Every finding on record at Pine Haven Home

Based on record review and interview conducted during the recertification and abbreviated survey (Case #s NY00309923 and NY00359733), the facility did not ensure provision of sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, between 3/23/2025 and 3/31/2025, the minimum hours of nursing care per resident day was less than the established minimum set by the Centers for Medicaid/Medicare Services. This is evidenced by: The Facility assessment dated [DATE], documented under Staffing plan, that the facility worked diligently to maintain staffing levels for all departments that met Center for Medicare and Medicaid Services Guidelines for providing optimal resident centered care. Facility Nursing Levels based on an Average Daily Census of 110 (in past 30 days) equaled 3.07 Hours Per Patient Day. Licensed Nursing equaled 1.43 Hours Per Patient Day. Certified Nurse Aides equaled 1.64 Hours Per Patient Day. Below were the facility's documented staffing levels per unit (including house staff and contracted agency staff). Day Shift (7 AM to 3 PM) Certified Nurse Aides: 4 standard (2 minimum) Licensed Nurse (Registered and Licensed Practical): 4 standard (2 minimum) Supervisor Registered Nurse: 1 House Supervisor every day, and 3 Unit Managers Monday through Friday Evening Shift (3 PM to 11 PM) Certified Nurse Aides: 4 standard (2 minimum) Licensed Nurse (Registered and Licensed Practical): 2 standard (1 minimum) Supervisor Registered Nurse: 1 House Supervisor Night Shift (11 PM to 7 AM) Certified Nurse Aides: 2 standard (1 minimum) Licensed Nurse (Registered and Licensed Practical): 1 standard Supervisor Registered Nurse: 1 House Supervisor It was noted that when there was a minimal number of Certified Nurse Aides on any unit, a licensed nurse would be assigned to assist with direct care. Continued efforts were being made to increase staffing levels to meet the minimum requirements. These efforts included, but were not limited to working with recruiters, negotiating agency contracts for temporary staff, enforcing attendance policies and offering incentives (bonuses and flexible schedules) to encourage staff to cover needed shifts. Recruitment and retention efforts were a constant operational focus to maintain adequate staffing levels while experiencing a state of emergency in the state regarding the health care worker shortage. Review of the untitled staff assignment sheets dated 3/23/2025 through 3/31/2025, documented less than Centers for Medicaid/Medicare Services' minimum hours of care per resident day nursing staffing levels for 8 out of 9 days, as follows: 3/23/2025 facility census 115. Requiring a total staffing hours of 402.5 hours. Per facility staffing sheets provided, 336 hours of resident care staff hours scheduled, facility short 66.5 hours of staffing care. Should have been 16 Licensed Nurses, 36 Certified Nurse Aides working to cover a census of 115. Schedule reflected that there were 16 Licensed Nurses and 26 Certified Nurse Aides working. 3/24/2025 facility census 116. Requiring a total staffing hours of 406 hours. 392 hours of resident care staff hours were scheduled. Facility short 14 hours of staffing care. Schedule reflected that there were 19 Licensed Nurses and 30 Certified Nurse Aides working. 3/25/2025 facility census 117. Requiring a total staffing hours of 409.5 hours. 408 hours of resident care staff hours were scheduled. facility short 1.5 hours of staffing care. There should have been 17 Licensed Nurses and 36 Certified Nurse Aides working to cover a census of 117. Schedule reflected that there were 19 Licensed Nurses and 32 Certified Nurse Aides working. 3/26/2025 facility census 117. Requiring a total staffing hours of 409.5 hours. 400 hours of resident care staff hours were scheduled. Facility short 9.5 hours of staffing care. There should have been 17 Licensed Nurses and 36 Certified Nurse Aides working to cover a census of 117. Schedule reflected that there were 22 Licensed Nurses and 28 Certified Nurse Aides working. 3/28/2025 facility census 117. Requiring a total staffing hours of 409.5 hours. 360 hours of resident care staff hours were scheduled. Facility short 49.5 hours of staffing care. There should have been 16 Licensed Nurses and 36 Certified Nurse Aides working to cover a census of 117. Schedule reflected that there were 19 Licensed Nurses and 26 Certified Nurse Aides working. 3/29/2025 facility census 115 Requiring a total staffing hours of 402.5 hours. 320 hours of resident care staff hours were scheduled Facility short 82.5 hours of staffing care. There should have been 16 Licensed Nurses and 36 Certified Nurse Aides working to cover a census of 115. Schedule reflected that there were 17 Licensed Nurses and 23 Certified Nurse Aides working. 3/30/2025 facility census 115 Requiring a total staffing hours of 402.5 hours. 328 hours of resident care staff hours were scheduled Facility short 74.5 hours of staffing care. There should have been 16 Licensed Nurses and 36 Certified Nurse Aides working to cover a census of 115. Schedule reflected that there were 13 Licensed Nurses and 23 Certified Nurse Aides working. 3/31/2025 facility census 116 Requiring a total staffing hours of 406 hours. 328 hours of resident care staff hours were scheduled. Facility short 78 hours of staffing care. There should have been 16 Licensed Nurses and 36 Certified Nurse Aides working to cover a census of 116. Schedule reflected that there were 18 Licensed Nurses and 29 Certified Nurse Aides working. During an interview on 4/01/2025 at 12:57 PM, Director of Nursing #1 stated that they knew the minimum hours of resident care required was 3.5 hours per day per resident. Director of Nursing #1 stated that the facility struggled to hire Certified Nurse Aides and attributed much of the difficulty to the remote location of the facility. Additionally, when there were large gaps in the staffing schedule, Licensed Practical Nurses would work as Certified Nurse Aides and that there was a team approach to resident care at the facility. During an interview on 4/01/2025 at 12:57 PM, Administrator #1 stated that Director of Nursing #1 had a solid orientation, low turnover, and that they were both looking to feel exclusive with their staffing so that the people that worked there felt important. The schedule was flexed for employees in school and cluster schedule people that carpooled to help with transportation as there was no public transportation due to the rural nature of the area. Additionally, Administrator #1 listed the ways they had been working to encourage people to come work at the facility including hiring 2 outside recruiters, offering a Certified Nurse Aide online course, working with the local Board of Cooperative Educational Services, ads, local boards in the community, by recruiting people that come and hand out applications in site. They also relied on word of mouth from other employees, incentives for picking up shifts and recruiting other people, and encouraging staff advancement. 10 New York Code Rules and Regulations 415.13(a)(1)(i-iii)

Based on observation and interview conducted during the recertification survey, the facility did not ensure food was stored in accordance with professional standards for food service safety. Specifically, (a) a container of tomato juice was found unlabeled in the refrigerator; and (b) a container of opened, unlabeled cranberry juice was found in the dry storage area. This is evidenced by: During the initial tour of the kitchen between 11:00 AM and 12:00 PM on 3/24/2025, the following was observed: (a) A pitcher with red liquid, unlabeled in the dessert refrigerator. At the time of observation, Kitchen Director #1 identified the red liquid to be tomato juice, stated there should have been a label on it stating it was opened today. Kitchen Director #1 then removed the pitcher and stated that they would refresh the supplies correctly. (b) An opened, unlabeled bottle of Ocean Spray Cranberry Juice in the dry storage area. At the time of observation, Regional Food Director #1 stated that a new employee that started a week prior had walked out an hour before the survey team arrived at the facility, and they believed the item was left by the employee. The facility's policy titled, Food from Home, dated 12/01/2022, documented that it was the policy of this facility to provide safe and sanitary storage, handling and consumption of all foods including those brought to residents by family and other visitors. Additionally, the policy documented that the food service workers, cooks, dietary aides, dishwashers, food prep aides, or any person (s) who were in the kitchen working with any type of food, were responsible for to adhere to the food safety requirements. During an interview on 3/24/2025 at 11:25 AM, Kitchen Director #1 stated that all food items must be dated and labeled when they were opened and prior to bring refrigerated. During an interview on 3/24/2025 at 12:15 PM, Regional Food Director #1 stated that they believed the two unlabeled bottles of liquid found in the refrigerator and the dry storage area belonged to the employee. 10 New York Codes of Rules and Regulations 415.14(h)

Based on record review and interviews during a recertification and abbreviated survey (Case #NY00309923), the facility did not ensure that all alleged violations involving abuse were reported immediately, or no later than 2 hours after the allegation was made for one (1) (Resident #115) of eight (8) residents reviewed for abuse. Specifically, an allegation of verbal abuse reported by a resident to a Certified Nurse Aide on 2/05/2023 was not reported to Administration until 2/06/2023, and not reported to The New York State Department of Health until 2/08/2023. This is evidenced by: Facility policy titled, Abuse Policy-Prevention and Management, reviewed August 2024, documented the Facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse. Under the heading Identification the policy documents instruct staff, resident/patient, family, visitor, to report immediately, without fear of reprisal, any knowledge or suspicion of suspected abuse. Under the heading Reporting the policy documents staff would notify the Shift Supervisor/Charge Nurse/Manager immediately of an allegation or suspected abuse. This responsible Manager would then notify the Administer and Director of nursing immediately. The designated State agency(s) would be notified within 2 hours after identification of the alleged/suspected abuse. Resident #115 was admitted to the facility with diagnoses of acute kidney failure (sudden loss of kidney function), osteoarthritis (inflammation of one or more joints), and anxiety disorder (intense, excessive and persistent worry and fear about everyday situations). The Minimum Data Set (an assessment tool) dated 1/28/2023, documented the resident could be understood, could understand others, and had no cognitive impairment. The facility Investigation Summary dated 2/14/2023 documented the resident reported that on 2/05/2023 Certified Nurse Aide #3 yelled at them, and they felt intimidated. The resident reported the incident was witnessed by Certified Nurse Aide #4. It was determined that the accused did not act with the intention to upset the resident, however, did not use an appropriate approach as outlined in the resident's care plan. The Summary also documented there was no awareness of this event until 2/06/2023 when the resident asked to speak with the social worker During an interview on 4/01/25 at 10:27 AM, Administrator #1 stated they were unable to substantiate the abuse allegation but terminated the agency staff because they were not receptive to being educated on how to speak to the residents. Administrator #1 stated they did question Certified Nurse Aide #4 about why they did not report the incident, and the Aide said they did not think of it as abuse because the accused was usually loud and gruff with everyone. Administrator #1 stated they were new to the position when this incident occurred and may have been unclear as to their responsibilities to report. They further stated they were now aware this should have been reported sooner and made sure all relevant incidents are reported within 2 hours as they should. 10 New York Codes, Rules, and Regulations 415.4(b)(2) 1

Based on record review and interview conducted during a recertification and abbreviated survey (Case #NY00356721), the facility did not ensure the environment remained as free of accident hazards as possible for one (1) (Resident #41) of seven (7) residents reviewed for accident hazards. Specifically, for Resident #41 the temperature of the resident's microwave reheated beverage was not checked prior to serving, resulting in a first degree burn to the resident's chest. This is evidenced by: The facility Policy and Procedure titled Food - Microwave Reheating, last revised 7/26/2024, documented the staff were to use the thermometer to ensure a maximum temperature of the reheated food or beverage was not greater than 140 degrees Fahrenheit prior to serving. Resident #41 was admitted to the facility with diagnoses of anxiety, chronic pain and peripheral venous insufficiency (veins have trouble sending blood from limbs back to the heart). The Minimum Data Set, dated dated dated [DATE] documented the resident could understand, be understood, and moderate cognitive impairment. The Care Plan initiated 5/2/2020, titled Functional Abilities/Eating, documented the resident required set-up and clean-up assistance. An Incident/Accident Report dated 10/8/2024 at 11:45 AM documented the resident spilled hot tea on upper chest resulting in a surface burn In a written statement dated 10/8/2024 Registered Nurse #1 documented they heated the Resident's tea in the microwave and placed it on the bedside table. Approximately ten minutes later an aide reported the resident had spilled the tea resulting in a burn. A Nurse Practitioner Note dated 10/8/2024 documented the resident was seen for a thermal burn resulting from hot liquid spilled on the chest. The diagnosis was first degree thermal burn with orders for cool compresses for comfort and topical antibiotic cream to be applied twice daily. During an interview on 3/25/25 at 12:10 PM, Resident #41 stated they remembered the incident because everyone made a big fuss out of nothing. I missed my mouth, spilled tea down the front of myself and got a little burn. Registered Nurse #1 is no longer employed by the facility and could not be reached for interview. During an interview on 3/27/2025 at 9:15 AM, Director of Nursing #1 stated the nurse responsible for the accident immediately reported they forgot to check the temperature prior to serving the reheated tea and felt terrible about it. The nurse was an excellent employee with no other issues. All nursing staff were re-educated regarding the microwave policy. 10 New York Codes, Rules, and Regulations 415.12(h)(1)

