the recertification survey, the facility did not store, prepare, distribute or serve food in accordance with professional standards for food service safety. The FDA Guidelines, a model code used by most jurisdictions to develop State and local regulations, and Chapter 1 Subpart 14 State Sanitary Code, the community standard for food service establishments operating in New York State both state that food packages shall be in good condition to protect the integrity of the contents, equipment and surfaces shall be kept clean, and employees shall wear hair restraint in food preparation areas. Specifically, the hermetic seals of canned foods in the common stock area were compromised, various food contact and non-food contact surfaces were not cleaned after use, and kitchen employees were not wearing hair nets correctly. This is evidenced as follows. The main kitchen was inspected on 01/08/2018 at 7:17 am. The can opener, chest freezer, handwashing sinks, fire extinguisher, and radio were soiled. The hermetic seals of one #10 nacho sauce and one #5 V8 juice were compromised with creasing dents. The can of nacho sauce and V8 juice were mixed with the common stock. The Director of Dining Services stated in an interview conducted on 01/08/2018 at 8:13 am, cans are checked for dents by the stock person, usually a dishwasher and prior to use by the cooks. During an observation on 01/08/18 at 08:11 am observed Dietary Worker #1 with a hair net only covering half her hair and Dietary Worker #2 with hair in a bun and hair net only covering bun. During an observation on 01/09/18 at 07:56 am observed Dietary Workers #3 and #4 without hair covered in kitchen area. During an interview 01/09/18 at 07:57 am, the Director of Dining Services stated he thought if hair was pulled back it did not need to be in a hair net. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.32, 14-1.110

Based on observation, interview, and record review during the recertification survey the facility did not establish and maintain an infection prevention and control program (IPCP) designed to help prevent the development and transmission of communicable diseases and infection for all residents and staff on 4 of 4 units during the recertification survey. Specifically, the facility did not maintain infection control for Resident #'s 19 and 86's dressing change and skin treatment respectively; did not maintain droplet precautions for Resident #9 and did not maintain infection control for Resident #52's eye medication administration. This is evidenced as follows. Finding 1 The facility did not maintain infection control for Resident #19 and 86's dressing change and skin treatment respectively. Resident #19: The Dressing change policy and procedure -clean dressing technique, dated 3/2007 documented: 1. Gather equipment, clean gloves, waterproof pad/barrier, irrigation syringe (if needed), ordered cleaning solution, scissors, prescribed treatment, sterile Q-tip, tape, disinfectant wipes, overbed table or clean surface space. 3. Clean over bed table. with soap or water or disinfectant, Air dry, set up barrier for supplies. 5. Wash hands apply clean gloves 6. Position resident for procedure for maintaining dignity. place waterproof pad beneath resident if irrigation is warranted. 7. Open all dressing packages and materials needed to clean wound, and place on barrier on table. 8. Remove old dressing and discard soiled dressing in trash. Wash hands and apply clean gloves. 9. Clean wound with saline and gauze in a circular motion from inside out, using one hand. 10. Use sterile Q-tip to apply treatment ordered. 11. Apply clean dressing using other hand. Secure dressing. 12. Remove gloves using inside out technique, dispose of trash, wash hands. The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident had no cognitive impairment, could understand and could be understood by others. The physicians order dated 12/20/17, documented treatment to left gluteal fold: Cleanse wound with 0.25 % Dakins solution with each dressing change, then flush with NS (normal saline). Cut a thin strip of [MEDICATION NAME] blue to pack wound and cover with a Tielle dressing. Change every other day and PRN (as needed). The Electronic Treatment Record (eTAR) for January 1, 2018, documented treatment to left gluteal fold: Cleanse wound with 0.25 % Dakins solution with each dressing change, then flush with NS. Cut a thin strip of [MEDICATION NAME] blue to pack wound and cover with a Tielle dressing. Change every other day and PRN. During observation on 01/10/18 at 02:06 pm, LPN #1 performed wound care to the residents left gluteal fold. LPN # 1 placed supplies on a overbed table without cleaning the table, then cleaned half the table and placed a barrier on the side that was cleaned. During hand washing, LPN #1 pushed the wet paper towels into the trash can. LPN #1 donned gloves, opened the supplies and dropped them on the barrier. As LPN #1 opened the supplies she dropped the outer wrappers of the dressings into the garbage can and pushed the wrappers into the garbage can. LPN #1 assisted LPN #6 in removal of the residents attends and LPN #1 changed her gloves without using any sanitizer. LPN #1 circled in and out of the wound several times with a Dakins' soaked Q-tip, flushed the wound with a saline bullet (single use vial of saline) touching the inside of the wound and placed the saline bullet back on the clean field. LPN #1 wiped the wound with 4 x 4 dry clean dressing (DCD) moistened with NS in a circular motion, then wiped up and down the wound before discarding the 4 x 4. LPN #1 touched the side of the buttocks while inserting [MEDICATION NAME] blue with a Q-tip into the wound. She applied the outer DCD without removing gloves, washing hands, or putting on clean gloves. LPN #1 left the room carrying the bottle of Dakins against her uniform and placed it on the table in the nursing office. During interview on 1/10/18 at 2:41 pm, LPN #1 stated she should not have gone into the wound bed with q tip back out and then back in. During an interview on 1/11/18 at 11:35 am, the Infection Control Registered Nurse (ICRN)stated that nurses are inserviced once a year on proper dressing change procedures. The bedside table or surface used should be cleaned entirely prior to starting wound care. Any thing brought into the residents room should stay in the room or be discarded after wound care is completed. She stated LPN # 1 should have followed the policy and procedure that was put in place to prevent a possible infection to the resident. She stated the nurse should clean a wound going from the inside out, whether using a q-tip or a gauze to prevent contamination of the wound. Resident #86: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) of 13/15, having intact cognitive skills for daily decision making, and further documented the resident could usually understand and could usually be understood by others. The MDS also documented the resident required extensive assistance for bed mobility and had total dependence with transfers requiring 2-person physical assist. A physicians order dated 1/10/18 documented apply triple paste (medicated ointment for diaper rash) to the residents left and right buttocks two times a day and PRN (as needed) for treatment of [REDACTED]. During an observation on 1/10/18 at 11:35 am, Resident #86 was checked for a skin related moisture associated skin damage (MASD) (inflammation of the skin, occurring by prolonged exposure to urine, stool, perspiration, and wound drainage) on his buttocks. While the resident was laying in bed, Registered Nurse Manager #2 (RNM) and LPN #1 removed the residents brief. RNM #2 washed her hand for 10 seconds, dried her hands and put on gloves. She removed a box of triple paste from her lab coat pocket, took the tube out of the box, placed the box on the bed, and squeezed the medication on to her gloved hand. RNM applied the medication to the residents compromised skin without cleaning the skin. During the application of the medication, LPN #1 held the residents hip and buttocks after the brief was removed with gloved hands. After the ointment was applied, LPN #1 reapplied the same brief and without removing gloves or performing any hand sanitizing, she handed the call bell to the resident. During an interview on 1/10/18 at 12:00 pm, RNM #2 stated the lab coat had been clean, but the box of triple paste should not have been placed in the pocket. She stated the resident was not soiled, but if he were she would have cleaned him before applying the medication. During an interview on 1/10/18 at 12:05 pm, LPN #1 stated she should have removed her gloves and washed her hands before handing the call bell to the resident. During an interview on 1/11/18 at 11:35 am, the ICRN stated a clean field should be set up when applying ointments or doing any treatment. She stated a nurse should not bring any type of ointment into the residents room in her uniform pockets. It should have been put in a medicine cup and applied after cleaning the resident and application should have been done using a Q-tip. The LPN should have removed her gloves and washed her hands prior to handing the resident his call bell. Recommended time to wash hands is 15 seconds. Finding #2 The facility did not maintain infection control during eye medication administration. Resident #52: A facility policy date 5/2014 for medication administration for external medication, (eye, ear, nose and throat.) documented: gather supplies, wash hands, apply gloves. Position head back, pull lower lid down, squeeze drop into conjunctival sac, provide a tissue or gauze to catch excess drainage. Use different clean gauze for each eye to prevent cross contamination. The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The MDS of 11/3/17, documented the resident could understand and was usually understood, with a BIMS of 6/15 and was severely cognitively impaired. A physicians order dated 10/23/17 and renewed 12/27/17, documented azelastine 0.05% eye drops: Instill 1 drop by ophthalmic (eye) route in each eye once daily. Every day at 9:00 am. The eMAR (electronic medical administration record) dated January 2018 documented azelastine 0.05% eye drops: Instill 1 drop by ophthalmic (eye) route in each eye once daily. Every day at 9 am. During an observation of a medication pass on 01/10/18 08:30 am, LPN #4 administered Resident #52, azelastine 0.05% eye drops 1 drop to both eyes, and blotted both eyes using the same tissue for each eye. During an interview on 1/10/17 at 8:42 am, LPN #4 stated she thought they used to use 2 tissues, but was told to change to use only one tissue. She was not sure of this and may not be remembering correctly. During an interview on 01/13/18 at 08:00 am, RNM #4 stated her expectation would be for the med nurse to use two tissues when giving eye drops