Every finding on record at MVHS Rehabilitation and Nursing Center

Based on observations, record review, and interviews during the recertification survey conducted 7/16/2025-7/22/2025, the facility did not ensure a process was in place for residents to have their grievances addressed appropriately for all190 of 190 residents residing in the facility. Specifically, information on how to file a grievance and grievance forms were not available to the residents and the facility did not have a process for residents to file an anonymous grievance. Additionally, 8 of 8 anonymous residents present at the resident group meeting did not know where to obtain grievances forms or their right to file anonymously and did not know who the facility grievance officer was. Findings include:The facility policy Complaint Management, revised 11/18 documented Grievance Officer posters were located by the elevators stating the grievance officer's name and contact number. The procedure for any staff was to report any complaints to their immediate Supervisor. The Supervisor/Manager/Leadership would initiate the Complaint Form at the request of any resident, resident representative, interested family, visitor, or advocate. The form would be forwarded to the Social Work Director/Designee by the end of the shift for tracking and distribution for follow-up. The policy did not include information about the process for filing an anonymous grievance.During a resident group meeting on 7/17/2025 at 11:18 AM, 8 of 8 anonymous residents stated they did not know how to obtain grievance forms, how to file a grievance anonymously, or who the grievance official was. During an interview on 7/18/2025 at 8:50 AM, Receptionist #3 stated there were no grievance forms at the nurse's station on [NAME] North, or out and about for resident use. If there was a concern, the resident should go to the Unit Manager or Social Work for a grievance. They stated there used to be a drop box for suggestions on the first floor, but it was no longer there, and there was nothing like that on the second floor. During an interview on 7/18/2025 at 1:25 PM, Licensed Practical Nurse #4 stated they had not seen grievance forms for the residents to complete, nor had they seen a suggestion or grievance drop box for the residents. If the residents had a concern, they should go to the Unit Manager or Social Work. They stated the residents should have a grievance form and drop box for the forms.During an interview on 7/19/2025 at 10:47 AM, Certified Nurse Aide #17 stated if a resident had a concern, they should go to the Unit Manager. They knew there was a form for grievances but did not know where they were kept. During an interview and observation on 7/21/2025 at 9:25 AM, Receptionist #5 was seated at the main entrance lobby sign in desk. They stated the did not see anything about reporting concerns or grievance forms. If a family member or resident had a concern, they should call the Unit Manager for that unit or the Supervisor to assist the family/resident. There were no available grievance forms observed in the main lobby.During observations on 7/21/2025 between 9:31 AM and 9:35 AM, there were no grievance forms or drop boxes in the lobby between the [NAME] Units or the lobby between the [NAME] Units. During observations on 7/22/2025 between 1:23 PM and 1:29 PM, there was no grievance poster identifying the grievance official, grievance forms, or drop boxes located in the lobby between the [NAME] Units, the lobby between the [NAME] Units, or either elevator. During an interview on 7/22/2025 at 10:53 AM, Manager of Social Services #9 stated the process for filing a grievance was to let staff know. The residents should let the Unit Manager, Social Worker, or Nurse know and they would pass it along to the Unit Manager or Social Work would write the formal complaint. The facility had specific grievance forms, but they were not out for people to complete and could be found on the facility's intranet and unit filing cabinets. The facility did not have an anonymous grievance policy. They did not get anonymous grievances, but that was likely because there was no policy for it. They stated they were the grievance official but was not sure if the resident knew this. The sign listing the grievance official was either in the elevator or in the lobby off the elevator in the glass cabinet, but they were not sure if it was still posted. The residents should be able to file an anonymous grievance to voice concerns without worrying about retaliation. They should be able to file an anonymous complaint about someone they did not feel comfortable talking to. The facility used to have a drop box, but when they painted it was taken down. They were not sure why it was not put back up. They stated the grievance forms were not available for residents to complete.10NYCRR 415.3(C)(1)(ii)

Based on observations, record review, and interviews during the recertification survey conducted 7/16/2025-7/22/2025, the facility did not ensure each resident received and the facility provided food that accommodated allergies, intolerances and preferences for 12 of 18 residents (Resident #3, #17, #47, #56, #67, #86, #110, #117, #146, #150, #158 and #187) reviewed. Specifically, Residents #3, #17, #47, #56, #67, #86, #110, #117, #146, #150, #158 and #187 were not provided hot beverages as specified on their meal ticket. Findings include: The facility policy Preparing and Assisting Residents with Meals, revised 6/2025, documented the facility assured a mechanism to deliver food in a safe, accurate, effective and timely manner to residents with prescribed diets and it was the responsibility of the licensed nurse/certified nurse aide to check trays for any missing food items.During an observation of the breakfast meal service on 7/18/2025 at 9:25 AM, the following residents had hot beverages listed on their meal tickets and were not provided the hot beverages:Resident #3 coffee Resident #17 coffeeResident #47 coffeeResident #56 coffeeResident #86 coffeeResident #110 teaResident #117 coffeeResident #146 coffeeResident #158 coffeeResident #187 hot chocolateDuring an observation of the breakfast meal service on 7/21/2025 at 8:57 AM, the following residents had hot beverages listed on their meal tickets and were not provided the hot beverages:Resident #47 coffeeResident #67 hot chocolateResident #86 coffeeResident #110 teaResident #146 coffeeResident #150 hot chocolateResident #158 coffeeDuring an interview on 7/22/2025 at 12:43 PM the Clinical Nutrition Manager stated the resident's meal profile was based on the resident's preferences. They thought dietary staff provided the cold drinks, and nursing provided the hot drinks. All items listed on the ticket should be offered including hot cocoa, hot tea, and coffee. They tried to provide 75% of the resident's fluid needs at meals and hot beverages were part of that 75% calculation. If residents were not consistently receiving their hot liquids it could impact their hydration status.During an interview on 7/22/2025 at 12:52 PM, Certified Nurse Aide #13 stated pouring drinks was a shared responsibility between nursing and dietary. Dietary started pouring and nursing finished. If coffee was on the meal ticket, they always asked the resident because most did not want it. If a resident refused, they made a notation of an R (for refusal) next to that item and let the nurses know so changes could be made. During an interview on 7/22/2025 at 1:04 PM, Food Service Worker #14 stated they brought the meal tickets up from downstairs and set them on the dining tables. It was the responsibility of nursing to pour drinks, including hot beverages, but sometimes they did not do so. In those instances, they poured the drinks especially if the resident was asking for something to drink. During an interview and observation on 7/22/2025 at 9:19 AM Registered Nurse Unit Manager #15 stated pouring drinks, including hot beverages, was a combined effort between nursing and dietary but ultimately it was nursing's responsibility. Residents should get hot liquids if they wanted, and staff knew which residents wanted it. Items listed on meal tickets were based on resident preferences and meant the resident enjoyed those items. Everything on the meal ticket should be provided because that was part of their nutritional plan. During the interview Resident #86 said to Registered Nurse Unit Manager #15 they would like a cup of coffee with cream and sugar. The resident had hot coffee listed on their ticket, but it was not provided. 415.14(d)(4)

Based on observations and interviews during the recertification survey conducted 7/16/2025-7/22/2025, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service for one (1) of three (3) walk-in coolers (the meat and dairy cooler) in the main kitchen. Specifically, the meat and dairy walk-in cooler did not maintain food temperatures below 41 degrees Fahrenheit as required.Findings include: The United States Food and Drug Administration Food Code (current as of 1/8/2025) Section 3-501.12 Time/Temperature Control documented temperature control for food under refrigeration would maintain the food temperature at 41 degrees Fahrenheit or less. The National Food Safety Information Network Gateway to Government Food Safety Information Guidelines documented cold food storage for eggs, luncheon meat, egg salad, tuna salad should be refrigerated at 40 degrees Fahrenheit or below.The undated facility document titled Hazard Analysis and Critical Control Points Weekly Refrigerator Temperature Log outlined procedures for monitoring refrigeration units used to store foods requiring time and temperature control for safety. It included critical limits indicating that refrigeration temperatures must be maintained at or below 40 degrees Fahrenheit during stable conditions. Staff should record temperatures once daily and initiate corrective actions if readings exceeded the threshold. Corrective measures included checking food temperatures, placing items on hold if necessary, and consulting the food safety manager for further evaluation. During a main kitchen observation with the Food Service Director on 7/17/2025 at 11:27 AM, the meat and dairy walk-in cooler's outside analog thermometer read 50.0 degrees Fahrenheit. The analog thermometer on the inside of the cooler read 39-40 degrees Fahrenheit. The temperatures of the food items in the cooler were measured using the New York State issued thermometer and included butter at 45.0 degrees Fahrenheit; pickles at 45.0 degrees Fahrenheit; feta cheese at 55 degrees Fahrenheit; bologna at 52.7 degrees Fahrenheit; and milk at 45 degrees Fahrenheit. The Food Service Director stated those foods should not have been out of temperature for more than 2 hours and the temperatures were not acceptable.During an interview on 7/17/2025 at 11:30 AM the Food Service Manager stated a temperature of 40 degrees Fahrenheit was considered acceptable for the cooler. Staff relied on the thermometer hanging inside the cooler to monitor temperatures, as the external thermometer was old and was not accurate. They stated internal food temperatures were only checked if there was a suspicion of a problem. Internal food temperature checks were not performed recently. They were not aware of the items in the cooler with elevated temperatures. They stated the temperatures were not acceptable. and acknowledged the staff would not have known the thermometer used to check temperatures had been inaccurate. On 7/17/2025 at 12:15 PM the food temperatures in the walk-in cooler were measured. - diced eggs - 37 degrees Fahrenheit - cottage cheese 52 degrees Fahrenheit (9 half gallons) - coleslaw dressing 50 degrees Fahrenheit (1 gallon opened) - provolone cheese 53 degrees Fahrenheit (6 pounds) - tzatziki 51 degrees Fahrenheit (1 quart) - sour cream 48 degrees Fahrenheit (3 half gallons) - liquid eggs 46-49 degrees Fahrenheit (7cases) - string cheese 48 degrees Fahrenheit 1(case) - ham 51-53 degrees Fahrenheit (5-10 pounds) - bologna 51 degrees Fahrenheit (2-10 pounds) During an interview on 7/17/2025 at 12:55 PM the Food Service Manager stated they were unaware how long the food in the walk-in cooler was out of temperature and they voluntarily discarded the items. They stated the vendor had been on-site for assessment of the coolers. During an observation with the Food Service Manager on 7/18/2025 at 1:00 PM the temperature of the walk-in cooler was re-checked using a bottle of water placed in the cooler on 7/17/2025.The water temperature measured 37.7 degrees Fahrenheit, and the comparison was made to the analog thermometer inside the walk-in cooler which measured 36.7 degrees Fahrenheit.During an interview on 7/22/2025 3:05 PM the Food Service Manager stated the temperatures for the walk-in coolers were monitored and documented once daily by the morning supervisor. The acceptable temperature range for the walk-in cooler was between 34 degrees Fahrenheit and 40 degrees Fahrenheit, with 40 degrees Fahrenheit as the upper limit. If a cooler was found out of temperature, the product inside was removed and discarded. The Food Service Manager stated there was a verification check in place to ensure accuracy of the cooler thermometer. Potentially hazardous food left out of temperature could lead to foodborne illness if consumed. Maintenance of proper food storage temperatures was important for food safety. 10 NYCRR 415.14(h) _

Based on record review and interviews during the recertification survey conducted 7/16/2025-7/22/2025, the facility did not ensure residents were screened for serious mental disorders, intellectual disabilities, and related conditions prior to admission to the facility for 1 of 35 residents (Resident #8) reviewed. Specifically, there was no documented evidence Resident #8 had a Preadmission Screening and Resident Review Level I completed by a qualified screener prior to admission to the facility to determine if the resident had a mental disorder, intellectual disability, or a related condition.Findings include:The facility policy Pre admission Screening & Resident Review (PASRR), dated 11/16, documented the responsibility of Admissions was to ensure [Preadmission Screening and Resident Review] screen was present on all admissions as indicated and reviewed for completion. All resident entering the facility must have a Level I [Preadmission Screening & Resident Review] completed. If one had not been completed, the facility must complete one. The purpose of the policy was to ensure the identification and delivery of specialized developmental and mental health services to those that require them. The facility policy admission Policy, revised 2/2020, documented all admissions required a current [Patient Review Instrument] and screen (Preadmission Screening and Resident Review, DOH-695 Screen) completed by a qualified screener. Resident #8 had diagnoses including encounter for orthopedic after care and osteomyelitis (bone infection). The 12/8/2024 Minimum Data Set assessment documented the resident was admitted from an acute hospital, did not require a level II Preadmission Screen Resident Review, was cognitively intact, and required extensive assistance with most activities of daily living. There was no documented evidence Resident #8 had a Level I Pre admission Screen and Resident Review completed prior to admission to the facility as required. During an interview on 7/22/2025 at 10:53 AM, Manager of Social Service #9 stated they typically audited charts for the Preadmission Screening and Resident Review form but did not complete those audits due to increased job duties. They often had to go into the hospital computer system to search for the forms. The form typically did not make it into the facility chart system for review until two to three days after admission. They stated the form should be reviewed prior to admission, as it was important to know what services a resident required, and the facility could meet those needs. They were not sure why some residents had the screening forms and others did not. The admission information came from the Admissions Coordinator, and it was the responsibility of the Manager of Social Services to review Preadmission Screening and Resident Review form. During an interview on 7/22/2025 at 11:58 AM, Admissions Coordinator #23 stated they used the hospital computer system to obtain records when residents were admitted from the partnering facility. If the resident came from another hospital everything was faxed with the initial referral. They printed the admission information from the hospital computer system and provided it to the Unit Manager where the resident would live. They used the hospital computer system to search for Resident #8. Admissions Coordinator #23 printed 2 separate documents from the hospital computer system that were labelled Patient Review Instrument and Screen. Neither file included the Preadmission Screening and Resident Review, DOH-695 screen form. They stated they just printed what was labelled. If that was not the required item, they might not be providing the unit with the correct information. The Unit Manager or the registered nurse on the unit reviewed the packet they made from the hospital documents the day of admission. They stated they were not sure where to find the document in the facility record, or what the Preadmission Screening and Resident Review, DOH-695 screen form looked like. During an interview on 7/22/2025 at 12:36 PM, the Director of Nursing stated they did not have the Preadmission Screening and Resident Review, DOH-695 form for Resident #8. The screening was supposed to be reviewed before the resident was accepted for admission. They reviewed the screening and would send an email to the unit with the things needed to be in place before the resident arrived. The screen was important to know what services residents needed and to ensure the facility could provide those services. During a follow up interview on 7/22/2025 at 1:50 PM, Manager of Social Services #9 stated the facility did not have the Preadmission Screening and Resident Review form on file for Residents #8. They should receive a form with every admission, as not everyone in the building had access to the hospital computer system. They did not recall reviewing a Preadmission Screening and Resident Review form for Resident #8. 10NYCRR 415.11(3)