Based on observation, record review, and staff interview during the recertification survey on 03/23/2022 through 03/30/2022 the facility did not ensure foods brought to residents by family and other visitors was in accordance with adopted regulations. Specifically, food brought to residents was not labeled and discarded per the facility policy. This is evidenced as follows: The policy titled Food from Home - Safety dated 09/2021, documented food brought in from the outside will be labeled by staff with the resident name and dated with the current date the item(s) was brought to the facility and will be discarded after 72 hours. The policy documented unlabeled/undated food found will be discarded immediately. During observations on 3/24/22 at 9:45 AM, store-bought cold cuts and a frozen entree were found in the North Unit Nourishment Station refrigerator. Both the bologna and baked ham cold cuts were not labeled with the resident room number, or the date received. The bologna had sell-by date printed on the package of 2/17/22, and the bologna was moldy. The surveyor witnessed the bologna discarded. The frozen entree was not labeled with the resident room number or the date received. On the West Unit Nourishment Station refrigerator, a package of frozen vegetables and two (2) frozen entrees were not labeled with a resident name, room number, or date received. During an interview on 3/24/22 at 10:10 AM, LPN #1 stated that food should be labeled with resident name, room number, and date brought in then discarded after 3 days. The cold cuts should have been discarded, and the refrigerator should be checked Wednesdays by nursing or housekeeping During an interview on 3/24/2022 at 1:24 PM, the Administrator stated that staff should have written the resident name and room number and the date received into the facility, and food should have been discarded after three (3) days. 10 NYCRR 415.14(h)

Based on observation, interview, and record review during a recertification survey on 03/23/2022 through 03/30/2022 the facility did not ensure each resident received adequate supervision to prevent accidents for 2 (Resident #s 22 and 59) of 8 residents reviewed for accidents. Specifically, for Resident #22 and #59, the facility did not ensure the residents' nursing assessments documented the residents were able to self-administer medications, had a care plan or a physician order to self-administer medications that were left at bedside by nursing staff. This was evidenced by: The Policy and Procedure (P&P) titled Medication Administration dated 1/2022 documented residents may self-administer their own medications if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. Resident #22: Resident #22 was admitted to the facility with diagnoses of gastro-[CONDITION(S)] reflux disease, [CONDITION(S)] heart disease, and [CONDITION(S)]. The Minimum Data Set (MDS - an assessment tool) dated 1/13/22, documented resident was cognitively intact, was understood and could make self understood. During an observation on 3/24/2022 at 10:27 AM, Resident #22 had 12 pills in a medicine cup at their bedside. The Comprehensive Care Plan did not include a care plan to address the resident's ability to self-administer medications. The Physician Orders did not include an order for the resident to self-administer medications. The assessment titled Nursing - Assessment of self-administration of medication dated 2/4/2019, 2/13/2020 and 11/3/2020 documented Resident #22 was not approved for self-administration of medication. During an interview on 3/24/2022 at 10:27 AM, Licensed Practical Nurse (LPN) #6 stated they left the pills for resident to take. The LPN did not know if Resident #22 was care planned for self-administration of medications. During an interview on 3/25/2022 at 9:26 AM, LPN #7 stated medications were not supposed to be left at the bedside. During an interview on 3/30/2022 at 10:06 AM, the Director of Nursing (DON) stated medications should not be left at the bedside. The assessment for self-administration of medication was done on admission and as needed after admission. In addition, the doctor needed to sign an order for self-administration of medication. Without an assessment documenting a resident can self-administer medication and a physician order reflecting that, medications should not be left with an unsupervised resident. Resident #59: Resident #59 was admitted with diagnoses of [CONDITION(S)] (MS), pain, and [CONDITION(S)]. The Minimum Data Set (MDS-an assessment tool) dated 2/14/2022 documented the resident was cognitively intact, could understand others and could usually make self understood. During an observation on: -3/24/2022 at 10:35 AM, Resident #59 had 2 white tablet pills in cup on the over bed table. The resident stated the pills in the cup were their MS medication ([MEDICATION(S)]) and Tylenol. The resident stated the nurse gave them their pills at 10:00 AM for the resident to take by themselves at 11:00 AM. The resident stated that was how they always did it. They were given their pills ahead of time to self-administer later. -3/25/2022 at 9:17 AM, Resident #59 had 3 pills at bedside on the over bed table. The resident stated the pills were [MEDICATION(S)], [MEDICATION(S)], and Senna. The resident stated they would take the [MEDICATION(S)] at 11:00 AM, but did not want to take the stool softeners, [MEDICATION(S)], and Senna. The Resident stated they would give the stool softeners back to the nurse when they saw the nurse again. -3/28/2022 at 9:25 AM, Resident #59 had 2 white tablet pills in cup on the over bed table. The resident stated the pills were [MEDICATION(S)] and Tylenol. The Resident stated they were always given their pills ahead of time to self-administer later. The Comprehensive Care Plan did not include a care plan to address the resident's ability to self-administer medications. The Physician Orders did not include an order for the resident to self-administer medications. The medical record did not include an assessment that documented the resident was able to self-administer medications. During an interview on 3/30/2022 at 9:17 AM, Certified Nursing Assistant (CNA) #2 stated it was the CNAs responsibility to tell the nurses when pills were left on the table at a resident's bedside. The CNA stated they once saw pills on Resident #59's bedside table and reported it. During an interview on 3/30/2022 at 9:38 AM, Licensed Practical Nurse (LPN) #5 stated Resident #59 did not like to take the [MEDICATION(S)] medication until exactly 10:00 AM, but the medication pass on that side of the unit was scheduled for 8:00 AM. Resident #59 usually received their medications around 9:00 AM. The LPN stated honestly, they thought they could leave Resident #59's medications with them at bedside. The LPN stated they thought it was ok and that the resident was care planned to have medications at bedside because other nurses were doing it. The LPN stated normally the nurses were not allowed to leave medication for any residents. LPN #5 stated they did not see that Resident #59 took their pills so they could not say they took them. During an interview on 3/30/2022 at 12:28 PM, the Director of Nursing (DON) stated they were once made aware medications were left at bedside and immediate education was completed. The DON stated nurses were not allowed to leave medication at the bedside and was not aware of nurses leaving medication at bedside. 10NYCRR 415.12(h)(2)

Based on observation, interview and record review during a recertification survey on 03/23/2022 through 03/30/2022, the facility did not ensure it provided separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility used single unit package drug distribution systems in which the quantity stored was minimal and a missing dose could be readily detected for 1 (South Unit) of 2 units reviewed. Specifically, the facility did not ensure the #2 narcotic cabinet for the South Unit had two functioning locked doors. This was evidenced by: During an observation on 03/30/2022 at 9:38 AM, the #2 double door narcotic cabinet on South Unit, did not have a functioning lock on the inner door. The inner door had a strip of greying white tape affixed to the bottom of the door with a small portion extended from the bottom of the door which was used to pull the door open. Licensed Practical Nurse (LPN) #5 was observed unlocking the outer door of the #2 narcotic cabinet with a key, then used the tape on the bottom of the inner door to pull it open. LPN #5 used the inner door key to demonstrate the key did not work to lock or unlock the inner door. During an interview on 03/30/2022 at 9:38 AM, LPN #5 stated they began working the South Unit 1 month ago and the #2 narcotic cabinet inner door lock was broken then. LPN #5 stated they asked the Unit Manager when the lock was going to get it fixed. LPN #5 stated the narcotic cabinets were supposed to be double locked. During an interview on 03/30/2022 at 9:51 AM, Maintenance Staff #1 stated they were not aware the inside lock on the #2 narcotic cabinet was not working. A work order for maintenance should have been done through the computer and maintenance would have fixed the lock. During an interview on 03/30/2022 at 10:11 AM, the Licensed Practical Nurse Unit Manager #4 (LPNUM) stated they were aware that the inner lock of the #2 narcotic cabinet was broken. LPNUM #4 stated they knew the #2 narcotic cabinet should have double locked doors. A while ago a request was put into maintenance to have the lock fixed. LPNUM #4 did not know how long it had been broken. During an interview on 03/30/2022 at 11:00 AM, the Maintenance Director stated they had checked the maintenance requests for the last month and there were no work orders to fix the #2 narcotic cabinet. The Maintenance Director did not know the #2 narcotic cabinet lock was broken. During an interview on 03/30/2022 at 12:28 PM, the Director of Nursing (DON) stated the #2 narcotic cabinet was getting fixed. The #2 narcotic cabinet should have been repaired and the DON should have been notified that it had been broken. 10NYCRR 415.18(e)(1-4)

Based on observation, record review and interview during the recertification survey, the facility did not ensure comprehensive care plans (CCP) were developed and implemented for each resident that included measurable objectives and time frames to meet a resident's medical, nursing and mental and psychosocial needs for 8 (Resident #'s 3, 14, 17, 29, 31, 46, 48, and 54) of 23 residents reviewed for comprehensive care plans. Specifically, for Resident #3, the facility did not ensure that the CCP for Feeding Tube did not include an incorrect physician order [REDACTED].#46, the CCP for mood state included person-centered non-pharmacological interventions; for Resident #29 and #48, the facility did not ensure the CCP for cognition due to dementia included person-centered interventions; and for Resident #54, the facility did not ensure that the CCPs for dementia care and behavior monitoring included individualized, person centered interventions. This is evidenced by: The Policy & Procedure (P&P) titled Careplanning dated 8/2018, documented the facility will develop a comprehensive, resident centered care plan for each resident. All resident care and interventions must be carried out per the Care Plan. Resident #46: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - an assessment tool) dated 9/2/19, documented the resident had severely impaired cognition, could sometimes understand others and could sometimes make self understood. The CCP for mood state related to restlessness and agitation, last revised 9/21/18, documented the resident would have decreased episodes of restlessness and/or inability to relax through next review. The interventions included support self-esteem through positive feedback, encourage participation in leisure and self-care activities, encourage family involvement and visits, obtain psychiatric consult and evaluation, and administer medications as prescribed. The care plan did not include person-centered non-pharmacological interventions to address the resident's mood state. During an interview on 10/22/19 at 9:57 AM, the Director of Nursing (DON) stated mood, behavior, and dementia care plans needed to be more individualized and the care plans tended to be very rote and not detailed specific to the resident. She stated it was an area where the facility was lacking but the facility was actively working to improve their care planning process. She stated the resident's care plan should have real interventions that are meaningful to the resident for her mood and/or behaviors. Resident #48: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - an assessment tool) dated 8/30/19 documented the resident had severely impaired cognition, could usually understand others, and could usually make self understood. The CCP for cognition due to dementia, last revised 8/16/19, documented the resident had severe cognitive impairment and behaviors related to rejection of care. The goal was the resident would participate safely in her care within her physical and cognitive abilities. The interventions were to engage the resident in appropriate social conversation within the facility and to encourage family support and involvement in daily routine and plan of care. The care plan did not include person-centered interventions to address the resident's cognitive impairment. During an interview on 10/22/19 at 9:57 AM, the DON stated the facility now had a dementia care committee and were working from the ground up with the staff to better understand dementia care. She stated the facility has started education on the fundamentals on dementia care and identified that the care planning was lacking meaningful activities that were specific to the resident. She stated the dementia care plan should be individualized, but in order to do that, the staff needed to really learn who the resident is now and was in their past. She stated the mood, behavior, and dementia care plans needed to be more individualized and the care plans tended to be very rote and not detailed specific to the resident. Resident #54: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had severely impaired cognition and was able to make himself understood and sometimes able to understand others. The CCP titled Dementia related to Impaired Decision Making, last revised 5/28/19, documented resident will be comfortable in this environment with minimal behaviors and anxiety. Interventions included, provide a low stimulation environment, calm approach, allow time to process, use simple words or instructions, evaluate medication regimen, and reduce psychoactive meds to reduce fall risk. The care plan did not include individualized, person-centered approaches to support the resident's dementia care needs. The CCP titled Behavior Monitoring, as evidenced by combative behavior, hitting, scratching, verbal abuse, insults to staff. CCP documented resident will maintain positive interactions with staff and peers, being receptive to receiving assistance from staff during care-related routines. Interventions included, initiate behavior monitoring record, Behavior monitoring sheet to be filled out every shift, nurse to review behavioral sheets routinely, provide medications per MD orders, document in progress notes the intensity, frequency, and duration of behavior, redirect negative behaviors, honor preference in care routines, notify Medical Doctor with changes in behaviors, follow up with psychology/psychiatry as indicated. The care plan did not include person-centered non-pharmacological interventions to address the resident's behaviors. During an interview on 10/22/19 at 12:52 PM Registered Nurse Manager (RNM) #3 stated the careplan's do need to be more individualized to the resident. The resident preferences and things he may relate to from his past, should be used for the interventions. Dementia training does need to happen here. 10NYCRR415.11(C)(1)