to both eyes. The RNM was informed that during observation of the med pass the nurse used the same tissue to blot both of Resident #52's eyes. Finding #3 The facility did not maintain infection control regarding droplet precautions. Resident #9: The facility policy dated 8/08 for Infection Control: Reporting and Precautions documented for Droplet Precautions a) droplet precautions are utilized to prevent the spread through close respiratory or mucous membrane contact with respiratory secretions. c) keep a distance of equal to or greater than 3 feet and drawing the curtain between the beds is important in rooms with multi residents; f) the methods utilized for droplet precautions are as follows: Time in Common areas-when residents are experiencing symptoms and are feeling ill they should have more time in their room and even in bed; during the time a resident is coughing and having secretions the residents: should be encouraged to remain in their room, avoid going to the MDR (main dining room) or Unit dining rooms, avoid contact with other residents. - residents may be allowed to go to planned activities or MDR if their acute symptoms have resolved and there is no cough. The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The MDS of 10/6/17, assessed that the resident was usually understood, sometimes understands and was severely cognitively impaired. A medical progress note dated 1/5/18, written by the Nurse Practitioner, documented the resident was seen for a productive cough and congestion, and noted to have an increase in chest congestion over the past few days. This includes a productive cough noted after eating breakfast. She has been afebrile during this time. The resident reported a cough upon awakening and throughout the day with clear nasal drainage. On exam the resident had unlabored respirations, productive cough noted with mild lower lobe expiratory wheezing. The resident has acute laryngopharyngitis. Will have Speech screen for aspiration related cough. Plan was to start [MEDICATION NAME] two times a day and Tussen DM 10 ml (milliliter) by mouth four times a day for 3 days. Nursing progress notes documented: 1/5/18 the resident had congestion/cough, vital signs stable and the resident was afebrile (without fever). The resident was assessed by the Nurse Practitioner (NP) and new orders for [MEDICATION NAME] (cough syrup) and [MEDICATION NAME] ( inhalant medication to open the airways) for three days ordered. 1/7/18 at 6:43 am, Temperature 100.4 degrees. Occasional congested cough. The resident had several blankets on per her usual. At 3:50 pm the resdient had been given [MEDICATION NAME] and [MEDICATION NAME] throughout the day. Upper airway congestion heard when coughing, rhonchi heard in upper lobes bilaterally, cleared by coughing. Lower lobes somewhat diminished. MD (physician) notified and changed [MEDICATION NAME] to every 4 hours as needed and [MEDICATION NAME] every 4 hours as needed and a STAT (immediate) chest x-ray. 1/8/18 at 7:09 am, the resident said she felt warm. At 2:00 am, she agreed to have all but one blanket removed. At 4:00 am, temp was 100.7 degrees. Occasional congested cough continues. At 7:20 am, the resident continued with cough/cold symptoms-flu swab ordered-resident placed on droplet precaution. At 2:09 pm the flu swab was negative and the resident remained on droplet precautions. On 1/10/18 at 6:19 am, droplet precautions maintained. On 1/8/18 at 9:30 am, the resident's room had isolation bins with droplet precautions equipment outside her door and a sign to see the nurse. On 1/8/18 at 9:30 am, the resident's room had isolation bins with droplet precautions equipment outside her door and a sign to see the nurse. On 1/09/18 at 12:03 pm, the resident was observed in the unit dining room coughing and blowing her nose. She did not cover the cough. She had yellow discharge from her nose. There was a box of tissues on the table in front of her and she had used a tissue to blow her nose. There was no one else at her table, but there were two residents at the table behind her. A Medical progress note dated 1/10/18, written by the MD, documented the resident has had a cough and congestion recently. She was negative for flu and the chest x-ray was unremarkable. She is using [MEDICATION NAME] and cough syrup with good relief. The Impression and Plan included URI, most likely [MEDICAL CONDITION]. Continue with conservative therapy. On 1/10/18 at 8:24 am, the resident was wheeled into the unit Dining Room. She was set up at a tray table facing other residents. The DR was full. The resident was coughing and sounded congested as she was eating her breakfast. She was not observed to cover her cough. At 8:49 am, the resident had eaten all her breakfast. She started coughing as another resident was wheeled by her into the DR. At 9:08 am, the resident was in the tea room (day room) which was full of residents. There was a resident on either side of this resident, wheelchair next to wheelchair. At 9:15 am, Licensed Practical Nurse (LPN) #8 was observed giving the resident cough medication. The resident coughed when the nurse left the room. A nursing progress note dated 1/10/18 at 9:39 am, documented the resident had been maintained on droplet precautions due to cough. A flu swab on 1/8/18 was negative and a chest x-ray was unremarkable. The resident continues to have a cough, is afebrile and is able to manage her secretions as she is observed to cover her her mouth when she coughs and is appropriately using tissues with a disposable bag at her side. Will discontinue droplet precautions at this time. On 1/10/18 at 10:57 am, the resident was observed in her room, there was no longer droplet precautions equipment or a sign on the door. During interview on 1/10/18 at 9:20 am, LPN #8, Clinical Coordinator, said the resident was on droplet precautions for a cough. Her flu swab was negative and they did a chest x-ray which was negative. She was asked if the resident should be with other residents. She said she was thinking of taking her off precautions because she had not heard a cough today. She stated the resident was not on antibiotics, it was upper airway infection. She said the resident was not diagnosed with [REDACTED]. She said colds are contagious. She was told the resident was in the tea room between two other residents. She said she would remove the resident who was closer than 3 feet away from other residents. During interview on 1/11/18 at 7:26 am, LPN #7 stated the resident was on droplet precautions because she had a cough and temperature. She thought a resident on droplet precautions would stay in their room but if they could contain their cough the resident could come out. LPN #7 stated she thought this resident could not contain her cough. During interview on 1/12/18 at 12:05 pm, Registered Nurse Manager (RNM) #5 said the resident was on droplet precautions on the 8th because we were testing her for the flu, she had a cough and low grade temperature. Precautions means staff entering the room wears gown, gloves and mask. We try to maintain the resident in their room, but it is difficult for some residents. The resident was kept on precautions due to the severity of her cough. We try to maintain a 3 foot distance from other residents if they are out of room. She stated all staff should monitor the resident to be three feet away from other residents. We try to avoid her in the DR but she requires supervision so would need to be monitored when eating. Once she exhibited good cough hygiene by covering her mouth, we took her off precautions. She was on precautions until the 10th when she wrote a note at 9:39 am. The RNM stated it was facility policy to put a resident on droplet precaution when a flu swab was done. She said she left the resident on after the flu swab was negative [MEDICATION NAME] because of the strong cough but she could have come off sooner. During interview on 1/12/18 at 12:56 pm, the Registered Nurse Infection Control/Staff Education Nurse stated the resident was started on droplet precautions for potential flu. While the sign is on the door and and isolation bins are there, the resident is on precautions. That means staff going into the room need to wear gown, gloves, and mask. The resident can come out of their room if it is not the flu and if a resident maintains the 3 foot rule from other residents. She was asked about the DR and she said she would isolate the resident 3 feet from other residents. She stated she kept the resident on precautions after the swab came back negative because of her signs and symptoms. 10NYCRR415.19(a)(1-3)

Based on record reviews and interviews during the recertification survey, the facility did not ensure each resident had a person-centered comprehensive care plan developed and implemented to meet the residents' preferences and goals, and addresses the resident's medical, physical, mental and psychosocial needs for 3 (Resident #'s 78, 106, and #124) of 31 residents reviewed. Specifically: For Resident #78, the facility did not ensure a person centered care plan was developed for pain management; For Resident #106, the facility did not ensure the care plan for [MEDICAL TREATMENT] was accurate, that the turning and positioning schedule on the care plan and care card matched, and that a care plan for advanced directives was in place on readmission to the facility; and that Resident #124's behavior care plan documented specific interventions for behaviors. This is evidenced by: Resident #78: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident was cognitively intact. The Pain Management care plan, with an effective date of 2/13/15, documented alterations in comfort related to [MEDICAL CONDITIONS], muscle weakness, pain in knees and chronic low back pain. The interventions, dated 2/13/15, included: 1) Administer medications as ordered, 2) Refer to rehab (rehabilitation) services as needed, 3) Monitor side effects and adverse reactions resulting from interventions rendered, 4) Discuss with patient pain management and 5) Monitor behavior and assess for pain/discomfort if change in behavior noted. During an interview on 01/11/18 at 2:11 pm, the Registered Nurse Unit Manager (RNUM) stated that knowing the resident, the care plan should have included rest breaks as an intervention when he ambulates and specific non-pharmacological approaches to pain management. Resident #106: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set, dated dated [DATE], documented the resident was cognitively intact. The [MEDICAL CONDITION] [MEDICAL TREATMENT] care plan, effective 11/28/17, documented to monitor HD ([MEDICAL TREATMENT]) site for thrill and bruit. During an interview on 1/9/18 at 10:43 am, the resident stated she did not have a [MEDICAL TREATMENT] fistula in her arm. During an interview on 1/11/18 at 2:25 pm, the RNUM stated