Based on observation, record review, and interviews during the recertification survey conducted 7/16/2025 -7/22/2025 the facility did not ensure sufficient nursing staff to provide nursing care to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for 8 of 8 anonymous residents who expressed concerns regarding the lack of sufficient staffing and 2 of 2 residents (Residents #56 and #135) who experienced prolonged wait time for care. Specifically, during a confidential group meeting (resident council) 8 anonymous residents stated the facility was frequently short staffed and there were often only two certified nurse aides assigned to a unit; and Residents #56 and #135 had prolonged call bell response times. Findings include:The Facility Assessment, last reviewed 6/26/2025, documented the facility was licensed for a total of 202 beds. The number/average or range of long stay residents dependent with activities of daily living was 40-60. The staffing plan documented there would be 5-10 licensed nurses providing direct care during both the week and weekend day, evening, and night shifts; 8-20 nurse aides during both the week and weekend day and evening shifts; and 5-8 nurse aides during the week and weekend night shift. That staffing plan was an estimated range used for staffing consideration; individual extenuating circumstances such as a residents needing 1:1, this would be reviewed and determined how to add the additional staff. The facility policy Resident's/Patient's Rights and Responsibilities, revised 2/2017, documented the residents had the right to receive services in the facility with reasonable accommodation of individual needs and preferences, except with the health or safety of the individual would be endangered.Facility actual staffing documented the following nursing schedule for the [NAME] unit with a census of 39 residents (one resident required one-to-one supervision):On Thursday 7/17/2025 evening shift: 1 licensed practical nurse3 certified nurse aides from 3:00 PM-11:00 PM 4 certified nurse aides from 4:30 PM-11:00 PM 1 certified nurse aide from 7:00 PM-11:00 PM 1 unit service aide from 3:00 PM-7:00 PMOn Friday, 7/18/2025 7:00 AM-3:00 PM day shift:1 Unit Manager2 licensed nurses (one marked as late)4 certified nurse aides (one to go to [NAME] North unit) and1 unit service aide.On Saturday 7/19/2025 7:00 AM-3:00 PM day shift:1 Unit Manager1 licensed nurse3 certified nurse aides1 unit service aideOn Sunday, 7/20/2025 7:00 AM-3:00 PM day shift:1 licensed nurse2 certified nurse aides from 7:00 AM-10:00 AM3 certified nurse aides from 10:00 AM-11:00 AM4 certified nurse aides from 11:00 AM-2:00 PM 3 certified nurse aides from 2:00 PM-3:00 PM 1 unit service aideOn Sunday, 7/20/2025 3:00 PM- 11:00 PM evening shift:1 licensed nurse3 certified nurse aides from 3:00 PM -5:30 PM 4 certified nurse aides from 5:30 PM-11:00 PMOn Monday 7/21/2025 7:00 AM-3:00 PM day shift:1 Unit Manager1 licensed nurse2 certified nurse aides from 7:00 AM-10:30 AM3 certified nurse aides from10:30 AM-2:00 PM2 certified nurse aides from 2:00 PM-3:00 PMThe facility staffing sheets did not reflect a resident assigned one-to-one supervision. During an interview on 7/16/2025 at 11:02 AM, Resident #148 stated they felt the facility was short staffed. There were usually only 2 staff members on the 7:00 AM-3:00 PM shift, particularly on the weekends. Most every day they waited at least an hour to use the bathroom and if their bell was not answered timely, they were incontinent. They had accidents and they soaked through their clothes because staff did not get to them in time. There were a lot of residents who required assistance of 2 for transfers and a resident who was on one-to-one supervision because they fell a lot. They stated there was not enough staff to go around.During an observation on 7/16/2025 at 1:17 PM, Resident #135 was arguing with their family member regarding not getting help. The family member stated they should call for staff again. At 1:49 PM the Administrator entered the resident's room. The resident told the Administrator staff told them they were not able to assist them at that moment and would be with them when they were available. They also stated their call bell was never answered timely. The Administrator explained the staff were busy and would answer as soon as they could. The Administrator stated they would stay with the resident until staff came back. After waiting, staff did not come back, the Administrator looked out into the hall, went back into the room and said staff must still be busy. The Administrator waited, talked with the resident, then went back out in the hall, where no staff was observed. They asked the resident to put their light on again. A certified nurse aide was summoned by the Administrator and the Administrator exited the room at 2:25 PM. During an interview on 7/22/2025 at 11:16 AM, Resident #135 stated sometimes it was hard to wait for the staff to come put them to bed. They did not like to wait and got frustrated easily.During a resident group meeting on 7/17/2025 at 11:18 AM, 8 of 8 anonymous residents stated the facility was frequently short staffed. It was most noticeable during mealtimes and when the certified nurse aides had to help with the residents on one-to-one supervision. Each unit had approximately 36-38 residents and only 2 certified nurse aides. One resident stated that the facility did not provide extra staff to assist with wandering residents and used the staff who were already scheduled. There was no one left on the unit to help the cognitively intact residents with their needs.During an interview on 7/17/2025 at 3:13 PM, Certified Nurse Aide #24 stated they were supposed to have 4 certified nurse aides but there were only 2. There was one nurse, and a unit service aide from 3:00 PM- 7:00 PM. At 7:00 PM one aide would have to take over the one-to-one resident supervision. If they did not get the additional 2 certified nurse aides, they did not know what they would do.During an interview on 7/18/2025 at 9:53 AM, Licensed Practical Nurse #25 stated they were down to 2 certified nurse aides and a unit service aide. Certified Nurse Aide #26 wanted to switch to another floor and walked off the unit. During an observation on 7/18/2025 at 8:33 AM, the call bell monitor documented Resident #56's call bell was on for 30 minutes. Staff were bringing residents into the dining room. The call bell was answered at 8:43 AM after 41 minutes. During an observation and interview on 7/21/2025 at 9:10 AM, the call bell monitor documented Resident #148's call bell light was on for 78 minutes. The resident stated they rang to use the bathroom, but they had been incontinent while waiting. They waited an hour and a half and was dry when they put their light on. They held it for about 20-30 minutes before they were incontinent.During an interview on 7/21/2025 at 9:21 AM, Licensed Practical Nurse #25 stated they had 3 aides but were down to 2 because Certified Nurse Aide #26 just left the unit and had no idea why. They had 2 nurses, but the rehab unit took second nurse these at 7:20 AM because that unit had to have more staff.During an observation on 7/21/2025 at 9:37 AM the call bell monitor showed Resident #56's call light was on for 33 minutes. It was answered at 9:39 AM after 35 minutes. During an interview on 7/21/2025 at 9:53 AM, Resident #56 stated they rang because they needed assistance with their electric wheelchair. Their call bell was sometimes not answered for hours, especially on the weekends because there was not enough help.During an interview on 7/21/2025 at 10:36AM, Certified Nurse Aide #27 stated they did not have enough staff to meet the resident's needs. Their unit had about 18 residents who required the use of a lift and 2 staff for transfers, a lot of behaviors, and a resident who was on one-to-one supervision. That day the unit was scheduled for 3 aides, but because there was not a unit service aide there were only 2 aides for the floor. Right now, there were residents still in bed who were not repositioned or bathed. Resident #3 was in a hospital gown at the nurses' station and did not have their shower. They were responsible for 13 residents if there were 3 aides. They worked many times with just 2 aides and one nurse especially on the weekends. Short staffing resulted in delays in providing toileting/incontinency care, showering, and answering call bells. Resident #148 was able to use their call bell and make their needs known and might be dry if their bell was answered in a timely manner. The resident was not dry that morning. The resident's call was on for over 90 minutes because they could not leave the dining room to answer it.During an interview on 7/21/2025 at 2:37 PM, Licensed Practical Nurse #29 stated current staffing levels were not desirable. On evenings there was usually 1 nurse and 3 or 4 aides: but more commonly 3. They had always had 3 plus someone to do the 1:1. They noticed call bell response times were long when there were only 3 aides.During an interview on 7/22/2025 at 10:39 AM, Staffing Coordinator #28 stated staffing numbers were determined by Administration. All units in the facility had a staffing goal of 2 nurses and 3 certified nurse aides. They did not participate in the Facility Assessment and did not review it. 8 certified nurse aides were not enough to cover the building for the day or evening shift. The minimum to schedule was 1 nurse and 3 certified nurse aides per unit, there were 5 units, which meant the minimum should be 15. If a unit had a resident that required one on one supervision they could use a unit service aide, but they could only sit or walk with the resident they could not help with care of the resident. They were able to schedule for 4 certified nurse aides, per unit for the first and second shifts. On average they had 2 certified nurse aides call out per day shift, and 1 on evenings. The weekends had higher call out rates. The agency staff tended to call out more. A large percentage of the certified nurse aides were agency staff from 4 different agencies. If they were directed to staff extra, they could, but they did not over staff the schedule. If the staffing numbers fell below the minimum, they would try to call people in to work. During an interview on 7/22/2025 at 10:54 AM, Registered Nurse Unit Manager #15 stated a reasonable call bell response time was 5-10 minutes. Some residents had complained about response times. Full day shift staff should be 2 licensed nurses 4 certified nurse aides and on evenings 1 nurse and 4 aides. Sometimes they had a unit service aide. Their unit had about 15 residents who required a mechanical lift. When they had 2 nurses, they were able to help the aides otherwise they did not have time to help. They did not usually staff a full day with just 2 aides. When short staffed, toileting and showers were delayed as they had to concentrate on getting residents up and feeding them first. 78 minutes was not an appropriate call bell response time, but Resident #148 knew it was breakfast time, knew what was going on at that time, and should wait. Resident #148 rang to be changed because they were incontinent. It was their right to use the bathroom whenever they needed to. Call bells should be answered timely to promote continency, to avoid self-toileting, and prevent urinary tract infections.During an interview on 7/22/2025 at 1:14PM, Licensed Practical Nurse #25 stated 50% of the time they were short staffed, and they considered 3 aides short staffed. They were the only nurse that day, and when that happened, they were unable to help with transfers and meals. They were unable to get the medications passed on time, and they did not get a lunch break. During the week it was harder to be short because there was more going on. They did not get any help from ancillary departments. When they were short staffed there were longer wait times for the residents and the aides were overwhelmed and frustrated. They stated they were asked a couple times a week to pick up extra shifts. Call bell response times should be 5-7 minutes; 78 minutes was excessive. Residents complained about the call bell response times. It was important to answer call bells in a timely manner because someone could be having a medical emergency or could have fallen. During a follow up interview on 7/22/2025 at 2:37 PM, Registered Nurse Unit Manager #15 stated the minimum staff for the unit was 1 nurse and 3 certified nurse aides, for 40 residents. The unit had approximately 20 residents that required a mechanical lift and a higher number of residents with mental health and behaviors than other units. The unit did not always have enough staff to care for the residents. They helped and assisted residents to the bathroom, but they had a workload of their own to cover. There should be enough staff to cover the resident needs. The ideal staffing was 2 nurses and 5 certified nurse aides, due to special needs and one on one supervision requirements. The residents knew when they were short staffed and noticed the bustle of the staff to get things done. On 7/21/2025, the unit had 1 nurse and 3 certified nurse aides. At the start of the day, 1 certified nurse aide walked out, and there was 1 resident that required one to one supervision. That left the unit with 1 nurse and 1 aide for approximately 40 residents. Staff could get frustrated, and they tried to jump in to help and allow staff to get a break off the unit when emotions got high. 415.(a)(1)(i-iii)

Based on observations, record review, and interviews during the recertification survey conducted 7/16/2025-7/22/2025, 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 the development and transmission of communicable diseases and infections for one (1) of seven (7) residents (Resident #91) reviewed. Specifically, Resident #91 was on enteric pathogen precautions for active clostridium difficile (a contagious bacteria causing inflammation of the colon). Housekeeper #7 entered and cleaned the room without wearing required personal protective equipment, and Certified Nurse Aide #9 entered the room and delivered a meal tray without wearing required personal protective equipment.Findings include: The facility policy Standard, Transmission, and Enhanced Barrier Based Precautions, created 7/2/2025, documented enteric pathogen precautions were used to prevent the spread of organisms (including clostridium difficile) through contact with resident or residents' environments. Red signage stating Enteric Pathogen Precaution would be placed on the outside of the resident room with a caddy on the outside of the resident door containing the necessary personal protective equipment. Residents on precaution for clostridium difficile required hand washing with soap and water prior to exiting the room. All precautions remained in place unless directed by the Infection Prevention Department.The Facility Policy Daily Cleaning of Posted Isolation Rooms-Contact Precaution C-Diff, updated 3/19/2024, documented cleaning personal must wear personal protective equipment listed on the door and use Defender (a sporicidal disinfectant and cleaner) chemical to clean the room. Resident #91 had diagnoses including clostridium difficile. The 6/20/2025 annual Minimum Data Set assessment documented the resident had moderate cognitive impairment and was always incontinent of bowel.The Comprehensive Care Plan initiated 12/23/2024 and revised 6/26/2025 documented the resident had a history of clostridium difficile. Interventions included contact isolation. The 7/14/2025 Physician #16 progress note documented Resident #91 had active diarrhea and clostridium difficile was likely recurring. The smell and characteristic of the stool, with the resident's abdominal discomfort, indicated high probability of recurrence. The plan included testing for clostridium difficile and the resident was started on oral vancomycin (antibiotic). During an observation on 7/17/2025 at 8:57 AM a sign was located outside Resident #91's door documenting Enteric Pathogen Precautions. Staff should wash hands and put on gloves and a gown before entering the room and discard them before exiting the room. Hands should be washed with soap and water when exiting the room. A personal protective equipment caddy was hanging on the door to the room.During an observation and interview on 7/18/2025 at 8:37 AM, Housekeeper #7 entered Resident 91's room without putting on a gown and proceeded to clean the room. Housekeeper #7 exited the room without changing their gloves and entered the shower room next door. Housekeeper #1 stated they wiped down every surface and cleaned Resident #91's room thoroughly. They stated they used a spray bottle of disinfectant and showed the surveyor the bottle. The disinfectant would not kill clostridium difficile spores. During a follow up interview on 7/18/2025 at 2:55 PM, Housekeeper #7 stated they usually wore gowns in a room with enteric pathogen precautions but forgot to today. They stated they went in the shower room to get the garbage and removed their gloves at that point. They stated they washed their hands in the sink in the janitor room. The janitor room sink was observed and was a chemical sink connected to different chemicals, and not a handwashing sink.During an interview on 7/18/2025 at 3:00 PM, Housekeeping Supervisor #8 stated rooms with enteric pathogen precautions were cleaned with a special mop bucket kept in the dirty utility room containing the Defender chemical, which killed clostridium difficile. They stated this was required to be used when cleaning Resident #91's room.During an observation on 7/21/2025 at 12:13 PM, Certified Nursing Aide #9 entered Resident #91's room and delivered the resident's lunch tray without putting on a gown, gloves, or performing hand hygiene. They exited the room without performing hand hygiene and proceeded to pass other trays to resident rooms. During an interview on 7/22/2025 at 10:45 AM, Registered Nurse/ Infection Preventionist #10 stated the enteric pathogen precautions sign in a shared room meant all staff who entered the infected side of the room should wash their hands and put on the personal protective equipment including a gown and gloves. When they left the room, staff should remove the gown and gloves using the proper technique, throw them in the designated receptacle, and wash their hands with soap and water in the room before leaving. They stated this process was used for any reason, including passing meal trays.During an interview on 7/22/2025 at 11:45 AM, Certified Nursing Aide #9 stated the enteric pathogen precautions sign was for the resident, to prevent getting them from getting sick. They stated gown and gloves were only required for hands on care.During an interview on 7/22/2025 at 11:50 AM Registered Nurse Unit Manager #11 stated the enteric pathogen precautions sign means contact precaution and staff should wash their hands and wear a gown and gloves when performing direct care. Precautions were only needed if staff touched the resident and not needed for food delivery.10 NYCRR 415.19(a)(b)

Based on record review and interview during the abbreviated survey (NY00326875), the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 of 3 residents (Resident #1) reviewed. Specifically, Resident #1: - did not have physician's orders implemented on admission for the care of their urinary catheter (tube that drains urine from the bladder), colostomy (artificial opening in the abdomen draining stool into a bag), and peripherally inserted central catheter (PICC, for intravenous medication) line. - Did not have a comprehensive care plan (CCP) developed and implemented on admission to direct staff in caring for the urinary catheter, colostomy, and PICC line. - Did not have a follow-up appointment scheduled with infectious diseases (ID) timely after order. - Did not have a stool specimen sent for C Difficile (C-Diff, bacterial infection causing diarrhea and bowel inflammation) timely after order. Finding include: The facility's 8/2017 Catheter Care Policy documented all residents with indwelling catheters (tube that drains urine from the bladder) would be given catheter care one time per shift and as needed to prevent urinary tract infections, promote hygiene, and prevent odors. The facility's 2/2020 Central Venous Access Device (CVAD) Therapy Policy documented central venous therapy would be managed and discontinued in accordance with accepted standards by appropriately credentialed members of the facility. The physician provided the order, credentialed registered nurses (RN) changed the dressing every 7 days, labeled the dressing, and documented the exposed length of the catheter in centimeters weekly. End caps were to be changed every 4 days or in the event integrity was compromised or residual blood remained in the cap. Tubing was to be changed every 4 days. The facility's 7/2021 Consults Policy documented residents that required specialized outside services from consulting physicians were to receive those services. Medical Services provided orders, licensed nurses reviewed orders and notified the unit secretary to make the referral and the unit secretary made the appointment, notified resident/family, arranged transport and prepared packet for consult. The facility's 5/2022 Ordering and Reporting of Laboratory Tests Policy documented the facility was to assure laboratory tests were scheduled upon medical orders and results reported to Medical Services. The 9/2023 Colostomy Pouch (drainage bag) Evacuation and Cleaning Policy and Procedure documented colostomy pouches were to be emptied when one third full or when inflated with air to prevent leakage, usually this would be early morning, after meals and at bedtime. Residents were taught and encouraged to perform their own procedure for cleaning the pouch when physically able to. Resident #1 had diagnoses including urinary retention, colostomy status (artificial opening in the abdomen draining stool into a bag), and discitis (infection of the spaces between the spine). The 8/24/2023 Minimum Data Set (MDS) assessment documented the resident's cognition was intact, they required extensive 2-person assistance with bed mobility and was dependent on staff for transfers. The resident had an indwelling urinary catheter (tube that drained urine from the body), an ostomy, and received intravenous (IV) medications. Devices (Urinary Catheter, Colostomy, and PICC line) The 8/17/2023 hospital discharge summary documented the resident was admitted to the hospital with discitis and per infectious disease (ID), they needed 8 weeks of IV antibiotics via a PICC line (peripherally inserted central catheter, device for IV access). The PICC line was placed in the hospital and the resident was discharged on daily antibiotics via the PICC line through 10/6/2023. The 8/17/2023 at 10:43 PM registered nurse (RN) #1's admission Summary documented the resident was admitted after they were hospitalized with discitis. The resident had an indwelling urinary catheter that was intact and draining, a colostomy, and a PICC line in their right upper arm. The resident's admission 8/17/2023 physician's orders did not include orders for the care for the indwelling urinary catheter, the colostomy, or the PICC line. The resident's 8/18/23 physician's orders documented daily IV antibiotics were ordered via the PICC line until 10/6/2023. The 8/18/2023 comprehensive care plan (CCP) documented the resident required assistance with activities of daily living (ADL). There were no documented goals or interventions related to the resident's indwelling urinary catheter, colostomy, or PICC line. The undated [NAME] (care instructions) did not document the resident had a colostomy. The [NAME] documented to monitor/document pain/discomfort due to indwelling urinary catheter. The resident's progress notes included the following documentation: - on 8/22/2023 at 11:51 PM and 9/3/2023 at 11:17 PM by RN #4, PICC line dressing change completed. - On 9/12, 9/13 and 9/16/2023 by licensed practical nurse (LPN) #2, the colostomy was intact. - On 9/19/2012 at 1:49 AM by RN #1, the colostomy continued in left lower quadrant. The 8/2023, 9/2023, and 10/2023 Medication Administration Record (MAR) included: - on 9/12/2023, orders were implemented for urinary catheter care every shift including to change the urinary drainage bag weekly and change the catheter every 4 weeks with instructions on the size of the catheter and balloon to be used. - From 8/17/2023 to 10/5/2023, the resident received an IV antibiotic daily. There was no documented evidence the resident had their PICC line dressing changed or IV tubing changed during that time. - There was no documentation the resident received colostomy care and there was no documentation of instructions for changing the wafer (adhesive device applied to skin that holds the drainage bag) and changing the drainage bag. Outside Medical Consults The 10/12/2023 neurosurgeon consult documented the resident had worsening redness and swelling and significant constant pain to the left knee and the resident needed to be referred to ID. The 10/13/2023 attending physician #8's progress note documented neurosurgery was concerned about the resident's left knee and persistence of infection with a history of discitis. The plan included IV antibiotics to be restarted and the resident needed to go to ID. There was no documented evidence of a physician order for the consult to ID. The 10/16/2023 physician's order (3 days after recommended by neurosurgery) documented refer to ID clinic. On 10/25/23, the resident was discharged to the hospital. There was no documented evidence the resident was evaluated by ID. Diagnostic Testing The 10/22/2023 at 9:32 PM, licensed practical nurse (LPN) #4's progress note documented the resident had a temperature of 102.9 Fahrenheit (F) and cooling cloths were applied. The resident's temperature was rechecked at 8 PM and was 100.3 F. The RN Supervisor (unnamed) was updated and stated to monitor. The 10/23/2023 attending physician #8's progress note documented the resident had a recent fever and history of discitis. They had liquid stool in their colostomy bag and the resident reported feeling weak. The assessment/plan documented the resident had a fever which was now resolved and a history of C-Diff (bacterial infection that caused loose stools) 1 month ago. The plan was to recheck stool for C-Diff and hold off on antibiotics for now. There was no documented evidence of a physician's order for the stool specimen for C-Diff. The 10/26/2023 at 9:28 AM, RN #7's progress note (documented as a late entry) noted they were alerted the resident was not looking well. They were observed in their wheelchair, pale and not able to hold a conversation. Blood pressure was 102/56. Labs were drawn and a stool specimen collected from the colostomy. Their condition did not improve, and they were sent to the hospital. The 10/26/2023 hospital report documented the resident was admitted with hypotension (low blood pressure), a high white blood cell count (indicates infection), acute kidney failure and septic shock of undetermined source. The family reported the resident vomited yesterday and nursing reported a significant amount of stool through the ostomy bag. The plan included checking the stool for C-Diff and continue antibiotics. The report documented the resident tested positive for C-Diff on 10/26/2023. On 11/8/2023 at 12:42 PM, an email was sent to the Director of Nursing (DON) at the facility requesting the resident's C-Diff results and no results were received prior to survey exit. During a telephone interview on 11/13/2023 at 10:38 AM, RN #1 stated during the nursing admission assessment, RN #1 completed a head to toe assessment and obtained orders based on what was in the hospital discharge summary. The Nurse Manager was responsible to develop the CCP. RN #1 would enter orders for urinary catheter care every shift and for the drainage bag to be changed weekly, and to empty the colostomy bag every shift. If a resident's urinary catheter or colostomy was not noted on the care instructions, the nurse would be responsible to tell direct care staff a resident had those devices. RN #1 stated they were not sure why they did not obtain orders for the resident's indwelling urinary catheter or colostomy on admission and stated they should have. During a telephone interview on 11/13/2023 at 11:36 AM, LPN #2 stated physician's orders were typically in place for urinary catheter care, changing the urinary drainage bag weekly, and for colostomy care which included emptying the bag and replacing the wafer and bag as needed. Care for the urinary drainage catheter was done by the certified nurse aides (CNA) and CNAs documented the drainage but they were not sure if they documented care. They were not sure if the resident had a CCP plan in place for their urinary catheter or colostomy and they were not aware there were no orders in place for the resident's urinary catheter or colostomy when they were admitted . During a telephone interview on 11/13/2023, CNA #3 stated they knew how to care for a resident by reviewing information in the computer or a sheet taped on the back of a resident's closet door that had care instructions. They could also ask other staff how to care for a resident. The resident had a urinary drainage catheter and they were responsible to empty the bag every shift. Care of the catheter was documented in the computer. They did not recall what care they documented for the resident's catheter. CNAs and nurses were responsible to empty colostomy bags once per shift and they documented in the bowel movement section of the chart. There was no place for them to document if they changed the wafer/bag. During a telephone interview on 11/14/2023 at 12:55 PM and on 11/15/23 at 10:26 AM, RN Manager #6 stated: - physician orders were needed when a resident was admitted with a colostomy, urinary drainage catheter, and a PICC line. - A CCP and care instructions were also needed and an RN, themselves or their assistant or the Charge Nurse, were responsible to initiate/update the CCP. - Urinary catheter orders included the size/balloon of the catheter, frequency to change the bag and catheter, and catheter care. - PICC line orders included the frequency of changing the dressing. - When an outside consultant made recommendations, the medical provider reviewed the recommendations, informed nursing if they agreed, and nursing entered the order. Orders should be entered within 30-60 minutes after the physician agreed with the recommendations. - When the medical provider wanted a lab test done, it required an order. - They were not aware, and it was not timely, when there were no orders or care planned interventions for the resident's colostomy, no orders or interventions added for 3 weeks after admission for the resident's urinary catheter and no orders for PICC line dressing changes from 8/17/2023 through 10/6/2023. - There should have been an order to obtain a stool specimen for C-Diff on 10/23/2023 and they expected one. - When the nursing note documented the stool specimen was obtained on 10/25/2023, it was not obtained timely. - On 10/13/2023, the unit secretary faxed information to ID regarding the resident. On 10/16/2023, the unit secretary called ID and ID said they were still reviewing the faxed information. They were unsure if anyone called again to inquire about the referral. 10NYCRR415.12