Based on observation and staff interview during the recertification survey, the facility did not store, prepare, distribute or serve food in accordance with professional standards for food service safety. Food preparation and serving area floors and equipment are to be kept clean, and kitchen equipment is to be kept in good repair. Specifically, equipment in the main kitchen and unit nourishment Stations were not clean and/or not in good repair; and the facility did not ensure proper food handling practices for residents in the Haven dining room. This is evidenced as follows. Finding #1: The main kitchen and the nourishment stations were inspected on 10/16/2019 at 08:51 AM. Drawers, mixer, slicer, microwave ovens, and stove were soiled with food particles. The floors next to walls and under equipment were soiled. The food preparation sink in the main kitchen had an open hole where the overflow drain and pipe should be connected, and open holes were found in the upper lip next to the faucets in the Nourishment Stations on the west and north units. The Food Service Director stated in an interview on 10/16/2019 at 08:51 AM, that she will clean all soiled items found and institute a cleaning schedule and submit work orders for the sinks. Finding #2: During an observation on 10/16/19 at 11:51 AM, Resident #17 placed a hair brush in her lunch meal. Certified Nursing Assistant (CNA) # 1 removed the brush from the lunch meal and discarded the brush. Resident #17 continued to eat the lunch meal and was not provided with a new meal. During an interview on 10/18/19 at 12:39 PM, CNA #1 stated she should have ordered another meal tray for the resident after she removed the brush from the food. During an interview on 10/18/19 at 2:37 PM, the Registered Dietitian stated staff should have gotten the resident a new tray if a hair brush was dropped into the food and the food should be discarded. Finding #3: During an observation on 10/18/19 at 12:05 PM, CNA #2 was seated next to Resident # 29, cupping his hands under her mouth while the resident was eating a sandwich. CNA #2 caught the sandwich using his bare hands when Resident #29 dropped the food, placed the sandwich on her plate, and did not discard it. During an interview on 10/18/19 at 2:37 PM, the Registered Dietitian stated the CNA should have discarded the sandwich after he touched it with his bare hands. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.95, 14-1.110, 14-1.170

Based on record review, and interviews during a recertification survey the facility did not ensure that residents who use [MEDICAL CONDITION] drugs receive gradual dose reductions (GDR's), and behavioral interventions, in an effort to discontinue these drugs and did not ensure as needed (PRN) orders for [MEDICAL CONDITION] drugs were limited to 14 days unless the attending physician or prescribing practitioner believed it was appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order for 3 (Resident #'s 14, 46, and #48) of 5 residents reviewed for [MEDICAL CONDITION] medications. Specifically, for Resident #14, the facility did not ensure the attending physician or prescribing practitioner was presented with the need to attempt a GDR in the absence of identified and documented clinical contraindications for a resident on [MEDICATION NAME] (a [MEDICAL CONDITION] medication); for Resident #46, the facility did not ensure that the resident's behaviors were monitored and documented to justify an increase in [MEDICATION NAME] (an antidepressant medication); for Resident #48, the facility did not ensure a PRN antianxiety medication ([MEDICATION NAME]) was not ordered for more than 14 days without a documented rationale by the attending physician. This is evidenced by: The Policy and Procedure (P & P) titled [MEDICAL CONDITION] Medications/Gradual Dose Reduction dated 09/2018, documented the provider was to attempt a GDR based on the current Department of Health guidelines, and the consulting pharmacist was to make recommendations for a possible gradual dose reduction. The policy documented nursing would monitor for the presence of target behaviors on a daily basis charting by exception (i.e., charting only when they behaviors were present), and the facility would make every effort to comply with state and federal regulations related to the use of psychopharmacological medications in the long-term care facility to include regular review for continued need, appropriate dosage, side effects, risks and/or benefits. Resident #14: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - an assessment tool, documented the resident had moderately impaired cognition, and could usually understand others, and could make self understood. The Comprehensive Care Plan (CCP) for [MEDICAL CONDITION] Drug Use last updated 8/26/19, documented the resident was taking [MEDICATION NAME] for a [DIAGNOSES REDACTED]. The physician orders [REDACTED]. A Psychiatry note dated 9/18/19, did not include documentation of a clinical contraindication for a dose reduction of [MEDICATION NAME]. During an interview on 10/22/19 at 8:30 AM, the Director of Nursing stated the resident's medical record should include documentation of the reason a [MEDICATION NAME] dose reduction was contraindicated, and it did not. Resident #46: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - an assessment tool) dated 9/2/19, documented the resident had severely impaired cognition, could sometimes understand others and could sometimes make self understood. The Comprehensive Care Plan for [MEDICAL CONDITION] Drug Use: Anxiety State, last revised 5/17/19, documented the resident received [MEDICATION NAME] at HS (hours of sleep) related to agitation and restlessness. A Physician order [REDACTED]. A Physician order [REDACTED]. A Nursing Progress Note dated 2/21/19 at 5:33 PM, documented [MEDICATION NAME] at HS was now PRN x 14 days for restlessness/[MEDICAL CONDITION] at HS and was to be monitored and documented when used to review in 14 days. A review of the (MONTH) 2019 and (MONTH) 2019 Medication Administration Records did not include documentation that the resident received the PRN [MEDICATION NAME] over the 14 days it was ordered (2/21/19-3/6/19). A review of the medical record dated 2/21/19-3/5/19, did not include documentation that the resident was having poor sleep or [MEDICAL CONDITION]. The resident was not on behavior tracking prior to the increase in [MEDICATION NAME] on 3/6/19. A Nursing Progress Note dated 3/6/19 at 2:33 PM, documented the resident's poor sleep was addressed with the psychiatric nurse practitioner. A Psychiatry note dated 3/6/19, documented staff reported the resident was having [MEDICAL CONDITION] and made the recommendation to increase [MEDICATION NAME] to 75 mg at HS (hours of sleep) for [MEDICAL CONDITION]. During an interview on 10/21/19 at 2:20 PM, the Director of Social Work stated behavioral tracking sheets were implemented in (MONTH) 2019, and prior to the behavioral tracking sheets the staff was leaning strictly on progress notes for documentation and were not capturing the behaviors with just the progress notes. She stated the resident's behaviors should have absolutely been noted somewhere prior to the change in medication in March. She stated the staff needed to be tracking resident behaviors and there should be documentation in the medical record. During an interview on 10/22/19 on 9:57 AM, the Director of Nursing stated she would have expected there to be documentation through behavior tracking or a written medical justification prior to an increase in the medication. She stated there should be clinical documentation to justify the order for [MEDICATION NAME] at 75 mg especially since the PRN [MEDICATION NAME] had not been give according to the MAR. She stated one of the things she identified when she came to the facility a year ago was a lack of education regarding [MEDICAL CONDITION] medications and behavior monitoring. Resident #48: The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - an assessment tool) dated 8/30/19, documented the resident had severely impaired cognition, could usually understand others, and could usually make self understood. The Comprehensive Care Plan for [MEDICAL CONDITION] Drug Use: Anxiety State, last revised 5/10/19, documented the resident received [MEDICATION NAME] related to anxiety. A physician order [REDACTED]. Pharmacist Consultant note to the attending physician dated 8/21/19, documented the Medical Doctor (MD) would be required to document in the medical record the ongoing necessity for PRN use vs. routine administration of [MEDICATION NAME]. The MD signed the Pharmacist's note on 10/5/19 and documented the resident was on 14-day [MEDICATION NAME] and to monitor and renew if needed. A psychiatry consult dated 10/9/19, documented due to risk for falls and lack of benefit to consider taper and discontinue [MEDICATION NAME]. The medical record did not include documentation of a medical justification by the attending physician or prescribing practitioner for continuing the PRN [MEDICATION NAME] order for [REDACTED].>During an interview on 10/21/19 at 2:03 PM, the Director of Social Work stated the facility physicians looked to psychiatry for a lot of [MEDICAL CONDITION] medication recommendations and a PRN was usually ordered in case the resident needed it. She stated there should be a 14-day check when a PRN was ordered and documentation to justify the continued use of a PRN. She stated the physicians were typically very good at keeping track of the PRN [MEDICAL CONDITION] medications and would document the need for the PRN in the medical record. During an interview on 10/22/19 at 9:57 AM, the Director of Nursing stated the facility had a Psych utilization meeting every week and was unsure why the resident's PRN antianxiety order slipped through the cracks. She stated there needed to be a clinical justification documented for the continued use of a PRN [MEDICAL CONDITION] medication. She stated the physician's documentation was usually in the medical record. 10NYCRR 415.12(1)(2)(ii)

Based on observation, interview, and record review during the recertification survey, the facility did not ensure each resident received treatment and care in accordance with standards of practice for 1 (Resident #81) of 4 residents reviewed for positioning. Specifically, the facility did not ensure a resident received the needed care or services for positioning resulting in one or more residents' failure to attain their highest practicable physical well-being, and did not ensure the resident's response to a positioning intervention was monitored and evaluated in a timely manner. This is evidenced by: Resident #81: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - an assessment tool) dated 9/25/19, documented the resident had severely impaired cognitive skills for daily decision making, could sometimes understand others and could sometimes make self understood. A Policy and Procedure (P&P) titled Positioning of the Resident dated (MONTH) (YEAR), did not include documentation related to proper positioning or repositioning in a (MONTH) chair (reclining medical chair). During an observation on 10/16/19 at 11:52 AM, the resident was in the Haven dining room seated in the (MONTH) chair leaning to the side with a meal tray in front of her on the table. During an observation on 10/16/19 at 12:10 PM, the resident was repositioned by Certified Nursing Assistant (CNA) #1 prior to assisting the resident with her meal. At 12:15 PM, the resident was leaning to the side, and the CNA repositioned again and continued to assist the resident with her meal. During an observation on 10/18/19 at 9:47 AM, Licensed Practical Nurse (LPN) #1 was in front of the (MONTH) chair and transported the resident backwards down 2 hallways while leaning to the side. During an obervation on 10/18/19 at 12:05 PM, the resident was in the dining room seated in the (MONTH) chair leaning to the right. A Comprehensive Care Plan (CCP) for Positioning last updated 7/9/19, documented the resident had impaired physical mobility and was forward leaning in the wheelchair. The CCP documented staff were to consult Physical or Occupational therapy as needed and monitor for safety while in the wheelchair, with the goal of maintaing optimal position for comfort, meals and activities while in the wheelchair. A CCP note dated 7/9/19, documented food pedals are used to prevent sliding in wheelchair and proper hip/leg alignment. An Occupational therapy evaluation and plan of treatment documented the resident was to receive therapy 9/24/19 - 10/23/19, with a short term goal of sitting upright in the chair for 2 hours without leaning forward or complaints of discomfort (target 10/7/19) and a long term goal of sitting upright in the chair for greater than 8 hours without leaning forward or compalints of discomfort (target date 10/23/19). A therapy recommendation noted 10/8/19, documented the patient was to sit in the (MONTH) chair daily to facilitate proper body alignment and posture. A therapy treatment encounter note dated 10/18/19, documented the resident demonstrated good sitting tolerance up to 4 hours in (MONTH) chair with no leaning to left or right or anteriorly. During an interview on 10/18/19 at 12:39 PM, CNA #1 stated the resident was in a regular wheelchair before and she would lean forward. She stated the resident was recently changed to a (MONTH) chair, and if she noticed a change in the resident's positioning, she would tell the charge nurse. During an interview on 10/21/19 at 11:30 AM, Occupation Therapy Assistant #9 stated she had been working with the resident on positioning, and was not aware the resident was leaning to the side until this morning. and she was not aware the resident needed to be repositioned at the lunch meal time for feeding. She stated the resident is woken up early, and is currently assessed to be able to maintain her position for approximately 4 hours. She stated the resident may have been up for that period or longer than 4 hours by the time she went to lunch. During an interview on 10/22/19 at 10:22 AM, the Director of Therapy stated the resident was changed from a wheelchair to a (MONTH) chair due to risk of falls, and that if she is leaning to the right or left, nursing staff should reposition her and/or assess her needs upon the observation. He stated if she is unable to maintain the re-positioning, therapy should be notified for evaluation, and/or nursing staff should assess her needs. During an interview on 10/22/19 at 8:30 AM, the Director of Nursing stated she would expect a re-evaluation of the resident's positioning would have occurred when staff noticed the resident was leaning in the (MONTH) chair, and the care plan should have been updated. She stated there was not a system in place at the current time for rehabilitation to provide caregiver training or to follow up on recommendations. 10NYCRR415.2