she should have removed the intervention of monitor HD site for thrill and bruit from the computerized, pre-filled library of care plans, as the resident does not have a [MEDICAL TREATMENT] fistula. The Pressure Injury care plan, effective date 11/27/17, documented impaired skin integrity related to pressure ulcers. The interventions documented: turn and reposition every two hours in bed and every 1 hour in chair or per resident preference. The Current Certified Nursing Assistant (CNA) care card, undated, documented turn and position every 3-4 hours. During an interview on 1/11/18 at 2:20 pm, the RNUM stated the care plan and the CNA care cards should match and she recognized she did not revise the CNA care card to reflect the plan of care. During review of care plans, there was no advance directive care plan in place. On admission, the residents' MOLST (Medical orders for life-sustaining treatment) documented the resident as full code status. On 1/10/18, the resident signed the MOLST form and her code status became a DNR (do not resuscitate). During an interview on 1/11/18 at 2:20 pm, the RNUM stated that all residents should have an advanced directive care plan on admission. She stated it is the responsibility of Social Services to do the advanced directive care plan. During an interview on 1/11/18 at 3:14 pm, the Director of Resident and Family Services stated advanced directive care plans are the responsibility of the Social Services Department and the resident's advanced directive care plan should have been developed upon admission and revised appropriately. Resident #124: The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], documented the resident as sometimes understands and sometimes understood, had severe cognitive impairment and never/rarely made decisions. The Behavior Symptoms care plan, dated 12/1/17, documented redirect negative behaviors. During an interview on 1/11/18 at 2:31 pm, the RNNM stated Social Services is responsible for behavior care plans and she knows what nursing is doing to redirect the resident. During an interview on 1/11/18 at 3:18 pm, the Director of Resident and Family Services stated the behavior care plan should have resident specific interventions related to redirection for behaviors. 10NYCRR415.11(c)(1)

Based on record review and interview during a recertification survey, the facility did not ensure acceptable parameters of nutritional status were maintained for one (Resident #504) of three newly admitted residents'. Specifically, for Resident #504, the facility did not ensure the resident's weight was monitored in a timely manner to identify and address weight loss. This is evidenced by: Resident #504: The Resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented the resident as sometimes makes self understood, sometimes understands others and severely impaired cognitively. The MDS documented weight on admission as 151 pounds and height as 68 inches. The Weights, General Principles policy and procedure, dated 10/2014 and reviewed on 12/2017, documented new admissions and readmissions weights are planned to be completed within 24 hours of admission and are to be done weekly for at least 4 weeks. Step 6 documented: The CNA (Certified Nursing Assistant) will inform the nurse of the weight results. The nurse will enter the weight into the EMR (Electronic Medical Record). The nurse will then compare to the previous weight and if there is a discrepancy of 5 or more pounds a re-weight will be done the following day. There will be a one- time order for a re-weight entered into the EMR for the following morning. Step 7 of the procedure documented: Upon verification of a 5-pound weight change (or 3 pounds if resident weighs less than 100 pounds), there will be an RN (Registered Nurse) assessment and dietary notification. The Resident's weight record documented: 12/19/17= 160 lbs., 12/26/17 =147 lbs., 12/28/17 = 151 lbs. Weight was requesed to be done on 1/10/18 and was 144 lbs. The Dietary-Nutrition Assessment completed 12/29/17, documented a weight of 160 pounds, weight a week ago was 151 lbs and there was a potential 9 lb. weight change in 7 days. The hospital Emergency Department recorded his verbal weight at 160 lbs. Intake has been variable since admission. Re-weight for week 1 is at 151 lbs, a significant decline over the last 7 days. There was a new order for Two Cal ( nutritional supplement) three times a day on 12/29/17 and will closely monitor the weekly weight checks. A Dietary Progress Note dated 12/29/17 documented: Resident has a history of poor intake, potential significant weight loss - admit weight was160 lbs (pounds) and then 151 (pounds) greater than 5 % weight loss, will monitor weight and intake closely and notify NP (Nurse Practitioner). The January 2018 Electronic Medication Administration Record [REDACTED]. During interview on 01/10/18 at 8:13 am, Licensed Practical Nurse (LPN) #5 stated the resident was not in the weight book for today, and the only way to know a weight is needed was if the computer flashes or it was documented in the weight book or in the nursing communication book. She stated dietary usually reviews weights and would reorder the weight so it would flash in the computer; to let nursing staff know a weight needed to be obtained. During interview on 1/10/18 at 8:41 am, the Diet Technician (DT) stated she looks at weights weekly. She was asked about the lack of a weight on 1/2/18. She stated she missed that the weight had not been obtained on 1/2/18 and 1/9/18, She stated she ordered a weight yesterday (1/9/18) and put the order into the computer, however, she was unable to find the order she put in and the weight was not done. During an interview on 01/10/18 10:33 am, with the RNNM, the RNNM stated that when a resident refuses a weight, staff should reattempt until obtained. Nursing staff should document refused and then enter a new order for a weight the following day. The RNNM could not find a reweight order that the DT stated she put in. RNNM reviewed the 1/2/18 weight refusal and stated there should have been a progress note as to why the weight was refused.

Based on record review, observation, and interviews during a recertification survey and a complaint investigation (Case # NY 608), the facility did not ensure that the residents' environment remained as free of accident hazards as was possible and each resident received adequate supervision to prevent accidents for 1 of 3 residents reviewed. Specifically, Resident #116 was provided with an incorrect texture of food and food items were accessible in his room. Resident #116: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident to have severe cognitive impairment with a Brief Interview for Mental Status of 1. Additionally, the MDS assessed the resident to rarely or never be able to be understood and rarely or never able to understand others. Review of Physician order [REDACTED]. Review of Facility Diet Manual, documented that meat served in a mechanical soft consistency must be very tender, small pieces, shredded, chopped or ground, and well moistened with gravy or cream sauce. Additionally, it documented to avoid dry/tough meats, whole pieces of meat, hot dogs, bacon, peanut butter or cheese by itself. Review of Nutritional Care Plan dated 4/10/2015 identified Resident #116 had a potential for altered nutritional status related to requiring assistance with feeding and requiring a mechanically altered food consistency. The Care Plan documented interventions including providing resident with a mechanical soft consistency diet, staff to assist with food choices and provide assistance with feeding. Review of Dysphagia Care Plan dated effective 1/28/2016 documented the resident had impaired swallowing and the interventions of assist with meals and to cue the resident to take small bites and sips at a slow pace. Review of Resident Nursing Instructions documented supervision with meals effective 6/5/15, mechanical altered diet effective 1/28/16, and an additional instruction to redirect the resident if he took large bites. Review of Facility Resident Investigative Report dated 6/19/16 documented that Resident #116 ordered and received regular consistency filet mignon. The meat was cut by 2 different staff members. The staff members noticed Resident #116 had been chewing for an excessively long period of time and was not swallowing. Resident #116, then became unable to clear his throat and the nursing staff performed the Heimlich Maneuver (a technique of abdominal thrusts for stopping choking) and a finger sweep (a technique for clearing a mechanical obstruction from the upper airway of an unconscious patient) to dislodge meat pieces from his throat. Resident #116 had been pocketing the filet mignon and had unsuccessfully tried to clear his throat through coughing. The resident had a history of [REDACTED]. The tender filet mignon was deemed as appropriate for the resident to eat by Expeditor #1 if cut up (rather than being served in a ground texture). The report further documented this was an inappropriate determination. The report was signed and dated 6/23/16 by the Director of Nursing (DON) and the Administrator. Review of signed statement by Expeditor #1 dated 6/19/16 documented he was aware the resident was on a mechanical soft texture diet when the filet mignon was ordered by resident and his family. Additionally, it was documented that the Expeditor felt the filet mignon was tender enough for Resident #116 to handle after being cut into small pieces. Review of signed statement from Dietary Server #1 (undated) documented Resident #116 and his family had ordered the filet mignon. Dietary Server #1 had given the meal ticket requests to Expeditor #1. The family had requested the resident's food be cut up when delivered. Additionally, it documented that Resident #116 began to cough continuously and Server #2 screamed for nurse assistance as the resident began to choke. Review of signed statement from Dietary Server #2 (undated) documented that on 6/19/16, during Father's Day meal Resident #116's family called Dietary Server #2 over and requested that Resident #116's food be cut up more (a second time) and stated the pieces were too big. Approximately 10 minutes later, Dietary Server #2 was notified by the resident's family that he seemed to be having trouble. The resident nodded in a yes motion that he was ok when asked by the dietary server. The dietary server then called for nurse assistance because it seemed to her the resident was having trouble breathing. The staff present attempted to get him to cough up whatever was in his throat and he began to actively choke. Review of Registered Nurse Supervisor (RNS) progress note dated 6/19/16 at 2:22 pm, documented the resident appeared to not be breathing while having lunch. The Heimlich had been performed several