Based on interview and record review during the abbreviated survey (NY 997), the facility failed to ensure all alleged violations involving mistreatment, neglect, or abuse were thoroughly investigated for 1 of 3 residents (Resident #1) reviewed. Specifically, Resident #1 had a fall as a result of a care plan violation and the facility's investigation was not thorough and complete as it did not correctly identify the 2 staff members that transferred the resident to the improper wheelchair; there was no documented evidence the staff members who violated the care plan were removed from resident contact while the investigation was pending, and no documented evidence those staff members were re-educated on resident care plans following the incident. Findings include: The facility policy Resident/Patient Safety Report (Accident/Incident) revised 4/2019, documented the Nurse Manager/Supervisor/registered nurse (RN) would assess the resident following an incident and complete the follow-up Safety Report; route the report to the Director of Nursing (DON) timely, and determine if the comprehensive care plan (CCP) was followed by completing an investigation to determine the root cause of non-compliance of the CCP. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 12/15/21 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, required extensive assistance of 2 persons with transfers, and had 2 or more falls without injury during the assessment period. The CCP initiated on 6/1/2018 and revised on 2/14/2022 documented the resident was at risk for falls, needed maximum assistance from 2 staff members for transfers with a mechanical lift, and used a high back wheelchair with an anti-thrust cushion (a seat cushion with a higher front surface and a lower rear surface to help prevent forward sliding in the wheelchair). The 2/15/22 occupational therapy (OT) progress note documented the resident was referred for evaluation of transfers and strengthening. A high back wheelchair with anti-thrust cushion was recommended. The Kardex (care instructions) dated 2/26/22 documented the resident was to use a high back wheelchair with an anti-thrust cushion. The 2/26/22 at 6:56 PM RN #9's progress note documented the resident was on the floor in their room with their head near the end of their bed. They were noted with a laceration above the right eye with [CONDITION(S)] (swelling) and a left knee abrasion. An order to send to the hospital was obtained. The 2/26/22 Accident and Incident Report completed by RN #9 documented at 6:06 PM (evening shift), the resident had an unwitnessed fall in their room, was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON noted the CCP was not followed, and an investigation was in process. The DON's 2/26/22 Investigative Summary documented upon investigation, it was noted the resident was seated in their roommate's wheelchair when they fell . Investigation and interview revealed the resident was assisted out of bed on 2/26/22 into their roommate's wheelchair by certified nurse aide (CNA) #12 and temporary nurse aide (TNA) #13 (day shift staff). CNA #12 and TNA #13 were suspended pending investigation, received remediation on 3/4/22, and then returned to work. The Director of Social Services' investigative summary dated 3/1/22 documented: - Upon investigation, it was found that at 6 AM on 2/26/22, the resident was transferred to the wrong wheelchair (their roommate's chair) as opposed to their high back wheelchair with an anti-thrust cushion. - CNA #12 and TNA #13 performed morning care, including the transfer, and reported they thought they were using the correct chair for the resident. Neither CNA #12 nor TNA #13 checked the name tag on the chair to ensure it belonged to Resident #1. - CNA #12 and TNA #13 were suspended and allowed to return to work on 3/4/22 after remediation. There was no documentation how the facility determined CNA #12 and TNA #13 assisted the resident to the chair prior to the 6 PM fall. No statements from them were provided and their account of the events of that date were not documented or provided. The 2/26/22 hospital record documented the resident had swelling to the right upper forehead and no signs of skull fracture. The resident found with a comminuted (broken in at least 2 places) odontoid (vertebrae) fracture at C1 (cervical, neck vertebrae) and a cervical collar (neck brace) had been previously placed. Preliminary computed tomography (CT, x-ray) of the abdomen showed fractures on the left superior and inferior pubic rami (pelvic bones). Preliminary CT of chest showed displaced fracture of left posterior tenth rib and small pleural effusion (build-up of fluid between the chest and lungs). On 6/6/22 at 2:19 PM, CNA #10 stated in an interview, they reviewed the CCP to find out how to care for residents. On 2/26/22, the resident was in bed when their shift started (evening shift). CNA #10 transferred the resident to the wheelchair before dinner and TNA #11 assisted. CNA #10 stated they did not realize they transferred the resident into the wrong wheelchair until after the fall and they reported their error to RN #9. A week or so after the fall, RN #9 questioned them and had them write a statement about the resident being in the wrong wheelchair. On 6/6/22 at 2:45 PM, RN #9 stated in an interview, following a fall they looked at the CCP to see if the proper interventions were in place. They were not familiar with the resident at the time of the 2/26/22 fall but the next day a CNA told them the resident was in the wrong chair when they fell . RN #9 notified the DON and the DON stated they would investigate the incident. RN #9 got statements from staff the evening of the incident (2/26/22) and then had them provide additional statements because of being told about the resident being in the wrong wheelchair. RN #9 stated they left a list of staff who needed to provide additional statements for the Nurse Manager and DON. On 6/7/2022 at 10:27 AM, physical therapist (PT) #2 stated in an interview, an anti-thrust cushion would be used to keep someone back in their chair and properly positioned. Resident #1 needed one because they were more lethargic and needed more support. On 10:42 AM, the PT reported to the surveyor the resident's anti-thrust cushion was implemented by OT to prevent sliding in the chair and improve posture. On 6/15/22 at 3:30 PM, TNA #11 was interviewed and stated on 2/26/22, they assisted the resident to the wheelchair before dinner with CNA #10. They knew how to care for residents because they were trained on reviewing care needs in the computer and then shadowed a CNA for a week. Residents also had a Kardex behind their closet doors. They thought they looked at the Kardex on 2/26/22 but did not recall what wheelchair was listed on the Kardex for the resident. After the fall, a nurse said the resident was in the wrong wheelchair at the time of the fall. On 6/15/22 at 1:53 PM, the Director of Social Services stated in an interview the DON completed the investigation into the 2/26/22 incident and their role included reporting to the New York State Department of Health (NYS DOH). On 6/15/22 at 2:15 PM, the DON stated in an interview: - They completed most of the investigation into the 2/26/22 incident and talked about it with the Director of Social Services and the facility's team. - At the time of the fall, the staff did not know the resident was in the wrong chair and when CNA #10 realized it, they reported it. - There was a sign on each wheelchair labeled with the resident's name. - The DON did not think the resident was transferred to the wheelchair on the evening shift prior to the fall and did not recall any statements from evening staff documenting they transferred the resident. - The DON determined the day shift staff got the resident out of bed not the evening shift staff as they would have gotten the resident up that morning for the day. They did not recall RN #9 telling them that the evening staff was involved in transferring the resident. - They were not aware TNA #11 and CNA #10 transferred the resident to the chair prior to dinner and prior to the fall. - Initially the DON stated there were no additional staff statements that were not provided to the NYS DOH related to this incident then the DON stated there were statements and they were provided after the interview. Following the 6/15/22 at 2:15 interview with the DON, the following statements were sent to the surveyor by the DON: - TNA #11's undated statement documented they assisted CNA #10 with transferring the resident to the wheelchair prior to dinner on 2/26/22 and did not recall what wheelchair they transferred the resident into. - CNA #10's undated statement documented after the resident went to the hospital it was noticed the resident was in the wrong chair, their roommate's chair, at the time of the fall. 10NYCRR 415.4(b)(3)

Based on interview and record review during the abbreviated survey (NY 496), the facility failed to ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 3 residents reviewed (Resident #1). Specifically, there was no documented evidence Resident #1's routine skin checks were completed, and the resident developed pressure ulcers to both heels that were not identified by facility staff. Findings include: The facility LTC (long term care) certified nurse aide (CNA) job description, revised 3/8/19 documented CNA responsibilities included: - Checking for reddened areas or skin breakdown and reporting to the registered nurse (RN) or licensed practical nurse (LPN). - Identification and reporting Stage 1 (intact skin with non-blanchable redness) pressure ulcers to prevent further break down; regular inspection of residents' feet and reporting need for podiatry. The facility policy Skin and Wound Care Management revised 7/2021 documented the goal of the skin care team was to identify residents at risk for potential skin break down in order to prevent it as well as to address the needs of those who currently have skin break down. The policy did not address weekly skin checks. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 12/15/21 Quarterly Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, required extensive assistance of 1 with bed mobility and extensive assistance of 2 with transfers. The resident was at risk for developing pressure ulcers and had no unhealed pressure ulcers. Interventions included pressure relieving devices for the bed and chair and nutrition/hydration interventions. The CNA Skin Findings Tool (skin check sheets) documented skin checks are to be done on bath days/nights and documented on the diagram below, any new bruises, skin tears, reddened areas, etc. Notify the LPN who will verify the change in skin integrity, who then notifies the RN/Supervisor/Manager for further follow up. The skin check sheets were in a binder on the unit. There were no documented skin checks for Resident #1 after 5/12/21. The facility was unable to provide any skin check documentation for Resident #1 after 5/2021. The comprehensive care plan (CCP) documented: - on 10/14/21, the resident required assistance with activities of daily living (ADL) and was at risk for impaired skin integrity. Interventions included 1 staff assistance with bed mobility, 2 staff assistance to pull up in bed, Maximove lift (mechanical lift) with 2 staff assistance for transfers, pressure reducing mattress and pillows to protect skin in bed, pressure relieving cushion in chair, and good nutrition/hydration. - on 12/2021, the resident had DM and [CONDITION(S)] with [CONDITION(S)] treatments. Interventions included check all body parts for breaks in skin, treat promptly, and refer to podiatrist or foot care nurse to monitor and document foot care needs and to cut long nails. The resident's medical record did not contain any podiatry progress notes. Nursing and nutrition progress notes from 2/1/22-2/12/22 did not include documentation related to the resident's skin, skin checks, or the condition of the resident's heels. The 2/1/22 to 2/13/22 CNA Task Sheet documented: - The resident's shower/bath day was Saturday. - Bathing on 2/5/22 (Saturday) was not signed as completed and 2/12/22 (Saturday) was marked N/A by CNA #16. - Bathing was signed as completed on 2/1/22 through 2/3/22, 2/8/22, 2/9/22, and 2/13/22. - On 2/13/22, CNA #16 signed for bathing at 10:35 AM. The 2/13/22 at 1:51 PM registered nurse (RN) #14's progress note documented the resident was noted to have dark fluid filled unstageable, possible deep tissue injury (DTI, purple or maroon colored intact skin) to the right heel, covering most of the heel tissue. The left heel was noted to have approximately 2 centimeters (cm) diameter DTI present. [MEDICATION(S)] (bordered foam dressing) in place, Z-flex boots (pressure relief booties) applied, and the CCP was updated. The family member was aware as they had alerted nursing to presence of these areas. On 5/27/22 at 11:48 AM, the resident's family member stated in a telephone interview, they tried to visit the resident every other day. On 2/13/22, the resident asked the family member to remove the resident's shoes and was rubbing their heels on the bed. The family member removed the resident's socks and found big ulcers and notified LPN #15. They also spoke with RN Manager #5 about the ulcers, who told the family member staff were re-educated. On 2/14/22, the CCP was updated and documented the resident developed DTIs to both the right and left heels and a pressure ulcer to the left malleolus (ankle). Interventions included application of an air mattress, [MEDICATION(S)] dressing changed daily, wounds measured weekly, no shoes to be worn and Z-flex boots to both feet to be worn at all times. The 2/14/22 Wound Observation Tool documented: - the resident had new onset DTI to the right and left heels and left lateral malleolus observed for the first time that date, and the wounds were facility acquired. - The left heel measured 3 cm in length and 5.8 cm in width; the right heel measured 6 cm in length and 5.8 cm in width, and the left lateral malleolus measured 0.6 cm in length and 0.3 cm in width. On 5/4/22 at 11:45 AM, LPN #1 stated in an interview, the CNAs were responsible to fill out the skin check sheets and they were done on a resident's shower day. The sheets documented bruising or open areas. Once completed, the CNAs gave the sheet to the LPN for review. They stated the LPN was not required to look at the resident's skin during the skin check. There was a binder in the conference room/office where the sheets were kept. Resident #1 could turn on their own and would try to get out of bed. Some days were better than others depending on how the resident felt. The resident used a wheelchair with footrests and the LPN recalled they wore socks and sneakers in the wheelchair. They were not on duty the day the resident's pressure ulcer was found. On 5/4/22 at 12:00 PM, CNA #4 stated in an interview the resident could not reposition themself, usually used pillows on both sides for positioning, and they did not recall if the resident was on a turning and repositioning schedule. Skin checks were done with the shower and the whole body was looked at. If a skin issue was found, the nurse was notified. When the skin check sheet was completed, they put it in the conference room binder. On 5/4/22 at 2:00 PM, CNA #3 stated in an interview skin checks were done by the CNAs, it was a head-to-toe check, and paperwork was completed after the shower indicating if they found skin issues. The paperwork was then given to the nurse. They stated Resident #1's skin was in good shape and they did not recall any skin issues on the heels. The resident was on [CONDITION(S)] and the night shift got them up for the day. The resident required a stand lift, but they could also use a Maxi lift (full mechanical lift) too. The resident was not alert enough to know to reposition themself and did not like to be moved and would complain. During a telephone interview on 6/17/22 at 11:46 AM, CNA #16 stated skin check sheets were completed weekly on residents' shower or bath days. In between showers or baths, the residents' skin would be checked during changing, but not a whole body skin check. If a bed bath was provided, then the CNA would look for new areas. The CNA was not sure about looking at Resident #1's heels and did not recall seeing anything prior to the DTIs being noted on 2/13/22. The CNA was not asked by a supervisor or nurse if they checked the resident's heels or noted any areas following the discovery of the DTIs on 2/13/22. During a telephone interview with RN Manager #5 on 6/17/22 at 12:00 PM, they stated the DTIs to the resident's heels were facility acquired and discovered by the resident's family member. Skin check sheets were to be completed weekly on bath/shower days by the CNAs and were kept in a binder in the unit office. If a resident refused a bath or shower or it was not completed for another reason, the RN Manager expected the skin check sheet to be completed as soon as possible after the scheduled shower day. When bathing was performed in between shower days (bed bath, hygiene) CNAs should always observe the resident's skin, including heels. On 5/4/22 at 11:15 AM, the Director of Nursing (DON) stated in an interview, skin check sheets were completed on paper which were typically disposed of after 6-8 months because they were not part of the resident's legal medical record. They stated the Nurse Manager was looking for the resident's skin check sheets. They could not locate any podiatry evaluations or skin check sheets for the resident after 5/2021. 10NYCRR 415.12(c)(2)