Based on observations, record review, and interviews during a recertification survey, the facility did not ensure that each resident received, and the facility provided food that accommodated resident allergies [REDACTED].#63) of one resident reviewed for dietary preferences. Specifically, for Resident #63, the facility did not ensure the resident was provided with his preference of Activia yogurt when available. This is evidenced by: Resident #63: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - an assessment tool) dated 9/9/19, documented the resident had severely impaired cognition, could understand others and could make self understood. The Policy and Procedure titled Flexible Dining Program Policy dated 12/1/2017, documented tray cards are used to communicate care plan interventions to the resident and staff for use in making mealtime selections. Resident's choices are honored. If the resident does not make a choice, the tray card and diet spreadsheet are used to serve the meal. The Comprehensive Care Plan for Nutritional Status, last revised 2/1/18, documented to evaluate the resident's needs, eating habits, and food preferences as needed. During an observation on 10/16/19 at 12:33 PM, the resident's wife was sitting with him at lunch in the main dining room. The wife got up from the resident's lunch table and went back to the kitchen doors. When she came walking back through the dining room, holding an Activia yogurt, she showed it to the Registered Dietician (RD) who was also in the dining room. The RD stated to the resident's wife to read the resident's meal ticket because the yogurt was on his meal ticket. During an observation on 10/17/19 at 12:23 PM, Resident #63 was served lunch and was not provided with an Activia yogurt. At 10/17/19 at 12:51 PM, the resident was removed from the dining room by staff. He had not received an Activia yogurt. At 1:00 PM, the surveyor went into the kitchen and observed Activia yogurt in the refrigerator. During an observation on 10/18/19 at 12:07 PM to 12:30 PM, the resident was served lunch and was not provided with an Activia yogurt. He was provided with a raspberry yogurt of a different brand. The RD opened the yogurt for the resident. At 12:30 PM, the surveyor went into the kitchen and observed Activia yogurt in the refrigerator. A Nutrition Risk assessment dated [DATE], documented the resident's wife requested the resident have [MEDICATION NAME] yogurt at meals, yogurt added to meal tracker with preference for Activia brand if available. A dietary progress note dated 3/18/19 at 12:30 PM, documented the RD spoke with the resident's wife and added yogurt (specifically Activia if available) to resident meals. On 10/17/19 at 11:50 AM, the Resident Diet and Preference List provided to the survey team documented Resident #63 was to receive an Activia Yogurt when available. A review of the resident's meal tickets for breakfast, lunch and dinner dated 10/16/19, 10/17/19, and 10/18/19, documented Activia Yogurt if available. During an interview on 10/22/19 at 9:12 AM, the RD stated the facility had different types of yogurt and the wife, who was the resident's health care proxy, preferred the resident receive Activia yogurt for the [MEDICATION NAME]. She stated the Activia yogurt preference was listed on the resident's meal ticket for all meals and if the facility had the yogurt, he should be getting it with his meal. She stated if the Activia yogurt was in the fridge it meant the yogurt was available for him and should be going on the tray. She stated she did recall the resident's wife going to the kitchen on 10/16 to get the Activia yogurt because it was not on the resident's tray. She stated she was responsible for putting the resident preferences on the meal ticket, but not ensuring the resident received the preference. During an interview on 10/22/19 on 9:14 AM, the Food Service Director stated dietary staff in the kitchen should be providing the Activia yogurt on the resident's tray when the yogurt was available. She stated 3 dietary staff looked at the tray and meal ticket before it was passed to ensure the resident received the correct meal. She stated dietary staff was responsible for ensuring the Activia yogurt was on the resident's tray. She stated if the Activia yogurt was in the fridge, then it was available for the resident to have and it should have been provided. 10NYCRR 415.14(d)(4)

Based on observations, record reviews, and interviews during the recertification survey, the facility did not ensure residents were treated with dignity and respect and cared for in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life in the Haven dining room for 4 (Resident #'s 24, 29, 30, and 46) of 5 residents reviewed for dignity, and did not ensure residents were transported in a dignified manner for 1 (Resident #81) of 5 residents reviewed for dignity. Specifically, the facility did not ensure residents' were provided dignity during dining, when staff were observed standing and feeding multiple residents at the same time, that food under a residents mouth was not caught by bare hands rather than using a clothes protector, that a resident was not transported in a wheelchair in a rear-facing position down 2 hallways, and did not attend to a resident who was yelling out and crying in a timely manner. This is evidenced by: Finding #1: The facility did not ensure residents' were provided dignity during dining, when staff were observed standing and feeding multiple residents at the same time, Resident #'s 24, 30, and 46: During observations in the Haven Dining Room on 10/18/19: - 12:10 PM, Registered Nurse (RN) #2 was standing and feeding Resident #30. - 12:11 PM, RN #2 was standing and feeding Resident #46. - 12:12 PM, RN #2 was standing and feeding Resident #24. - 12:17 PM, RN #2 continued to stand and feed Resident's #'s 24, 30, and 46 at the same time. During an interview on 10/18/19 at 2:37 PM, the Registered Dietitian stated staff who assist residents in the dining room should be seated when feeding residents. During an interview on 10/18/19 at 2:50 PM, RN #2 stated she had been in-serviced on dining with dignity, including to feed residents at eye level. She stated based on where the residents were sitting, she felt she had to walk between them in order to feed them before their food got cold. Finding #2: The facility did not ensure that a resident was not transported in a wheelchair down 2 hallways in a rear-facing position. During an observation on 10/18/19 at 9:47 AM, the resident was transported down the hallway rear-facing by LPN # 1. During an interview on 10/21/19 at 11:10 AM, the ADON stated she would not expect a resident to be transported down the hallway rear-facing behind an LPN. During an interview on 10/22/19 at 8:30 AM, the DON stated the resident should not have been brought down the hallway rear-facing behind the Licensed Practical Nurse (LPN). She stated this was a dignity concern. Finding #3: The facility did not ensure that food under a residents mouth was not caught by bare hands rather than using a clothes protector. Resident #29: During an observation on 10/18/19 at 12:05 PM, Certified Nursing Assistant #2 was seated next to Resident #29, cupping his hands under her mouth while the resident was eating a sandwich. CNA #2 caught the sandwich in his bare hands when Resident #29 dropped the food, placed the sandwich on her plate The sandwich was not discarded. During an interview on 10/18/19 at 2:37 PM, the Registered Dietitian stated staff should not be placing their hands underneath the resident's mouth to catch food. She stated the resident should be offered a clothing protector. Finding #4: The facility did not ensure a resident who was yelling out and crying out was attended to in a timely manner; Resident #81: During an observation on 10/16/19 at 11:50 AM, the resident was in the dining room, yelling out and crying, and staff that were present in the dining room did not address the resident's behaviors. During an observation on 10/16/19 at 12:00 PM, a staff member entered the Haven dining room, approached the resident and asked what is the matter. During an interview on 10/21/19 at 11:10 AM, the Assistant Director of Nursing (ADON) stated she would expect staff in the dining room to intervene as soon possible when resident's behaviors occur. During an interview on 10/22/19 at 8:30 AM, the Director of Nursing stated the actions of the staff were likely related to habit and lack of dementia care related education, and the facility is currently addressing issues as they come up and working on a dementia care program for the future. 10NYCRR415.3(c)(1)(i)

Based on record review and interview, during an abbreviated survey (Case# NY 891), the facility did not maintain all mechanical equipment in safe operating condition. Specifically, the 4-point wheelchair securement system was not maintained according to the manufacturer's recommendations. This was evidenced by: The Policy and Procedure (P&P) titled Maintenance Department Policies & Procedures dated 8/20/18, documented the maintenance department was responsible for inspecting all equipment as required, and performing required maintenance as necessary. Written records of reports and maintenance repairs were to be maintained. The maintenance department was responsible for providing monthly preventative maintenance checks of equipment on a monthly basis. Services not performed by maintenance personnel were to be performed by authorized outside contractors. The maintenance department was responsible for scheduling preventative maintenance of equipment. Vehicle inspections were to be done annually. The undated P&P titled Transportation Policy - Internal documented the transportation vehicle would be maintained in good condition. An annual inspection of the safety devices and lifts was to be conducted. The 4-Point Wheelchair Securement Systems User Instructions revised 10/2010, documented instructions for maintenance and care of the securement system. All systems and components were to be regularly inspected, cleaned, and maintained. The Retail Certificate of Sale dated 10/9/12, documented the facility purchased the van with Vehicle Identification Number (VIN) 1FDEE3FLXCDB . The facility van Dual Post Lift Operational Maintenance checklist dated 5/2/19, included a section for inspection of the manual tie-down (4-point wheelchair securement system). Comments written on the report, documented that one of the four wheelchair retractors (components in the wheelchair securement system that take up the slack in the tie-downs to ensure the passenger in a wheelchair is secured) checked was found to be bad. There was no documented evidence the 4-point wheelchair securement system in facility van VIN #1FDEE3FLXCDB was maintained or inspected prior to 5/2/19. During an interview on 5/15/19 at 8:23 AM, Director of Maintenance (MNT #1) was asked about regular maintenance and inspection of the 4-point wheelchair securement system per manufacturer instructions in facility van VIN #1FDEE3FLXCDB . He stated, We never had them done. The bus wasn't that old. MNT #1 said the facility only has the NYS motor vehicle safety inspection done. During an interview on 5/15/19 at 11:55 AM, Administrator stated, he was aware that there were no inspections of the 4-point wheelchair securement system in facility van in facility van VIN #1FDEE3FLXCDB prior to 5/2/19. 10NYCRR 415.29(b)

Based on observation, interview and record review during a recertification survey the facility did not establish and maintain an infection prevention and control program (IPCP) designed to help prevent the development and transmission of communicable diseases and infection. Specifically, the facility did not develop a Water Management Plan (WMP) in accordance with adopted regulations, and did not ensure that proper hand hygiene occurred while cleaning an isolation room. This is evidenced as follows. Finding #1: When requested on 07/19/2018, a WMP that included a description of the potable water system with a flow chart and written description, and a description of Legionella growth control measures was not available for survey review. The Assistant Administrator stated in an interview conducted on 07/19/2018 at 1:30 PM, that a comprehensive WMP that includes the required elements to control Legionella growth has not been developed. Finding #2: During observation on 07/18/18 at 11:21 AM, a housekeeper was noted in a contact isolation room changing the garbage without gloves. The full garbage bag was removed from the trash can and brought out to the garbage on the housekeeping (HK) cart. The HK then dust mopped the floor, brought the dust mop back out and placed it on the HK cart, took a broom and dustpan from the cart, cleaned up a pile of dirt, and brought the items back out to HK cart. At no time during this process did the HK wash his hands or wear gloves. The HK left the area then returned a couple minutes later, put a liner in the resident's trash can and left the room again without gloves or hand hygiene. 07/18/18 11:36 AM, the HK stated that the resident in that room was on isolation, but there was no special protocol that he should be using while cleaning the room. During an interview on 07/23/18 at 01:36 PM, RNUM #1 stated that the resident in that room was on isolation for Methacillin Resistant Staphylococcus Aureus (MRSA) in a wound. The HK should have worn gloves because they were cleaning things and should have assumed what they were cleaning was contaminated. The HK definitely should have washed hands. During an interview on 07/24/18 at 11:56 AM, the Infection Control Nurse (ICN) stated the HK should wash hands and wear gloves when going in and leaving the isolation room. 10 NYCRR 483.80(a)(1)(2)(4)(e)(f)

Based on observation and staff interview during the recertification survey the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Adequate handwashing facilities are to be provided in food preparation areas; food contact surfaces shall be cleaned after use; and floors are to be kept clean. Specifically, the main kitchen handwashing sink was not accessible and food contact surfaces and floors were not clean. This is evidenced as follows. The main kitchen and unit kitchenettes were inspected on 07/18/2018 at 9:27 AM. The handwashing sink was blocked from access with carts; upon survey observation, the carts were moved away from the sink then returned blocking sink within 5 minutes. The can opener holder, Buffalo chopper, and the main kitchen and unit kitchenette floors were not clean. The Director of Food and Nutrition (corporate manager) and the Food Service Director stated in an interview conducted on 07/18/2018 at 9:27 AM that the handwashing sink would be more convenient for use if located near the cooking line and the areas identified in the kitchen and kitchenettes will be cleaned. 10 NYCRR 415.14(h); State Sanitary Code Subpart 14-1.110, 14-1.143, 14-1.170

Based on record review and interview conducted during the recertification survey, the facility did not provide operative oversight to ensure that an effective system was in place to communicate malfunction of equipment essential to maintain health, safety and the highest practicable well-being of residents. Staff did not report to the Administrator when electrical beds were in disrepair and when electrical receptacles were dislodged from the metal receptacle wall boxes. This is evidenced as follows. Observations on 07/24/2018 at 11:15 AM, revealed that the electrical receptacle wall outlet behind the bed in resident room S-8 was pulled away and hanging from the resident room wall; the bed was located approximately 5-inches from the wall and the bed wheel castors were locked precluding resident access. The metal bed-bumper attached to the bed was loose and damaged. No nursing or housekeeping staff or residents were present during survey observations. The maintenance department work order logs for (MONTH) (YEAR) and (MONTH) (YEAR) were reviewed on 07/25/2018. No work order regarding the loose electrical receptacle outlet and damage to the resident bed were available for survey review. The Director of Building Services stated in an interview conducted on 07/24/2018 at 12:15 PM, that his department too often does not receive necessary repair work orders, and a work order for the outlet and bed repair should have been submitted. Review of the work order policy on 07/25/2018, revealed that work orders are to be submitted when repairs to the facility or facility equipment are needed. 483.70