times to assist the patient in breathing. It documented that after several Heimlich attempts and finger sweep clearing three chunks of beef the patient started to breath followed by a coughing episode. The resident was assisted back to bed and started on 10 liters of oxygen via facial mask. The RNS continued to check on the resident and there were no further episodes of coughing or choking. The resident was changed to puree foods until evaluated by the dietician. The facility educational record dated 6/19/16 for Expeditor #1 documented that the staff member was immediately educated by his Dietary Supervisor, that Expeditor #1 should not have interpreted the diet consistency differently than what was written on the diet card. The Expeditor agreed. The facility educational record dated 6/19/16 for the Dietary Server #1 documented that the staff member was immediately educated by her Dietary Supervisor. It documented that she should check the consistency of all meals prior to serving to the residents and make sure the meal matches the diet card. Any inconsistencies in the meal should be questioned with the expeditor and they should only serve foods as written. Review of Facility CNA Assignment Summary printed 6/20/16 documented the resident required supervision , set up help with a mechanical soft diet for eating. Review of Speech Therapy progress note dated 6/20/16 at 12:33 pm, documented the resident received a regular cut up steak instead of a ground steak. The resident was on a mechanical soft consistency requiring ground meat. The resident was to remain on current mechanical soft diet consistency with supervision for all meals. Review of Speech Therapist statement dated 6/22/16 documented that she evaluated Resident #116, per Physician order [REDACTED]. The resident demonstrated functional skills for mechanical soft consistency. The resident presented with mild oral dysphagia due to cognitive impairment and supervision with meals was recommended to ensure the resident didn't stuff his mouth and he swallowed what was in his mouth, before taking an additional bite. Review of signed statement by Licensed Practical Nurse (LPN) #2, dated 6/22/16, documented that she was called to Resident #116's table and noted he appeared to be having trouble chewing his food. LPN #2 asked the resident to spit the food out but he did not and he continued chewing. LPN #2 offered the resident fluids but the fluids ran out of his mouth and his lips began to appear blue. She then attempted the Heimlich maneuver and the resident became unresponsive and was transported to his room. She went and obtained the oxygen and mask and upon return to the resident's room she stated the Heimlich was being attempted again on Resident #116. At that time a piece of steak was removed from the resident's mouth and oxygen was applied because the resident was still coughing and three more pieces of steak were removed from his mouth. Vital signs were taken and were within normal limits, oxygen saturation (a measure of how much oxygen the blood is carrying as a percentage) was 99% on 10 liters of oxygen via mask delivery and the Physician was made aware. Review of CNA #1 statement dated 6/22/16, documented that she ran to the dining room and LPN#2 was attempting the Heimlich Maneuver and 3 other staff members assisted the resident into his wheelchair and back to his room. CNA#1 then put her fingers in his mouth and removed his dentures and two pieces of steak came out of his mouth. The Heimlich was then attempted again and LPN #1 put her finger in his mouth and removed a large piece of steak from his throat and the resident then began to breathe normally. The resident was then transferred to his bed in an upright position and LPN #2 removed another piece of steak from his mouth and the resident was fine then. Review of signed statement by LPN #1 dated 6/23/16, documented that someone had called for a nurse from the lunch room. As LPN #1 approached the resident, she observed his lips appeared blue and she went and got the Supervisor. The Heimlich was unsuccessfully attempted and the resident was then transported back to his room. A Certified Nurse Aide (CNA) checked the resident's mouth and removed his dentures with some food particles as requested by the Supervisor but the resident still appeared to have serious breathing difficulty. The Heimlich was performed again and the resident began to turn blue in the face. The resident was then assisted to his bed and oxygen was applied via mask. It was documented the resident almost became unconscious and the nurse removed the oxygen mask, performed a finger sweep. At that time a large piece of unprocessed steak was removed from his mouth. The resident's color began to return and he gasped for air. During an observation on 8/23/16 at 10:23 am of Resident #116's room, the resident's care card ( a document staff use to know what care the resident requires) posted on the resident's bathroom door documented the resident was on a mechanical soft diet, to redirect the resident if he takes large bites, and that the resident required supervision for eating. Additionally, in the resident's room was a basket on a table located to the left of his television with 3 unopened 3 ounce bags of Russell Stover Sugar Free candy and 1 opened 3-ounce bag of Russell Stover Sugar Free candy. During an interview with Registered Nurse Unit Manager (RNUM) on 8/23/16 at 10:35 am, she stated she was not aware that Resident #116 had 4 bags of candy in his room and that she did not feel that the candy should be in his room. The RNUM removed the candy. During an interview with CNA #3 on 8/23/16 at 10:45am, she stated that Resident #116's family brings in the candy and that it is usually in his dresser drawer. CNA#3 did go to his room and verified there was no other candy in his dresser drawer. Additionally, she stated that Resident #116 was not capable of getting the candy from the basket on his own. During an interview with CNA #4 on 8/23/16 at 3:20 pm, she stated that Resident #116 did sit in his wheelchair in his room and was capable of pushing himself around in his room. She also stated that he had once went into another room at the end of the hall independently. During an interview on 8/23/16 at 1:55 pm with RNUM, she stated that Resident #116's brother was educated on 6/20/16 regarding the resident's need for supervision when eating and that he was not to have food in his room. She further stated that the family should have been instructed on how to feed and supervise meals for the resident after he had choked on a hotdog back on 1/27/2016. During an interview with the DON on 8/23/16 at 3:40 pm, she stated the server had asked Expeditor #1 about the consistency of the filet mignon and he said the meat was soft and that it melted in his mouth. He then instructed the server to cut the meat up for Resident #116. She stated the Expeditor is supposed to check the tray to ensure it matches the dietary card, then the dietary server also checks when she delivers the tray. If the resident required assistance with their meal, then the assisting CNA would also check the meal consistency with the diet card. The DON further stated that she was not aware of whom had provided Resident #116 with candy in his room 10NYCRR 415.12(h)(1)

Based on record review and interview during an abbreviated survey (Complaint # 848) the facility did not ensure that one ( Resident #1) of two residents reviewed received adequate supervision to prevent accidents. Specifically: The resident left her unit, went through double doors and proceeded down a ramp unsupervised. The resident fell out of her wheelchair sustaining a laceration that required stitches. This is evidenced by: Resident #1: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set of 3/31/15 assessed that the resident was understood, usually understands, had a Brief Interview of Mental Status of 3/15 or severe cognitive impairment. It further documented the resident had a fall without injury since the last assessment. The resident's Comprehensive Care Plan (CCP) for the problem of Risk of Wandering/elopement was dated 4/1/15. It documented that the resident exhibits wandering behavior as evidenced by history of leaving AL (assisted living) unattended. At previous placement, the resident stated she was a visitor and went out to the parking lot. Staff redirected her back into the building. Family also expressed concerns that she would try to leave unattended. The Goal was that the resident would not demonstrate any unsafe wandering or elopement behavior. Interventions included: redirect negative behaviors, ensure proper placement of ankle alert and check any malfunction, regularly assess and evaluate risks for elopement. The CCP for falls dated 3/27/15, documented the resident was at risk for falls. The goals were: the resident would be free from falls and the resident would be free from injuries related to falls. Interventions included; use appropriate assistive device and level of assistance as recommended, provide education on safety techniques, ensure that call bell is within easy reach at all times, and bed and chair alarms. The Notes section documented: On 3/27/15, the resident was found on the floor, had been attempting self toilet, lost balance and slid from the wheelchair to the floor; No injuries; On 4/4/15 there was a fall without injury; On 5/29/15 there was a fall going to the bathroom. No injury; On 8/22/15 the resident fell going down a wing ramp. Right forehead laceration. Sent to hospital. The CNA (certified nurse aide) Assignment Summary for this resident (undated) documented the resident did not walk and the resident was independent in locomotion with set up help only. The resident's room was on the D wing. Nurses notes for August 2015 documented: On 8/7/15 at 5:37 pm: The resident wheeled herself to the water fountain by the recreation room this afternoon. The resident continued to state she was looking for her room and did not know where to go each time. She requested chocolate milk and was given it. On the second time, the resident was yelling help me by the water fountain and asked for a glass of water. It was given to her and she was assisted back to her room. On the third time, the resident was yelling help me at the water fountain writer offered to bring her outside. the resident accepted outdoors visit but stated it was cold and wanted back to her house. On the fourth time, the resident propelled back to the water fountain she again yelled help me. The resident stated she was lost, writer assisted back to her room. On the fifth time, the resident propelled to the water fountain and yelled help me, the resident was assisted back to her room per her request. On 8/9/15 at 1:46 am: The fire alarm triggered near the A-wing unit door. The resident was discovered seated