Every finding on record at Maplewood Nursing Home Inc

Based on observations, interviews, and record review conducted during the Recertification Survey from 05/19/2025 to 05/23/2025, the facility did not ensure that all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and all drugs and biologicals were stored in locked compartments with access limited to authorized personnel for two (2) (Elmgrove and [NAME] East Hall) of four (4) medication carts and one (1) (Elmgrove) of two (2) medication rooms reviewed. Specifically, medications were left unattended by staff, +expired medications were stored in medication carts and medication rooms, and an unlabeled and undated tube of Medihoney (a treatment used for wounds) was stored in a medication cart. The findings include: Review of the undated facility policy Medication Storage revealed medications would be stored in their original packaging. Antiseptics, disinfectants, and germicides used in any aspect of a resident's care must have legible, distinctive labels that identify the contents and the directions for use. The facility would not use discontinued, outdated, or deteriorated medication and those medications would be returned to the dispensing pharmacy or destroyed. Review of the facility policy Administration of Medication, dated March 2018, documented during administration of medications no medications are kept on top of the cart. 1. During an observation on 05/22/2025 at 11:28 AM, a medication cart sitting outside resident room [ROOM NUMBER] had a medicine cup on top of the cart that contained two (2) unidentified medications. There was no staff in sight. During an interview on 05/23/2025 at 9:07 AM, the Director of Nursing stated the medication cup should have been secured in the medication cart. 2. During an observation and interview on 05/22/2025 at 11:05 AM on [NAME] East Hall, a medication cart contained four (4) amoxicillin capsules (an antibiotic) with an expiration date of 04/10/2025 and a 15 milliliter tube of Medihoney (wound treatment) that was unlabled with resident identifyers or open date on it. During an immediate interview with Licensed Practical Nurse #4 and Licensed Practical Nurse #1, Licensed Practical Nurse #4 stated they were unsure who was responsible for checking expiration dates on medications. Licensed Practical Nurse #1 stated all nurses should be checking for expiration dates when giving medications. During an interview on 05/23/2025 at 9:07 AM, the Director of Nursing stated the safest practice for a house stock (items which a facility routinely keeps on hand) treatment stored in a common area would be to label it with a resident's name (who the treatment was prescribed for). 3. During an observation on 05/22/2025 at 10:44 AM in the Elmgrove Unit medication room there were three (3) boxes of Fast Acting Dairy Aid (used to treat lactose intolerance), two (2) boxes were unopened (32 capsules each) with an expiration date of March 2025 and one (1) box was opened (number of capsules unknown) with an expiration date of February 2025. During an interview on 05/23/2025 at 9:07 AM, the Director of Nursing stated night shift nurses are responsible for monthly audits of medication rooms and carts. Night shift nurses should pull all expired medications and send them back to pharmacy for disposal. The expired medications should have been caught on a monthly audit. 10 NYCRR 415.18(d) 10 NYCRR 415.18(e)(1-4)

Based on observations, interviews, and record review conducted during the Recertification Survey from 05/19/2025 to 5/23/2025, for one (1) (Resident #17) of three (3) residents reviewed, the facility did not ensure a paid feeding assistant provided dining assistance only for residents who have no complicated feeding problems. Specifically, Unit Assistant #2 provided eating assistance to Resident #17, who was diagnosed with dysphagia (difficulty swallowing). The findings includes: Review of the facility's training manual Assisting with Nutrition and Hydration in Long-Term Care (used for paid feeding assistant training), dated 2004, included federal regulations prohibited paid feeding assistants from assisting residents who have more complicated problems, such as lung aspirations (accidental inhalation of food into the respiratory tract), difficulty swallowing, residents with feeding tubes or intravenous feedings. Dysphagia which means difficulty swallowing and paid feeding assistants would not be assigned to feed residents who had dysphagia. Resident #17 had diagnoses including dysphagia, vascular dementia, and dyskinesia of the esophagus (muscles in the esophagus do not function properly leading to difficulty in moving food and liquids from the throat to the stomach). The Minimum Data Set (a resident assessment tool), dated 02/12/2025, documented Resident #17 had severe cognitive impairment, was dependent on staff for eating, and was on a mechanically altered diet. During an observation and interview on 05/21/2025 at 12:19 PM, Unit Assistant #2 was assisting Resident #17 with lunch in the main dining room. The resident had a divided plate that contained pureed food items (veggie burger, tomato soup, and broccoli). Resident #17 coughed occasionally throughout the meal. During an interview at this time, Unit Assistant #2 stated the food was thickened (thickened consistency to prevent choking). Review of Resident #17's lunch meal ticket (ticket that comes with the meal that includes what is being served and assistance required) revealed the resident was a feed (required assistance from staff to complete the meal), received a pureed vegan diet, and nectar thickened fluids. Review of the resident's current Comprehensive Care Plan (last revised 11/12/2024) included interventions for staff to supervise and assist Resident #17 as needed for meal consumption. Review of current physician's orders, dated 02/07/2025, included a regular diet, pureed texture, and nectar (thickened liquid) consistency. Review of the facility document List of residents eligible for assistance and who are currently receiving assistance from paid feeding assistants, received on 05/19/2025, included Resident #17. Review of the facility document Name of staff who have successfully completed training for paid feeding assistants and who are currently assisting selected residents with eating meals and/or snacks, received on 05/19/2025, included Unit Assistant #2. Review of Unit Assistant #2's employee file revealed a completed Nursing Home Training Program for Paid Feeding Assistant Skills and Knowledge Checklist dated 06/29/2022. In a nursing progress note, dated 02/06/2025, Licensed Practical Nurse #2 documented Resident #17 was fed by staff, used straws with thin liquids, had a pureed diet, staff must be aware to cue the resident not to talk while drinking or eating, and the resident often coughed with liquids during the day's meal. In a nursing progress note, dated 02/06/2025, Licensed Practical Nurse #6 documented Resident #17 had difficulty with swallowing medications and during dinner. The Unit Assistants were reminded to use a spoon for safer results and to let the writer know if there were continued issues. During an interview on 05/22/2025 at 11:42 AM, Unit Assistant #2 stated in their role (as feeding assitant), they guide or assist residents with their meals and their training included assisting residents with eating. Unit Assistant #2 stated they could assist residents with pureed or mechanically soft diets and there were not any residents they could not assist. They stated Resident #17 received thickened liquids and if the resident were to cough or choke, they would back off (on giving more food or drink). During an observation on 05/22/2025 at 12:20 PM, Unit Assistant #2 was assisting Resident #17 with their lunch meal in the dining room. There was a divided plate that contained pureed food items (veggie burger, tomato soup, and green beans). During an interview on 05/22/2025 at 12:54 PM, Licensed Practical Nurse #2 stated the nurses, Certified Nursing Assistants, and trained Unit Assistants could assist residents with meals. For the staff that had undergone the feeding assistant training, there were no restrictions on residents that they could assist including residents that had swallowing difficulties and mechanically altered diets or fluids. During an interview on 05/22/2025 at 3:40 PM, the Nurse Educator stated the Unit Assistants undergo feeding assistant training with their orientation. The state requirement included feeding assistants should not be assisting residents with swallowing difficulties, and they told the feeding assistants this during their training. The Nurse Educator stated the feeding assistants should not be assisting residents who had mechanically altered diets or altered liquid consistencies. During an interview on 05/23/2025 at 9:22 AM, the Director of Nursing stated most of the feeding assistants were unit assistants that had gone through the training, along with some other non-clinical staff. The Director of Nursing stated they would look to the nurses and the nurse managers to guide which staff (including feeding assistants) should assist which residents with their meals. The Director of Nursing stated they believed the feeding assistants could assist residents with swallowing difficulties since there are varying levels. When asked if they were aware the regulation included paid feeding assistants could not assist residents with difficulty swallowing, the Director of Nursing stated they may have known but it had been a while. 10 NYCRR 415.14