Based on record review and interview conducted during the recertification survey, the facility did not ensure the development and implementation of comprehensive person-centered care plans (CCPs), that included measurable objectives and timeframe's to meet the resident's medical, nursing, and mental and psychosocial needs for 4 (Resident #'s 20, 66, 71, and #361) of 24 residents reviewed. Specifically, the facility did not ensure that CCPs were developed to address the use of a psychoactive medication to treat Resident #71's [MEDICAL CONDITION], the care of Resident #66's leg brace, Resident #361's constipation and Resident #20's contractures/ROM needs. Additionally, the facility did not ensure that the CCP that addressed Resident #71's [MEDICAL CONDITION] included relevant interventions. This was evidenced by: Resident #71: The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], documented the resident was understood, could understand, and had moderately impaired cognition. A physician's orders [REDACTED]. Finding #1: The facility did not ensure that a CCP was developed to address the use of [MEDICATION NAME]. During an interview on 07/25/18 at 09:52 AM Registered Nurse (RN) #3, covering for the Nurse Manager, reported the resident had been on [MEDICATION NAME] for two months and there should be a psychoactive medication care plan to address it. RN #3 did not know why the Nurse Manager she was covering for had not put one in place, but she would make sure it was done today. Finding #2: The CCP dated 6/4/18, titled: Sleep Disturbances - [MEDICAL CONDITION], documented one intervention, discuss with patient the rationale for assistive device at sleep. During an interview on 07/25/18 at 09:52 AM, RN #3 reported the care plan for [MEDICAL CONDITION] does not have any appropriate interventions. The resident does not use any sleep devices, not sure why that is there. There should be things staff can do to help the resident sleep. Resident #66: The resident was admitted to the nursing home on 5/10/18 with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having moderately impaired cognitive skills for daily decision making. It documented that the resident understood and was understood by others. A Physician order [REDACTED]. A CCP for Musculoskeletal Disorder: Fracture with the use of a splint/brace, dated 5/11/18, documented to monitor skin for red or open areas. A revision was added on 5/30/18 that the resident was seen by the orthopedic MD and a different brace was suggested before the resident could be weight bearing. The CCP was not personalized for the resident's needs, did not include timeframes for the skin checks, and that the brace could be removed for bathing. An Orthopedic Vendor Patient Note dated 6/13/18, documented that the resident was seen for a fitting and delivery of a left femoral fracture orthosis (a brace that was length of the entire leg with a hinge at the hip and continued up and around the resident's waist). PT staff would oversee the orthotic use with the CNAs applying and removing the brace. During an interview on 07/23/18 at 01:19 PM, Registered Nurse Unit Manager (RNUM) #1 stated that she was responsible for care planning and the resident should have had a person-centered care plan in place. She was not aware that the CCP did not address the brace coming off for care or that the brace could be removed to check the skin. During an interview on 07/25/18 08:35 AM, the Director of Nursing stated that instructions should have been made clearer so staff would know what to do and all staff should have been trained on putting on and removing the brace. Resident #361: The resident was admitted to the nursing home on 7/6/18, with [DIAGNOSES REDACTED].>acute [MEDICAL CONDITION], and unilateral primary osteo arthritis left knee. The resident was assessed as being alert, oriented and that he could understand. During an interview on 07/19/18 at 01:01 PM, the resident stated that he had needed bowel medication and had to continually ask for it. Physician (MD) Orders dated 7/7/18, documented [MEDICATION NAME] (a narcotic pain medication that causes constipation) 5 milligrams (mg)-325 milligrams one tablet every four hours for pain and [MEDICATION NAME] 5-325 mg one tablet every 4 hours as needed for pain; may give two hours after scheduled dose. The resident's medical record did not include a Comprehensive Care Plan for Constipation. During an interview on 07/24/18 at 09:09 AM, Registered Nurse Unit Manager (RNUM) #1 stated that she was responsible for care planning and that the resident should have had a care plan in place for constipation especially since he was on narcotic pain medication. 10NYCRR415.4(b)(1)(i)

Based on observations, record review, and interviews during a recertification survey the facility did not ensure that all care was provided based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #66) of one resident reviewed for orthotic devices. Specifically, the facility did not ensure that Resident #66's leg brace was removed and skin checked for breakdown. This is evidenced by: Resident #66: The resident was admitted to the nursing home on 5/10/18, with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having moderately impaired cognitive skills for daily decision making. It documented that the resident understood and was understood by others. A Physician order [REDACTED]. A CCP for Musculoskeletal Disorder: Fracture with the use of a splint/brace, dated 5/11/18, documented to monitor skin for red or open areas. A revision was added on 5/30/18, that the resident was seen by the orthopedic MD and a different brace was suggested before she could be weight bearing. The CCP was not personalized for the resident's needs and did not include timeframes for the skin checks or that the brace could be removed for bathing. Treatment Administration Records (TAR) from 5/10/18-7/ 22/18, documented to check brace for proper placement and for skin breakdown; may remove for for bathing, and knee brace (splint) at all times, remove splint daily for care and skin assessment. There were initials in the boxes for 7:00 AM - 3:00 PM, 3:00 PM - 11:00 PM, and 11:00 PM - 7:00 AM, since 5/10/18, indicating that the brace was removed and that skin checks were done. An Orthopedic Vendor Patient Note dated 6/13/18, documented that the resident was seen for a fitting and delivery of a left femoral fracture orthosis (a brace that was length of the entire leg with a hinge at the hip and continued up and around the resident's waist) and that nursing and Physical Therapy (PT) were present for education of proper use and wear. PT staff will oversee the orthotic use with the CNAs applying and removing the brace. During an interview on 07/19/18 at 12:07 PM, the resident stated that she wore the brace all the time and staff did not remove it. During an interview on 07/23/18 at 01:19 PM, Registered Nurse Unit Manager (RNUM) #1 stated that she was responsible for care planning and the resident's care plan should have addressed her particular needs regarding skin checks, brace removal to check the skin . She thought that staff were looking under the brace every shift to check the skin because they were signing that they were. She did not believe the CNAs were trained to remove and replace the brace and would not expect them to do it without training, but could get Physical Therapy to do it. During an interview on 07/23/18 at 11:12 AM, Licensed Practical Nurse (LPN) #2 stated she had never done anything with the resident's brace. The resident got a bath on the night shift and they checked her skin. During an interview on 07/23/18 11:15 AM, CNA #2 stated that when care is provided she undoes the strap around the waist to push her shirt down. The brace stays on at all times. During an interview on 07/23/18 11:20 AM, LPN #1 stated that she would check to see that the brace was on properly, but she did not check the skin under the brace, because the resident got up on night shift and a complete skin check was done then. During an interview on 07/23/18 11:24 AM, LPN #4 stated that she checked the brace placement, but not the skin. The CNA s checked the skin when they removed the brace for bathing, and if they notice an issue they would alert the nurse. During an interview on 07/23/18 at 01:51 PM, the resident's Physical Therapist (PT) stated she did not inservice nurses or CNAs on how to put on and remove the brace. When the prosthetic person came in to deliver the brace, there was a CNA there when the orthotist showed them how to put on and remove the brace. During an interview on 07/24/18 at 12:20 PM, Certified Nursing Assistant (CNA) #5, stated that she gave the resident a bed bath every day but had never removed the brace. It was not supposed to come off; she would loosen the waist and tuck her clothes under the brace so they do not rub on her skin. CNA #5 stated she was never trained to remove the brace. During an interview on 07/25/18 08:35 AM, the Director of Nursing stated that instructions should have been made clearer so staff would know what to do and all staff should have been trained on putting on and removing the brace.

Based on observation, record review and interview the facility did not ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion (ROM) and/or to prevent further decrease in ROM for one (Resident #20) of three residents reviewed for ROM during the recertification survey. Specifically: the facility did not ensure that ROM was performed as planned; that the performance of ROM was monitored; and that the resident's refusal of ROM was communicated between nursing and therapy. Additionally, the facility did not ensure a Comprehensive Care Plan CCP) specific to contractures/ROM needs was developed. This is evidenced by: Resident #20: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) of 4/30/18, assessed the resident was understood and understands, and had moderately impaired cognitive ability. It documented the resident did not walk, had limitation in ROM of lower extremity on one side, with mobility devices of wheel chair. The admission MDS of 7/4/16, documented no walking, limitation in ROM one side lower extremity. A Contracture assessment dated [DATE], documented a contracture of the right and left legs. Therapy recommendations documented: refuses bilateral knee splints, staff to perform PROM (Passive Range of Motion) to bilateral (both) lower extremities two times a day. On 7/19/18 at 2:25 PM, the resident was observed in bed. His legs were contracted, right worse than left. The Comprehensive Care Plan (CCP) of 6/30/17 for Alteration in comfort related to [DIAGNOSES REDACTED]. Interventions included: Staff to do PROM bilateral lower extremities twice a day. The resident refuses knee splints. The intervention was dated 5/2/18. There was no CCP specific for Contracture/ROM . The computerized Care Card (used by care givers to provide needed care) was undated. It documented: PROM to bilateral lower extremities with AM and PM care. During interview on 7/23/18 at 11:00 AM, Physical Therapist #9 said the resident has contractures of the legs and was not on therapy at this time. He is at baseline for last year, so therapy is not warranted. Directions to nursing after he finished therapy were to do passive ROM with AM and PM care to both lower extremities. This recommendation was ongoing, we have not changed it. Nursing does the CCP for contractures/ROM During interview on 7/23/18 at 12:11 PM, CNA #10 said today the resident would not let her touch him, yesterday he did. He refuses to get out of bed past couple of months. He does not have splints for legs, just put pillows between legs, right is very contracted, the left is bent inward a little. He came from north wing so don't know if the resident was able to walk when he came in. Do not do any ROM to legs, if touch him he screams. He is very strong minded, in 5 days he may let me care for him 3 days. During interview on 7/23/18 at 3:27 PM, CNA #13 said the resident usually lets her care for him; wash him up, put pillows between his legs, however, sometimes he does not want them. She does not do ROM to his legs, he yells if you touch his legs the wrong way, it hurts him. She said she had been here since (MONTH) and the resident had not gotten out of bed that she knew of. The nurses know the resident does not allow ROM. She had not reported it, but was told he would not allow ROM when she first started. During interview on 7/23/18 at 3:33 PM, Licensed Practical Nurse Manager (LPNM) #7 stated the resident did not have a CCP specific to contractures/ROM, she thought it would be in a pain or activities of daily living CCP. She looked at the Care Card and and said it was there to do ROM. She would expect there to be a CCP to address contractures/ROM. She said she had been there only since December. She stated the resident refuses alot, they could give pain medication before trying ROM, but it was not in a CCP. The CNAs should let the nurse know they were not doing ROM. She was not notified. She said the CNAs were not documenting they were not doing ROM for the resident. When the ROM was put in the CNA kiosk(computerized care card) it was not set up for them to document if doing it/refusing it. LPNM #7 stated the CNAs are still required to let nursing know the resident was refusing ROM. During interview on 7/25/18 at 1:12 PM. the Occupational Therapy Director of Rehabilitation said the resident refuses a lot. He was not aware of a referral from nursing that staff were not able to do ROM due to pain. If he was made aware he would screen the resident. He stated, contractures are irreversible, so try to prevent further decline. He said they do a yearly inservice on how to do ROM for residents. The best thing for the resident is to do the ROM. If staff are not doing it, they need to document it. During interview on 7/25/18 at 1:26 PM, LPN #5 said the CNAs have told her they could not do ROM for the resident. She did not think she told the Nurse Manager, During repeat interview on 7/25/18 at 1:28 PM, LPNM #7 said she thought she was told the aides were not able to do ROM for the resident. She did not know if she notified therapy. If she was made aware the aides were consistently not doing ROM for the resident, she would have talked with him. If she was aware there was a major problem with pain and not allowing ROM she would have told therapy. 10NYCRR415.12(e)(1)