in wheelchair, indicating that she had pulled the alarm to get the girls together. On 8/12/15 at 11:14 am: Yesterday the resident was propelling her wheelchair up and down the Stockade Hallway. The resident would propel into the doorway of her room and then get caught and call for help. This resident has been able to propel her wheelchair in and out of her doorway with ease prior. Resident then propelled into her room again and then got stuck in her doorway and began to call out help again. This writer addressed the behavior with the clinical leader and was informed the resident's son was on vacation, historically the resident has negative behaviors when the son does not visit daily. On 8/15/15 at 11:26 pm: the resident at start of shift roaming hall and confused, oxygen applied and now less confused and more appropriate. On 8/22/15 at 4:14 pm: Called to A wing ramp area, resident seen lying on her right side with her body up against the wall slightly. She has a large laceration on the right forehead approximately 9 centimeters and bleeding. She is alert and oriented as per usual mental status but complained of headache. She can move all 4 extremities. Dr notified and agreed to send to the hospital. The Accident/Incident Report dated 8/22/15 at 4:14 pm, documented the LPN (Licensed Practical Nurse) heard the chair alarm go off then observed the wheelchair tipped over and the resident was on her right side near/up against the wall. This was an unobserved fall with injury at the foot of the A-wing ramp. The resident interview section documented the resident couldn't explain what she was doing. The resident said I couldn't stop (referring to going down the ramp. The review of findings/determination of cause section documented that the resident most probably went through the double doors connecting D to A wing and went down the ramp without control of her wheelchair, then toppled over at the bottom of the ramp. The resident ambulated independently and had poor safety awareness. During an interview on 8/26/15 at 1:30 pm, the Nurse Manager stated that the door to the ramp had no restrictions. All the residents in the facility are allowed to wander throughout the facility independently, and all of the units are open for the residents to travel through with no restrictions# NY00. During an interview on 8/26/15 at 2:00 pm, the Administrator stated that all residents in the facility wander the building independently. The facility has no rules specifically to the doors that lead to the ramp, the residents are allowed to wander through to the other units. The ramp that was built was approved by the Department of Health 5 years ago. 10NYCRR415.12(h)(1)

Based on observations and interviews during the standard recertification survey, the facility did not ensure it maintained an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection for three (Units A, C and D) of four units observed. Specifically, the facility did not ensure that all nebulizer machines had filters in place and/or had dated the filters to ensure filters were changed in accordance with manufacturer recommendations. This is a repeat deficiency from an abbrieviated survey #NY 155 dated 1/23/15. This resulted in no actual harm with the potential for more than minimal harm that was not immediate jeopardy. This was evidenced by: The undated Manufacturer's User Manuals for Nebulizer Machines documented that the machine filter was to be changed every six months or sooner if the filter turned completely gray in color. During an observation on 7/7/15 at 9:47 am, with the Infection Control Registered Nurse (ICRN) present, on Unit A, one nebulizer machine in a resident room had no filter, and two machines had no date that the filter had been changed. On Unit C, one nebulizer machine in a resident room had no filter. On Unit D, two nebulizer machines in resident rooms had no filters. During an interview on 7/7/15 at 9:47 am, the ICRN stated that all nebulizer machines were supposed to have filters, and that the filters were to be changed every six months. She stated that she did not know why the machines found without filters were missing them, and that because there was no sticker with a filter change date on the two machines on Unit A, there was no way to know how old the filters were. During an interview on 7/9/15 at 12:15 pm, a Nebulizer Company Representative stated that the machine filters were important to the functioning of the machine and to the cleanliness of the air going through the nebulizer tubing and into the resident's lungs. She also stated that the machine should not be run without a filter. 10 NYCRR 415.19(a)(1-3)

Based on record review and staff interviews during the standard recertification survey, the facility did not ensure each resident's drug regimen was free from unnecessary medications for one (Resident #102) of three residents reviewed for unnecessary medications. Specifically, Resident #102 was administered an antianxiety medication ([MEDICATION NAME]) without documented non-pharmacological interventions prior to administration. Additionally, for Resident #102, the facility did not develop a plan of care that included non-pharmacological interventions to be used by staff to attempt to reduce the resident's anxiety prior to administering the medication. This resulted in no actual harm with the potential for more than minimal harm, that is not immediate jeopardy. This was evidenced by: Resident #102 This resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented that the resident was cognitively intact, and was able to make herself understood and could understand others. The Policy and Procedure (P&P) for [MEDICAL CONDITION] Medication, with an effective date of 10/14, documented that [MEDICAL CONDITION] medications included anti-anxiety, hypnotic, antipsychotic and antidepressant classes of drugs. Nursing staff were to appropriately chart all resident behaviors, and assist with the development and implementation of behavior care plans. The Comprehensive Care Plan (CCP) for [MEDICAL CONDITION] Drug Use: Behavioral Problem, with an effective date of 9/10/14, documented that the resident was on an anti-anxiety medication for management of behavioral problems of depression and anxiety. Staff Interventions included: establish appropriate [DIAGNOSES REDACTED]. There were no documented non-pharmacological interventions to be used by staff to attempt to reduce the resident's anxiety prior to administering the medication. A physician's orders [REDACTED]. The Medication Administration Record (MAR) for 6/2015, documented that the resident received PRN [MEDICATION NAME] for breakthrough anxiety on the following dates: June 1, 2, 3, 6, 7, 8, 9, 10, 11, 13, 21, 22, 23, 25, 26 and 29, 2015. For each administration, it was documented on the MAR that the medication was effective for the resident. Review of the Progress Notes for 6/1/15 through 6/30/15 revealed that on 6/1/15, 6/2/15, 6/6/15, 6/8/15, 6/9/15, 6/11/15, 6/23/15, 6/25/15, 6/26/15 and 6/29/15, there was no documentation that the PRN [MEDICATION NAME] was given or of non-pharmacological interventions implemented prior to giving the medication. During an interview on 7/8/15 at 8:25 am, Licensed Practical Nurse (LPN) #1 stated that this resident usually received Clonazepate on the night shift because she would get anxious and request the medication. She stated that prior to giving PRN anti-anxiety medications, staff were supposed to attempt non-pharmacological interventions first. She stated that examples of interventions would be to try to redirect the resident or find ways to help the resident calm down. LPN#1 also stated that when a resident received a PRN medication, nurses were supposed to document in the resident record the signs or symptoms that were present at the time, and the attempted interventions. During an interview on 7/8/15 at 8:32 am, Registered Nurse Manager (RNM) #1 reviewed this resident's record and stated that the CCP did not include non-pharmacological interventions to be used by staff to attempt to reduce the resident's anxiety prior to administering the Clonazepate, and that there should have been. She also stated that the nurses should have documented in the record the signs and symptoms the resident was displaying that caused the PRN medication to be administered. 10NYCRR 415.12(I)(1)

Based on record review and staff interview during complaint investigation (#NY 758), the facility did not implement the Abuse Policy and Procedure after an incident of suspected neglect. Specifically, a Licensed Practical Nurse (LPN #2) assigned to monitor the laboratory reports, reported to the Director of Nursing (DON) suspected neglect of medication administration to residents by a specific Licensed Practical Nurse (LPN #1). The facility initiated an investigation, including a medication audit on the specific shift and medication cart of the LPN, however, did not implement the Abuse Policy and Procedure to insure resident's were safe guarded while the investigation was in process. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. This is evidenced by: Abuse Policy and Procedure last revised 11/2008 documented that alleged allegations of abuse, mistreatment or neglect are immediately reported to their supervisor, an investigation is initiated and the facility administrator is advised. The investigation standards included that for any allegations which identifies a specific individual the facility will immediately safeguard the residents. Undated hand written note signed by the DON documented "Physician aware of suspicions" and medication audit done. Resident Investigation Report Form documented that a medication count was conducted on 1/30/15 after review of a resident's medication revealed that only two of the four doses ordered by the physician had been removed from the medication packaging. The report documented that a medication count was completed on 1/30/15 on the medication cart assigned specifically to the LPN #1 for the medications to be administered on LPN #1's shift. The report documented that another medication count was conducted on 1/31/15 and discrepancies were noted and reported to the DON. The report further documented that three resident's were interviewed, that report receiving medications from the LPN on Saturday morning on 1/31/15. In an electronic message dated 1/31/15 at 12:43 pm from the DON to the Administration, the DON reported that "LPN #1 signed for medications last evening that were not given...LPN #2 had done a a count audit and the numbers are the same this morning on approximately 10 residents...8:00 pm medications! She worked this morning too before RN #1 had audit count done and has since left for (specific) medical reasons...of course is off schedule indefinitely." LPN #1's timesheet documented she punched into the facility on [DATE] at 2:21 pm and punched out at 11:13 pm. On 1/31/15, LPN #1 punched in at 6:17 am and punched out at 12:44 pm. Review of medication administration for LPN #1 on the morning of 1/31/15, revealed signed medication administration for 19 residents of the facility. During an interview on 2/13/15 at 11:00 am, the DON stated that LPN #2 reported a concern on 1/30/15 that a resident's laboratory values had not increased despite an order for [REDACTED].