Based on interviews and record review conducted during the Recertification Survey from 05/19/2025 to 05/23/2025, the facility did not maintain a quality assessment and assurance committee that consisted of, but not limited to, the Medical Director or their designee. Specifically, the facility could not provide documented evidence the Medical Director or their designee attended the Quality Assurance and Performance Improvement (QAPI) meetings on a regular basis. The finding includes: Review of the facility's undated Quality Assurance and Performance Improvement Program Overview revealed a list of members who attend the Quality Assurance Meeting and did not include the Medial Director or their designee. Review of the facility document Quality Assurance Members 2025 revealed members included, but were not limited to, the Medical Director. Review of the facility's Quality Assurance Attendance Log from May 2024 to May 2025 revealed the Medical Director and/or their designee did not attend three (3) of the five (5) meetings held. During an interview on 05/22/2025 at 4:19 PM, the Assistant Administrator stated they did not know that either the Medical Director or a designee was required to attend the meetings. 10 NYCRR: 415.27(a-c)

Based on interviews and record review conducted during a Recertification Survey from 05/19/2025 to 05/23/2025, for four (4) (Residents #1, #30, #70, and #73) of ten (10) residents reviewed, the facility did not develop and implement a baseline care plan that included the minimum healthcare information necessary to properly care for a resident within 48 hours of their admission and provide a summary of the baseline care plan to the resident and their representative. Specifically, for Residents #30, #70, and #73, there was no documented evidence a baseline care plan was developed, and a summary of the baseline care plan provided to the resident and/or their representative. For Resident #1, a comprehensive care plan was developed within 48 hours of admission, however, there was no documented evidence a summary of the care plan was provided to the resident or their representative prior to the admission care plan meeting. The findings include: The facility policy Baseline Care Plan, dated May 2018, included baseline care plans would be developed within 48 hours of the resident's admission to address initial care goals of the resident, a list of medical provider orders and dietary orders, and services and treatments to be administered by the facility. The facility would provide the resident and the resident's representative with a written summary of the baseline care plan and list of medications within 48 hours. 1. Resident #30 had diagnoses that included congestive heart failure (a condition where the heart cannot pump blood efficiently), chronic respiratory failure with hypoxia (low supply of oxygen in the blood), and chronic obstructive pulmonary disease (a condition that restricts the flow of air into and out of the lungs). The Minimum Data Set (a resident assessment tool), dated 03/19/2025, documented Resident #30 was cognitively intact. Review of Resident #30's Comprehensive Care Plan revealed it was dated as initiated more than 48 hours after the resident's admission. There was no documented evidence that a baseline care plan had been completed or a summary of either care plan had been provided to the resident and/or their representative prior to their admission care plan meeting held. 2. Resident #1 had diagnoses including hypertension (high blood pressure), atrial fibrillation (an irregular heartbeat), and diabetes. The Minimum Data Set, dated dated [DATE], documented Resident #1 had moderate cognitive impairment. Review of Resident #1's Comprehensive Care Plan revealed it was initiated within 48 hours of the resident's admission. There was no documented evidence that a summary of the Comprehensive Care Plan or a baseline care plan had been provided to the resident and/or their representative prior to their admission care plan meeting. 3. Resident #73 had diagnoses including Alzheimer's disease, aphasia (impaired ability to communicate), and hypertension (high blood pressure). The Minimum Data Set, dated dated [DATE], documented Resident #73 had severely impaired cognition. Review of Resident #73's electronic health record revealed no documented evidence a baseline care plan had been developed within 48 hours of the resident's admission or a summary of the baseline care plan provided to the resident and/or their representative prior to their admission care plan meeting. During an interview on 05/22/2025 at 3:46 PM, Licensed Practical Nurse Manager #3 stated the day shift nurse managers and therapy staff usually develop and implement the baseline care plans within 6 to 12 hours of the resident's admission. The baseline care plan includes resident-specific information such as advance directives, transfer status, dietary information, and nursing diagnoses, and is documented on the Therapy/Rehabilitation Care Plan form. Licensed Practical Nurse Manager #3 stated the nurse manager transcribes the information from the form into the electronic health record and a copy posted in the resident's room. The resident or their representative should be provided with a copy of the form, and it should be documented in the admission note. During an interview on 05/23/2025 at 8:49 AM, the Director of Nursing stated the baseline care plans are automatically generated in the electronic health record based on information documented by the different departments and should be completed within 48 hours of the resident's admission. The nurse manager should provide a copy of baseline care plan to the resident or their representative, and it should be documented in the electronic health record. The Director of Nursing stated there is no training for the baseline care plan process in place for new nurse managers. 10 NYCRR 415.11(c)