Based on record review, observation, and interview during the abbreviated survey (NY 696), the facility failed to ensure residents were free from abuse for 1 of 3 residents (Resident #1) reviewed. Specifically, the facility did not prevent Resident #1 from being sexually abused by certified nurse aide (CNA) #15. The sexual assault of Resident #1 resulted in actual harm to Resident #1 that was not Immediate Jeopardy. Findings include: The facility's Reporting Abuse to Facility Management Policy effective since 3/2000 documented for Sexual Abuse/Rape; staff reports immediately any suspected rape/sexual abuse of a resident/patient to his/her Manager/Supervisor, the person in charge of the facility at the time the report is made, and/or the Director of Nursing (DON)/designee. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 6/18/20 Minimum Data Set (MDS) assessment documented the resident's cognition was severely impaired, and they required extensive assistance and/or were dependent on staff for activities of daily living (ADL). The 5/29/20 comprehensive care plan (CCP) documented the resident had an ADL deficit. Interventions included extensive 2 person assistance with bed mobility and transfers using a Hoyer (mechanical) lift. The resident was at risk for falls and had floor mats. The 8/20/20 at 7:30 AM Incident Report documented a condom was found under the resident's floor mats by certified nurse aide (CNA) #10 and the resident was sent to the hospital for a sexual trauma evaluation. There was no accused staff member identified at that time. Two staff members (RN #14 and CNA #15) were suspended pending the outcome of the investigation based on their gender. New interventions included care by two staff members and no male care givers. Evidence was taken by the police department and the facility reported the incident to the New York State Department of Health (NYS DOH). On 8/20/20, registered nurse (RN) Manager #3's progress note documented: - at 7:35 AM, CNA #10 notified them after CNA #10 moved a fall mat in the resident's room, they found an opened condom on the floor. The condom was placed in sealed bag and the resident's sheets and gown were placed in a bag. The Director of Nursing (DON) and Administrator were notified. - at 9:20 AM, the resident had an external exam completed with no issues found. The physician was notified and would be completing an exam as well - at 12:20 PM, the resident's family member wanted the resident sent to the emergency room (ER) for evaluation. - at 2:06 PM, the physician examined the resident around 10 AM, and had no findings. The 8/20/20 Summary of Events completed by the DON documented: - at approximately 7:35 AM, they were notified by RN Manager #3 that CNA #10 provided care to the resident and when cleaning the resident's room, they found an unwrapped condom underneath a floor mat. - RN Manager #3 collected the condom into a bag as well as sheets and the resident's nightgown. - CNA #10 was interviewed and denied knowledge of how the condom got under the floor mat. - The Administrator and physician were notified. - RN Manager #3 and the physician completed an external exam on the resident and had no findings. - The resident's family member was notified and requested the resident be sent to the hospital to have a rape kit (the collection of samples for forensic evaluation) completed. The preliminary report from the hospital did not show evidence of trauma. A vaginal culture was obtained. - The police department and Human Resources was notified of the findings in the resident's room. Two staff (RN #14 and CNA #15) that worked the overnight shift on 8/19/20 into 8/20/20 were suspended pending the outcome of the investigation. - Staff interviews were in the process of being conducted with statements being obtained. The CCP, updated on 8/21/20, documented the resident was involved in an investigation and may have been the victim of abuse. Interventions included 30 minute checks, 2 care givers at all times, semi-private room, and no male caregivers for personal care. On 8/21/20 at 1 PM, the resident was observed in their new room in a Geri chair being fed by staff. On 8/21/20 at 1:15 PM, the resident's prior room (where the incident occurred) was observed. The room was a private room that was currently vacant. The room was past the nursing station and midway down the hallway. On 8/21/20 at 1:20 PM, RN Manager #3 stated in an interview: - the resident was very demented, could be uncooperative with care and the resident was not able to give an account of the incident. - The resident usually went to bed after dinner about 9 to 9:30 PM, their bed was against the wall and floor mats were on the right side of the bed when the resident was sleeping. The floor mats would be on the floor throughout the night shift and then picked up when the resident needed to be got out of bed in the morning. - CNA #15 and RN #14 were on duty the night of 8/19/20 into 8/20/21 and both were suspended pending the outcome of the investigation based on their gender. - CNA #15 was a full-time employee and typically worked from 2 PM to 6 AM. CNA #15 was not typically assigned to the resident but at times, might be the only CNA on the unit and would be assigned to provide care to the resident. They had not had any issues with CNA #15 since they started employment at the facility. - RN #14 was a good employee and never had any issues at the facility. RN #14 reported to them in the past there were not enough staff on the night shift. - On 8/19/20 on the night shift, the unit was short on staff. The licensed practical nurse (LPN) that was scheduled called in and RN #14 had to perform LPN duties including passing medications to approximately 38 residents on the unit and they were also responsible to Supervise the facility. - RN #14 could have potentially been off the unit for most of the night Supervising which left just the 2 CNAs including CNA #15 alone on the unit. On 12/9/21, a grand [NAME] indicted CNA #15 for first-degree rape related to the incident with Resident #1 and an arrest warrant was issued. On 3/29/22, CNA #15 was taken into custody and indicted on a charge of rape in the first degree, a class B felony, related to the incident with Resident #1. On 3/31/22 at 9 AM, the DON stated in a telephone interview, they were off duty on 8/20/20 when they received a call from RN Manager #3 who reported a condom was found in the resident's room. They secured evidence, notified police, started their investigation and suspended certain staff that worked that night (RN #14 and CNA #15). They were told by police to not interview the staff that were suspended including CNA #15. They had no idea who left the condom in the resident's room, were not able to interview the night shift staff so they continued to interview other staff that were recently on duty. The facility had no further contact with CNA #15, they were suspended immediately after the incident and eventually terminated. They had just learned that CNA #15 was arrested on 3/30/22 regarding the incident. On 4/5/22 at 12:05 PM, CNA #10 stated in an interview, they worked the day shift on 8/20/20 and took care of the resident. Around 7:30 AM, the resident was still in bed in a night gown and nothing seemed out of the ordinary. They gave the resident a bed bath and got them dressed and when they went to remove the bedside mats, they discovered a condom not in a wrapper. They reported finding the condom to RN Manager #3 and the police arrived around 10:30 AM. On 4/5/22, CNA #9 stated in an interview, they worked the night shift 8/19/20 into 8/20/20. CNA #15 was on duty as was RN #14 who was the nurse on the unit and also the Supervisor for the building. RN #14 was only on the unit a short time that night to pass medications and then off the floor Supervising other units. There was nothing out of the ordinary about their shift that night and they saw CNA #15 more that night than they typically did. The 4/4/22 addendum to the Summary of Events, completed by the DON documented: - RN #14 was the RN Supervisor at the time of the alleged incident and was suspended on 8/20/20. - CNA #15 was suspended on 8/20/20 and had no further contact with the resident. Several attempts to reach CNA #15 for interview were unsuccessful and the police department instructed the facility to not attempt any further interviews. CNA #15 was terminated from employment. - The police department conducted their investigation of the incident. The case was taken to the grand [NAME] in 12/21, CNA #15 was taken into custody on 3/29/22 and sent to jail awaiting trial. On 4/6/22 at 10:12 AM, RN #14 was not able to be reached for an interview. 10NYCRR 415.4(b)

Based on record review and interview during the abbreviated survey (NY 399) conducted on 6/18/21, the facility did not ensure a resident received treatment and care in accordance with professional standards of practice for 1 of 4 residents (Resident #1) reviewed. Specifically, Resident #1 had open areas to their toes and the areas were not assessed or treated timely. Findings include: The Skin and Wound Care Management policy, revised 11/2018, documents: - When an area or potential area is identified, the registered nurse (RN) will initially assess and note a treatment per the skin care protocol, will complete an initial wound assessment in the electronic medical record (EMR), is responsible for sending an email to the skin care team, and the resident should be added to the skin rounds list. - The skin care team will complete rounds weekly, the wound will be observed, measured, described, and re-dressed. - The weekly documentation will be entered into the EMR by the Nurse Manger or RN designee under the Wound Weekly Observation Tool. Nutrition has a section to complete as well. Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/9/20 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment and did not reject care. The resident required extensive assistance of one person for bed mobility, transfers, personal hygiene, and dressing, and limited assistance of one person for walking in the room and corridor. The resident was at risk for pressure ulcers, had no unhealed pressure areas, and had other open [CONDITION(S)] on the foot. The 1/2/20 at 6:09 PM, RN #1's admission nursing progress note documented the resident was alert and oriented to person, place, and time, and skin issues included small sores between the toes. The 1/2/20 Admit/Readmit Screener assessment completed by RN #1 documented small sores in between the resident's toes measuring 2 inches by 2 inches and gauze (2x2) was placed between the toes. The 1/2/20 comprehensive care plan (CCP) documented the resident had skin issues including a right heel crack and toe sores. The CCP documented interventions were a pressure relieving cushion in the chair and pressure reliving mattress on the bed. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/20 Treatment Administration Record (TAR) did not document the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The treatment was discontinued on 1/4/20. The 1/4/20 Skin Observation Tool documented the resident had blisters between the toes. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - on 1/4/20, wash and dry the toes of bilateral feet, in the morning. Apply lotion and 2x2 gauze between the toes, start 1/5/20, discontinued 1/6/20. This treatment was documented as completed on 1/5/20 and 1/6/20. - On 1/6/20, [MEDICATION(S)] cream (skin protestant), apply to toes/feet topically two times a day for sensitive toes, start date 1/6/20. - On 1/6/20, wash and dry toes on bilateral feet. Apply lotion and 2x2 gauze between toes, once per day for sensitive toes, start 1/7/20. - The 1/2020 TAR did not contain documentation for the ordered 1/6/20 treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The CCP, updated 1/7/20, documented the resident had skin impairment including toe blisters. Interventions included: monitor/document location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/15/20 at 5:00 PM, RN #4's progress note documented the resident complained of foot pain. The 1/16/20 facility's podiatrist's (podiatrist #2) progress note documented the resident had skin ulcers to the 2nd, 4th, and 5th digits of the left foot. Attention was directed to the toenails and the skin ulcers were to be closely monitored. The note was initialed twice, one set of initials could not be identified and the other set of initials were physician #3's initials and were dated 1/22/20. The 1/20 TAR documented [MEDICATION(S)] cream, apply to toes/feet two times a day for sensitive toes was administered twice daily from 1/7-1/23/20. There was no documentation the ordered treatment (1/6/20) of wash and dry toes on bilateral feet, apply lotion, 2x2 gauze between toes once per day starting 1/7/20 was included on the TAR and no documentation that treatment was completed. The 1/23/20 consulting podiatrist #7's progress note documented the resident had sores on the left 2nd, 4th, and 5th toes of the left foot, the foot was red and swollen that appeared to be vascular in nature. The 1/25/20 at 5:44 PM, RN #5's progress note documented the resident's family member was concerned about the resident's left foot. RN #5 assessed the foot and the resident had ulcers to the left 4th and 5th digit, and a new order was implemented. The resident recently saw the podiatrist who recommended a follow-up with vascular. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] - [MEDICATION(S)] cream, apply to toes/feet two times a day for sensitive toes was administered twice daily on 1/30/20; administered one time on 1/24, 1/27-1/29. The second administration was not documented on 1/24 and 1/27, and it was documented the resident refused on 1/28-1/29/20. - The 1/25/20 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/2020 TAR documented this treatment was administered 1/26/20-1/31/20. The 1/29/20 at 1:00 PM, RN #4's progress note documented the resident had open areas on the left foot, 2nd, 4th, 5th digits, evaluated by Wound Care Coordinator #6. Maxsorb with xeroform were applied to the open wounds. An arterial ultrasound was ordered per physician #3 for follow up for vascular due to skin issues per the podiatrist referral. The 1/29/20 Wound Weekly Observation Tool documented: - Wound 1 was on the left foot, 2nd digit, acquired 1/27/20. It was the first observation with necrotic tissue (dead or devitalized tissue that must be removed) present. The treatment plan included maxsorb with xeroform daily. - Wound 2 was on the left foot, 5th digit, acquired 1/27/20. It was the first observation with epithelial (outer skin) tissue present. The treatment plan included maxsorb with xeroform daily. - Wound 3 was on the left foot, 4th digit, acquired 1/27/20. It was the first observation with epithelial tissue and slough (dead) tissue present. The treatment plan included maxsorb with xeroform daily. There were no documented physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 6/1/21 at 11:50 AM, physician #3 stated if any skin issues were noted at admission, the skin team would include the resident on rounds and evaluate for treatment. The physician did not participate in wound rounds but was notified of changes for possible new orders. Blisters or areas on the toes should be included in wound rounds and observed. The physician could not recall the resident or any concerns addressed by the family. When interviewed on 6/2/21 at 10:47 AM, RN #5 stated if open areas were noted, the physician should be called, and the resident would be added to weekly wound rounds. Blisters should be included on wound rounds to ensure monitoring. The nurse who initially identified or assessed the wounds was responsible for sending an email to the wound team. RN #5 could not recall Resident #1's situation and stated based on their 1/25/20 progress note, it was the resident's family member who initiated the assessment. Provider consults should be reviewed by the physician and the RN was unaware of the reasons there were no orders after the 1/16/20 podiatry referral. The RN reviewed the 1/16/20 podiatry note and stated the resident's toes should have been followed by the wound team and they were unaware of the reasons it did not happen. When interviewed on 6/2/21 at 11:03 AM, physical therapist (PT) and wound care coordinator #6 stated they ran the wound care team. Any open areas noted on admission should be brought to the attention of the wound team via email. The wound team would then add the resident to wound rounds and determine if the resident would be followed by the wound team. Newly identified areas should be brought to the attention of the wound team immediately and typically the PT would see the resident within 24 hours. The emails sent to the wound team were not retained and the PT/wound care coordinator #3 was unable to state if they were notified of the resident's skin issues prior to 1/29/20. They recalled the resident's family member spoke to them near the end of the resident's stay to request they look at the resident's foot. The resident appeared to have arterial insufficiency and moisture between the toes. They advised the family member not to apply so much lotion to the feet. The PT did not recall completing the wound assessments on 1/29/20 and stated the resident was not on wound rounds. The PT reviewed the 1/16/20 podiatry note and stated they would expect to be notified to place the resident on wound rounds. When the resident went to another podiatrist on 1/23/20, the PT stated the resident's toes should have been assessed and monitored immediately following the appointment. During a telephone interview with podiatrist #7 on 6/16/20 at 1:45 PM, they stated the resident's family member brought them in for a second opinion due to concerns with the resident's foot. Podiatrist #7 called physician #3 and spoke to them while the resident was present in the office and recommended a vascular surgeon consult and discussed the resident's open areas to the toes, which appeared to be vascular. The podiatrist would leave treatment decisions to the attending physician and stated they could not comment on the type of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] During a follow up interview with physician #3 on 6/2/21 on 11:22 AM, they stated they initialed the 1/16/20 podiatry note and expected nursing to continue to monitor the areas. The physician could not recall anything else about the resident. The physician could not recall the 1/23/20 podiatry visit or referral and stated it would be in their notes. If there were additional concerns regarding the resident's foot, the physician expected to be contacted by nursing. During a telephone interview on 6/18/21 at 10:00 AM, the Director of Nursing (DON) stated open areas, including vascular areas should be included on wound rounds. Upon identification of open areas, the wound team was to be notified and would evaluate the resident to determine proper course of treatment. The process for notification of the wound team was being updated in 1/2020 and the DON was unable to locate any referrals or documentation prior to 1/29/20 regarding the resident's toes and inclusion in the wound rounds. Based on the 1/16/20 podiatry note, the DON stated they expected the resident's toes to be monitored. The lotion treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documentation of a RN assessment or treatment to the open areas prior to 1/25/20, which was not timely, based on the 1/16/20 and 1/23/20 podiatry progress notes. 10NYCRR 415.12

Based on observation, record review, and interview during the recertification survey conducted 5/24/21-5/28/21, the facility did not ensure food and drinks were palatable, attractive, and at a safe and appetizing temperature for 3 of 3 meals (5/26/21 lunch, 5/27/21 lunch, and 5/28/21 lunch) reviewed. Specifically, food and drinks were not served at palatable temperatures including chef salad, lemon mousse, yogurt, turkey and cheese sandwich, tossed salad, fries, coleslaw and milk). Findings include: The April 2021 Food Committee Meeting minutes documented that vegetables were mushy, and juices/milks were not as cold as residents would prefer. The May 2021 Food Committee Meetings documented that mushy vegetables were getting better and hot food items were losing temperature somewhere between the serving and delivery process. During a resident council meeting on 5/24/21 at 2:02 PM, two residents stated food was not being served at proper temperatures. On 5/26/21 at 12:28 PM, a lunch meal tray was delivered to Resident #47. Temperatures and taste tests were conducted on the tray and the resident received a replacement. The chef salad, which contained eggs and cheese, had a temperature of 65 Fahrenheit (F), and the provolone cheese within the chef salad had a temperature of 68 F. The lemon mousse had a temperature of 63 F. During an interview on 5/26/21 at 12:28 PM, Food Service Supervisor #17 stated that the chef salad and lemon mousse were too warm and within the temperature danger zone. All cold foods should be served at a temperature of 40 F or lower, below the temperature danger zone. On 5/27/21 at 12:29 PM, a lunch meal tray was delivered to Resident #52. Temperatures and taste tests were conducted on the tray and the resident received a replacement. At 12:34 PM, the yogurt had a temperature of 53 F, the turkey and cheese sandwich had a temperature of 59 F, the French fries had a temperature of 99 F and the tossed salad had a temperature of 55 F. The cheese in the sandwich was not appealing and the sandwich was not palatable. During an interview on 5/27/21 at 1:00 PM, the Operations Manager 2 stated that yogurt was placed in the walk-in cooler of the main kitchen and then placed into the unit nourishment preparation room refrigerator. Yogurt at 53 F was not acceptable and should be maintained at 40 F. Cold cuts were kept in the walk-in cooler at 40 F or lower. Sandwiches should be served at 50 F or lower to be palatable, and a 59 F sandwich was not palatable. Fried food was not great at holding hot temperatures well, and fries should be over 120 F to be palatable. During an interview on 5/27/21 at 1:35 PM, the Operations Manager 2 stated they had not heard of any resident complaints that cold food items were too warm. During an interview on 5/28/21 at 10:47 AM, the Dining Room Manager stated the first week of every month there was a meal committee for food issues. This committee indicated that there were hot food items on resident room trays that were cold (below 140 F). Once the facility went to plexiglass divided tables, and 10 more residents were served in the dining rooms, there had been no food complaints. The Dining Room Manager had never been told about cold items being hot. They stated air temperatures of the nourishment preparation rooms have felt to be over 90 F and have been warm/hot for a year. A hot nourishment preparation room cause a quicker rise in temperature of a cold item outside of the temperature range. During a joint interview on 5/28/21 at 10:50 AM, the Dining Room Manager and Operations Manager 2 both stated that the overhead exhaust in all six nourishment preparation rooms have been out of service for over a year. During an observation on 5/28/21 at 12:09 PM, there were 1/2 gallons of milk in ice bins in the [NAME] East unit nourishment preparation room. The milk was being poured into glasses for resident hall trays and then being placed into two rolling carts. The milk was not placed into the refrigerator within the nourishment preparation room. The doors to both rolling carts were kept open and remained open at 12:34 PM. During observation on 5/28/21 at 12:21 PM, the [NAME] East unit nourishment preparation room counter had an ice bath with a bin of coleslaw inside it. The coleslaw was still on the counter at 12:45 PM. During an interview on 5/28/21 at 12:27 PM, food service worker #21 stated an extra person was heating plate bottoms in [NAME] North unit nourishment preparation room. If both doors are closed to this room, the air temperature in this room can reach over 90 F. During observation on 5/28/21 at 12:31 PM, the heating plate bottoms for the [NAME] East unit nourishment preparation room were brought back from [NAME] North unit nourishment preparation room. During an observation on 5/28/21 at 12:49 PM the [NAME] East unit meal cart was sent out to residents and the trays started being delivered immediately. On 5/28/21 at 12:56 PM, the second hall cart was delivered and a temperature and a taste test was conducted on a resident meal tray. The resident received a replacement. At 12:57 PM, the milk had a temperature of 55 F, and the coleslaw had a temperature of 49 F. The milk was not palatable, and the coleslaw was not cold. During an observation on 5/28/21 at 1:04 PM, with the Dining Room Manager present, the following temperatures were made from the meal tray for verification: - the milk had a temperature of 56 F using the surveyor thermometer, and a temperature of 56 F using the facility thermometer; and - the coleslaw had a temperature of 52 F using the surveyor thermometer, and a temperature of 53 F using the facility thermometer. During an interview on 5/28/21 at 1:04 PM, the Dining Room Manager stated the coleslaw bin in the container of ice bath should have been out while filling the first resident hall cart and then should be placed back in refrigerator until next cart is ready. The milk should have been poured just before hot items were placed on the food tray. It was not acceptable for cold milk to be held in a hot room for 22 minutes or longer before it was to be sent out to the floor. Although the nourishment preparation rooms were always warm/hot, he had never checked the air temperature of these rooms during meal service. During an interview on 5/28/21 at 1:49 PM, the Director of Environment Services stated there were no overhead pumps just exhaust fans in the nourishment rooms. Both doors to the nourishment preparation rooms have magnetic hold open devices on them. This would allow cooler air to flow into the room from both the hallway on the outside and the dining room on the inside. 10NYCRR 415.14(d)(1)(2)