#2 reported that review of the medication packaging revealed only two of four physician ordered medications were gone. Review of the assigned LPNs revealed that two LPNs were potentially involved, one assigned only one day and LPN #1 assigned two of the days. The DON stated that on 1/30/15, LPN #2 conducted a medication audit with plans for comparison audit on 1/31/15, which revealed that 10 resident's had not received medications but LPN #1 had signed that they were administered. The DON stated that she was notified about the discrepancies but LPN #1 had already left the facility when she arrived on 1/31/15. During an interview on 2/13/15 at 11:45 am, the Administrator stated that he was made aware of the results of the medication count on 1/31/15. The Administrator stated that he was not in the facility on 1/30/15 and was not aware of a suspicion of LPN #1 not administering medications. The Administrator stated that if he had been made aware, he would have made sure that LPN #1 was not working until the second count was completed. During a follow-up interview on 2/13/15 at 12:00 pm, the DON stated that she was unaware on 1/30/15 that LPN #1 was scheduled to work the morning of 1/31/15. The DON stated that she only knew that LPN #1 had arranged the second count with the RN on the morning of 1/31/15. During an interview on 2/13/15 at 12:30 pm, LPN #2 stated that after a resident's laboratory value had not improved as expected, she reviewed the medication packaging for the resident. LPN #2 stated that she identified that only two of four doses were removed from the packaging and that the Medication Administration Record [REDACTED]#1's assignment and a recount to determine if all medications were administered properly. LPN #2 stated that she reported all of the information to the DON. LPN #2 stated that she was not scheduled in the facility the following day so she asked the RN assigned the next day to complete the count. LPN #2 stated that she had no idea that LPN #1 was scheduled to work in the morning on 1/31/15. During an interview on 3/2/15 at 2:00 pm, RN #1 stated that she is not typically scheduled to work on weekends but had been approached by LPN #2 who informed her of a medication administration concern related to LPN #1. RN #1 stated LPN #2 asked that she come into the facility on [DATE] and recount specific medications that would have been administered by LPN #1 the night before. RN #1 stated that since LPN #1 works evenings, she arrived at the facility in the morning and planned the recount when it would not interrupt the daytime medication pass. RN #1 stated that during the recount, she realized that LPN #1 was working on another medication cart, and quickly finished the recount, identifying discrepancies. RN #1 stated that she immediately reported her finding to the DON, and arranged for LPN #1 to be relieved from the medication cart and sent home. 10NYCRR 415.4(b)

Based on record review, and staff interview conducted on an abbreviated survey (NY 155) the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for the residents residing on four (4) of four (4) units reviewed. Specifically, the facility Administrator (ADM), the Director of Nursing (DON), Infection Control Nurse (ICN), and Medical Director did not ensure line lists for an outbreak of upper respiratory symptoms were initiated in a timely manner, the line lists were not monitored and appropriate steps were not taken to prevent spread of infection, and the Medical Director was not notified of the outbreak in a timely manner. Additionally, the facility did not initiate influenza [MEDICATION NAME] in accordance with the Centers for Disease Control (CDC) guidelines, and did not report an outbreak of influenza like illness (ili) to the New York State Department of Health (NYSDOH) Regional Epidemiology office in a timely manner. Resident #'s 1-4, 7, 8, and #13 were identified to have upper respiratory symptoms, however, the facility did not monitor their symptoms or initiate appropriate steps to prevent further spread of these symptoms. Resident #'s 5 and 6 showed signs and symptoms of upper respiratory symptoms prior to being identified by the facility on the line list. This resulted in no actual harm, but with the potential for more than minimal harm that is Substandard Quality of Care. This was evidenced by: Copy of Email communication provided to the DOH Surveyor by the DON, dated 12/23/14 at 12:16 pm and addressed to; Nurse Managers (NM), Unit Secretaries and Nursing Supervisors (NS), with subject documented, Respiratory illness line list form. Documentation of the Email included; could we please start a line listing form to track all respiratory illness each week. Start new form each Monday and forward old form to Nursing Office on the following Tuesday for Infection Control (IC) filing. Please start one for this week and list all residents with current respiratory issues. Update daily with any new additions. Resident ill from previous week to be carried over onto the next week form. Be sure the original onset date is carried over. If Chest X-ray (CXR) is done please indicate under lab testing, type of test and results along with any antibiotic ordered. Indicate resolution of signs & symptoms by dating and yellowing out the entire line. If flu outbreak occurs we will already be familiar with the form. (Do not routinely swab for influenza, swab only when criteria has been met and physician has ordered test. Criteria consists of sudden onset of fever over 100, sore throat, cough and body aches (myalgia) along with the acute respiratory illness and we want to identify/track trends and clusters. Notify IC and DON promptly when sending out swabs. Review of facility Line List Form for upper respiratory symptoms revealed the following: 12/21/14: symptoms of ILI identified in (3) residents, affecting units A & B 12/22/14: (2) more residents with ILI, affecting units A & C (5 residents total) 12/23/14: (3) more residents with ILI, affecting units A, C, & D (8 residents total) 12/24/14: (6) more residents with ILI, affecting units A, C, & D (14 residents total) *At this point in the facility they had 14 residents with ILI within 72 hours ( had already met outbreak definition). The facility did not recognize the trend and did not initiate swabbing residents to rule out influenza. There is no documented evidence that residents with ILI were placed on droplet precautions. NYSDOH was not made aware of the suspected outbreak until 12/29/14 at which point there were 52 residents identified with ILI. The numbers of identified ILI continued to rise up until 1/1/15, when a total of 61 residents presented with ILI. The Influenza-like Illness Timeline given to the DOH surveyor on 1/23/15, and according to the DON was written on 1/23/15; described the time line of events during the Influenza like illness in December 2014 as follows: 12/22/14 Upper respiratory symptoms noted on twenty four hour report. 12/23/14 Line listing began on all four units (per interview with NM's, line list for Unit C was not written until 12/29/14). Daily review of line listing for clusters, prompt assessments, treatment orders and family/MD notification (there was no line list to review until 12/29/14). Hand washing and cough etiquette reminders for staff during rounds. ILI residents to remain in rooms. Droplet precautions initiated for any resident with uncontrolled secretions (per NM (nurse manager) interview there was no individual resident started on isolation until 12/29/14). 12/26/14 MD (Medical Doctor) #1 rounding in facility and assessed Resident #1, order received for Influenza swab (only one resident was swabbed, however at this time a total of 32 residents presented with ILI). 12/27/14 Lab report returned, positive swab for Type A Influenza on Resident #1. [MEDICATION NAME] ordered for Resident #1, droplet precautions initiated for Resident #1. Medical Director in building, facility closed and signage up regarding Influenza presence. (Despite the positive Influenza A lab result and CDC guidelines for Influenza [MEDICATION NAME], facility wide [MEDICATION NAME] was not started until 12/29/14). 12/28/14 Three residents with temperature (temp) spikes. Resident #11 with temp of 100.3 (per facility line list noted with ILI beginning 12/26/14); Resident #12 with temp of 101 (per facility line list noted with ILI beginning 12/27/14); Resident #9 with temp of 101.8. All three residents were swabbed and sent to lab. [MEDICATION NAME] and droplet precautions started on all three residents by MD #2. Staff education regarding hand washing, precautions and mask use continued throughout the weekend by supervisors during frequent rounds. 12/29/14 Flu swab results received from swabs sent on 12/28/14; two negative, one positive for Influenza A on Resident #9. An Influenza meeting was held in the morning of 12/29/14. The Administrator, DON, ICN, QA Nurse, and Medical Director attended. Units reopened (despite new onset of upper respiratory symptoms); [MEDICATION NAME] treatment and [MEDICATION NAME] initiated full house; All attending MDs were called for dosages for treatment and [MEDICATION NAME] of [MEDICATION NAME] based on Creatinine Clearance laboratory tests; notification to all families regarding [MEDICATION NAME]; continued restricted visitations of sick persons from visiting facility; all residents receiving [MEDICATION NAME] for treatment were put on droplet precautions as well as residents with uncontrolled secretions; NYSDOH and Schenectady Health Department notified, Nosocomial Outbreak Reporting Application (NORA) report sent; admissions within facility community only and with notification of flu presence. 12/31/14 Admissions opened with notification/[MEDICATION NAME]. 1/12/15 Influenza Impact Assessment Survey submitted. 