Based on record review and staff interviews the Administration failed to ensure that the facility operated in a manner that enabled it to effectively use its resources to maintain the highest practicable well-being and safety of each resident during a abbreviated partial extended survey (#NY 689) Specifically, for 11(1, 2, 4, 5, 6, 7, 8, 9, 10, 11, and 12) of 25 newly admitted or readmitted residents and 1 (# 12) of 11 residents with new orders the administration failed to have an effective system in place to obtain and administer physician ordered medications timely. This resulted no actual harm with potential for serious harm that is Immediate Jeopardy to the health and safety of all residents. The facility was able to remove the immediacy prior to exit by implementing the following: 1. Revision of the Policy and Procedures regarding medication, transcription of MD orders, medication error reporting, emergency kit, admission review, and medication administration. 2. Review and audit all new orders given by attending physicians for accuracy and timeliness. The facility's pharmacy has increased its twice daily delivery schedule to three times daily on Monday through Friday. 3. All licensed staff were educated on the areas of concern noted in the deficiencies, including admission/readmission procedure, timely medication administration, unavailable medication policy, transcription of MD orders, medication error reporting, emergency kit, medication administration, and licensed practical nurses will be inserviced on their scope of practice regarding physicians' orders. 4. The Administrator and Director of Nurses met with the physicians to review timely responses to calls from the facility, phoning required scripts to the pharmacy when necessary, and timely response when addressing any nursing, resident or disignated representative concern. This was evidenced by: Refer to F 333 scope and severity- K- Medication Errors During an interview on 7/31/13 at 1:20 pm, the Medical Director stated that he visits the facility for a couple of hours every two to three weeks to work on policies and to attend Quality Assurance meetings. The Medical Director stated that he was unaware that there were delays in getting newly admitted or readmitted residents their medications. The Medical Director stated that upon arrival of a new admission or readmission, nursing staff should contact the attending physician, the attending physician should order medications, and if necessary, the physician should call the pharmacy and the pharmacy should deliver the medications to the facility to be administered to the resident. The Medical Director stated that he was not aware that there were delays in physicians responding to nursing staff but on a few occasions, he has been contacted to authorize medications. The Medical Director stated "however, I don't take care of residents or back up for MDs". The Medical Director stated that the facility staff could contact him for assistance in obtaining medication orders, however, "I'm not on call and there is no guarantee they are going to get me." During an interview on 8/1/13 at 1:00 pm the DON stated that the Social Work Department was responsible for admissions, they would receive patient information and it would be reviewed by the DON and ADON for approval. DON was not aware of a problem with admissions and readmissions not receiving their medications on the day of admission. DON did not think about the late delivery from the pharmacy potentially causing medication administration delays. The Nurse Managers are responsible for reviewing the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During an interview on 8/1/13 at 12:45 the Administrator stated he was not aware of a delay in medication administration of new medications. Quality Assurance Committee (QA) was working on Incident reports and all of them were now being reviewed in morning report with the interdisciplinary team. Careplans were also a focus of QA recently, but there were no medication issues being addressed recently. Medication audits had been done in the past but was not sure when. The Nurse Managers should be checking the medication administrations and the physicians should be notified when a medication is unavailable. Administrator stated that the facility has used the present pharmacy for five years. The QA committee would meet monthly with the department heads and Nurse Managers and there were no issues raised in regards to medication administration delays. The quarterly QA meetings would also include the Medical Director and the pharmacy; a board member would attend on an as needed basis. During an interview on 8/2/13 at 8:45 am the ADON stated that last summer it was noted that unavailable medications were occurring due to refill orders of medications. This followed the change in the pharmacy ordering system, to be done in the computers instead of faxed. Memos were sent to staff by the ADON because she wanted to make sure everyone knew the new process. In the summer of 2012 an interdisciplinary meeting took place with a pharmacy representative present to address the issue of unavailable medications and a new tracking system was developed for the refill ordered medications. ADON was not aware of new admission and readmission's not receiving their medications as ordered by physician. 10NYCRR 415.26

Based on medical record review and staff interview during a partial extended abbreviated survey (#NY 689) the facility failed to ensure that the Quality Assurance Committee (QA) identified issues that had the potential to cause serious harm to residents. Specifically, the QA failed to ensure residents received significant necessary medications on the day new orders were received and when residents are admitted /readmitted . This resulted is no actual harm with potential for serious harm that is Immediate Jeopardy to the health and safety of all newly admitted and readmitted residents. The facility was able to remove the immediacy prior to exit by implementing the following: 1. Revision of the Policy and Procedures regarding medication, transcription of MD orders, medication error reporting, emergency kit, admission review, and medication administration. 2. Review and audit all new orders given by attending physicians for accuracy and timeliness. The facility's pharmacy has increased its twice daily delivery schedule to three times daily on Monday through Friday. 3. All licensed staff were educated on the areas of concern noted in the deficiencies, including admission/readmission procedure, timely medication administration, unavailable medication policy, transcription of MD orders, medication error reporting, emergency kit, medication administration, and licensed practical nurses will be inserviced on their scope of practice regarding physicians' orders. 4. The Administrator and Director of Nurses met with the physicians to review timely responses to calls from the facility, phoning required scripts to the pharmacy when necessary, and timely response when addressing any nursing, resident or designated representative concern. Refer to F- 333, scope and severity- K- Medication Errors During an interview on 8/1/13 at 12:45 pm the Administrator stated he was not aware of a delay in medication administration of new medications. The QA Committee was working on incident reports and all of them were now being reviewed in morning report with the interdisciplinary team. Careplans were also a focus of QA recently, but there was no medication issues being addressed. The Administrator stated medication audits had been done in the past but was not sure when. The Nurse Managers should be checking the medication administrations and the physicians should be notified when a medication is unavailable. Administrator stated that the facility has used the present pharmacy for five years. The QA committee would meet monthly with the department heads and Nurse Managers and there were no issues raised in regards to medication administration delays. The quarterly QA meetings would also include the Medical Director and the pharmacy; a board member would attend on an as needed basis. During an interview on 8/1/13 at 1:00 pm the Director of Nursing (DON) stated that the Social Work Department was responsible for admissions. They would receive patient information and it would be reviewed by the DON and Assistant Director of Nursing (ADON) for approval. DON was not aware of a problem with residents not receiving medication upon admission/readmissions. The DON did not think about the late delivery from the pharmacy potentially causing medication administration delays. The Nurse Managers are responsible for reviewing the medication administration records (MARS) for blanks, they did not notice an issue with admissions and readmissions not receiving their medications on the day of admission. During an interview on 8/2/13 at 8:45 am the ADON stated that last summer it was noted that unavailable medications were occurring due to refill orders of medications. This followed the change in the pharmacy ordering system, to be done in the computers instead of faxed. Memos were sent to staff by the ADON because she wanted to make sure everyone knew the new process. In the summer of 2012 an interdisciplinary meeting took place with a pharmacy representative present to address the issue of unavailable medications and a new tracking system was developed for the refill ordered medications. ADON was not aware of residents not receiving medications on admission and readmissions as ordered by the physician. 10NYCRR 415.27(a-c)