Based on interviews and record review conducted during the Recertification Survey, the facility did not provide influenza and/or pneumococcal immunizations as required or appropriate for one of five residents reviewed. Specifically, the facility was unable to provide evidence that Resident #44, who was eligible for the vaccine, had been offered, declined and/or educated regarding Pneumococcal immunization during their admission. This is evidenced by the following: The undated facility policy, Pneumococcal Immunization included that unless contraindicated, pneumococcal immunizations are highly recommended for all residents of the facility per the facility's protocol. The policy included that all new resident admissions would have their vaccine history checked with their community medical provider prior to admission to the nursing home. Routine physician admission orders would include the pneumococcal vaccine on admission if they (resident) had not had it or were out of the recommended window of being immunized, unless contraindicated by a medical provider. The policy included that the resident and/or representative would be provided a current Vaccine Information Statement (VIS- a document providing information about the pneumococcal vaccine), and the nurse would document in the medical record the date the information was provided to the resident and/or representative. The signed immunization consent or declination forms would be filed in the resident's medical record. A resident's immunization record should be documented in the 'Immunization' section of the electronic medical record and would be reviewed periodically to ensure that vaccination(s) were current. Resident #44 is a [AGE] year-old resident of the facility admitted in 2022, with diagnoses that included vascular dementia, macular degeneration, and anxiety. The Minimum Data Set Resident Assessment that was provided by the facility and dated 2/14/24, revealed Resident #44 was severely impaired cognitively and that their pneumococcal vaccine was not up to date. The question asking the reason why the vaccine had not been received was left blank. Review of Resident #44's immunizations in the electronic health record revealed Resident #44 received a Pneumococcal Polysaccharide vaccine (PPSV23) on 5/22/2002. Review of physician orders since the resident's admission did not reveal any evidence that a pneumococcal vaccine had been administered since the 2002 vaccine. Review of the facility's 'Immunization Worksheet,' on 3/13/24 revealed Resident #44 had received a Pneumococcal Polysaccharide vaccine 23 (PPSV23) on 5/22/2002. On 3/12/24 Resident #44 received the Pneumococcal Conjugate vaccine (PCV) 13 or 20 vaccine (after surveyor intervention and resident representative consent). Additionally, seven residents were highlighted on the spreadsheet that indicated the residents were eligible for a pneumococcal vaccination. The facility could not provide evidence that Resident #44 or their representative were offered, accepted, or declined the pneumococcal vaccine since the resident's admission to the facility prior to the survey. During an interview with the Director of Nursing/Infection Preventionist and the Director of Staff Education (previous Infection Preventionist until January 2024) on 3/12/24 at 1:03 PM, the Director of Staff Education stated that residents' immunizations are reviewed on admission and if eligible the vaccine is offered. The Director of Staff Education said a spreadsheet is used to keep track of residents' immunizations and due dates for revaccinations, dependent on which vaccine they were previously administered and when. The Director of Nursing/Infection Preventionist stated they could not find any evidence that Resident #44 (including information from their representative) had been offered the pneumococcal vaccine since their admission in 2022. The Director of Staff Education said that during the COVID-19, there was changing guidance on not administering different immunizations too closely (timeframe) together and more spaced out and that there had also been issues with obtaining the vaccines. The Director of Nursing/Infection Preventionist stated (after review of the immunization worksheet) they identified additional eligible residents with outdated pneumococcal immunizations. During an interview on 3/13/24 at 8:54 AM, the Medical Director stated the Infection Control Officer (Infection Preventionist) was responsible for auditing residents' immunization records ensuring that all residents' immunizations are up to date and inform them if not. The Medical Director stated if a resident had received the Pneumococcal Polysaccharide Vaccine 23 prior, they would encourage the resident to be re-vaccinated, but that the resident (or their representative) did have the right to refuse. The Medical Director stated that based on their previous pneumococcal immunization in 2002, Resident #44 could have received the pneumococcal vaccine when admitted to the facility in 2022. The Medical Director stated they had not been aware of any supply issues obtaining the vaccines in 2022 or 2023. 10 NYCRR 415.19 (a)(3)

Based on interviews and record review during the Recertification Survey the facility did not ensure that for one (Resident #73) of two residents reviewed, the resident, the resident's representative, and/or the State Ombudsman had been notified of the transfer and/or discharge from the facility and the reasons for the transfer and/or discharge in writing in a language and manner that they understood. Specifically, Resident #73 was transferred to the hospital and there was no evidence that a notification of the transfer and the reasons for the move had been provided to the resident, the resident's representative, or the State Ombudsman per the regulations. Additionally, there was not documented evidence that the facility was notifying the State Ombudsman program of any hospital transfers/discharges. This is evidenced by the following: The current facility policy, Maplewood Discharge Policy and Procedure, included that the Director of Social Work is the discharge coordinator and responsible to review with the resident or resident representative the Resident Notification of Transfer/Discharge Form and provide a copy of the form at time of discharge. If the discharge meets the criteria for a facility-initiated transfer (a transfer or discharge which the resident objects to, did not originate through a resident's verbal or written request , and/or is not in alignment with the resident's stated goals for care or preferences) then the facility will send the Resident Notification of Transfer/Discharge to the resident, the resident's representative and to the Office of the State Long-term Care Ombudsman. Resident #73 was recently admitted for short term rehabilitation following a surgical procedure and with diagnoses that included high blood pressure and heart failure. In a medical provider note, dated 1/4/24 the Physician documented that the resident was alert and oriented. Review of nursing progress notes, dated 1/4/24 revealed Resident #73 was sent to the Emergency Department, was admitted to the hospital, and did not return to the facility. There was no documented evidence that a written notification and reason for the transfer had been provided to the resident, their representative, or to the State Ombudsman Office per the regulations. During an interview on 3/7/24 at 10:55 AM the Ombudsman stated the facility had not been sending resident's transfer/discharge notices. The Ombudsman stated they had spoken with the facility staff previously and additionally had sent a letter to the facility in February of 2024 regarding not receiving copies of the transfer/discharge notices. During an interview on 3/12/24 at 4:08 PM and again at 4:32 PM the Assistant Administrator stated there was no evidence a Resident Notification of Transfer/Discharge Form for Resident #73 had been sent to the Ombudsman Office and that the facility did not have a process for notifying the Ombudsman office of facility discharges. The Assistant Administrator stated the facility had a change in the Ombudsman in early 2023 and have not had a process for communicating notice of transfer/discharges to the Ombudsman Office since then. The Assistant Administrator stated that a resident who was admitted and then went to the hospital would be considered discharged , but that they do not complete Resident Notification of Transfer/Discharge Forms for these residents. When asked why not, the Assistant Administrator stated Social Work was responsible for the discharge notices. During an interview on 3/12/24 at 4:55 PM the Director of Social Work stated that the Resident Notification of Transfer/Discharge Form is not completed for residents who go to the hospital and do not return to the facility. Social Worker #1 stated that the facility only sends a Resident Notification of Transfer/Discharge Form for facility-initiated discharge which the Director of Social Work stated were discharges that the facility had to initiate that the resident or their representative did not agree with. State Operations Manual, Appendix PP Rev.211,02-03-23 includes that an Emergency Transfer is identified as when a resident is temporarily transferred on an emergency basis to an acute care facility, this type of transfer is considered to be a facility-initiated transfer and a notice of transfer must be provided to the resident and resident representative as soon as practicable before the transfer, according to 42 CFR S483.15(c)(4)(ii)(D). Copies of notices for emergency transfers must also still be sent to the ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis, as long as the list meets all requirements for content of such notices at S483.15(c)(5). 10 NYCRR 415.3(i)(1)(iii)(a-c)

Based on observations, interviews, and record reviews conducted during a Recertification Survey the facility did not consistently post the daily nurse staffing information to include the daily resident census, the total number and actual hours worked by the licensed and certified nurses and post the correct data daily at the beginning of each shift and be readily accessible to residents and visitors. Specifically, the nursing staff information was not updated to reflect any staffing changes throughout the day per the regulations. This is evidenced by the following: During observations on 3/7/24, 3/8/24, 3/11/24, 3/12/24 and 3/13/24 at various times from 8:30 AM to 4:30 PM the posted daily nurse staffing forms revealed the resident census and the number and hours of the licensed and certified nursing staff on for each shift. None of the posted staffing forms contained any changes (including call-ins) for the posted nurse staffing for any shifts on any of the days. Review of the nursing staffing schedules provided by the facility for 3/7/24, 3/8/24, 3/11/24, 3/12/24 and 3/13/24 revealed staffing changes that had not been identified on the posted forms for resident and/or representatives information. Review of the printed daily nurse staffing postings dated 2/1/24 through 3/13/24, revealed there was no evidence that any changes had been made to the postings to reflect any updated staffing changes throughout each day (each shift), if applicable. During an interview on 3/12/24 at 8:11 AM, the Nursing Staff Manager stated that they are responsible for posting the daily nursing staffing information and that they post it every morning between 8:00 AM and 10:00 AM. The Nursing Staff Manager said they make changes (if needed) to the daily nursing staffing forms in the morning and then post it. The Nursing Staff Manager said for the weekends (Saturdays and Sundays), they post the daily nursing staffing postings on Friday before they leave for the day. The Nursing Staff Manager stated any staffing changes (changes to staffing levels via call-ins, etc.) are updated in the electronic scheduling program for staff access but that the posted daily nursing staff forms are not updated (with handwritten changes) to reflect any staffing changes, nor are they printed from the computer program and then posted with the updated staffing levels. Additionally, the Nursing Staff Manager said no one else in the facility updates the posted staffing forms after they leave for the day. During an interview on 3/13/24 at 12:47 PM, the Director of Nursing stated that the Nursing Staff Manger generated the daily nursing staffing forms, including any call-ins at that time and posts it by midmorning for the day. The Director of Nursing said on weekends the staffing is posted on Friday afternoon for Saturday and Sunday and then checked on Monday for any changes but that the posted forms do not get updated. 10 NYCRR 415.13