Based on observation and interview during the recertification survey conducted from [DATE]-[DATE], the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety in three isolated rooms (the main kitchen, the [NAME] West nourishment room, the [NAME] North staff lounge, and the [NAME] North nourishment room). Specifically, in the main kitchen there were 4 whole pork roasts not cooled safely after being cooked, miscellaneous debris on the floors of the walk-in freezer and dairy cooler, outdated food in the cooler, an unclean slicer, and a section of the hood vent was missing; in the [NAME] West unit nourishment room there was a broken refrigerator; and in the [NAME] North nourishment room there were loose miscellaneous sized cup lids and cups not protected from dust/debris. Findings included: The facility Cooling and Chilling Guidelines revised [DATE] documents cooked TCS (temperature control for safety)/PHF (potentially hazardous foods) food shall be cooled from 140 Fahrenheit (F) to 70 F within two hours or less and then to 40 F or below within an additional 4 hours (total maximum cooling time is 6 hours). Cooling and chilling of temperatures must be taken with a calibrated thermometer and recorded on the HACCP (a system which addresses food safety) cooling and chilling log. The undated facility policy Food Storage documents food shall be protected from contamination by storing food in a clean, dry location, in an area where it is not exposed to splash, dust, or other contamination. The facility policy Nutrition Floor Supplies revised [DATE] documents nutrition ambassadors shall remove any expired items from refrigerator/freezer daily and shall clean/sanitize unit refrigerators/freezers and kitchenette daily. MAIN KITCHEN 1. Food Cooling During an observation on [DATE] at 10:50 AM, there were four whole pork roasts (approximately ,d+[DATE] pounds each) in the main kitchen walk-in cooler covered with plastic. The pork was hot to touch. The cook #12 measured the temperature of the meat at ,d+[DATE] F using a probe thermometer. The cook uncovered and moved the pork to the walk in freezer. During an interview on [DATE] at 10:50 AM, cook #12 stated that the four whole pork roasts were cooked and cooled that morning. Staff normally would record the cooling process in a logbook but they forgot to enter today's pork roast into this log. The pork was cooked to 172 F and placed in the walk in cooler between 8:30 AM-9:00 AM. The meat was left with a thermometer in it to check the temp as it cooled. After one hour the pan was changed. After two hours the meat was at 138 F, covered and returned to the cooler. Cook #12 stated they were unsure of the cooling curve. During an observation on [DATE] at 11:40 AM, the pork roast temperatures were measured at 104 F. During an observation on [DATE] at 12:45 PM the pork roast temperatures were measured at 69 F. 2. Debris on Ground During an observation on [DATE] at 10:20 AM, the main kitchen walk-in freezer had miscellaneous debris on the floor under the storage racks, and there was a puddle of an unknown brown substance present on the floor in the milk walk-in cooler. During an observation on [DATE] at 11:10 AM, the brown puddle of unknown substance was still present on the milk walk-in cooler floor. During an interview on [DATE] at 11:10 AM, the Operations Manager 2 stated that the coolers racks and floors of the main kitchen were cleaned daily. During an observation on [DATE] at 11:15 AM, the main kitchen walk-in freezer had miscellaneous debris on the ground under the racks. There was no documented evidence the log for the cleaning of the racks and floors in the main kitchen had been completed on [DATE]. During an observation with the Operations Manager 2 on [DATE] at 2:30 PM, there was water seeping along the wall in the milk walk-in cooler. During an interview on [DATE] at 2:30 PM, the Operations Manager 2 stated the floor in the milk walk-in cooler had been mopped the night before and the puddle was back when they came in the next day and a work order was placed that morning. 3. Broken Refrigerator During an observation on [DATE] at 2:18 PM, the thermometer inside the [NAME] West nourishment room refrigerator measured 52 F. During an observation on [DATE] at 2:50 PM, the temperature inside the [NAME] West nourishment preparation room refrigerator was 60 F using a state DOH thermometer and 58 F using a facility thermometer. During an interview on [DATE] at 1:35 PM, the Operations Manager 2 stated the temperatures of the main kitchen and the nourishment preparation room refrigerators were checked daily between 6:15 to 6:30 AM every morning by a morning supervisor. 4. Unclean Equipment/Areas During an observation on [DATE] at 12:55 PM, a slicer in the main kitchen was soiled with dried on food debris around the handles and control knob. The back of the blade was also soiled with food debris. During a joint interview on [DATE] at 12:55 PM, the Operations Manager 2 and cook #12 both stated the slicer in the main kitchen was cleaned after each use, about ,d+[DATE] times per week. The Operations Manager 2 stated that it was not clean now. During an observation on [DATE] at 2:17 PM, the [NAME] North nourishment room had loose miscellaneous sized cup lids and cups that were not protected from dust/debris. The uncovered cups and cup lids were located inside a cabinet. During an interview on [DATE] at 2:30 PM, food service worker #18 stated they could not reach or see the top shelf in the [NAME] North nourishment. They had tried to keep all shelves organized and clean and did not like clutter. There should be no loose cups/lids on the counter or on shelves. During an interview on [DATE] at 2:40 PM, the Operations Manager 2 stated that the cups and cup lids in the [NAME] North nourishment room should have been stored inside a container or kept inside the plastic sleeve they arrived in to avoid contamination. 5. Outdated Food During an observation on [DATE] at 10:20 AM, in a main kitchen walk-in cooler there was a container of pizza sauce with a discard date of [DATE] and a container of mushrooms with a discard date of [DATE]. During an interview on [DATE] at 11:10 AM, the Operations Manager 2 stated that there was no outdated food in main kitchen coolers when they came in that morning. Managers were responsible for inspecting the walk-in coolers to check dates and remove expired items. They had not worked the previous day, and a log they had for daily checks had not been completed. If there was no discard date, the date on the label was the open date. 6. Kitchen Hood During an observation on [DATE] at 10:20 AM, there was one section of the kitchen hood vent that was out of place/open. During an observation on [DATE] at 11:26 AM, the same section of the kitchen hood vent was out of place/open. The kitchen hood label on the side of the hood documented the last time the hood was inspected was [DATE]. During an interview on [DATE] at 11:26 AM, the Operations Manager 2 stated they were not aware how long the hood vent had been open and thought this had been out of place since it was done by the company that cleans the hoods on [DATE]. 10NYCRR 415.14(h)

Based on observation, record review and interview during the recertification survey conducted from 5/24/21-5/28/21, the facility did not maintain all mechanical, electrical, and patient care equipment in safe operating condition for 3 of 5 unit nourishment preparation rooms ([NAME] West, [NAME] East and [NAME] North) reviewed. Specifically, the [NAME] West and the [NAME] North unit nourishment preparation room had electric steam tables turned on and the room was unlocked and accessible to residents. The [NAME] East unit nourishment preparation room had a steam table with a missing knob and staff were not aware if it was turned off or on. Findings include: During an observation on 5/24/21 at 2:10 PM, the small soup warmer in the [NAME] West unit nourishment preparation room was turned on, in the high position, after meal service had been completed. The door to the room was unlocked and accessible for entrance. During an interview on 5/24/21 at 2:10 PM, food service worker #19 stated that all equipment in the [NAME] West unit nourishment preparation room was off. When made aware that the small soup warmer was still on, they stated the food service had been running late and they had forgotten to turn off all equipment when food service was completed. During an observation on 5/24/21 at 2:50 PM, the left knob of the four bay steam table in the [NAME] East unit nourishment preparation room was missing and the table was still on. During an interview on 5/24/21 at 2:50 PM, food service worker #20 stated that all equipment was off. The [NAME] East unit nourishment preparation room four bay steam table knob had been missing since at least Sunday. During an interview on 5/24/21 at 2:50 PM, the Maintenance Director stated that a work order had been put in on the previous Friday (5/21/21) for the [NAME] East unit nourishment preparation room four bay steam table knob. During an observation at 5/24/21 at 6:00 PM, there was a four bay steam table in the [NAME] East unit nourishment preparation room turned on after the completion of the evening meal. The door to the room was unlocked and accessible for entrance. During an interview on 5/25/21 at 10:50 AM, food service worker #20 stated they had been instructed by Food Service Supervisor #17 to turn off the broken [NAME] East unit nourishment preparation room four bay steam table by unplugging it from the wall. During an interview on 5/25/21 at 12:00 PM, Food Service Supervisor #15 stated that the facility food service managers turned the equipment on in the morning, it was to be left on the entire day, and they would turn it off at the end of the day. The food service workers in that area could turn off the equipment after each meal but were then responsible for turning it back on in time for the next meal service. When the equipment was left on the doors to the room were required to be closed and locked between meal services. These small rooms tend to get hot, so staff usually preferred to turn off the equipment. During an observation on 5/25/21 at 2:20 PM, the [NAME] North nourishment preparation room was open, the dining room dark and there were no staff present. One of four bays on the steam table and plate warming units was on was hot to the touch. During an interview on 5/25/21 at 2:25 PM, food service worker #18 stated that it was the food service workers duty to turn off all equipment after each service, but the manager's responsibility to turn it on. During an interview on 5/25/21 at 2:30 PM Operations Manager 2 stated that the unit nourishment preparation rooms should be closed and locked when not in use. The Operations manager 2 and supervisors were responsible for turning on the equipment in the morning and off at the end of dinner service. 10 NYCRR 415.29

Based on observation, interview, and record review during the recertification and abbreviated surveys (NY 797) conducted from 5/24/21-5/28/21 the facility did not implement corrective measures after an allegation of abuse was made for 1 of 2 residents (Resident #56) reviewed. Specifically, Resident #56 alleged rough treatment by certified nurse aide (CNA) #22. The facility's plan to prohibit CNA #22 from no longer caring for the resident was not documented and not implemented as planned as a corrective measure to prevent further allegations of abuse. Findings include: The facility policy Abuse Prevention and Training revised 2/2018 documents the facility will promote an environment free from all forms of abuse from all parties including residents/patients, R/P/Rs, employees, families, visitors and any other person who may come in contact with our residents/patients. Resident #56 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The comprehensive care plan (CCP) initiated 4/23/19 and updated on 5/3/19 documented the resident resident required assistance with ADLs (activities of daily living) and mobility. Interventions included assistance of one for bed mobility, assistance of 2 to pull up in bed and transfer and toileting assist of one with standing lift. A nurse practitioner (NP) progress notes dated 5/7/21 at 1:11 PM documented the resident was seen for new onset of right shoulder pain with [CONDITION(S)] to the right upper arm. The resident stated their shoulder started hurting during routine care when their right upper extremity (RUE) was lifted over their head. A right shoulder and humeral X-ray was done. The radiologist stated there was an anterior right shoulder dislocation and with given history was acute. The dislocation was to be reduced (put back into place) in the emergency room . During an interview on 5/25/21 at 2:02 PM with Resident #56's family member, they reported someone was rough with their family member and the facility reported it to the state. They were notified the next day. The orthopedic physician told them the resident could not have dislocated their shoulder by themselves, but the facility told them that it was possible the resident dislocated it when trying to move around. The DON told the family member that CNA #22 would not care for the resident anymore and would not be on that unit. The family member received a letter in the mail saying staff was being rotated. The facility investigation dated 5/7/21 documented: - on 5/7/21 at 9:30 AM, the resident went to physical therapy and told PTA #26 (physical therapy assistant) their shoulder hurt and thought the person who took care of them yesterday was rough with their care. - PTA #26's statement documented on 5/7/21, the resident complained their right shoulder hurt. The resident gave a physical description of the staff member (CNA #22) and stated CNA #22 got them up the previous day, was too rough, and was often rough with the resident. - The resident was brought to the Nurse Manager who assessed the resident and notified the NP who ordered an x-ray which showed a suspect dislocation of the right shoulder and the resident was transferred to the emergency room for repair of the dislocation. - Staff caring for the resident during the previous 24-hour period were interviewed including CNA #22. - CNA #22's statement dated 5/7/21 at 2:50 PM, documented they cared for the resident 3 times on 5/6/21 and assisted with taking the resident to the bathroom. The resident complained of leg pain and needed help placing their hands on the stand lift. The resident was able to pull themselves up with help. - On 5/8/21, the resident was interviewed by the Director of Nursing (DON) in the presence of their family member. The resident denied any mistreatment by CNAs. - No findings of abuse or mistreatment were discovered during the investigation. There was no documented evidence of a plan to address CNA #22 who was the accused CNA. The staffing schedule documented CNA #22 worked on the resident's unit from 6 AM-2 PM on 5/10/21, 5/15/21 and 5/18/21. The ADL documentation documented CNA #22 provided Resident #56 assistance with dressing, bed mobility, personal hygiene, toileting, and transfer on 5/10/21, 5/15/21, and 5/18/21. There was no documentation in the resident's CCP or Kardex (care instructions) specific staff were restricted from providing care to the resident. During an interview on 5/27/21 at 8:00 AM, with registered nurse (RN) Manager #24 they stated on 5/7/21, therapy was working with the resident and the resident reported pain. Therapy told the RN the resident reported during morning care their arm was lifted too high and they described the specific staff member and CNA #22 met the description and cared for the resident on that date. RN Manager #24 spoke with CNA #22 and told them they were not able to care for the resident anymore. CNA #22 still worked on the unit. The unit staff knew verbally CNA #22 was not allowed to provide care for Resident #22 but they did not think they could not put the CNA's name on the care plan, so it was not documented anywhere. RN Manager #24 stated CNA #22 knew they could not care for the resident. During an interview with CNA #25 on 5/27/21 at 8:30 AM they stated they were never told there was a CNA that was not allowed to care for Resident #56, and anyone could provide care to them. During an interview with CNA #22 on 5/27/21 at 10:22 AM, they stated the resident reported no pain prior to the incident and no one told them anything about the resident's arm until the next shift they worked on 5/10/21. They stated they did not work with the resident during the investigation which took one day and now they could care for any resident on the unit. 10NYCRR 415.4(b)(3)