Based on medical record review and staff interview the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs) to meet the needs of each resident for 11(1, 2, 4, 5, 6, 7, 8, 9, 10, 11 and 12) of 25 newly admitted or readmitted residents and for 1 (# 12) of 11 residents with a new physician s order. Specifically, the facility failed to have an effective system in place to obtain and administer newly ordered medications timely. This resulted is no actual harm with potential for serious harm that is Immediate Jeopardy to the health and safety of all newly admitted /readmitted residents. The facility was able to remove the immediacy prior to exit by implementing the following: 1. Revision of the Policy and Procedures regarding medication, transcription of MD orders, medication error reporting, emergency kit, admission review, and medication administration. 2. Review and audit all new orders given by attending physicians for accuracy and timeliness. The facility's pharmacy has increased its twice daily delivery schedule to three times daily on Monday through Friday. 3. All licensed staff were educated on the areas of concern noted in the deficiencies, including admission/readmission procedure, timely medication administration, unavailable medication policy, transcription of MD orders, medication error reporting, emergency kit, medication administration, and licensed practical nurses will be inserviced on their scope of practice regarding physicians' orders. 4. The Administrator and Director of Nurses met with the physicians to review timely responses to calls from the facility, phoning required scripts to the pharmacy when necessary, and timely response when addressing any nursing, resident or designated representative concern. P&P entitled Unavailable Medication Policy and dated 11/1/2005 documented purpose as to set forth a procedure to ensure the availability of medications necessary for resident health. Objective included to ensure residents are given medication necessary for their well being. Procedure included a note, if a medication is not available for the resident in the medication cart, the following steps must be taken; pharmacy is to be informed of the missing medication, if medication cannot be made available in a timely manner by the pharmacy the physician is to be notified for any new orders. The use of "unavailable" is not acceptable for nursing to write in the MAR ( medication administration record), the physician needs to be advised of this protocol. The physician also needs to give a telephone order stating the medication is on hold until available from the pharmacy or use an available alternative medication. P&P entitled Responsibilities of Staff/Consulting/Attending Physicians and dated 3/10/2005 documented the purpose was; to provide optimum medical care to all Residents of Pine Haven. The responsibility was of the Medical Director and Administrator. Procedure documented the personal physician agrees to be called in any emergency, to be notified of any significant changes in the patient's clinical conditions, and the operator agrees to provide emergency medical care from his own medical staff pending visit and orders of the personal physician. The physician in charge must give medical orders for the resident's immediate care after admission. If the physician does not adhere to these provisions, privileges will be withdrawn and the Medical Director will care for the patient/resident. Pharmacy Services Agreement dated 9/1/2008 documented under the title of supply, pharmacy will furnish and replenish, on a regular basis, an emergency and interim medication supply, the composition of which will comply with federal and state regulations, and be mutually agreed upon in writing by pharmacy and facility. Documented under the title delivery, pharmacy agrees to provide delivery services to facility Monday through Sunday during pharmacy regular business hours and on an emergency basis, except for circumstances and conditions beyond its control, which will include, but not limited to situations where pharmacy manufacturer/supplier is unable to provide the required item and pharmacy is unable to provide an acceptable alternative. In the event pharmacy cannot furnish an ordered medication on a prompt and timely basis, pharmacy will make arrangements with another pharmacy supplier in a community local to the facility to provide such services to the facility. The facility Administrator, DON and ADON were unaware that a pharmacy issued policy and procedure manual existed, and was unable to produce such a manual. Resident #1: The resident was admitted to the facility on [DATE] from the hospital in house Hospice unit with [DIAGNOSES REDACTED]. The Minimum data Set ((MDS) dated [DATE], assessed the resident as having a short term memory problem and moderately impaired in skills for daily decision making. The Community Hospice Level of Care Transfer Report dated 4/23/13 and timed 11:00 am, documented the resident's current pain medication regimen included Roxanol 10 mg by mouth every 8 hours and Oxycontin 10 mg by mouth twice daily. Documented under the reason for transport was the patient is stable. The Nursing Progress Note dated 4/23/13 and timed 1:15 pm, documented the resident arrived to the facility at 12:25 pm. The Physician's (MD)Order Form dated 4/23/13 and timed 2:16 pm, documented an order for [REDACTED]. The physician's orders [REDACTED]. The Nursing Progress Note dated 4/24/13 and timed 7:30 am, documented that the resident's daughter called the facility to clarify that her mother did not have an allergy to Oxycontin and that she had taken it in the past. The physician's orders [REDACTED]. The Medication Administration Record (MAR) for April 23, 2013 through May 23, 2013, documented the following: Oxycontin 10 mg by mouth every 12 hours, at 8:00 am and 8:00pm (the 4/24/13 8:00 pm dose signature box had a line through it). The first dose of Oxycontin 10 mg was documented as administered on 4/25/13 at 8:00 am. The Nursing Progress Notes dated 4/23/13 (7-3 shift) through 4/25/13 (11-7 shift), documented the resident complained of pain every shift. Documentation of the pain varied from crying, and complaining of very bad pain all over, to pain scales of six out of ten to eight out of ten. During an interview on 8/1/13 at 9:45 am the pharmacy Account Services Director stated that the pharmacy called the facility on 4/23/13 at 3:00 pm to notify nursing staff that the resident had an allergy to codeine. During an interview on 7/29/13 at 1:15 pm Licensed Practical Nurse (LPN) # 3 stated that the pharmacy had called on the evening of the Resident ' s admission (4/23/13) to alert the facility of the listed allergy to codeine. The physician was made aware of this and ordered to discontinue the Oxycontin, therefore the Resident did not receive the 8:00 pm dose on 4/23/13. LPN # 3 stated that the Hospice nurse on-call was unfamiliar with the Resident but was notified of the Oxycontin being discontinued. The pharmacy sometimes messes up and the delivery times change, if a medication does not come in an arrow would be placed on the MAR to the next time bracket (indicating the medication will not be given as ordered). This happens very, very often and if medication is a critical one, the physician would be notified. Some medications do not come in until the next day. During an interview on 7/29/13 at 1:15 pm LPN # 2 stated that Resident # 1 had an issue with pain medication (Oxycontin) on the day of admission because of an allergy and the physician did not want her on it. The 11:00 pm-7:00am (night shift) of 4/24/13 following the day of admission reported on the morning of 4/24/13 that the Resident was having a lot of pain. The Resident ' s daughter called that morning and said there was no allergy to Oxycontin, the physician was notified of this and ordered the Oxycontin , there were no other orders received for an alternate medication to be given while awaiting the arrival of the Oxycontin. LPN # 2 stated the order was sent to pharmacy and the physician also had to notify the pharmacy because it was a narcotic order. The pharmacy will sometimes deliver a medication order the same day, usually later in the evening or the next day. There was no process to get medications earlier, but does remember that a local pharmacy delivered something about a year ago. During an interview on 8/1/13 at 9:45 am the pharmacy Account Services Director stated that the order for the Oxycontin on 4/24/13 was called into the pharmacy at 1:00 pm. The Oxycontin was delivered on 4/24/13 at 10:23 pm. During an interview on 7/25/13 at 9:45 am the Registered Nurse Supervisor (RNS) # 2 stated that the evening delivery from pharmacy could be anywhere between 10:00 pm and midnight. RNS stated that the supervisor would be the one to initiate a call to the pharmacy to request the back-up pharmacy be used. RNS was not aware of Resident # 1 waiting until the following day to receive the ordered Oxycontin. She stated cannot remember last time the back-up pharmacy was used. During an interview on 7/23/13 LPN # 4 stated Resident # 1 was in a lot of pain and she had received a lot of Roxanol. When a medication was ordered from the pharmacy the facility would not get it until the next day. The cut off time to order medications during the day was 2:00 pm to receive on the last run which is on the 3-11 pm shift. This is how it is done at the facility. During an interview on 6/27/13 at 12:30 pm ADON stated that she was not aware of Resident # 1 ' s level of pain , that the unit nurses are responsible to monitor for pain or discomfort and document it in the nurses notes. ADON was not aware that the Resident did not receive her Oxycontin that was ordered on [DATE] in the morning until the following morning (4/25/13). The Resident should have received her Oxycontin the day it was ordered. During an interview on 6/27/13 at 1:00 pm the DON stated that she remembers the Resident # 1 was receiving scheduled pain medication and that the CNAs were responsible to report to nurses if they see a Resident is in pain. The DON was not aware that the Resident did not receive her Oxycontin that was ordered on [DATE] until the next day. During an interview on 8/1/13 at 11:00 am Physician # 2 stated that she did remember Resident # 1 and that she had made several order changes with her Roxanol. Physician did not remember if she was notified of the Oxycontin not being available the day she ordered it. Resident # 4 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/20/13, the resident was sent to the emergency room status [REDACTED]. The resident was readmitted to the facility 7/22/13. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having both short term and long term memory problems, and moderately impaired in skills for daily decision making. The Patient Discharge Instructions provided by the hospital, dated 7/22/13, documented the following discharge medications: Azopt 1% (a medication used for Glaucoma) one drop to each eye twice daily (start tonight) Aspirin Chewable (a blood thinner) 81 mg by mouth daily at 4:00 pm Depakote (a medication used for psychosis) 500 mg by mouth twice daily (take tonight) Potassium Chloride (a supplement) 20 mEq by mouth three times a day (take tonight) Lasix (a diuretic) 40 mg by mouth twice daily (start tonight) Plavix (an anti-coagulant) 75 mg by mouth daily at 5:00 pm Advair Diskus (a medication used to treat COPD) 250/50 via inhalation twice daily (take tonight) Albuterol (a medication used to increase air flow to the lungs) 2.5 mg via nebulizer daily at 8:00 am, 12:00 pm, 4:00 pm, and 8:00 pm The Nursing Note dated 7/22/13 and timed 7:30 pm, documented the resident returned to the facility at 4:10 pm. The physician's orders [REDACTED]. Azopt 1% one drop in both eyes two times a day at 9:00 am and 5:00 pm Aspirin Chewable 81 mg by mouth one time a day at 4:00 pm Depakote 125 mg four capsules by mouth two times a day Potassium Chloride 10 mEq two capsules by mouth three times a day at 9:00 am, 1:00 pm, and 5:00 pm Lasix 40 mg by mouth two times a day Plavix 75 mg by mouth daily at 5:00 pm Advair Diskus 250/50 mcg one inhalation by mouth two times a day Albuterol 2.5 mg via nebulizer four times a day The Medication Administration Record (MAR) dated July 22, 2013 through August 21, 2013 documented the following: Azopt 1% one drop in both eyes two times a day at 9:00 am and 5:00 pm (the 7/22/13 5:00 pm dose signature box was blank) Aspirin Chewable 81 mg by mouth one time a day at 4:00 pm (the 7/22/13 4:00 pm dose signature box was blank) Depakote 125 mg four capsules by mouth two times a day (the 7/22/13 4:00 pm dose signature box had an " X " in it) Potassium Chloride 10 mEq two capsules by mouth three times a day at 9:00 am, 1:00 pm, and 5:00 pm (the 7/22/13 5:00 pm dose signature box had an " X " in it) Lasix 40 mg by mouth two times a day (the 7/22/13 5:00 pm dose signature box had an " X " in it) Plavix 75 mg by mouth daily at 5:00 pm (the 7/22/13 5:00 pm dose signature box was blank) Advair Diskus 250/50 mcg one inhalation by mouth two times a day (the 7/22/13 5:00 pm dose signature box was blank) Albuterol 2.5 mg via nebulizer four times a day (the 7/22/13 5:00 pm and 9:00 pm dose signature boxes were blank) During an interview on 7/31/13 at 10:00 am LPN # 5 stated the time orders are placed in the computer depends on when the physician returns the call to the facility, and it could be hours. LPN stated that a line is drawn on the MAR over the times that medications are not available, and they would start administration of the medication on the next time documented on the MAR. New admission orders [REDACTED]. The physicians are not made aware of this because they know this is the process. While LPN reviewing Resident # 4 records she stated that the Resident was readmitted at 4:10 pm, nurse notes documented at 10:00 pm that the orders were verified with the physician and the orders were entered into the computer at 8:22 pm. LPN stated that the medications would not be administered until the physician verified the orders and that the medications that were due prior to the physician calling back would have a line written through those times and the Resident would only receive those medications that were due after the physician giving the orders. Technically, orders do not start until orders arereceived by physician. There is no P&P to clarify medication times that were missed and not given. During an interview on 7/31/13 at 1:30 pm LPN # 6 stated that the orders are sent to the pharmacy after the orders are received by the physician. The medications are usually received on the last run and medications that are in the emergency kit can be used if needed. If the time a medication is to be administered has passed when the medications arrive a line is put through that time and the medication is started on the next time documented. LPN # 6 was working on the night of the readmission of Resident # 4 and he received his HS (at bedtime) medications and anything due after the physician verified the orders sometime around 9:00 pm. Medications that were due prior to obtaining the physician orders [REDACTED]. The LPN did not know why she did not sign for any of the medications. During an interview on 8/1/13 at 12:15 pm the ADON reviewed Resident # 4 readmission records and stated that the time of the orders should have been earlier than it was, that the MD should be contacted within the first hour. The physicians all take their own calls unless covering for vacation and other time off. If the physician does not call back within an hour the nurses should place a second call to them. ADON was not aware of Resident # 4 not receiving his medications on the day of his readmission. Resident #12: The resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as having severe cognitive impairment. The 24 Hour Resident Care Report dated 7/27/13, documented that on the 7-3 shift the resident was noted with three 1 cm vesicles to the left buttock and a call was made out to the physician. The Nursing Progress Note dated 7/27/13 and timed 2:40 pm, documented a call was made to the resident's physician regarding areas to the resident's left buttock. The note further stated they were awaiting a return phone call from the physician. The physician's orders [REDACTED]. The Nursing Progress Note dated 7/27/13 and timed 10:00 pm, documented the physician was updated regarding the areas on the resident's left buttock, and a new order for Zovirax 800 mg by mouth three times a day for seven days was obtained. The Medication Administration Record (MAR) dated July 9, 2013 through August 8, 2013 documented the first dose of Zovirax 800 mg was given on 7/28/13 at 4:00 pm. The Nursing Progress Note dated 7/28/13 and timed 9:00 pm, documented the area to the resident's left buttock remained and that the Zovirax treatment was started tonight. During an interview on 8/1/13 at 11:10 am, the Registered Nurse Manager (RNM) #2 stated that the Zovirax order was obtained on a Saturday night and therefore the facility would not obtain the drug until Sunday. She stated that on the weekends the pharmacy only makes one run to the facility each day. She further stated that the physician should have been made aware that the drug was not available and that there was a delay in treatment. She further stated the facility has an emergency medication kit with other anti-viral medications, and they could have asked the physician if he would have wanted to substitute the Zovirax with an anti-viral they had on hand in the facility. During an interview on 8/1/13 at 3:45 pm the Registered Nurse Supervisor # 1(RNS) stated that the pharmacy delivered the medications late on the evening shift. Normally the facility would try to contact the physician as soon as the discharge summary arrived. She stated that sometimes waiting for the physician to return a call to the facility could be hours, and Physician # 1 could sometimes take three to four hours. The Medical Director had been contacted once or twice in the past for orders, but not for new admissions. The supervisor would sometimes make a call to the physicians herself when the wait became too long. During an interview on 7/31/13 at 10:00 am LPN # 5 stated the time that medications are put into the computer depends on when the physician calls back. Physician # 1 takes the longest to call back and also will not call the pharmacy for narcotic orders. If a narcotic is ordered by Physician # 1 the facility has to send someone to his office to pick up the paper script, adding more time to the delay. The doctor is very difficult to deal with. LPN stated there is no back-up pharmacy, delivery times are 3:30 pm and between 10:00 pm and 11:00 pm and it is common for residents not to receive their new medications until the following day. Pharmacy does not call the facility to notify if a medication will not be delivered on the next run. During an interview on 8/1/13 at 11:45 am RNS # 3 stated that new admission orders [REDACTED]. Medications would come in partial or full order and there was not notification from the pharmacy that a medication would not be sent with the first delivery. If the medication did not arrive on time for a documented delivery time the physician should be notified and a notation should be made on the back of the MAR. RNS never saw a delivery from the back-up pharmacy. RNS was not aware of nurse putting lines or arrows through administration times if the medication would not be available. During an interview on 8/1/13 at 1:00 pm the DON stated that the Social Work Department was responsible for admissions, they would receive patient information and it would be reviewed by the DON and ADON for approval. DON was not aware of a problem with admissions, readmissions and residents with new orders not receiving their medications. She did not think about the late delivery from the pharmacy causing medication administration delays. The Nurse Managers are responsible for reviewing the MARS for blanks, they did not notice an issue with admissions and readmissions not receiving their medications on the day of admission. During an interview on 8/1/13 at 12:15 pm ADON stated that the pharmacy will generally call to see if admissions are coming in that day. The cut-off times to get orders into the pharmacy to be delivered the next run were around 10:00 am to receive at 1:30 pm and 5:00 pm to receive at 10:30 pm. The admission and readmission discharge summary arrives on the unit, the unit manager, charge nurse and supervisor gets a copy. When the resident arrives they are assessed and a review of the medications is done from the hospital discharge list. The physician is then contacted; orders are transcribed and sent to pharmacy. ADON was not aware of arrows being placed on the MAR for a medication to start the following day or after the orders are received. She stated that the physician should be asked when to start an unavailable medication, or if it was not in the emergency kit would they like to order a substitution. The nurses could also request the pharmacy use the local back-up pharmacy. ADON was not made aware of admission or readmission residents not receiving their medications until the following day. During an interview on 8/2/13 at 8:45 am the ADON stated that last summer it was noted that unavailable medications were occurring due to refill orders of medications. This followed the change in the pharmacy ordering system to be done in the computers. Memos were sent to staff by the ADON because she wanted to make sure everyone knew the new process. In the summer of 2012 an interdisciplinary meeting took place with a pharmacy representative present to address the issue of unavailable medications and a new tracking system was developed for the refill ordered medications. ADON was not aware of new admission and readmission's not receiving their medications as ordered by physician. During an interview on 8/1/13 at 12:45 pm the Administrator stated he was not aware of a delay in medication administration of new medications. Medication audits had been done in the past but was not sure when. The Nurse Managers should be checking the medication administrations and the physicians should be notified when a medication is unavailable. Administrator stated that the facility has used the present pharmacy for five years. During an interview on 7/31/13 at 2:00 pm, Physician #1 stated that he visits the facility one time per week. Physician #1 stated that nursing staff calls him when a new admission or a re-admission comes into the facility to obtain orders. Physician #1 stated that the nursing staff either contact his office during business hours (9 am - 5:00 pm, Monday through Friday) or the call the answering service after hours. Physician #1 stated that the time it takes him to return the call to the facility "depends on how busy I am, it's quicker when I am not busy but if I am busy it may take a while, it all depends on how busy I am." Physician #1 stated that for residents requiring narcotics, facility staff need to come to his office during normal business hours to pick up the prescription to be sent to the pharmacy. Physician #1 stated that after hours, staff use the facility emergency kit to obtain certain medications or they have to get it another way, and stated "you'd have to talk to administration about that." Physician #1 stated that nursing staff will call if a resident has missed their medications and that he will call back but "8 to 12 hours without medications is okay." During an interview on 8/1/13 at 11:00 am Physician # 2 stated that it was not frequent that she was notified of medications not being available. They cannot give medications if it does not arrive, if the hospital does not send the resident until late, the pharmacy does not deliver until midnight, it is the hospital ' s fault. Physician stated it is absolutely fine to X out a medication time, that the nurses can make common sense decisions. The Registered Nurse (RN) can use their own discretion with medications that will be two hours late. Medications like antibiotics and pain medications should not wait, but we do the best that we can. There is an emergency pharmacy in Latham, NY that could be used. Physician stated she was aware of the rules pertaining to nurses not notifying the physician of unavailable medications and they do notify her. During an interview on 8/1/13 at 9:00 am Physician # 3 stated he had only received one call from the facility in regards to medications not available. The one call he received was in the last two weeks asking for a substitute of a medication that was available in the emergency kit. Physician stated that he and Physician # 2 took call for one another, Physician # 3 took call after 8:00 pm Monday through Friday and Physician # 2 took call during the day and weekends. Physician stated he would always return calls to the facility right away unless he was in a dead zone with his cell phone and then would call as soon as possible. The physician should always be notified to make the judgment whether a medication could be held, LPNs should not be making judgment calls for medications not available. The Medical Director would call the other physicians when there was a problem, he had not received a call in some time and was not aware of any problems. 10 NYCRR 415.18(a)