Based on observations, interviews, and record reviews, conducted during the Recertification Survey completed on [DATE], it was determined that for one of one main kitchen, the facility did not store, prepare, distribute, and serve food in accordance with professional standards (U.S. Food and Drug Administration's Food Code) for food service safety. Specifically, there were cold foods prepared on-site and held for greater than seven days, expired/outdated food products not discarded, food items undated, unlabeled and/or stored uncovered, lack of hair restraints in food preparation areas, and cleaning tools were not stored in a manner to prevent contamination of food, utensils, or equipment. This is evidenced by the following: 1. Observations in the presence of the Dining Manager during the initial brief tour of the main kitchen on [DATE] from approximately 8:48 a.m. to 9:30 a.m., included the following: a) Three 3-gallon tubs of ice cream were stored uncovered, in the ice cream freezer. b) Hair restraints were not available for use and one staff member working in the kitchen was observed not wearing a hair restraint. c) One-gallon containers of Caesar dressing, Catalina dressing and barbeque sauce, a five-gallon container of sour cream, and a half-gallon container of fat free milk were open and undated in the double glass-door cooler. d) A container of sauce prepared on-site and located in double glass-door cooler was dated 44 days prior. e) An open container of coconut milk located in the double-glass door cooler was marked with an expiration date of [DATE]. f) A container of cheese sauce was uncovered in the walk-in refrigerator. g) A container of what was identified by the Dining Manager as meatballs was unlabeled, undated, and uncovered. h) A partial block of what was identified by the Dining Manager as deli turkey was open, undated, and unlabeled in the walk-in refrigerator. i) A large tray of chicken chowder and a small container of chicken sauce in the walk-in refrigerator were marked as prepared 9 days earlier. j) A large tray of what was identified by the Dining Manager as Swedish meatballs in sauce and another large tray pan of what was identified by the Dining Manager as meat sauce were unlabeled and undated in the walk-in refrigerator. k) A clear bag of what was identified by the Dining Manager as pastry dough was unlabeled and undated in the walk-in freezer. Additionally, a large box of single serve cheese pizzas, beef patties, tater tots, veggie burgers, pizza dough and frozen penne were open and undated in the walk-in freezer. l) Bags of elbows, bow-tie pasta, spaghetti, couscous, and rice were open and undated in the dry storage area. m) Brooms and upright dustpans were stored abutting an open rack of clean dishes and equipment that included an immersion blender. 2. Observations in the presence of the Executive Chef during a follow-up visit to the main kitchen on [DATE] from approximately 11:02 a.m. to 12:10 p.m. included the following: a) Hair restraints were not available for use and a kitchen staff member was observed without a hair restraint. b) Three 3-gallon tubs of ice cream were uncovered, in the ice cream freezer. c) Two small containers of sausage were uncovered in the double glass-door cooler. d) Nine bags, each containing eight bread rolls, located on the bread rack were marked with a 'best by' date 10 days prior. e) A small container of meatballs marked as being prepared 9 days earlier, was located in the walk-in refrigerator. f) The container of cheese sauce was uncovered in the walk-in refrigerator. g) The large tray of what was previously identified by the Dining Manager as Swedish meatballs in sauce and another large tray pan of what was previously identified by the Dining Manager as meat sauce, which were previously unlabeled and undated remained in the walk-in refrigerator unlabled and undated. h) Large bags of ravioli and fish patties were open, unlabeled, and undated in the walk-in freezer. The previously identified pastry dough, large box of single serve cheese pizzas, tater tots, pizza dough and frozen penne remained in the walk-in freezer open and undated. i) A small container of cooked rice was marked as being prepared 20 days earlier and located in the cooler under the cooks' prep area. j) Small containers of what were identified by the Executive Chef as tofu and barbeque sauce were outside of their original packaging, unlabeled and undated, in the cooler under the cooks' prep area. k) Brooms and upright dustpans were stored abutting an open rack of clean dishes and equipment that included an immersion blender. 3. During an interview on [DATE] at 11:15 a.m., the Executive Chef stated that the foods should have been covered, labeled, and dated on the day the food was made and that there was a five-day rotation on prepared foods. The Executive Chef stated that foods older than that should have been thrown out. The Executive Chef stated there was a lot of new staff that probably didn't understand the process. The Registered Dietitian and Director of Food Service were not available for interview. No written policies were provided for review with regard to holding, storage, labeling, or discarding food items. 10NYCRR: ,d+[DATE].31(a), ,d+[DATE].42, ,d+[DATE].43(e), ,d+[DATE].72(c), ,d+[DATE].172 U.S. Food and Drug Administration's (FDA) Food Code Centers for Disease Control and Prevention's (CDC) food safety guidance