1/20/15 Closeout/Epidemiology. During an interview on 1/22/15 at 10:30 am the DON stated that on 12/22/14 in morning report it was noted that a couple of residents were having upper respiratory symptoms. The DON stated that on 12/23/14 she told her staff to start line listing to keep track of when signs & symptoms (s/s) started and to track temperatures. The line lists were done in pencil, then the temps and symptoms would be erased and the higher temp and symptoms for that day would be written (This practice made it very difficult to monitor day to day changes with the resident's symptoms). DON stated that after report each day she was trying to keep track of the residents with s/s of upper respiratory symptoms. DON stated that those residents who were diagnosed with [REDACTED]. DON stated she called the facility on 12/27/14 and spoke with the day supervisor who initially told the DON that the swab on Resident #1 was negative (the lab report dated 12/27/14 revealed the swab was positive for Influenza A). DON stated that later in the day on 12/27/14 she read the nursing notes for Resident #1 via her computer at home and saw that the swab on Resident #1 was documented as positive. She then called the afternoon supervisor and was told that the swab on Resident #1 was positive. Supervisor told the DON that the Medical Director wanted to close the building. The facility was closed on the 27th, residents remained on their units, and the Activity and Main Dining Room were closed. DON stated she spoke with the ICN and told her that the four residents minimally, should be on the [MEDICATION NAME] (despite guidelines recommending [MEDICATION NAME] treatment for [REDACTED]. During an interview on 1/22/15 at 2:20 pm the Medical Director stated he was not aware of the widespread influenza like illness in the facility until he came in for routine visits on 12/27/14 and was made aware of a positive swab for Influenza Type A. He stated at this point he instructed staff to isolate units and send ill staff home in an attempt to contain the spread of infection. He stated he would have liked to have been notified earlier, and would have attempted containment prior to this date if he had been aware. He stated the facility's daily documentation could have been much better, and that a timeline should have been written to properly track and trend the spread of infection. He stated he did not agree with [MEDICATION NAME] per Guidelines, (referred to other evidence based practice studies against the use of [MEDICATION NAME]) and that he had to follow what he felt was right for his residents. He stated he would not stop another physician from prescribing [MEDICATION NAME], and eventually started [MEDICATION NAME] for most residents 12/29/14. During an interview on 1/23/15 at 1:40 pm the DON stated she had no explanation for why Unit C did not start the line list on 12/23/14, and did not start the list until 12/29/14 (despite having residents with ILI beginning 12/22/14). DON stated she checked the line lists in morning report and thought she had looked at them through 12/24/14. (DON was not in facility on 12/25/14 through 12/28/14). DON stated she was aware of the CDC Guidelines for suspected Influenza Outbreaks, and she did not know why only one Resident was swabbed on 12/26/14. DON did not talk to the MD that day, the ICN was in the facility. DON stated it was not acceptable what was done and when. On 12/27/14 [MEDICATION NAME] was ordered for Resident #1 only, the guidelines state that every resident should be evaluated and given [MEDICATION NAME] as appropriate. The guidelines and P&P was what was expected and they should have been followed. DON stated that on 12/27/14 she felt the swab was negative and everything was under control. When she talked to the supervisor about the [MEDICATION NAME], the supervisor told the DON, I am not getting into this [MEDICATION NAME] thing, the swab was negative (the lab report dated 12/27/14 revealed the swab was positive for Influenza A). DON stated she spoke with the Administrator on the phone and let him know that one swab was positive and that the MDs did not want to do the house [MEDICATION NAME]. DON was aware of the pharmacy shortage of [MEDICATION NAME] but she knew they had [MEDICATION NAME] for the facility. The Medical Director said he would evaluate the residents. DON stated she told the Administrator that she was on top of the situation and it was under control and she (DON) would be monitoring. DON stated that on 12/29/14 (Monday) she verified that the isolation set ups were in place and that all symptomatic residents were kept in their rooms. The doors to the units were opened on 12/29/14 and residents who were asymptomatic (without symptoms) were allowed to go to the Main Dining Room and Activities room. DON was aware that there were new cases on 12/29/14 and thereafter. DON stated she felt that if those residents on droplet precautions stayed in their rooms and no one symptomatic left the unit that it was fine to allow the asymptomatic people to leave their units. DON stated, to me the droplet precautions were the most important and new symptoms would be put on droplet precautions, that it would not be beneficial for asymptomatic residents to be isolated to the units. During an interview on 1/23/14 at 2:15 pm the Infection Control Nurse (ICN) stated that she was out of the facility from 12/8/14 through 12/26/14. When she returned to work on 12/26/14 she reviewed the line lists looking for temperatures, that part of the criteria was sudden onset. ICN did not notice that Unit C did not have a line list. ICN stated that when a resident was positive for pneumonia that their upper respiratory symptoms would no longer be considered for that resident. Thought was that any pneumonia would no longer be considered for influenza/upper respiratory symptoms. In previous interview on 1/21/15 at 9:50 am the ICN stated she called NYSDOH Epidemiology on 12/26/14 and was told by the Epidemiologist to keep the line list going, and ICN told him the facility was awaiting temperature spikes to begin swabbing. ICN then stated that she called the Epidemiologist again on 12/29/14 and reported the house was on [MEDICATION NAME]. Epidemiologist instructed no further swabs to be done. Upon further interview with the ICN, it was discovered and she admitted she did not contact Epidemiology on 12/26/14, but rather for the first time on 12/29/14. Upon review of the line list by the ICN during interview on 1/23/14 at 2:15 pm, the ICN stated that the NYS Epidemiology should have been called on 12/23/14. ICN stated that opening the units on 12/29/14 when everybody was already sick, that letting the well people get to the Main Dining Room for a meal was probably good (despite new onset upper respiratory symptoms 12/29/14 and thereafter). Resident #2 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 4, or severely impaired cognition. The Progress Note dated 12/17/14 at 10:14 pm documented Resident #2 did not meet ambulation goal; had increased confusion and was unsteady on her feet. The Progress Note dated 12/20/14 at 3:11 pm documented Resident #2 was noted to have a congested cough this morning while being lowered to the floor in her bedroom. Resident appeared very drowsy and refused breakfast. Was assisted back to bed and head of bed elevated for comfort. Breathing treatment given. Resident had small amount of intake at lunch. Physician notified, order for chest x-ray and CBC (complete blood count). Chest x-ray results shows slight coarsening of [MEDICATION NAME] markings which can be seen in [MEDICAL CONDITION] with early [MEDICAL CONDITION] vascular congestion. Nothing suggesting pneumonia. Physician made aware and no new orders at this time. Fluids encouraged. The Progress Note dated 12/20/14 at 11:17 pm documented Resident #2 did not meet ambulation goal this shift, continues to have increased confusion. A review of the facility's ILI Line List Form documented Resident #2 began with symptoms on 12/21/14. She was noted to have a cough and myalgia. There was no documented temperature. The Progress Note dated 12/21/14 at 2:55 pm documented Resident #2 did not ambulate due to increased lethargy. Resident stayed in bed all shift. The Progress Note dated 12/21/14 at 10:48 pm documented resident did not meet ambulation goal this shift, continues to have increased confusion. The Progress Note dated 12/22/14 at 3:19 pm documented Resident #2 complained of increased tiredness. Productive cough noted with congestion. Cough medicine and breathing treatment given. Resident had poor intake. Nurse Practitioner in and ordered breathing treatment three (3) times per day for 3 days and cough medicine twice a day. Resident refused to get out of bed and requested not to be disturbed so she can rest. Family is aware and updated with recent changes. The Progress Note dated 12/23/14 at 2:13 pm documented resident continues with increased coughing with congestion. Resident had poor intake. Unable to ambulate this shift. She requested to remain in bed after breakfast. The Progress Note dated 12/23/14 at 10:54 pm documented Resident #2 was tolerating breathing treatment and cough medicine for [DIAGNOSES REDACTED]. The Progress Note dated 12/24/14 documented Resident #2 continued with congestion. The Progress Note dated 12/25/14 documented Resident #2 had increased confusion, unable to ambulate, and had poor intake. The Progress Note dated 12/26/14 at 4:27 am documented Resident #2's temperature was 99.1. Loose stool X 1. Small amount of fluids taken. The Progress Note dated 12/26/14 at 3:15 pm documented resident very confused this shift. Had to be reapproached several times for am medications and care. Resident refused breakfast. Able to consume small amounts of liquid. Slight congestion noted. The Progress Note dated 12/27/14 at 12:09 pm documented resident continues with increased confusion. Did not want to get out of bed. Had no solid intake and 25% liquid intake. The Progress Note dated 12/27/14 at 10:49 pm documented resident slept most of shift and refused to eat dinner. The Progress Note dated 12/28/14 at 11:44 am documented resident continues to have increased drowsiness and confusion. Did not eat this shift. 