Based on observation, interview, and record review during a recertification survey conducted from 5/24/21-5/28/21, the facility did not ensure each resident received adequate supervision to prevent accidents for 2 of 7 residents (Residents #12 and #95) reviewed. Specifically, Resident #12 rode the elevator to an unsupervised area of the facility where they fell out of their wheelchair. The resident was not re-assessed for wandering or elopement and the incident was not reported to the New York State Department of Health (NYS DOH) as required. Additionally, a plan was not implemented to prevent residents without wanderguards from going to the basement (a non-resident area). Resident #95 was observed ambulating in an unsupervised closed unit ([NAME] North) while maintenance was making repairs in rooms and the plan of care was not updated to ensure adequate supervision to prevent further wandering. Findings include: The facility Elopement Management policy, revised 11/2018, documents: - Residents are evaluated for wandering/elopement risk on admission, readmission, quarterly, with significant change and as needed utilizing the Wandering Risk Assessment 2 tool. - The Wandering Risk Assessment 2 tool determines if a resident needs a Wanderguard (electronic monitoring device). - Nursing checks the Wanderguard placement every shift and documents on the electronic treatment administration record (ETAR). - The Wanderguard device is documented on the comprehensive care plan (CCP) and Kardex (care instructions). The facility Resident Safety Report policy, revised 4/2019, documents: - An unusual occurrence will be documented in the record and a safety report completed. This includes a resident fall or resident found on the floor/ground. - The registered nurse (RN) Unit Manager and Director of Nursing (DON) are to complete an investigation and determine with the interdisciplinary team (IDT) a root cause analysis of the incident. 1) Resident #12 was admitted to the facility with diagnoses including arthritis and [CONDITION(S)]. The 3/4/21 Minimum Data Set (MDS) Assessment documented the resident had severe cognitive impairment, required extensive assistance of one person for locomotion off the unit, had a history of falls and had no wandering behaviors. The comprehensive care plan (CCP) initiated 1/14/21 documented the resident required supervision with wheelchair mobility and was at high risk for falls. Interventions included to keep the resident close to nursing station when able and the resident was to be on the early morning get-up list as they had the most falls in the early morning. The CCP documented the resident had falls on 1/20/21, 3/16/21, 3/18/21 from wheelchair, 3/20/21, 3/21/21 from wheelchair, and 3/23/21, 3/29/21 and 5/25/21. The Wandering Risk Assessment tool documented the resident was assessed on 1/13/21. The resident was deemed not at risk for wandering or elopement. There was no Wandering Risk Assessment tool completed when the resident moved from [NAME] North (the rehab unit) to [NAME] East on 3/17/21. The Facility Safety (incident) Report dated 3/21/21 at 8:15 AM and completed by registered nurse Supervisor (RNS) #8 documented the resident was found in the basement on the floor in front of their wheelchair. The resident stated they fell out of the chair and denied pain. An assessment was done and there were no injuries. The resident was assisted to their wheelchair by 2 staff members and was taken back to [NAME] East (second floor). Analysis of the incident included analysis of the incident and documented the root cause was resident was wandering, staff were not educated and the care plan was followed. The follow-up action included a wanderguard was applied and the resident would be on hourly rounds. There was no documentation the resident was reassed for elopement risk or a determination of how the resident was able to enter the elevator and exit in the basement unnoticed. The CCP revised 3/22/21 documented the resident had a fall in the basement on 3/21/21. The resident fell from their wheelchair and there no injuries. The CCP did not document elopement risk or use of a Wanderguard. During an interview on 5/27/21 at 9:14 AM, RNS #8 stated they received a phone call from the housekeeping supervisor on the morning of 3/21/21 notifying them Resident #12 was found on the floor in the basement. They were not sure how the resident got there as they were not a known wanderer. The resident had been seen eating breakfast on [NAME] North not too long before they received the phone call the resident was in the basement. The resident was assessed and had no injuries. They were taken back to the unit and a Wanderguard was applied to the resident's ankle. During an interview 5/27/21 at 9:26 AM, laundry staff #16 stated on 3/21/21, they saw Resident #12 in the basement on the floor just outside the elevator, trying to pull themselves up by the linen cart. The resident was stuck in between the elevator doors. Their wheelchair was still in the elevator. They called RNS #8 and RNS #8 arrived with a certified nurse aide (CNA). The resident was assessed and taken back to the unit. During an interview 5/27/21 at 9:39 AM the Director of Nursing (DON) stated they did not think the 3/21/21 incident was reportable to NYS DOH because the resident was alert and oriented and was not a wander risk. If the resident had been a known wanderer and ended up in the basement, they would have reported it to NYS DOH. The facility team typically discussed residents who were trying to get out of the building in morning report. Resident #12 was not trying to get out of the building. On 5/27/21 at 1:23 PM, the DON stated in a second interview, this resident's incient was an isolated incident. It was rare for residents to get on the elevator and make it to another floor. Nothing was put into place to prevent other residents from doing this. The incident should have been reported to NYS DOH. 2) Resident #95 was admitted to the facility with diagnoses including dementia and [CONDITION(S)]-fibrillation (irregular heartbeat). The 4/22/21 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, had difficulty focusing attention, wandered 1 to 3 of 7 days, ambulated in room and corridor with supervision, did not use mobility devices and used a wander/elopement alarm daily. Resident #95's Wandering risk assessment, effective 4/15/21, documented the resident was at high risk for wandering and a Wanderguard was placed on the resident's left ankle. The comprehensive care plan (CCP), revised 4/19/21, documented the resident was at risk for wandering as they had a history of wandering throughout the neighborhood at home, had a diagnosis of dementia, and was asking daily to go home and tried to find a ride to get there. The intervention was to apply a Wanderguard to the resident's left ankle. The certified nurse aide (CNA) Care Sign-Off Form dated 4/19/21 documented the resident was on one-hour safety checks. The resident's Kardex (care instructions) active on 5/24/21 did not document the resident wore a Wanderguard or was a wandering risk. An elopement book on [NAME] West documented 5 residents were at risk for elopement, including Resident #95. Nursing Progress notes documented the resident had wandering and exit-seeking behaviors and was asking to go home on 4/15/21, 4/16/21, 4/17/21, 4/19/21, 4/20/21, 4/21/21, 4/25/21 and 5/8/21. During the entrance conference interview with the Administrator on 5/24/21 at 10:18 AM, they stated four of the five units of the facility were open. [NAME] North, on the second floor, was closed and had no residents residing on it for the past few months. During an observation on 5/24/21, at 10:50 AM the [NAME] North unit was dark and only the 24-hour emergency hall lights were on. During an observation on 5/24/2021 at 11:41 AM, [NAME] North unit resident room 267 had water damage with buckets collecting dripping water, there was a dismantled air conditioner/heater unit on the floor, and there was exposed wiring. The door to the room was not secured or locked. On 5/24/21 at 1:15 PM, the resident was observed ambulating in the hall on [NAME] West, asking how they could get to Utica and on 5/24/21 at 3:00 PM, the resident was observed being escorted out of [NAME] North (a closed unit) by two maintenance staff. There was no documentation in the medical record the resident wandered onto the closed unit, [NAME] North, on 5/24/21. During an interview 5/24/21 at 4:30 PM CNA #9 stated if a resident with a Wanderguard went near the elevator the alarm sounded and the elevator would not move. The buzzing noise heard on the unit was for [NAME] North which was a closed unit and the buzzing indicated when someone entered the first set of doors. The door alarmed when it was opened. Residents with Wanderguards could enter the closed unit. During an interview 5/24/21 at 4:36 PM, CNA #12 stated when a resident with a Wanderguard went near the elevator an alarm went off. If a resident walked from unit to unit, staff had to let the other unit know as most residents did not have 1:1 supervision. During a review of the video footage of [NAME] North with the Maintenance Director on 5/24/21 at 5:40 PM, Resident #95 was observed exiting [NAME] North on 5/24/21 at 3:00 PM with the two maintenance staff. There was no camera located at the other end of the hall to [NAME] North where the resident possibly entered. During an interview 5/24/21 at 5:53PM, CNA #13 stated hourly checks meant to check every hour to see if a resident was in their bed or if they needed something. They check the residents' care plans to see if the resident wears a Wanderguard. During an interview 5/24/21 at 6:00 PM, maintenance staff person #4 stated they were with another staff member working on a heating pump in room #267 on [NAME] North when they heard the door alarm. They responded and observed Resident #95 ambulating in the hall. They had never seen this resident on [NAME] North before. The Director of Nursing (DON) happened to be in the area and heard the alarm and helped guide the resident off the unit and back to their room on [NAME] West. During an interview 5/24/21 at 6:45 PM maintenance staff #5 stated they had never seen any residents on the closed unit, [NAME] North. When they have heard a door alarm in the past, they would stop what they were doing and check the hallway. They would escort a resident back to their room and then report it to the supervisor immediately. During a phone interview 5/24/21 at 6:49 PM, CNA #7 stated they cared for Resident #95 on 5/24/21. They saw the resident just before they left at the end of their shift at 3:00 PM. The resident would wander on [NAME] West and East all shift. They stated Resident #95 was not on any set checks, but they would usually check on the resident every 15 to 30 minutes. The staff would try to bring back Resident #95 when went onto [NAME] North and it was not very often. CNA #7 would hear the door alarm on [NAME] North when the resident entered. The recreation department used a room for activities on [NAME] North because there was not enough room on [NAME] East and West. They were not aware that Resident #95 attempted to enter [NAME] North today. The resident wore a Wanderguard which alarmed when the resident went near the elevator. During an interview 5/24/21 at 7:00 PM maintenance staff #6 stated they were working on [NAME] North on 5/24/21, the far end near the fire doors and room #267. They placed a cart on wheels in front of the doors at the far end of the unit to prevent any residents from entering while they were working there. They stated residents attempt to enter [NAME] North 1 - 2 times a day and it was usually Resident #95. They have not reported this because other staff members would enter to try to find Resident #95 and would redirect them out of the closed unit. At 4:30 PM today, Resident #95 attempted to enter the far end of [NAME] North (near room #267) but the cart kept them from pushing through the doors and they left. During an interview 5/24/21 at 7:23 PM on [NAME] West, RN Manager #11 stated Resident #95 received a Wanderguard the day they arrived on the unit. The resident wandered to [NAME] East and was never found in an unsupervised area. [NAME] North was a closed unit and had a door alarm when opened. At 7:28 PM RN Manager #11 stated Resident #95 did enter [NAME] North the other day but not since then. Residents were not supposed to go on [NAME] North but some residents can be sneaky and get through the door. Residents with Wanderguards can go through the doors on [NAME] North as there is no Wanderguard alarm like the elevator has. Staff should be checking to see why the door is alarming. During an interview 5/24/21 at 8:30 PM, the DON stated they have not been documenting in a progress note when a resident wandered onto [NAME] North. They would call the incident with Resident #95 today a near miss. If it was something consistent, they might document a progress note. If it is just a breach it was not anything they would discuss in morning report. They heard the door alarm around 3:00 PM and that is when they caught up with the two maintenance staff escorting Resident #95 off [NAME] North. The resident did not get very far. All staff was expected to respond to the door alarm. Most residents wander unsupervised on this floor. The residents did not understand [NAME] North is closed as they used to be able to wander onto it like they do [NAME] East and West. The doors to [NAME] North do not have a Wanderguard alarm. On 5/25/21 at 10:19 AM, the resident was observed ambulating on [NAME] East stating they were looking for a way out. On 5/27/21 at 3:28 PM, the resident was observed ambulating on [NAME] East and stated they were looking for their car. During an interview 5/28/21 at 2:58 PM the DON stated they do not have any protections in place to prevent residents from wandering onto [NAME] North, the closed unit. They did not want any residents wandering onto the closed unit with the potential for getting into an accident. 10 NYCRR 415.12(h)(2) Surveyor: [NAME], Shari

Based on observation, interview and record review conducted during the recertification survey, the facility did not maintain stored drugs and biologicals in accordance with currently accepted standards for 1 of 3 medication rooms (Barton West), 3 of 5 medication carts (Barton East Team 2,(NAME)North, and(NAME)West Team 1), and 1 treatment cart (Barton North) inspected. Specifically, a narcotic cabinet was not secured as required, expired medications were found in medication carts, and a treatment cart was unlocked and unsupervised for an extended period. Findings include: The 6/2015 Storage and Maintenance of Medication pharmacy policy documented there were to be separate storage areas for topical medications in the facility. Medications were checked regularly for expiration dates and deterioration, and expired medications were removed from use and destroyed. The 6/2015 Medication Carts pharmacy policy documented carts were to be locked when not in use or under the direct supervision of the designated nurse. The 8/2018 revised Narcotics/Controlled Substances policy documented all Schedule II-V controlled medications were stored under double lock. During an inspection of the(NAME)West medication room on 12/11/18 at 3:19 PM with licensed practical nurse (LPN) #1, the narcotic cabinet labeled pink was observed with both doors open and unlocked. During a concurrent interview, LPN #1 stated she had the doors open to get her narcotics out for the night and got busy. She stated the doors were only left that way for a couple of minutes. She stated they should be locked. During an interview on 12/11/18 at 3:37 PM, registered nurse (RN) Unit Manager #2 stated the narcotic cabinet should never be unlocked when staff were not in the medication room. During an inspection of the(NAME)East team 2 medication cart on 12/12/18 at 10:15 AM with LPN #3, there was a bottle containing Calcium with Vitamin D tablets with a manufacturer's expiration date of 06/2018 in the top drawer. There was a clear bag containing 12 vials of [MEDICATION NAME] 5 mg/ml solution, 8 of which had a manufacturer's expiration date of 11/2018. LPN #3 stated checking the cart for outdates was the responsibility of the person assigned to the medication cart. She stated it was not assigned to a specific shift, it was everyone's responsibility. She stated she missed these expired medications. On 12/12/18 at 11:14 AM, an unlocked treatment cart stationed in a cubby area in the(NAME)North hall was observed. There were no staff in the immediate area. The cart remained unsecured and unattended until 11:36 AM, when LPN #4 noticed it and locked it. During a medication cart inspection on 12/12/18 at 11:36 AM with LPN #4, there was a blister pack containing [MEDICATION NAME] 25 mg tablets with an expiration date of 11/06/18 and had 10 tablets of 30 remaining. The treatment cart was also inspected. There were various medicated ointments including mupirocin and [MEDICATION NAME] in the top drawer. LPN #4 stated it was acceptable to leave a treatment cart unlocked if it was within her eyesight. She stated she was unsure how long the cart had been unlocked. She stated many of the items in the cart were medicated. She stated if a resident got into the drawers because they were unlocked and got the ointments it was possible they could be hurt. She stated the 11:00 PM-7:00 AM shift usually checked the carts for outdated medications but it was everyone's responsibility. She stated she just overlooked the [MEDICATION NAME]. During a medication cart inspection on 12/13/18 at 9:06 AM on the(NAME)West unit with LPN #6, there was an open box containing [MEDICATION NAME] 2 mg tablets with a manufacturer's expiration date of 07/2018. LPN #6 stated checking for outdates was not assigned to one person specifically. She just overlooked the [MEDICATION NAME]. During an interview on 12/13/18 at 9:02 AM, RN Unit Manager #5 stated everyone was responsible for checking the medication cart for expired medications. During an interview on 12/13/18 at 9:45 AM, RN Unit Manager #7 stated that treatment carts were not to be left unlocked. She stated staff should get the treatment out they need and then immediately relock it. She stated the treatment cart should be left locked at all times. 10NYCRR 415.18(e)(1-4)

Based on observation, record review and interview conducted during the recertification survey the facility did not ensure 2 of 9 residents (Residents #18 and 133) reviewed for positioning received the necessary care and services to maintain proper body alignment. Specifically, for Resident #18 staff did not implement interventions for positioning as planned. Resident #133 had a visual impairment and was not assisted at meals as planned. Findings include: The 9/2018 revised Preparing and Assisting Residents with Meals policy documented staff were to present items from tray and place them in front of the resident. Nursing staff were to assist or supervise feeding in accordance with the resident's care plan. 1) Resident #133 was admitted to the facility on [DATE] and [DIAGNOSES REDACTED]. The 11/13/18 Minimum Data Set (MDS) assessment documented the resident had severely impaired vision, was cognitively intact, required limited assistance for most activities of daily living (ADLs), and supervision for eating. The 6/29/18 revised comprehensive care plan (CCP) documented the resident was legally blind in her left eye and had a right eye prosthetic. Her special needs included orienting her to her surroundings due to [MEDICAL CONDITION]. Staff were to tell the resident where they were placing items and to be consistent. The undated certified nurse aide (CNA) care instructions documented to orient the resident to surroundings due to [MEDICAL CONDITION]. The resident was to be told where items were being placed and to be consistent. When interviewed on 12/11/18 at 9:31 AM, the resident stated staff did not always orient her to her surroundings. She had told them not to switch her things in her room. During the noon meal on 12/12/18 at 12:33 PM, the resident was seated in the unit dining room. The resident was served her meal tray including entree, side dishes and fluids. The surveyor did not observe the resident being oriented to the meal items in front of her by staff. The resident was struggling to find items in front of her and dropped food on the floor. When asked, the resident stated staff did not tell her what she was served for lunch. On 12/13/18 at 9:36 AM, the resident was served breakfast by food service worker #31. The food service worker placed a plate of food and walked away without telling the resident what was in front of her. When interviewed on 12/13/18 at 9:36 AM, food service worker #31 stated he did not tell the resident what was served to her. At 9:45 AM, he stated he knew he was supposed to tell the resident what was served and where it was on the plate. When interviewed on 12/13/18 at 9:47 AM, resident aide #32 stated when serving a visually impaired resident, staff had to tell a resident what was on their plate and where it was located. She stated she would tell the resident what was there and occasionally guide her hand towards items, such as her tea, to orient her. When interviewed on 12/13/18 at 9:53 AM, CNA #33 stated when serving visually impaired residents, staff must announce that they are there, place the food in front of them, tell them where the food was on their plate, ask if they need assistance and put the silverware in their hand. She stated the resident could see shadows and would say that she knew what was in front of her when staff tried to orient her. When interviewed on 12/13/18 at 9:55 AM, registered nurse (RN) Unit Manager #7 stated when staff were serving food to a visually impaired resident, they should explain where food was in relation to a clock. When approaching the resident, they should introduce themselves, tell them what meal they are serving, and ask what's being served. When interviewed on 12/13/18 at 2:03 PM, the Food Service Director stated the food service staff were expected to tell visually impaired residents what was on their plate when serving meals. She stated this was required for the Resident was she was legally blind. She said the food service worker should have told the resident what was served and should not have walked away. 2) Resident #18 was admitted to the facility on [DATE] and had a [DIAGNOSES REDACTED]. The 6/29/18 comprehensive care plan (CCP) documented the resident had a Broda recliner chair in place and staff were to make sure her hips were midline in the chair, recline the chair when the resident was sleeping, place pillows under both arms, place a rolled blanket on her right side and over her right shoulder to support her head. The certified nurse aide (CNA) instructions active on 12/12/18 documented the resident was to be positioned in chair with support devices as specified in the CCP. The resident was observed in the Broda chair, leaning to the right, with her head tilted to the right with no supportive devices: - On 12/11/18 at 9:51 AM, 9:58 AM, and 10:20 AM in the hallway with multiple staff walking by. - On 12/11/18 at 11:52 AM, 12:22 PM, 12:27 PM, and 12:32 PM at the dining table awaiting her meal. - On 12/11/18 at 3:20 PM, with her head almost touching the arm rest of the chair. From 3:55 PM-4:09 PM, with a blanket to her right side, the resident continued to lean and there was no support to her neck. - On 12/12/18 at 10:12 AM and 10:50 AM in the activity room; and at 11:37 AM and 12:48 PM in the dining room. At 12:56 PM, the resident was drinking a beverage through a straw while leaning to the right and her chin was tucked down towards her right shoulder and chest. During an interview with CNA #9, who cared for the resident, on 12/13/18 at 10:05 AM she stated the resident's head and body position were always to the right. She was not aware if the resident had a positioning plan for her chair. She stated staff could put a blanket to her side and that should straighten her head out as well. During an interview with CNA #10, who cared for the resident, on 12/13/18 at 10:15 AM, she stated the resident's positioning varied. Some days she leaned and some days she did not. She stated on this date the resident was more contracted and may have been tired. She stated the resident would have a blanket placed to her side and that should help support her head. On 12/13/18 at 10:23 AM registered nurse (RN) Unit Manager #7 reviewed the resident's plan of care for positioning and she stated it had been in place for several months and if the resident's body or head were leaning, staff should be implementing these interventions. During an interview with occupational therapist #11 on 12/13/18 at 10:45 AM, she stated the resident had been referred to occupational therapy in 6/2018 for positioning. She stated the resident was on program from 6/26-7/9/18 to improve positioning in the Broda chair. She stated the resident tended to lean to the right. On discharge she recommended the resident keep her hips midline in her chair, a rolled blanket to her right side of body, head, and under her arms. She stated these interventions were in place and should be implemented by staff. She stated she had not received any referrals the resident had any change in her positioning. 10NYCRR 415.11(c)(1)

Based on record review and interview conducted during the recertification survey the facility did not ensure 1 of 2 residents (Resident #9) reviewed for vision received the necessary treatment to maintain vision. Specifically, for Resident #9 recommendations by an outside consult was not implemented to treat the resident's eyes. Findings include: Resident #9 was admitted on [DATE] with [DIAGNOSES REDACTED]. The 11/28/18 Minimum Data Set (MDS) assessment documented the resident was cognitively intact and had impaired vision. The 10/18-12/2018 comprehensive care plan (CCP) had no documentation regarding the resident's vision. A 10/11/18 optometry consult note documented the resident had a history of [REDACTED]. There were no correlating nursing or medical progress notes related to the 10/11/18 optometry consult. Physician orders [REDACTED]. The medication administration and treatment administration records had no documentation the resident was ordered, offered or provided artificial tears or ointment for dry eye syndrome between 10/1/18-12/14/18. During an interview with the resident on 12/10/18 at 2:50 PM, she stated her vision had worsened in one eye, she had seen an eye doctor and she did not know what had happened following her appointment. During an interview on 12/13/18 at 2:20 PM, LPN #18 reviewed the resident's record. She stated there was not an order in place for artificial tears routine or as needed. She stated the resident had eye drops in place for [MEDICAL CONDITION]. She stated she administered the resident's medications frequently and she had never provided the resident with any artificial tears. During an interview with physician #12 on 12/13/18 at 3:10 PM, he stated consults are placed in a folder for his review. He stated he could not recall any specifics regarding the resident's eyes or recommendations for medications. On 12/13/18 at 3:38 PM, the Assistant Director of Nursing (ADON) stated she did not know why recommendations would not be in place for the resident. She was not familiar with the situation and she would look in to the matter. During follow up with the ADON on 12/14/18 at 5:00 PM, she stated she could not find any additional information on the resident's eye treatments and she did not know why the eye drops had not been implemented. 10NYCRR 415.12(3)(b)