Based on interviews and record reviews during the COVID-19 Focused Infection Control Survey conducted on [DATE], the facility did not inform all residents, their representatives, and families of suspected or confirmed COVID-19 cases in the facility in a timely manner for four (Residents #1, #2, #3, and #4) of four residents reviewed. Specifically, the facility did not provide verbal or written notification by 5:00 p.m. the next calendar day following 6 residents and 16 staff who tested positive for COVID-19 and one resident that was positive for COVID-19 had expired. This is evidenced by, but not limited to, the following: CMS guidance titled, Interim Final Rule Updating Requirements for Notification of Confirmed and Suspected COVID-19 Cases Among Residents and Staff in Nursing Homes (Ref: QSO-,[DATE]-NH), dated [DATE], provided that as part of a skilled nursing facility's COVID-19 reporting requirements, facilities must Inform residents, their representatives, and families of those residing in facilities by 5:00 p.m. the next calendar day following the occurrence of either a single confirmed infection of COVID-19, or three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other. The facility's policy Pandemic Emergency Plan, Emerging Infectious Disease Response Plan dated [DATE] revealed they will ensure all residents and families are updated at least weekly on the number of pandemic related infections and deaths at the facility. Review of the COVID Test Positive Residents list and the emails sent to family members revealed the following: a. On [DATE] and [DATE] three residents tested positive for COVID-19. The email notification was not sent to representative and famililies until [DATE]. b. On [DATE] and [DATE] four residents tested positive for COVID-19 and the email notification was not sent to representatives and families until [DATE]. c. There were five resident deaths that occurred related to COVID-19 between [DATE] through [DATE]. 1. Resident #1 had [DIAGNOSES REDACTED]. Review of progress notes, from [DATE] through [DATE], revealed no documentation that Resident #1's representative had been notified of any positive COVID-19 cases in the facility. During an interview on [DATE] at 2:45 p.m., the resident's Health Care Proxy (HCP) stated that an email is received once weekly on Tuesdays about COVID- 19 cases in the nursing home. 2. Resident #2 had [DIAGNOSES REDACTED]. The MDS Assessment, dated [DATE], revealed the resident had severely impaired cognition. Review of progress notes, from [DATE] through [DATE], revealed no documentation that Resident #2's representative had been notified of any positive COVID-19 cases in the facility. During an interview on [DATE] at 11:35 p.m., Resident #2's HCP stated they received weekly emails on Tuesdays regarding updates on COVID-19 positive staff and resident's in the nursing home. 3. Resident #3 had [DIAGNOSES REDACTED]. The MDS Assessment, dated [DATE], revealed the resident was cognitively intact and identified by the facility staff as interviewable. Review of the progress notes, from [DATE] to [DATE], revealed no documentation that Resident #3 had been notified of any positive COVID-19 cases in the facility. During an interview on [DATE] at 11:25 a.m., Resident #3 stated they had not been notified of any positive COVID-19 cases in the facility and was not aware that there were positive cases of residents or staff currently in the facility. During an interview on [DATE] at 2:45 p.m. and again at 5:17 p.m., the Assistant Administrator stated that they were notified on [DATE] and [DATE] of four residents who tested positive for COVID-19 and that they had 16 staff members who tested positive over the past week. She said the facility Administrator sends a family drop (email) to family members regarding COVID-19 within the facility every Tuesday. When asked if anyone was informing the residents of the COVID-19 cases, she said the Social Worker (SW) informed residents who are cognitively able to be informed. During an interview on [DATE] at 3:29 p.m., and again at 4:09 p.m. the Social Worker (SW) stated that she provides a hard copy of the email written by the Administrator on Tuesday of each week to residents. When asked for documentation that cognitively intact residents had been notified of all positive COVID-19 activity in the facility residents, the SW was unable to provide. (10 NYCRR 42 415.19 ) (10 NYCRR 42 400.2)

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that the facility did not ensure that menus were reviewed by the staff dietitian or other qualified professional for nutritional adequacy. Specifically, the facility's new program of farm to table menus were not analyzed for nutrient adequacy. This is evidenced by the following: Review of the facility's menu included the daily farm to table menu (daily specials) which highlights ingredients from local farms in addition to the items on the standard menu. When interviewed on 2/2/20 at 10:45 a.m., the Nutrition Assistant said if a resident can make their needs known, the dining assistant will ask them if they want the special of the day. She said if a person cannot make their needs known, they receive the special of the day. She said each resident gets a tray slip for their meal which includes their preferred beverages and food consistency. She said it does not include the specific food items the resident selected. She said staff completes meal intakes based on percentages of a meal consumed. She said the items served to a resident on a three day calorie intake are not written on the tray ticket so that the information can be analyzed. When interviewed on 2/3/20 at 10:08 a.m., the Registered Dietitian said they offer farm to table menu specials of the day which change every two weeks. When interviewed on 2/3/20 at 10:55 a.m., the Food Service Director said the facility does not have a nutrient analysis of the current menus. He said the menus are based on protein needs (3 to 4 ounces per meal). He said staff use a standard 4 ounce serving for vegetables for lunches and dinners. (10 NYCRR 415.14(c)1-3)