25% fluid intake. The physician's orders [REDACTED]. The resident did not receive the first dose of [MEDICATION NAME] until the following day, 12/30/14. The Progress Note dated 12/29/14 at 4:03 pm documented resident continues with general malaise. She refused all meals but was able to take sips of liquids this shift. The Progress Note dated 12/29/14 at 10:35 pm documented Resident #2 did not ambulate and remained in bed. She did not eat dinner. The Progress Note dated 12/30/14 at 3:39 pm documented Resident #2 was unresponsive to verbal and tactile stimuli. Poor intake. Appeared with increased restlessness, breathing appeared slightly labored. Resident did not eat lunch. There was no documented evidence that the physician was contacted or updated regarding Resident #2's continued decline in status from 12/22/14 when she was seen by the Nurse Practitioner (NP), until 12/30/14 when she was seen by the NP again. In the Progress Note dated 12/30/14 at 4:17 pm the NP documented resident recently noted to have cough, chest x-ray (CXR) and CBC ordered last week, within normal limits (of note, CXR showed slight coarsening of [MEDICATION NAME] markings which can be seen in [MEDICAL CONDITION] with early [MEDICAL CONDITION] vascular congestion). Condition has continued to decline, resident with minimal intake, only reactive to painful stimuli. Respiratory effort increased. Expected poor prognosis. Will treat empirically with [MEDICATION NAME] (an antibiotic). [MEDICATION NAME] for comfort. Will follow up in am. The resident continued to deteriorate until she passed 1/1/15. Resident #5 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] assessed the resident as having a BIMS score of 8, or moderately impaired cognition. The Nursing Progress Note dated 12/17/14 at 2:35 am documented Resident #5 complained of a sore throat. Temperature 98.6. The Nursing Progress Note dated 12/22/14 at 4:17 am documented Resident #5 continued to cough despite order for [MEDICATION NAME], and is not getting appropriate sleep at night. The Nursing Progress Note dated 12/22/14 at 9:04 am documented Resident #5 noted with shortness of breath and wheezing. Will start breathing treatments 3 times daily and every four hours as needed. A review of the Nursing Progress Notes dated 12/23/14 through 12/28/14 documented the resident continued with a cough. Resident #5 was not placed on the facility's ILI Line List until 12/29/14. Resident #6 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] assessed the resident as having a BIMS score of 3, or severely impaired cognition. The Progress Note dated 12/21/14 at 9:59 am documented Resident #6 stated she does not feel well. Expiratory wheeze noted, productive cough. Temperature 101.4. A review of the facility's ILI Line List documented the resident began with symptoms of fever, cough, and myalgia as of 12/21/14. There was no documented evidence Resident #6 was swabbed by the facility to rule out influenza. *The Health Advisory titled, Influenza Surveillance and Reporting Requirements, 2014-2015, from NYSDOH Bureau of Communicable Disease Control and Bureau of Healthcare Associated Infections, dated October 9, 2014 documented: Nursing homes must report all confirmed or suspected healthcare facility associated influenza outbreaks to the NYSDOH Healthcare Epidemiology and Infection Control Program (HEIC) via the Nosocomial Outbreak Reporting Application (NORA) located on the Health Commerce System (HCS). *The facility's Policy & Procedure (P&P) dated 10/2014, titled Influenza Prevention, Treatment and Reporting documented; facility will follow all of NYSDOH recommendations for preventing, treatment and reporting of Influenza. A cluster of influenza like illness (defined as a measured temperature of 100 degrees or greater along with a cough or sore throat) occurs when there is, a. one or more cases of confirmed influenza in residents, and/or b. two or more cases of influenza like illness among health care workers and residents of a facility on the same unit within seven days. Respiratory specimens, via nasopharyngeal swabbing, are to be obtained from six (6) to twelve (12) residents with recent (48 hours) onset of fever and/or respiratory symptoms when a cluster has occurred. Control measures are to be implemented, confine ill residents to their rooms and place them on Droplet Precautions for seven days or until twenty four hours after fever has resolved without the aid of anti-pyretic medication (drugs that reduce fever), movement of residents from affected units will be limited; if one or more specimens test positive for influenza, anti-[MEDICAL CONDITION] medication for influenza treatment will be provided, and new admissions will be placed on anti-[MEDICAL CONDITION]. This [MEDICATION NAME] will not be delayed while awaiting test results; the NYSDOH respiratory line list form will be maintained on all affected units; facility will participate with NYSDOH influenza reporting requirements. Reference cited in P&P, CDC recommendations of Advisory Committee 2014/2015 Influenza Season. 10 NYCRR 415.12

Based on observation, staff interview, and medical record review during an abbreviated survey (Case #NY 155) the facility did not establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection on four (4) (Units A, B, C, and D) of four (4) units reviewed. Specifically, open personal care products were observed in shower rooms unlabeled. Oxygen tubing as well as nebulizer (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) face masks were out-dated. Staff were observed disposing of soiled items inappropriately or caring for ill residents without gloves or without washing their hands afterward. This resulted in no actual harm, but with the potential for more than minimal harm that is not immediate jeopardy. This was evidenced by: Unit A During an observation on 1/23/15 at 8:40 am Certified Nurse Aide (CNA) #1 was observed exiting a resident's room with a bag of garbage in one hand and soiled linen in her other hand. She was not wearing any gloves. The soiled linen was pressing up against her uniform and was not in a bag. She walked up the hallway and disposed of the linen in a basket in the hall. Unit B During an observation on 1/23/15 at approximately 8:00 am the shower room was noted to have three (3) open bottles of shampoo in it, that were not labeled. These bottles remained in the shower room throughout the day. During an observation on 1/23/15 at 8:25 am Resident #9's tubing and mask for her nebulizer were noted to be dated 12/15/14 (over one month prior). The tubing was on the floor. During an interview on 1/23/15 at 10:00 am Licensed Practical Nurse (LPN) #1 stated that Resident #9's face mask should have been thrown out and replaced weekly. During an observation on 1/23/15 at 9:00 am LPN #2 was observed in Resident #10's room giving medications. Resident #10 was currently being treated for [REDACTED]. The LPN exited the room with what appeared to be a syringe, alcohol pad, and plastic cup in her hands. She had not washed her hands after giving Resident #10 his medications. She proceeded to her medication cart down the hall and around the corner, where she threw out the items in her hands and began working on the computer. She did not wash her hands until approached by the surveyor. During an interview on 1/23/15 at 9:03 am LPN #2 stated she had just given Resident #10 his medications and that he did currently have an URI. When it was brought to her attention that she had not washed her hands after giving the resident his medications, she grabbed the hand sanitizer off her medication cart and put some on her hands. Unit C During an observation on 1/23/15 at 8:02 am the shower room across from room [ROOM NUMBER] was noted with a tube of lipstick, a brush, a hair pick, deodorant, body wash, and mouth wash on the sink unlabeled. There was also soiled clothing in a ball sitting on top of the sink, not in a bag. The shower chair appeared dirty and had wet, soiled towels on it. Underneath the shower chair was a bucket with a cloudy yellow substance in it. There was a wet, dirty towel hanging over the railing as well as dirty towels stained with a pink/red substance on the floor. During an interview on 1/23/15 at 8:04 am CNA #2 stated she did not realize that unlabeled personal care products should not be left in the shower room. She further stated that she would clean up the soiled linen left in there. During an observation on 1/23/15 at 8:05 am CNA #2 was observed leaving the shower room with gloves on her hands, holding the soiled linen up against her uniform, not bagged. She then walked across the hallway to the soiled utility room where she disposed of the soiled linen. During an observation on 1/23/15 at 8:08 am room [ROOM NUMBER] was noted to have oxygen tubing that was connected to a concentrator on the floor and partially in the garbage can. A plastic cup with a syringe and alcohol pad was noted on the dresser. During an interview on 1/23/15 at 8:10 am the Nurse Manager stated that the syringe should not have been left in the resident's room and that the oxygen tubing should not be on the floor or in the garbage. During an observation on 1/23/15 at 8:10 am the Nurse Manager was observed picking the oxygen tubing off the floor and securing it on top of the concentrator. She did not dispose of the oxygen tubing. Unit D During an observation on 1/23/15 at 8:19 am the resident in room [ROOM NUMBER] was noted resting in bed. The Foley catheter (a thin, sterile tube inserted into the bladder to drain urine) drainage bag was noted to be uncovered and resting on top of the resident's floor mat on the side of the bed. During an observation on 1/23/15 at 8:35 am the shower room was noted to have 3 bottles of skin cream and a hair pick unlabeled on the sink. On the ledge there was a pink basin with tissues and what appeared to be dried vomit in it. During an observation on 1/23/15 at approximately 8:50 am these items were still noted in the shower room even after they were brought to the attention of the ICN. During an observation on 1/23/15 at approximately 9:15 am CNA #3 was observed in room [ROOM NUMBER] picking up soiled clothing and linen off the floor. She picked up a soiled comforter with her bare hands and exited the room with it secured under her arm and against her uniform. She then entered room [ROOM NUMBER] with the soiled comforter still in her arm and closed the door. She exited room [ROOM NUMBER] a few seconds later without the comforter. She then proceeded to the dining room where she began passing breakfast trays. During an interview on 1/23/15 at 9:20 am CNA #3 stated that she had the comforter so she could bring it to be washed, but went into room [ROOM NUMBER] to check on the resident and had forgot the comforter in there. She stated she would retrieve the comforter and dispose of it in the proper place for laundry. During an observation on 1/23/15 at 9:21 am CNA #3 was observed passing room [ROOM NUMBER] without retrieving the soiled comforter. The comforter was observed rolled up in a ball on top of the bed in room [ROOM NUMBER]. An Activities worker that was now in the room with the resident was observed picking up the comforter and spreading it out on the resident's bed. As the surveyor was about to enter the room and stop her, CNA #3 came running up to the room stating "No, I have to clean that!" and went to grab the comforter without gloves. During an interview on 1/23/15 at 2:15 pm the observations noted above were reviewed with the Infection Control Nurse. She stated this was unacceptable and was surprised by the breaches in infection control witnessed by the surveyor. She stated she would continue to educate staff regarding proper infection control practices. During an interview on 1/23/15 at 1:40 pm the observations noted above were reviewed with the Director of Nursing. She stated the practices witnessed by the surveyor were unacceptable, and they would continue to educate and audit staff regarding proper infection control measures. 10 NYCRR 415.19(a)(1-3)