Based on observation, record review and interview during the recertification survey, the facility did not ensure residents with limited range of motion received the appropriate treatment and services to increase or prevent decrease in range of motion for 1 of 6 residents (Residents #145) reviewed for range of motion. Specifically, Resident #145 was not provided assistive devices or range of motion (ROM) exercises to prevent further reduction of ROM and mobility. Findings include: The Nursing ROM Policy effective 8/1996, revised 8/2010, documented that certified nurse aides (CNAs) were to perform daily ROM exercise, and to report any decreases in ROM. It was the responsibility of the registered nurse (RN) to supervise CNAs performing ROM at appropriate times; to assess any changes in the resident's range of motion, document these changes and make appropriate referrals to therapy. It is the responsibility of therapy to ensure that nursing staff are educated to perform active and passive nursing range of motion. The Nursing Positioning Policy effective 8/1996, revised 8/2010, documented the CNA is to maintain the resident's proper body alignment through positioning techniques and devices such as splints, etc.; and to report any intolerance or refusal of positioning devices. Resident #145 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 11/13/18 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment and required total dependence on staff for all activities of daily living (ADLs). The 5/23/18 and 7/06/18 comprehensive care plan (CCP) for alteration in position with contractures, documented the resident was totally dependent on staff for all ADLs, mobility and positioning. Interventions included providing palm pillows, towels to bilateral hands in bed or as tolerated, light stretching to both hands into extensions 2-3 times repetitions before and after removal of palm splint/pillow. On 11/02/18 the CCP was updated with additional interventions for the left hand; to include gentle passive ROM to left hand, with gentle finger extension 3 to 5 repetitions with AM and PM care; after exercises staff were to place red carrot (a positioning device) in the resident's left hand. On 11/08/18 the physical therapy (PT) and occupational therapy (OT) progress notes documented the resident was referred to therapy for evaluation for impaired ROM, decrease in skin integrity of bilateral hands, decline in upper and lower extremity function, contractures and joint stiffness and equipment needs. The resident was considered not to be a candidate for skilled therapy due to her limited cognitive status. OT recommended for nursing staff to continue splint/palm carrots and ROM exercises. PT placed foam around her foot bucket (wheelchair foot rests). The resident was observed without hand splints, palm supports or devices on as planned on 12/10/18 at 11:51 AM and 4:10 PM (the resident stated her hands hurt); On 12/11/18 at 9:33 AM and 3:50 PM; On 12/12/18 at 02:22 PM; and on 12/13/18 at 03:16 PM. During an observation of the resident's morning care on 12/13/18 at 10:26 AM, CNA #39 did not perform ROM exercises. The resident's left hand was observed to be contracted tightly into a fist and the resident cried out in pain saying, ow ow it hurts! CNA #39 struggled to open the resident's left hand. The resident's left palm was reddened, inflamed and moist and immediately returned to a fist after inspection. The CNA placed the palm carrot into the resident's left hand. When interviewed on 12/12/18 at 10:24 AM CNA #38, who was assigned to the resident this date, stated she thought the resident was supposed to have the splints/carrots in her hands at all times. The CNA stated the resident's hands were very reddened and her left palm was swollen, and her nails needed clipping. She stated she placed the blue carrot in the resident's right hand before breakfast on 12/12/18. When interviewed on 12/12/18 at 10:55 AM, registered nurse (RN) Unit Manager #37 stated the splints and palm carrots should be applied every day. The resident's palms and hands were not checked during the skin assessment. The RN stated they should be, especially since the resident was unable to open her hand on her own. The RN stated she was not aware the resident was unable to open her left hand, or the resident's hand was very red and painful. During an interview with CNA #39 on 12/13/18 at 10:45 AM, she stated she did not know if the resident was supposed to have palm carrots in both her hands or only in one and when she was to have them. She stated she frequently forgot to check the CNA care instructions located in the resident room and she depended on staff report at the beginning of each shift to inform her on the ADL needs of each resident. She stated she would sometimes perform ROM exercises with the resident. She stated she had not informed anyone of the resident's red, swollen and very contracted left hand. When interviewed on 12/13/18 at 11:11 AM, occupational therapist #40 stated the ROM program started 2 months ago. She would expect nursing staff to comply and implement the interventions in the resident's care plan specific to ROM and contractures. She stated that if the resident was not agreeable, or declining in ROM, or the plan of care was not being followed, then nursing should have should notified therapy. The resident should have had the splints/carrots in place daily and the ROM exercises done with daily care. She had not received any recent referrals for Resident #145. She stated the resident should have had the splints/carrots in place daily and the ROM exercises done with daily care. 10NYCRR 415.12 (e)(2)

Based on observation, interview, and record review conducted during the extended survey, it was determined for 5 of 35 sampled residents (Residents #1, 3, 4, 15, 35) and 1 resident outside of the sample (Resident #38), the facility failed to provide the necessary care and services to residents to attain or maintain the highest practicable physical well-being. Specifically, the facility: - failed to ensure Residents #15 and 35's advanced directives wishes for resuscitation were accurately identified; - failed to implement a system to ensure Residents #1, 3, 4, 15, 35, and 38's advanced directive (code) status were communicated accurately and consistently implemented. In addition, the facility did not ensure Resident #3 was thoroughly assessed when he bit his lip with enough force to cause bleeding, and a plan of care was not implemented to address the resident's lip biting. This resulted in no actual harm, with potential for serious harm, that is Immediate Jeopardy to residents health and safety, and Substandard Quality of Care for Residents #1, 3, 4, 15, 35, and 38. Findings include: CONCERNS WITH IMPLEMENTATION OF ADVANCED DIRECTIVES: 1) Resident #35 was admitted to the facility with [DIAGNOSES REDACTED]. The Medical Orders for Life-Sustaining Treatment (MOLST) dated [DATE] documented the resident's resuscitative status was full code (CPR, cardiopulmonary resuscitation in the event the heart stopped). The comprehensive care plan (CCP) dated [DATE] documented the resident was alert with slight confusion and was able to make her needs known. The MOLST documented the resident's wishes were for full code resuscitative status. The Minimum Data Set ((MDS) dated [DATE] documented the resident was severely cognitively impaired, was easily distracted, had disorganized thinking and required extensive assistance with all activities of daily living. During an interview on [DATE] at 3 PM, the registered nurse (RN) manager of Barton North stated if a resident wore a green bracelet it represented full code resuscitative status, and if the resident wore a blue bracelet it represented a do not resuscitate (DNR) status. The RN said corresponding colors green (full code) and blue (DNR) were also on the spine of the residents' medical record, and on sheets posted on the inside of residents' closet doors. On [DATE] at 2:10 PM, the resident was observed wearing a blue bracelet. identifying her resuscitative status as DNR. The resident also had a green paper posted in her room identifying her code status as full code. On [DATE] at 2:20 PM the unit clerk stated in an interview, she was responsible for ensuring the paper posted in the residents' closets, and their bracelets were the correct color representing their resuscitative status. She stated she checked every resident on the unit on Wednesdays and ensured the spine of the medical record, the bractlet, and the paper posted in the closet matched the resident's resuscitative status. She stated blue was DNR and green was full code. She said she was not able to provide any documented evidence regarding the weekly checks. During an interview on [DATE] at 4:35 PM, the registered nurse (RN) Manager stated she thought the resident was DNR status and "she has a blue bracelet." At that time, she checked the resident and stated she was wearing a blue bracelet. The RN then checked the spine of the medical record which was green. She then checked the resident's MOLST and stated she was a full code resuscitative status and was wearing the incorrect bracelet. On [DATE] at 7:10 PM, the Director of Nursing (DON) stated, in an interview, she was not informed by the RN Manager that the resident was wearing an incorrect code status bracelet on [DATE]. The Administrator, who was present during the interview, stated she too was not aware of the resident wearing the incorrect bracelet. 2) Resident #3 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessments dated [DATE] and [DATE] documented the resident was in a persistent vegetative state with no discernible consciousness. The MDS recorded the resident received suctioning of the [MEDICAL CONDITION], required total assistance with all aspects of care, and was short of breath when lying flat. The Medical Orders for Life-Sustaining Treatment (MOLST) form dated [DATE] documented the resident was a full code. The MOLST recorded that cardio-pulmonary resuscitation (CPR) should be performed in the event the resident heart stopped, or the resident stopped breathing. A progress note dated [DATE] documented the resident's wife was contacted and confirmed the resident was to remain a full code resuscitative status. During an interview on [DATE] at 3 PM, the registered nurse (RN) Manager stated if a resident wore a green bracelet it represented full code resuscitative status, and if the resident wore a blue bracelet it represented a do not resuscitate (DNR) status. The RN said corresponding colors green (full code) and blue (DNR) were on the spine of the residents' medical record, and on sheets posted on the inside of residents' closet doors. During an observation on [DATE] at 12 PM the resident was in the dining room. The resident was not wearing a bracelet and there was no bracelet on the resident's chair. During an observation on [DATE] at 12:40 PM there was no green sheet in the resident's closet. An empty clear plastic sheet protector was observed on the closet door opposite the resident's bed. During a continuous observation on [DATE] from 4:10 PM until 5 PM the resident was observed without a bracelet or sheet on his closet door. During an interview on [DATE] at 6 PM the registered nurse (RN) Manager RN took the surveyor to the resident's room to show her the green color resuscitative status sheet on the closet door. Upon entering the room, the RN stated to the surveyor "there should be a green sheet here." The RN said she did not know why there was no resuscitative status sheet in the resident's closet and that the resident should a green bracelet. On [DATE] at 2:20 PM the unit clerk stated in an interview, she was responsible for ensuring residents wore the correct bracelet and had the correct paper posted in their closet. She stated she checked every resident, on the unit, on Wednesdays and ensured the spine of the medical record, the bracelet, and the paper posted in the closet matched. She stated blue represented DNR and green represented full code resuscitative status. She said she was not able to provide any documented evidence regarding the weekly checks. 3) Resident #15 had [DIAGNOSES REDACTED]. The care plan face sheet, dated [DATE], documented the resident was a do not resuscitate (DNR, allow natural death in the event the heart/breathing stopped) code status. An Inter-Disciplinary Re-Admission assessment dated [DATE] documented the resident was alert and oriented. The assessment recorded the resident did not have an order for [REDACTED]. The resident's comprehensive care plan (CCP) dated [DATE] documented the resident had Medical Orders for Life-Sustaining Treatment (MOLST) that reflected the resident's wishes for DNR. An Interdisciplinary Advance Care Planning Treatment Preference Form documented the resident had a MOLST dated [DATE] and did not have a physician order [REDACTED]. The MOLST was signed by the resident on [DATE], and documented the residents wishes for life sustaining treatment as cardio-pulmonary resuscitation (CPR). A nursing progress note dated [DATE] documented the resident's advanced directives were changed, while in the hospital, to full code status (CPR). The note recorded the resident's family member "was not interested at this time in discussing a DNR status." The physician's orders [REDACTED]. The resident's CCP dated [DATE] documented the resident had a "full code MOLST effective [DATE]." physician's orders [REDACTED]. A physician's note dated [DATE] documented "Her MOLST form is up to date. She is still full code." The resident's MOLST form was signed as updated, by the physician, on [DATE] and documented there was "No change" in the resident's resuscitative status. The Minimum Data Set (MDS) assessment, dated [DATE], documented the resident's cognition was intact, and the resident required extensive to total assistance for most activities of daily living. The care plan face sheet dated [DATE] documented the resident was DNR code status. A social work note dated [DATE] documented the social worker met with the resident regarding her full code status. The social worker documented the resident "wishes to remain a full code at this time." The CCP dated [DATE] documented the resident remained a full code resuscitative status. physician's orders [REDACTED]. A physician's note dated [DATE] documented the resident's MOLST form was up to date and the resident was full code resuscitative status. The MOLST form was signed as updated by the physician on [DATE] and documented "No change" in the resident's resuscitative status. physician's orders [REDACTED]. A physician's note dated [DATE] documented the resident was full code resuscitative status. The resident's care plan face sheet dated [DATE] documented the resident had a DNR. The resident's MDS dated [DATE] documented the resident's cognition was intact. The resident's primary social worker was not available for interview. The covering social worker stated in an interview, on [DATE] at 1:50 PM, she was not aware of the resident's current advanced directives or when they were implemented. She stated the process to complete advanced directives would begin on admission and be reviewed quarterly. During an interview with the registered nurse (RN) Manager, on [DATE] at 2:40 PM, she stated the process for implementing the resident's advanced directives would begin with the social worker. She said the change in a resident's resuscitative status was noted on the resident census sheet, and the physician, the unit clerk, and applicable departments were notified. The RN stated new physician orders [REDACTED]. The licensed practical nurse (LPN), the night shift nurse and the physician checked the new orders for accuracy. The Director of Social Work stated in an interview on [DATE] at 3:45 PM, all conversations regarding advanced directives should be documented in the resident's medical record, and the residents MOLST forms were checked and reviewed quarterly. During a follow up interview with the RN Manager, on [DATE] at 9:30 AM, she stated the Director of Social Work told her the resident was full code resuscitative status since her admission. The resident's primary physician was unavailable for interview during the standard survey. OTHER QUALITY OF CARE CONCERNS: 4) Resident #3 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessments dated [DATE] and [DATE] documented the resident was in a persistent vegetative state with no discernible consciousness. The MDS recorded the resident received suctioning of his [MEDICAL CONDITION], and required total assistance for all aspects of care. The resident was short of breath when lying flat. The MDS did not document a pain assessment. A nursing progress note dated [DATE] documented the resident was grinding his teeth and there was blood noted on the right side of his mouth. The note recorded the nurse manager was aware. A nursing progress note dated [DATE] documented the resident had bleeding of his lower lip. A pain assessment dated [DATE] at 4:27 PM, by registered nurse (RN) #7, documented the resident was in a "vegetative state, no signs and symptoms of pain." An incident report dated [DATE] documented the resident had a self inflicted injury. The report recorded the resident bites on his lower lip, and had and open area 0.3 centimeters (cm) x 0.2 cm on the left lower lip. The comprehensive care plan (CCP) dated [DATE] documented the resident would "experience minimal anxiety related to shortness of breath." Interventions included assessing the need for anti-anxiety interactions such as relaxation techniques or medication. The CCP documented staff should identify possible causes of increased discomfort. The plan included to medicate the resident as ordered, observe for desired effects and undesirable side effects. There was no documentation regarding the resident's lip biting in the CCP. A progress note dated [DATE] documented at 8:55 PM the resident had a 1 cm bite on the right lower lip. The resident's family members were seen wiping the resident's mouth with a wash cloth. The note recorded a wet gauze pad was applied to the resident's lip and the bleeding stopped easily. An incident reported dated [DATE] documented the incident as above. During an observation on [DATE] at 5 PM, the resident was biting his lips, and there were dark secretions coming from the side of his mouth. During an interview on [DATE] at 5 PM, with licensed practical nurse (LPN) # 6, he stated that the resident "has been biting his lips." On [DATE] at 5:20 PM, the resident was observed, while being suctioned, biting his lips, his face was purple, bright red blood was visible on the resident's right lower lip, and there were brown secretions coming from the side of his mouth. During an interview with CNA #6 on [DATE] at 11:25 AM, she stated the resident "bites his lip a lot, I think because of pain. He clenches down especially if he is coughing a lot." During an interview with CNA #2 on [DATE] at 12:10 PM, she stated she thought the resident could hear her when she spoke to him. She stated he moved his head back and forth and opened and closed his eyes. CNA #2 said the resident tried to grab the bar with his left hand, and during his bath he screamed out and bit his lip. During an interview with the registered nurse (RN) Manager on [DATE] at 2 PM, she stated the resident just started biting his lip on [DATE]. The RN said she was in the process of conducting an investigation, and a dental consult was ordered. She stated the biting behavior might be caused by pain, but the resident showed no other signs of pain. A physician progress notes [REDACTED]." The physician recorded the resident's lip biting was "a bit concerning." He is going to see the dentist later in the week for a bite block. The physician also documented a plan to consider adding [MEDICATION NAME] or [MEDICATION NAME] ([MEDICAL CONDITION] medications) to the resident's medication orders. A dental consult dated [DATE] documented the resident refused to open his mouth, and was therefore unable to examine. The resident had a blister on lower lip possibly from biting or trauma. The recommendation was to keep an eye on the lip injury. 10NYCRR 415.12