Based on interviews and record reviews conducted during a Recertification Survey and a complaint investigation (#NY 444) completed on 12/12/18, it was determined that for one (Resident #120) of three residents reviewed for palliative or end of life care, the facility did not provide necessary care and services to attain and maintain the resident's highest practical wellbeing prior to the resident's death in the facility. This is evidenced by the following: Resident #120 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 2/28/18, revealed the resident was cognitively intact. Review of the physician re-admission progress note, dated 1/15/18, revealed that the resident was recently diagnosed with [REDACTED]. The Comprehensive Care Plan, dated 1/12/18, included that the resident and family desired palliative services. Interventions included, but were not limited to, observe the resident closely for signs of distress which include pain, discomfort, shortness of breath and anxiety, administer medications as ordered, notify physician/Nurse Practitioner immediately if unrelieved, and to provide the resident and family members end of life disease process education. Physician orders, dated active as of 4/1/18, included that the resident was on [MEDICATION NAME] 5 milligrams (mg) three times a day for pain/discomfort. There was also an as needed order for [MEDICATION NAME] 5 mg every eight hours with instructions not to be given within one hour of the routine dose, and on 4/6/18 the order included to hold for lethargy. Review of the Interdisciplinary Progress Notes revealed the following: a. On 3/29/18, the Assistant Director of Nursing documented that the palliative care team met to review the resident regarding care at the facility versus hospitalization for a new onset pneumonia. The resident was being treated with antibiotics and her preference was to remain at the facilily for care. The resident denied pain but stated she felt unwell and remained on antibiotics. b. Nursing notes, dated 3/29/18 through 4/6/18, included that the resident was refusing to get out of bed, had increased periods of malaise, poor appetite, and some refusals of medications. c. On 4/6/18, the Social Worker (SW) documented that she was visiting the resident more often due to her change in status, and that she was weaker and unable to engage in a conversation of any length. d. On 4/6/18 at 2:23 p.m., the Registered Nurse documented that the resident had increased lethargy, had no intake except sips of water, had a shallow non-productive cough, diminished breath sounds, and that family and the Nurse Practitioner were notified. At 2:52 p.m., the SW left a message for the Pastor requesting a supportive visit. e. On 4/6/18 at 10:43 p.m., Licensed Practical Nurse (LPN) #1 documented in her note that the resident remained in bed all shift, had loose stools, complained of stomach discomfort, refused all food and medications except her pain medication ([MEDICATION NAME]), and a message was left for the on- call physician to request something for her nausea but the on-call physician did not return her call. f. On 4/7/18 at 3:19 a.m., LPN #2 (night shift) documented that at 12:15 a.m., the family reported that the resident requested more pain medication and wanted the physician to be called again to request [MEDICATION NAME] for comfort and that the resident needed to be suctioned due to increased secretions. LPN #2 documented that the resident denied pain and nausea but that the family member said that the resident will tell the family but not the staff. The family member reported that the resident told them that her pain was all over and she was coughing up phlegm. The note did not include that the resident was suctioned as requested by the family. g. On 4/7/18 at 4:00 a.m., the RN documented that the resident's family was staying with her overnight advocating for her needs, and that the resident was coughing up sputum. The RN documented that the resident did not seem to be in pain and was talking about going to the edge. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. [MEDICATION NAME] (anti-nausea medication) and [MEDICATION NAME] (pain medication often used for severe pain) were not administered until 5:40 a.m. on 4/7/18. On 4/7/18 the LPN/Nurse Manager (NM) wrote that the family informed them that the resident ceased respirations at 6:50 a.m. Review of the medical provider notes revealed that there was no documention that medical followed-up after being notified of the resident's change in status on 4/6/18 at 2:23 p.m. Interviews conducted on 12/11/18 included the following: a. At 12:43 p.m., the LPN/NM stated that medical was on-call 24 hours a day seven days a week. She said that she did not know why medical did not call back on 4/6/18 (evening shift) but they should have responded. The LPN/NM said that the family was upset about the nights events regarding not getting an increase in the resident medications for pain and nausea. The LPN/ NM said that the night nurse told her when she came in that they needed to get an increase in pain medication. b. At 1:05 p.m., the Administrator stated that the family did come to him with concerns that in the last hours of the resident's life she was not attended to for pain as she should have and was concerned with the lack of response from the medical team. The Administrator stated when they reviewed the record they did not see signs of distress. c. At 1:33 p.m. the Director of Nursing (DON) stated that the staff called the medical team on the evening shift, and she did not know why they did not respond. The DON said she would have expected medical to call back before morning. She said staff should have called medical again. The DON said that it sounded like the resident was comfortable but the family members reported the resident said she was in pain. Interviews conducted on 12/12/18 included the following: a. At 6:05 a.m. and again at 6:40 a.m., LPN #2 (night shift) stated she was aware that the evening nurse called the on-call medical team to request medication for nausea, but they never called back. LPN #2 stated that the resident complained of nausea, but she thought she was comfortable when she gave her the [MEDICATION NAME] at midnight. She said the family was insistent the resident was in pain and asked her to suction the resident. LPN #2 said she did not suction the resident because she did not think she needed it. She said she called the on-call physician at 5:00 a.m. because by then the resident took a turn for the worse, was complaining of pain and nausea and looked bad. When asked by the surveyor what she meant by looking bad, LPN #2 said that the resident was having difficulty breathing, was gurgling and grimacing. She said at first the on-call physician said to just give her [MEDICATION NAME] and not to give her any more [MEDICATION NAME], LPN #2 said she called back again and got an order for [REDACTED].#2 stated she was not sure. b. At 9:40 a.m., the DON stated that they have made several changes in their palliative care team since that time. When asked for a palliative care policy that was active at the time of the incident (as opposed to the current policy, dated (MONTH) (YEAR)), the DON was unable to provide one. c. At 11:00 a.m., the Assistant Administrator/Quality Assurance (QA) Representative stated that they do not have a contract with any Hospice group. She said the facility has always provided their own end of life care, and information is reviewed with residents and family members on admission. The QA representative said that the facility recently re-educated staff on what to do if the on-call physician does not call back, including at night and with identifying end of life signs. d. At 11:45 a.m., the education nurse stated they are revamping the nursing education program to include more information regarding end of life care. She said she was unable to find documentation of staff education pertaining to end of life care prior to her starting that position approximately a month ago. (10 NYCRR 415.12)

Based on observations and interviews conducted during the Recertification Survey, it was determined that for one of one main kitchen, the facility did not provide safe and sanitary food storage. Specifically, food was contaminated by condensate in the walk-in freezer. This is evidenced by the following: Observations conducted on 8/1/17 at 2:45 p.m. revealed that the walk-in freezer had large amounts of condensate dripping from the condenser and ceiling of the freezer onto packages of food items. Several food items such as ice cream, containers of cheesecake brownies, and apple turnovers had their entire containers covered in ice. An open box of breakfast sausage links had several large spots of ice on the top of the box and the plastic bag inside also had frozen condensate on it. An open box of blueberries had frozen condensation drips inside the packaging on the actual blueberries. In an interview at that time, the Dining Services Director (DSD) stated that he thought it was unlikely that condensate could be a contaminant to food items, it comes from the air. When asked the DSD stated that the condensate could be dripping off of the condenser and freezer ceiling onto the food items. When interviewed on 8/1/17 at 3:19 p.m., the DSD stated that after thinking about it, he decided to throw away all food items which had frozen condensate on them. He said he called a vendor to look at the freezer. A review of the Food Source and Handling policy revealed that the policy did not address condensate in the walk-in freezer. (10 NYCRR 14-1.43, 14-1.44)

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #22) of four residents reviewed for dignity, facility staff did not promote care for each resident in a manner that maintains or enhances dignity. Specifically, staff entered the resident's room without knocking and did not provide care in a dignified manner. This is evidenced by the following: Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 6/14/17, included that the resident's cognition is severely impaired. The Comprehensive Care Plan, dated 6/22/17, revealed that the resident is care-planned for cognitive loss with a goal to maintain dignity. During an observation on 8/1/17 at 2:13 p.m., without knocking, Certified Nursing Assistant (CNA) #1 was observed entering the resident's room with another CNA. While the resident's room door was open, both staff proceeded to pull covers back to the resident's knees exposing his naked perineum (pelvic region), turned him to his side to a place positioning wedge, and then left the room. Neither staff spoke to the resident prior to or while providing care. When interviewed on 8/1/17 at 2:14 pm, CNA #1 stated that when the covers were pulled off the resident, his perineum area was exposed. She said that she should have closed the door to turn the resident but she forgot. When interviewed on 8/4/17 at 9:32 a.m., the Registered Nurse Manager stated that when providing care for a resident she would expect staff to knock and wait for a response before entering the room. She said staff should close the room door, greet the resident, and explain to the resident what they are going to do. (10 NYCRR 415.5(a))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #1) of five residents reviewed for unnecessary medications, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. Issues involved a lack of documentation that a Gradual Dose Reduction (GDR) was attempted or was contraindicated for the use of an antianxiety medication. This is evidenced by the following: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 5/17/17, revealed that the resident's cognition is moderately impaired, and receives antianxiety and antidepressant medications. The current Comprehensive Care Plan included alteration in mood related to anxiety and depression. The resident receives [MEDICATION NAME] (antidepressant) and [MEDICATION NAME] (antianxiety). It was noted on 2/24/14 that the resident was exhibiting increased irritable and disinhibited behavior. Review of the physician orders [REDACTED]. Review of an Optum (health service) Physician Assistant Note, date 8/8/16, revealed that the resident had no reported anxiety, mood swings, or depressed mood, and had a recurrent major depressive order. The resident's behaviors related to her [DIAGNOSES REDACTED]. The plan was to continue [MEDICATION NAME] and [MEDICATION NAME], and no GDR as the resident benefits from these medications, and occasionally gets anxious. Review of the Progress Notes from 1/1/17 to current, included two behavior notes: a. On 6/3/17, the resident was upset about doodling that she found on her activity calendar. She was provided with a new calendar and there was no further mention of the incident. b. On 6/8/17, the resident was counting her money. She stated that she owed her mother money. Review of the physician notes, dated 1/16/17, 3/8/17, 5/1/17 and 6/30/17 do not address behaviors, anxiety or the use of [MEDICATION NAME]. A review of the monthly Pharmacy Medical Regimen Reviews did not include any recommendations for the use of [MEDICATION NAME]. Observations and interviews conducted on 8/3/17 included the following: a. At 10:00 a.m., the resident was observed in a music activity in the common area, sound asleep. At approximately 2:00 p.m., the resident was observed in her room sorting through mail. The resident was alert and pleasantly conversed with the surveyor. b. At 1:47 p.m., the Certified Nursing Assistant said that she has never known the resident to have behaviors or panic attacks or anything like that. c. At 1:53 p.m., the Licensed Practical Nurse (LPN) said that the resident does not have any behaviors or anxiety. Observations and interviews conducted on 8/4/17 included the following: a. At 8:31 a.m., the resident was observed self-propelling around the unit in her wheelchair. The resident was alert and oriented to name and place, and was pleasantly conversing with staff and residents. b. At 8:35 a.m., the LPN Charge Nurse said that the resident has a long-standing history of anxiety. She said for example the resident likes to call her family for candy and stuff, but nothing major. She said the resident does not have panic attacks and has been very stable. c. At 8:38 a.m., the Nurse Practitioner (NP) said that GDRs of [MEDICAL CONDITION] medications are addressed at different levels. She said the pharmacy recommendations and 60-day physician visits are reviewed. The NP said that if there is a change in behaviors, the staff notify medical and it is addressed. After reviewing the medical record, the NP stated that the resident was an Optum resident, and they were good about reviewing GDRs. The NP said that since the resident transferred to the facility's medical providers there is no mention of the [MEDICATION NAME]. d. At 9:02 a.m., the Director of Nursing (DON) stated that the resident's [MEDICATION NAME] had not been reviewed since the previous summer. The DON said that the resident was followed by Optum, however the facility physician renewed her orders. The DON stated that she knew that the facility was late in reviewing GDRs for residents on [MEDICAL CONDITION] medications. e. At 10:02 a.m., by telephone, the Consultant Pharmacist stated that during a review, he looks at medical record documentation and has a discussion with the nurses. He said if he does not see documentation of on-going issues, then he sends a recommendation for a GDR at least once a year. The Consultant Pharmacist added that he depends on nursing documentation and physician notes to determine how the resident is doing. He said without his notes, he is unsure about the specifics of the resident. (10 NYCRR 415.12(l)(1))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for 5 (Residents #1, #20, #52, #60, and #79) of 40 residential beds reviewed for siderails, the facility did not properly maintain all essential patient care equipment in a safe operating condition. Specifically, siderails were loose and wobbly. This is evidenced by, but not limited to, the following: 1. Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 7/12/17, revealed the resident is cognitively intact. The current Certified Nursing Assistant (CNA) Kardex directed the use of two upper siderails while in bed as an enabler. During an observation on 8/1/17 at 10:22 a.m., the residents two upper siderails were loose and wobbly when raised. 2. Resident #52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 7/12/17, revealed the resident is cognitively intact. The current CNA Kardex directed the use of one upper siderail as an enabler. During an observation on 8/1/17 at 10:33 a.m., the right lower and upper siderails were loose and wobbly when raised. 3. Resident #79 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 6/28/17, revealed the resident's cognition is severely impaired. The current CNA Kardex directed the use of two upper siderails while in bed as an enabler. During an observation on 8/1/17 at 10:12 a.m., the resident had four siderails on the bed (two upper and two lower) that were loose and wobbly when raised. When interviewed on 8/3/17 at 10:21 a.m., the CNA stated that Resident #52's siderails were loose. She said that she would notify maintenance. When interviewed on 8/3/17 at 1:04 p.m., the Maintenance Team Leader said that there is no preventive maintenance program for siderails. He said that siderails will be added or removed from the beds at the nurse's discretion. (10 NYCRR 415.29(b))

Based on interviews and record reviews, it was determined that for 6 of 17 residents reviewed for accuracy of the Minimum Data Set (MDS) Assessment, facility staff did not accurately code the MDS Assessment to reflect the residents' status. Specifically, the brief interview for mental status (BIMS) was not attempted for Residents #22, #34, #46, #53, #54, and #70. This is evidenced by, but not limited to, the following: 1. Resident #22 has [DIAGNOSES REDACTED]. Review of the MDS Assessments, dated 9/23/15 and 3/9/16, revealed that the resident has clear speech, is understood, and understands others. The BIMS was not attempted for either assessment. When interviewed on 6/2/16 at 10:57 a.m., Certified Nursing Assistant (CNA) #1 stated that the resident does talk and will answer yes or no. In an interview on 6/3/16 at 9:15 a.m., the Licensed Practical Nurse (LPN) Manager reported that some days this resident is interviewable and some days he is not. She said she was not familiar with the instructions included in the MDS Assessment manual related to completing the BIMS. 2. Resident #46 has [DIAGNOSES REDACTED]. Review of the MDS Assessments, dated 12/9/15 and 3/2/16, revealed that the resident has clear speech, is understood and understands others. The BIMS was not attempted for either assessments. When interviewed on 6/2/16 at 10:29 a.m., CNA #2 said that the resident is able to make her needs known. In an interview on 6/3/16 at 9:15 a.m., the LPN Manager stated that this resident sometimes understands and is usually understood. 3. Resident #34 has [DIAGNOSES REDACTED]. Review of the MDS Assessment, dated 5/11/16, revealed that the resident has clear speech, is usually understood, and understands others. The BIMS was not attempted for this assessment. When interviewed on 6/3/16 at 10:25 a.m., CNA #3 stated that the resident has clear speech and she understands when asked a question. In an interview on 6/2/16 at 9:14 a.m., the MDS Coordinator stated that staff are supposed to attempt a BIMS interview, and if the resident is unable to answer the first few questions, the assessment is coded 99, which triggers a staff assessment for mental status. Review of the Long Term Care Facility Resident Assessment Users Manual, Version 3.0, October 2015, page C1, revealed that the cognitive patterns in this section are intended to determine the resident's attention, orientation, and ability to register and recall information. These items are crucial factors in care planning. Most residents are able to attempt the BIMS interview. Without an attempted structured cognitive interview, a resident may be mislabeled based on his or her appearance or assumed diagnosis. Structured interviews will efficiently provide insight into the resident's current condition that will enhance good care. (10 NYCRR 415.11(b))