Based on observation, staff interview and record review conducted during the extended survey, it was determined for 5 of 10 residents (Residents #1, 3, 14, 27 and 33) reviewed for oxygen/respiratory concerns, the facility failed to provide adequate respiratory care and services. Specifically, for residents who required oxygen the facility: - failed to ensure ventilator dependent Residents #1 and 3, and Resident #33 were provided with continuous oxygen as ordered by the physician; - failed to appropriately assess Resident #3 when he exhibited respiratory distress and decompensation; and - failed to ensure there were physician's orders [REDACTED]. This resulted in no actual harm with potential for serious harm that is Immediate Jeopardy to resident health and safety, and Substandard Quality of Care for Residents # 1, 3, 14, 27, and 33. Findings include: 1) Resident #3 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was in a persistent vegetative state with no discernible consciousness. The resident received suctioning of his [MEDICAL CONDITION], and required total assistance with all activities of daily living (ADL). The Medical Orders for Life Sustaining Treatment (MOLST) form dated [DATE] documented the resident was a full code (CPR, cardiopulmonary resuscitation in the event the heart stopped). The physician's orders [REDACTED]. The orders documented to suction the resident as needed, and provide oxygen 30% at 8 liters per minute, via the [MEDICAL CONDITION]. What was the order change The comprehensive care plan (CCP) dated [DATE] documented the resident received respiratory treatments, oxygen at 10 liters per minute, and 28% warmed humidification, via [MEDICAL CONDITION] (plastic mask that fits over the trach, used to deliver oxygen). The CCP recorded the resident would be free from signs and symptoms of shortness of breath. The CCP documented to monitor and report changes in the resident's respiratory status, such as decreased tolerance to previously established activity level, and any change in lung assessments. On [DATE] at 9:35 AM, the resident was observed in his room receiving oxygen at 10 liters per minute via the [MEDICAL CONDITION] collar On [DATE] from 10:50 AM, until 11 AM, the resident was observed in the hallway being transported. He was not receiving oxygen at that time. On [DATE] at 11:20 AM, during a [MEDICAL CONDITION] care observation, licensed practical nurse (LPN) #4 stated to the surveyor she did not check the resident's oxygen saturation level (measure of oxygen in the blood). She stated she did not listen to the resident's lungs with a stethoscope, she would know to suction him if he sounded congested or had a lot of secretions. On [DATE] at 4:10 PM, 4:20 PM, 4:35 PM, and 4:50 PM, the resident was observed in his room, lying semi-reclined in bed, on his back. The resident was not wearing [MEDICAL CONDITION] or receiving oxygen. [MEDICAL CONDITION] was on the bedside table, and there was an empty nebulizer (device that delivers medication as a mist) delivery cup on the bed next to the resident. The resident had a loose congested cough. Observations on [DATE] at 5 PM, showed the resident remained without [MEDICAL CONDITION] and oxygen. The resident was wheezing. The surveyor approached LPN #6 and asked him to check the resident. LPN #6 applied the resident'[MEDICAL CONDITION] and oxygen at 10 liters per minute, and left the room. At 5:05 PM, LPN #6 re-entered the resident's room and checked the resident's oxygen saturation at 99%. LPN #6 stated the first time he would see the resident, during his shift, was around 5 PM. He stated the CNAs saw the resident more, than he would, when they changed and positioned the resident. Observations on [DATE] at 5:15 PM, showed LPN #6 was listening to the resident's lungs with a stethoscope. LPN #6 stated, to the surveyor, the resident's lungs sounded congested, and "I am going to suction him, this is almost normal for him, that is why we keep the head of his bed elevated." LPN # 6 left the room to retrieve supplies and upon re-entering the room, the RN Manager came in, and stood behind the privacy curtain, out of the resident's view. She asked LPN #6 if he had everything he needed, and when he said yes, she exited the room, without visualizing or assessing the resident. Observations of the resident'[MEDICAL CONDITION] on [DATE] at 5:30 PM, showed: - LPN # 6 opened a suction catheter, and dipped the suction catheter in normal saline while applying suction. - He removed the resident's [MEDICAL CONDITION] collar and inserted the catheter into the [MEDICAL CONDITION]. - The resident was coughing, his facial color was purple, and he was biting his lip. - LPN # 6 reapplied the [MEDICAL CONDITION] collar with oxygen for approximately 1 minute, and then suctioned the resident 2 more times without administering oxygen in between. - The resident was coughing forcefully, his face was purple, there were thick white secretions from the trach, - The surveyors remained in the room until 6 PM, and during that time period, the RN Manager did not re-enter the resident's room to assess the resident. On [DATE] at 6 PM, during an interview the RN Manager stated she expected staff to make rounds and check on the resident at least every 2 hours. Staff were to check the resident's oxygen tubing, connections, and humidified air, and if the resident was without oxygen, it would have been noted on those rounds. She stated if the resident was breathing more rapidly, it should be reported. The RN said the resident's last nebulizer treatment was at 2 PM and "I am not sure how long it takes, about 20 minutes." She stated an RN should assess the resident if there was a change in the resident's secretions, and if the resident had a change in skin/face color, while being suctioned, you should stop suctioning and give him "a few minutes." The hourly rounding report dated [DATE] documented the resident was observed by facility staff at 3 PM, 4 PM, and 5 PM. On [DATE] at 6 PM, during an interview, certified nursing aide (CNA) #4, who signed the hourly rounding report for 3 PM, stated when she performed checks on the resident she went in the room to see if he was there. She stated she did the checks after she received report and she did not remember if the resident was on report. On [DATE] at 6:15 PM, during an interview CNA #5, who signed the resident's hourly rounding report for 4 PM, stated she made sure the resident'[MEDICAL CONDITION] intact and he looked comfortable. She stated she "didn't notice anything with his tubing today." The facility's investigation report dated [DATE] included a statement by LPN #4, that documented she administered a nebulizer treatment to the resident at 2:35 PM, on [DATE]. The statement recorded LPN #4 "did not pass on to the evening charge nurse that this treatment was in process." On [DATE] at 7:10 PM, the Director of Nursing (DON) stated in an interview, the RN Manager reported to her that she visually assessed the resident on [DATE] after the surveyors notified them the resident was without oxygen for an extended period of time. She stated the assessment should have been documented in a progress note and she could not "speculate" on what the RN did when she conducted the assessment. She stated the resident's assessment, by an RN, should have included oxygen saturation levels, vital signs, and lung sounds. During an interview on [DATE] at 2:30 PM, with the Medical Director, he stated it was his expectation an RN would assess a resident who had any significant change in condition. He said he was aware the resident was without oxygen for "awhile" and the RN should have assessed the resident. He stated when oxygen was ordered to be administered continuously it should be on at all times. 2) Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The Medical Orders for Life-Sustaining Treatment (MOLST) dated [DATE] documented the resident was a full code (CPR, cardiopulmonary resuscitation in the even the heart stopped). The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was alert and oriented, able to make his needs known and was totally dependant on staff for all activities of daily living. The comprehensive care plan (CCP) dated [DATE] documented the resident was able to operate his electric wheelchair and when out of bed. The resident could often be found wheeling around the facility and outdoors, during nice weather, socializing with peers and staff. The CCP documented the resident was oxygen dependent, ventilator dependent, and used a portable ventilator when he was out of bed. The physician's orders [REDACTED]. During the resident group meeting on [DATE] at 2:10 PM, the resident notified 2 surveyors that he was out of oxygen. At that time, a surveyor notified the reception desk that the resident required assistance with his oxygen. Several minutes later a staff person arrived to assist the resident. During an interview on [DATE] at 9:45 AM, with the registered nurse (RN) Manager, the RN Manager said the resident was alert and oriented and would tell staff when his oxygen tank needed to be changed. She said the resident told her he did not run out of oxygen, but if he did he would be okay for a short period of time as the ventilator would deliver room air. She said the resident could use his phone to call nursing if there was a problem with his oxygen when he was off the unit. The RN Manager said there was no formal system in place to assure the resident did not run out of oxygen. On [DATE] at 11:15 AM, the resident stated in an interview, when he was up in the chair it was easier to breathe so he could tolerate his oxygen being down to 3 liters/minute. He stated how long the tank of oxygen lasted depended on the seals and who filled the tank. On [DATE] at 7:10 PM, the Director of Nursing (DON) stated in an interview, she was not sure how long the resident could be without oxygen and she would have to check the resident's ventilator recommendations. She stated the staff should monitor the resident's oxygen tank to ensure he had an adequate supply. During an interview with licensed practical nurse (LPN) #9 on [DATE] at 12:56 PM, she stated that she had last checked the resident about 9:55 AM on [DATE], when she was passing medications. She stated that his oxygen was set at 5 liters and the amount he had at that time would last about 1 hour. She stated she did not know he was going to be gone long and she did not notify another nurse when she went on break at 11 AM that he may need more oxygen and was off the unit. She stated she returned from break at approximately 11:20 AM. She stated staff knew where he was and could find him when they needed to and there was not a system in place if the resident did not call staff or come back to the unit on his own when he needed oxygen. The resident's attending physician was not available for interview during survey. During an interview on [DATE] at 2:30 PM with the Medical Director, he stated oxygen that was ordered continuously should be on at all times. 3) Resident #33 was admitted to the facility with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident made herself understood, and understood others. The MDS recorded the resident was cognitively intact, and felt tired/depressed. The resident required limited assistance with activities of daily living (ADL) and received tube feedings. The comprehensive care plan (CCP) dated [DATE] documented the resident was to receive oxygen as ordered. The CCP recorded the resident's respiratory status was to be monitored closely and any changes were to be reported to the physician. The current, undated, Individual Plan Report (care instructions) documented the resident was on continuous oxygen. During the resident group meeting on, [DATE] at 2:10 PM, the resident stated to the surveyor that she was out of oxygen and needed assistance. At that time the reception desk was notified to contact the unit and send assistance. Approximately 5 - 10 minutes later another resident (Resident #1) notified the surveyor he was out of oxygen. At that time, the reception desk was notified the resident required nursing assistance. Approximately 5 minutes later, a staff person came to assist Resident#1, and Resident #33 continued to wait for assistance. The staff person who responded to help Resident #1 was asked to assist Resident #33. During an interview on [DATE] at 7:10 PM, the Director of Nursing (DON) stated she was not informed by her nursing staff that the resident ran out of oxygen at the resident group meeting. She stated staff should monitor residents' oxygen tanks and ensure they had an adequate supply. On [DATE] at 10:35 AM, the resident was observed sitting in the hallway on the unit near the nurses desk, waiting for the dining room to open to attend Bingo. The resident was in a wheelchair and her oxygen was in place. During an interview on [DATE] at 10:35 AM, the resident stated she sometimes ran out of oxygen and had to ask for it to be replaced. She stated it happened at times when she was at an activity and it was usually replaced timely. 10NYCRR 415.12(k)(6)

Based on record review and staff interview conducted during the extended survey, it was determined the facility failed to provide a quality assessment and assurance program (QA) that readily and effectively identified issues with the potential to cause serious harm to the health and safety of residents for 5 of 10 residents reviewed for oxygen/respiratory concerns (Residents #1, 3, 14, 27 and 33), 5 of 35 sampled residents (Residents #1, 3, 4, 15, 35), and 1 resident outside of the sample (Resident #38). This resulted in no actual harm with potential for serious harm that was Immediate Jeopardy to the health and safety of Residents #1, 3, 4, 14, 15, 27, 33, 35, and 38. Findings include: Refer to F309 for 5 of 35 sampled residents (Residents #1, 3, 4, 15, 35) and 1 resident outside of the sample (Resident #38). Refer to F328 for 5 of 10 residents (Residents #1, 3, 14, 27 and 33) reviewed for oxygen/respiratory concerns. ADVANCED DIRECTIVES CONCERNS: On 8/29/2013 between 2 PM and 3 PM, the QA Coordinator stated in an interview, the facility was currently reviewing residents' advanced directives by reviewing the MOLST (Medical Orders for Life Sustaining Treatment) forms for accuracy. On 8/29/2013 at 7:10 PM, the Administrator and Director of Nursing (DON) were interviewed. The Administrator stated she was not previously aware of concerns with the facility's code status identifiers including the bracelets residents wore, the color on the binding of the charts, and/or the color coded papers posted in their rooms. They both stated they were not aware that a resident who was a full code was observed wearing a blue bracelet (indicating DNR, do not resuscitate, allow natural death in the event the heart stopped). On 8/30/2013 at 2:30 PM, the Medical Director stated in an interview, he was not aware there were concerns with the facility's system for identifying residents' code status. OXYGEN/RESPIRATORY CONCERNS: On 8/29/2013 between 2 PM and 3 PM, the QA Coordinator stated in an interview, the facility was currently auditing oxygen use for residents with [MEDICAL CONDITIONS] as part of their QA process. On 8/29/2013 at 7:10 PM, the Director of Nursing (DON) stated in an interview, when Resident #3 was without oxygen for an extended period of time, the registered nurse (RN) Manager reported she visually assessed the resident. The DON stated the assessment done at that time should have been documented in the medical record and should have been a physical assessment including oxygen saturation levels, vital signs, and lung sounds. The DON stated staff should monitor residents who were on oxygen to ensure they had an adequate supply of oxygen and it was provided as ordered. During an interview on 8/30/13 at 2:30 PM with the Medical Director, he stated it was his expectation that a RN assessment would be completed with any significant changes in a resident's condition, and that he was aware that the resident was without oxygen for a while. The Medical Director stated that his expectation was that the RN should have assessed the resident. The Medical Director stated residents who had continuous oxygen ordered should be provided with the oxygen that was ordered. 10NYCRR 415.27(a-c)

Based on observation, record review, and interviews conducted during the abbreviated survey (# NY 8529), it was determined for 3 of 3 residents identified with aspiration precautions, the facility did not provide food in a form that meets residents' needs. Specifically, the facility did not: provide the proper food consistency for Resident #1 on two occasions, adequately supervise the resident at meals, and institute direct supervision in a timely fashion. subsequently, the resident was sent to the emergency department on three occasions and on one occasion underwent endoscopy to have food removed. The facility did not adequately supervise Residents #2 and 3 during meals to ensure their ordered feeding plans were implemented. This resulted in actual harm to Resident #1 and no actual harm with potential for more than minimal harm that is not immediate jeopardy for Residents #2 and 3. Findings include: Resident #1 had [DIAGNOSES REDACTED]. The care plan noted the following: 1. August 9, 2010: documented the resident was at risk for aspiration based on videofluoroscopy (a test that shows the resident swallowing while being x-rayed) performed on April 23, 2009. Pureed meats with no string beans continue per resident request. 2. September 10, 2010: The resident had a choking episode on September 9, 2010 on corn with transfer to emergency room (ER) for evaluation. Corn was taken off the dietary regimen as well as all vegetables with "skins." 3. October 26, 2010: The resident had two episodes of choking on foods during the past quarter with transfer to ER. The resident was encouraged to follow the speech language pathologist's (SLP) recommendation of alternating liquids and solids to prevent this. The resident used self induced vomiting to clear her throat at times. Slow consumption at meals was also encouraged. 4. December 9, 2010: A videofluoroscopy was completed. The recommendation was for a mechanical soft diet and thin liquids. The physician orders, dated December 9, 2010 documented the diet as mechanical soft, pureed meats, no string beans, and regular liquids. In an order dated December 14, 2010, the diet was documented as discontinue pureed meats and continue with mechanical soft diet. The Minimum Data Set assessment, dated December 28, 2010, documented the resident had no cognitive impairment, needed supervision (oversight, encouragement, or cueing) and set up help at meals. The nurse documented "no" in response to the question "Any increased difficulty swallowing?" and "regular" to the question, "Liquid consistency okay?" The nurse circled N for no to the question, "cough/choke/drool?" and documented the ordered diet as mechanical soft. A care plan update of January 7, 2011 documented the resident's acceptance of ground meats instead of pureed meats was fair. Resident had two episodes of choking over past quarter, one on corn and the other on rice. A care plan update of January 19, 2011 documented the resident choked on lettuce at lunch and was sent to ER with recommendation to repeat swallow evaluation and avoid lettuce. A care plan entry of January 24, 2011 documented a swallow evaluation was completed. The recommendation was mechanical soft and thin liquids, standard aspiration precautions, small sips/bites, avoid dry crumbly food , soften foods as needed and obtain GI (gasroenterology) consult A care plan note of February 21, 2011 documented the resident was sent toER on [DATE] due to " food stuck in throat." A physician order [REDACTED]. A care plan update of February 23, 2011 noted the resident stated she choked on a piece of roast beef on February 20, 2011. A care plan entry of February 25, 2011 documented a swallow evaluation was completed. The recommendation was for mechanical soft diet and thin liquids. A physician order [REDACTED]. The diet order was to upgrade diet to mechanical soft solids and thin liquids with pureed meats. No string beans, corn or lettuce. A care plan entry dated March 10, 2011 documented the resident was transferred to ER yesterday due to choking episode on meat with needed endoscopy. Resident stated she received a slice of meatloaf, knew it was not pureed, but ate it anyway. Recommendation was clear liquids for a day and then pureed diet. Resident #1 was interviewed on March 16, 2011 at 11:25 AM. She stated she did not like the pureed consistency, especially the meats, but she understands why she needs it. She stated since she went to the emergency room the last time someone sits with her during meals. She said prior to that, staff did not really do much with her for meals except bring the tray. She stated she has had a problem with her esophagus and swallowing for a long time. She stated she had the esophagus stretched (dilation), a few years ago. She said she has been to the ER for choking 2 or 3 times because staff served her the wrong foods. The registered dietitian was interviewed on March 16, 2011 at 11:30 AM. She stated the resident had swallowing problems since April 2009. She said the SLP and the team tried to give the resident the least restrictive diet as possible. She stated the resident did not like the pureed meats, so the team tried to give her the mechanical soft meats. She said there was confusion between the food server and staff sometimes regarding which consistency to serve. The diet card would read "Ground. Server ask about meat" or "Ask about vegetable." This meant the food service worker was to ask the staff setting up the tray what meat or vegetable to serve. The staff could be an aide, LPN or RN. She stated the resident received the wrong consistency meat on March 9, 2011. She should have received puree and was served a regular piece of meatloaf which was for the mechanical soft consistency. She stated corn was restricted from the resident's diet in September 2010. She commented that on March 3, 2011 the resident was served corn and she choked on it. She stated the SLP placed the resident on alternating solids and liquids on February 25, 2011. She stated a nurse was always present in the dining room for supervision. She stated that she could not be sure the staff was following the feeding plan of alternating solids with liquids from a distance of across the dining room. She stated 1:1 supervision at meals was not started until March 9, 2011, and the diet was downgraded to puree on March 10, 2011 to ensure the resident's safety. Resident #1 was observed during the lunch meal March 16, 2011 from 12 PM -12:45 PM. She was served all pureed foods as per diet order. She was supervised by a staff member who sat adjacent to her during the meal. In summary, the facility caused harm to the resident by serving the wrong food consistency on two occasions leading to ER visits and an endoscopic procedure to remove the food on March 9, 2011; and not offering timely or adequate supervision at meals to ensure the feeding plan was followed with regards to alternate liquids with solids until March 9, 2011 when she was placed on 1:1 supervision at meals. 2) Resident #2 had [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] noted the resident's cognitive skills were intact and she needed extensive assistance with eating. The resident's diet order since October 21, 2008 as documented in the physician orders [REDACTED]. The care plan dated February 17, 2011 documented the resident was at very high risk for aspiration. Interventions enlisted as standard aspiration precautions were to alternate solids and liquids, sit upright during meals /snacks and for 30 minutes afterward, eat slowly, small sips /bites, and no straws. The physician diet order of March 16, 2011 was for a regular diet at request of resident. Risk of aspiration fully understood. Position upright for all meals and for 45 minutes afterwards, no straws, and alternate liquids with solids. The resident was observed during the lunch meal on March 16, 2011 from 12 PM -12:45 PM in the North Barton dining room. The diet card listed aspiration precautions. The resident's tray was brought to her and was set up by the aide. The aide did not encourage the resident to eat slowly or provide direction to alternate liquids and solids during the meal. The aide asked the resident if she was finished eating and removed the resident's tray at 12:35 PM. Aide #1 was interviewed at 1 PM on March 16, 2011. She stated she was aware the resident was on aspiration precautions and needed to eat slowly and take small bites. She was not aware of the plan to alternate liquids with solids. In summary, for this resident at high risk for aspiration, the facility did not adequately supervise the resident during the meal to ensure implementation of the aspiration prevention feeding strategies. 3) Resident #3 had [DIAGNOSES REDACTED]. The physician orders [REDACTED]. Alternate liquids with solids. The Minimum Data Set assessment dated [DATE] documented the resident with severe cognitive impairment. The resident was listed as requiring limited assistance for eating. The care plan, updated on March 16, 2011, documented the resident was at risk for aspiration secondary to an October 2010 swallow evaluation. The interventions were listed as standard aspiration precautions. alternate solids with liquids, sit upright for all meals /snacks and for 30 minutes afterwards, eat slowly, small sips and bites, and no straws. Resident #3 was observed during the lunch meal on March 16, 2011 from 12 PM -12:45 PM in the North Barton dining room. The diet card listed aspiration precautions. The resident's tray was brought to her and was set up by the aide. The aide did not encourage the resident to eat slowly or provide direction to alternate liquids and solids during the meal. The aide asked the resident if she was finished eating and removed the resident's tray at 12:30 PM. Aide #2 was interviewed at 1:15 PM on March 16, 2011. She stated she was aware the resident was on aspiration precautions and needed to eat slowly and take small bites. She was not aware of the plan to alternate liquids with solids. In summary, for this resident at high risk for aspiration, the facility did not adequately supervise the resident during the meal to ensure implementation of the aspiration prevention feeding strategies.