Based on observations, interviews, and record review, it was determined that for one of three residents reviewed for unnecessary medications and one of three residents reviewed for accidents, the facility did not provide services in accordance with the resident's written plan of care. Specifically, Resident #46 was not wearing gauze pads to protect the palms, and Resident #12 was not wearing geri sleeves to protect the arms. This is evidenced by the following: 1. Resident #46 has [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) Assessment, dated 3/2/16, documented that the resident has severe impairment of cognitive function, requires extensive assist of staff for dressing and personal hygiene, and has a functional limitation in range of motion of the upper extremities. The Comprehensive Care Plan (CCP) and the Kardex, both dated as last reviewed on 5/13/16, directs staff to cleanse and dry the resident's hands every shift and after meals. Keep a gauze pad (4 x 4) in the palms of the resident's hands at all times, other than at meals, to keep the palms dry and to prevent fingernail tips from pressing into the tissue of the palms. During observations on 5/31/16 and 6/1/16 throughout the day shift, there were no gauze pads in the resident's hands. Both hands had contracted fingers, and fingernails digging into the palms of the resident's hands. Interviews conducted on 6/2/16 included the following: a. At 10:29 a.m., Certified Nursing Assistant (CNA) #1 stated that the resident's hands are contracted, so gauze pads are placed in her palms to prevent her fingernails from digging into her skin. She said sometimes the resident takes them out. b. At 12:39 p.m., the Licensed Practical Nurse (LPN) Manager stated that the resident does not always allow them to cut her fingernails, so the gauze is placed in her palms to protect the skin and prevent odor that is sometimes there. When interviewed on 6/3/16 at 8:51 a.m., CNA #2 stated that the night shift provided morning care for the resident on 6/1/16. She said she should have double checked to see if the gauze was in the resident's hands but she did not. She added that sometimes the resident removes the gauze, but if asked, the resident will allow staff to replace the gauze and leave it in place. 2. Resident #12 has [DIAGNOSES REDACTED]. Review of the MDS Assessment, dated 8/20/15, revealed that the resident's cognition is severely impaired and that she requires extensive assistance with dressing. The CCP and Kardex currently in place included alteration in skin integrity related to [MEDICATION NAME] therapy. Interventions include arm protectors (geri sleeves) to be worn when the resident is wearing short sleeved tops. During observations on 6/1/16 and 6/2/16, throughout the day shift, the resident was not wearing geri sleeves. Interviews conducted on 6/2/16 included the following: a. At 11:03 a.m., CNA #3 stated that the night shift provides morning care and gets the resident up daily. She said she did not put geri sleeves on the resident this morning, and the resident is supposed to wear them. She added the resident is on [MEDICATION NAME] and gets skin tears, and sometimes she removes the geri sleeves. b. At 11:10 a.m., the Licensed Practical Nurse (LPN) Manager stated that the resident should be wearing the geri sleeves because she is on [MEDICATION NAME] and has fragile skin. She said the resident does remove the sleeves a lot. When interviewed on 6/3/16 at 9:15 a.m., the LPN Manager stated that it is her expectation that the resident is wearing her geri sleeves, and if she refuses, the nurse should be notified. She said she was not sure if the care plan addresses that the resident sometimes removes the geri sleeves. (10 NYCRR 415.11(c) (3) (ii))

Based on observations and interviews, it was determined that for one (Eastman Unit) of four resident sleeping units, the facility did not maintain an environment free of accident hazards. Specifically, there were resident accessible bathrooms that lacked nurse call stations whose doors were not equipped with emergency hardware. This is evidenced by the following: 1. Observations on 5/31/16 at approximately 8:40 a.m., revealed a men's and women's restroom adjacent to the Crystal room on the Eastman unit. The doors to each restroom had a key inserted into each lock on the outside of the handles. Neither of the restrooms were equipped with a nurse call system, and the doors and doorframes lacked emergency hardware (able to be opened without having to push against a resident who may have collapsed within the room). In an interview at this time, the Director of Environmental Services (DES) stated that these bathrooms are mostly for staff and visitor use. Staff get annoyed because people keep asking for the keys. The DES then removed the keys and brought them back to the nurse station nearby. 2. Observations on 6/1/16 at 8:15 a.m., revealed the keys to the men's and women's restrooms adjacent to the Crystal room were inserted into each lock on the outside of the door handles. In an interview at this time, the Director of Nursing stated that there are some residents who wander and some that self-propel in wheelchairs but doubts that any of the residents would have the strength to open the doors because they are heavy doors. (10 NYCRR: 415.29(a)(1))

Based on observations, interviews, and record review, it was determined that for one (Resident #22) of one resident observed for incontinence cares, the facility staff did not follow appropriate infection control techniques and procedures. Specifically, the resident was not cleaned after an episode of urinary incontinence. This is evidenced by the following: Resident #22 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 3/9/16, includes that the resident requires extensive assist of staff for toileting and personal hygiene and is frequently incontinent of urine. The Comprehensive Care Plan, dated 3/18/16, includes that the resident is incontinent and uses incontinence briefs. Staff are to check and change the resident every two hours. During an observation of incontinence cares on 6/1/16 at 12:52 p.m., the resident was transferred back to bed via a stand lift. The resident's brief was heavily soiled with urine. The resident was laid down on a clean incontinence pad. Staff did not inspect or cleanse the soiled peri area, scrotum, penis, or buttocks. The resident was covered and staff left the room. When interviewed at this time, the Certified Nursing Assistant (CNA) #1 stated that the resident was not washed and should have been. They also usually inspect his bottom and just forgot that day. At 1:09 p.m., that day CNA#2 stated that no, they did not wash the resident or look at his skin and they should have, but there was just too much to remember. During an interview on 6/2/16 at 2:39 p.m., the Director of Nursing stated that if a resident is incontinent of urine, she expects that staff clean the resident using peri wash and a disposable cloth. When interviewed on 6/3/16 at 9:15 a.m., the Licensed Practical Nurse Manager stated that she expects peri care to be done after every incontinent episode. (10 NYCRR 415.19(a)(1-4))

Based on observations, interviews, and record reviews, it was determined that for one (Resident #15) of five residents reviewed for unnecessary medications, the facility did not maintain accurate and complete clinical records. Issues involved incomplete physician orders for the administration of oxygen. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following: 1. Resident #15 has [DIAGNOSES REDACTED]. According to the Comprehensive Care Plan (CCP), initiated on 10/26/12, the resident is to receive oxygen at 2 Liters (L) continuously. In a progress note, dated 3/3/15, the Nurse Practitioner documented that the resident's oxygen saturation level was 91 percent on room air and 97 percent on 2L of oxygen. The assessment and plan included to continue oxygen at 2L. There was no physician's order in the record for the oxygen at 2L continuously. Review of the April 2015 Treatment Administration Record (TAR) revealed that the resident should receive oxygen via nasal cannula to maintain an oxygen saturation level of greater than 90 percent. Oxygen saturation levels documented by the night shift ranged from 91 percent to 98 percent. This TAR lacked documentation to show that oxygen was administered. The 5/1/15 physician orders included oxygen via nasal cannula to maintain oxygen saturation levels above 90 percent. The orders did not include a liter flow (amount) of oxygen to be administered or to monitor the oxygen saturation levels. Interviews conducted on 5/1/15 included the following: a. At 1:15 p.m., Licensed Practical Nurse (LPN) #1 stated the resident wore oxygen continuously at 2L. LPN #1 stated the liter flow should be in the order and usually is. b. At 1:31 p.m., the LPN Nurse Manager (NM) stated the resident is supposed to wear the oxygen continuously and that oxygen is administered per the physician's order. The NM said she did not know the physician's order did not include the amount of oxygen to be administered. c. At 2:50 p.m., LPN #2 stated the resident wore oxygen at 2L continuously and the order does not indicate that. LPN #2 said the house order is 2L to 5L and to maintain oxygen saturation levels. Observations on 5/1/15 and 5/5/15 between 8:00 a.m. and 3:00 p.m. revealed the resident with oxygen at 2L via nasal cannula administered continuously. (10 NYCRR 415.24(a)(1-4))