Based on medical record review and staff interview during a partial extended abbreviated survey (#NY 689) the facility failed to ensure that residents were free of significant medication errors. Specifically, for 11(1, 2, 4, 5, 6, 7, 8, 9, 10, 11 and 12) of 25 newly admitted or readmitted residents and for 1 (# 12) of 11 residents with new orders reviewed the facility failed to have an effective system in place to obtain and administer newly ordered medications. Lack of an effective system resulted in residents not receiving medications until the following day or longer if the medication was a controlled substance requiring a written prescription. The medications identified included [MEDICATION NAME] for pain relief, antihypertensive medications, [MEDICAL CONDITION] medications and medications for respiratory disease. This resulted is no actual harm with potential for serious harm that is Immediate Jeopardy and Substandard Quality of Care to the health and safety of all residents. The facility was able to remove the immediacy prior to exit by implementing the following: 1. Revision of the Policy and Procedures regarding medication, transcription of MD orders, medication error reporting, emergency kit, admission review, and medication administration. 2. Review and audit all new orders given by attending physicians for accuracy and timeliness. The facility's pharmacy has increased its twice daily delivery schedule to three times daily on Monday through Friday. 3. All licensed staff were educated on the areas of concern noted in the deficiencies, including admission/readmission procedure, timely medication administration, unavailable medication policy, transcription of MD orders, medication error reporting, emergency kit, medication administration, and licensed practical nurses were inserviced on their scope of practice regarding physician's orders. 4. The Administrator and Director of Nurses met with the physicians to review timely responses to calls from the facility, phoning required scripts to the pharmacy when necessary, and timely response when addressing any nursing, resident or designated representative concern. Policy & procedure (P&P) entitled Pain Management and dated 6/9/2005 documented the purpose to set forth a procedure that all residents should be maintained at the highest practical level of comfort. The responsibility documented the Nursing staff and physicians. The procedure included, all residents admitted with an existing pain management regime will have their regime continued without interruption. P&P entitled Transcription of MD orders and dated 4/19/13 documented the objective is to ensure safe, consistent transcription of orders in a timely and safe manner. Documentation included, block out all spaces (dates) prior to and end of medication date using arrows. 11-7 shift will look at each chart every night to be sure no new orders have been overlooked. No physician order is to be altered in anyway. If there is a question concerning an order consult the physician for clarification. P&P entitled Unavailable Medication Policy and dated 11/1/2005 documented the purpose was to set forth a procedure to ensure the availability of medications necessary for resident health. The objective included to ensure residents are given medication necessary for their well being. The procedure included a note, if a medication is not available for the resident in the medication cart, the following steps must be taken; pharmacy is to be informed of the missing medication, if medication cannot be made available in a timely manner by the pharmacy the physician is to be notified for any new orders. The use of "unavailable" is not acceptable for nursing to write in the MAR, the physician needs to be advised of this protocol. The physician also needs to give a telephone order stating the medication is on hold until available from the pharmacy or use an available alternative medication. P&P entitled Responsibilities of Staff/Consulting/Attending Physicians and dated 3/10/2005 documented the purpose was; to provide optimum medical care to all Residents of Pine Haven. The responsibility was of the Medical Director and Administrator. Procedure documented the personal physician agrees to be called in any emergency, to be notified of any significant changes in the patient's clinical conditions, and the operator agrees to provide emergency medical care from his own medical staff pending visit and orders of the personal physician. The physician in charge must give medical orders for the resident's immediate care after admission. If the physician does not adhere to these provisions, privileges will be withdrawn and the Medical Director will care for the patient/resident. Pharmacy Services Agreement dated 9/1/2008 documented under the title of supply, pharmacy will furnish and replenish, on a regular basis, an emergency and interim medication supply, the composition of which will comply with federal and state regulations, and be mutually agreed upon in writing by pharmacy and facility. Documented under the title delivery, pharmacy agrees to provide delivery services to facility Monday through Sunday during pharmacy regular business hours and on an emergency basis, except for circumstances and conditions beyond its control, which will include, but not limited to situations where pharmacy manufacturer/supplier is unable to provide the required item and pharmacy is unable to provide an acceptable alternative. In the event pharmacy cannot furnish an ordered medication on a prompt and timely basis, pharmacy will make arrangements with another pharmacy supplier in a community local to the facility to provide such services to the facility. Resident #1: The resident was admitted to the facility on [DATE] from the hospital in house Hospice unit with [DIAGNOSES REDACTED]. The Minimum data Set ((MDS) dated [DATE], assessed the resident as having a short term memory problem and moderately impaired in skills for daily decision making. The Community Hospice Level of Care Transfer Report dated 4/23/13 and timed 11:00 am, documented the resident's current pain medication regimen which included [MEDICATION NAME] 10 mg by mouth every 8 hours and [MEDICATION NAME] 10 mg by mouth twice daily. Documented under reason for transport was patient stable. The Nursing Progress Note dated 4/23/13 and timed 1:15 pm, documented the resident arrived to the facility at 12:25 pm. The Physician's Order Form dated 4/23/13 and timed 2:16 pm, documented an order for [REDACTED]. The Physician's Order Form dated 4/23/13 and timed 4:42 pm, documented an order to discontinue [MEDICATION NAME] 10 mg by mouth two times a day. The Nursing Progress Note dated 4/24/13 and timed 7:30 am, documented that the resident's daughter called the facility to clarify that her mother did not have an allergy to [MEDICATION NAME] and that she had taken it in the past. The Physician's Order Form dated 4/24/13 and timed 11:11 am, documented an order for [REDACTED]. The Medication Administration Record (MAR) for April 23, 2013 through May 23, 2013, documented the following: [MEDICATION NAME] 10 mg by mouth every 12 hours, at 8:00 am and 8:00 pm (the 4/24/13 8:00 pm dose signature box had a line through it). The first dose of [MEDICATION NAME] 10 mg was documented as administered on 4/25/13 at 8:00 am. The Nursing Progress Notes dated 4/23/13 (7-3 shift) through 4/25/13 (11-7 shift), documented the resident complained of pain every shift. Documentation of the pain varied from crying, and complaining of very bad pain all over, to pain scales of six out of ten to eight out of ten. During an interview on 7/23/13 LPN # 4 stated Resident # 1 was in a lot of pain and she had received a lot of [MEDICATION NAME]. When a medication was ordered from the pharmacy the facility would not get it until the next day. The cut off time to order medications during the day was 2:00 pm to receive on the last run which is on the 3-11 pm shift. This is how it is done at the facility. During an interview on 7/25/13 at 9:45 am the Registered Nurse Supervisor (RNS) # 2 stated that the evening delivery from pharmacy could be anywhere between 10:00 pm and midnight. RNS stated that the supervisor would be the one to initiate a call to the pharmacy to request the back-up pharmacy be used. RNS was not aware of Resident # 1 waiting until the following day to receive the ordered [MEDICATION NAME]. RNS stated she cannot remember last time the back-up pharmacy was used. During an interview on 7/27/13 at 12:30 pm ADON stated that she was not aware of Resident # 1's level of pain , that the unit nurses are responsible to monitor for pain or discomfort and document it in the nurses notes. ADON was not aware that the Resident did not receive her [MEDICATION NAME] that was ordered on [DATE] in the morning until the following morning (4/25/13). The Resident should have received her [MEDICATION NAME] the day it was ordered. During an interview on 7/27/13 at 1:00 pm the DON stated that she remembers the Resident # 1 was receiving scheduled pain medication and that the CNAs were responsible to report to nurses if they see a Resident is in pain. DON was not aware that the Resident did not receive her [MEDICATION NAME] that was ordered on [DATE] until the next day. During an interview on 7/29/13 at 1:15 pm Licensed Practical Nurse (LPN) # 3 stated that the pharmacy had called on the evening of the Resident ' s admission (4/23/13) to alert the facility of the listed allergy to [MEDICATION NAME]. Physician was made aware of this and ordered to discontinue the [MEDICATION NAME], therefore the Resident did not receive the 8:00 pm dose on 4/23/13. LPN # 3 stated that the Hospice nurse on-call was unfamiliar with the Resident but was notified of the [MEDICATION NAME] being discontinued. The pharmacy sometimes messes up and the delivery times change, if a medication does not come in an arrow would be placed onto the MAR to the next time bracket (indicating the medication will not be given as ordered). This happens very, very often and if medication is a critical one, the physician would be notified. Some medications do not come in until the next day. During an interview on 7/29/13 at 1:15 pm LPN # 2 stated that Resident # 1 had an issue with pain medication ([MEDICATION NAME]) on the day of admission because of an allergy and the physician did not want her on it. The 11 pm-7am (night shift) of 4/24/13 following the day of admission reported on the morning of 4/24/13 that the Resident was having a lot of pain. The Resident's daughter called that morning and said there was no allergy to [MEDICATION NAME], the physician was notified of this and ordered the [MEDICATION NAME] , there were no other orders received for an alternate medication to be given while awaiting the arrival of the [MEDICATION NAME]. LPN # 2 stated the order was sent to pharmacy and the physician also had to notify the pharmacy because it was a narcotic order. The pharmacy will sometimes deliver a medication order the same day, usually later in the evening or the next day. There was no process to get medications earlier, but does remember that a local pharmacy delivered something about a year ago. During an interview on 8/1/13 at 9:45 am the pharmacy Account Services Director stated that the order for the [MEDICATION NAME] on 4/24/13 was called into the pharmacy at 1:00 pm. The [MEDICATION NAME] was delivered on 4/24/13 at 10:23 pm. The pharmacy Account Services Director stated that the pharmacy called the facility on 4/23/13 at 3:00 pm to notify nursing staff in regards to an allergy to [MEDICATION NAME]. During an interview on 8/1/13 at 11:00 am Physician # 2 stated that she did remember Resident # 1 and that she had made several order changes with her [MEDICATION NAME]. Physician did not remember if she was notified of the [MEDICATION NAME] not being available the day she ordered it. Resident # 4 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 7/20/13, the resident was sent to the emergency room status [REDACTED]. The resident was readmitted to the facility 7/22/13. The MDS dated [DATE], assessed the resident had both short term and long term memory problems, and was moderately impaired in skills for daily decision making. The Patient Discharge Instructions provided by Hospital, dated 7/22/13, documented the following discharge medications: [MEDICATION NAME] 1% (a medication used for [MEDICAL CONDITION]) one drop to each eye twice daily (start tonight) Aspirin Chewable (a blood thinner) 81 mg by mouth daily at 4:00 pm [MEDICATION NAME] (a medication used for [MEDICAL CONDITION]) 500 mg by mouth twice daily (take tonight) Potassium Chloride (a supplement) 20 mEq by mouth three times a day (take tonight) [MEDICATION NAME] (a diuretic) 40 mg by mouth twice daily (start tonight) [MEDICATION NAME] (an anti-coagulant) 75 mg by mouth daily at 5:00 pm [MEDICATION NAME] Diskus (a medication used to treat [MEDICAL CONDITION]) 250/50 via inhalation twice daily (take tonight) [MEDICATION NAME] (a medication used to increase air flow to the lungs) 2.5 mg via nebulizer daily at 8:00 am, 12:00 pm, 4:00 pm, and 8:00 pm The Nursing Note dated 7/22/13 and timed 7:30 pm, documented the resident returned to the facility at 4:10 pm. The Physician ' s Order Form dated 7/22/13 and timed 8:22 pm, documented the following medication orders: [MEDICATION NAME] 1% one drop in both eyes two times a day at 9:00 am and 5:00 pm Aspirin Chewable 81 mg by mouth one time a day at 4:00 pm [MEDICATION NAME] 125 mg four capsules by mouth two times a day Potassium Chloride 10 mEq two capsules by mouth three times a day at 9:00 am, 1:00 pm, and 5:00 pm [MEDICATION NAME] 40 mg by mouth two times a day [MEDICATION NAME] 75 mg by mouth daily at 5:00 pm [MEDICATION NAME] Diskus 250/50 mcg one inhalation by mouth two times a day [MEDICATION NAME] 2.5 mg via nebulizer four times a day The MAR dated July 22, 2013 through August 21, 2013 documented the following: [MEDICATION NAME] 1% one drop in both eyes two times a day at 9:00 am and 5:00 pm (the 7/22/13 5:00 pm dose signature box was blank) Aspirin Chewable 81 mg by mouth one time a day at 4:00 pm (the 7/22/13 4:00 pm dose signature box was blank) [MEDICATION NAME] 125 mg four capsules by mouth two times a day (the 7/22/13 4:00 pm dose signature box had an " X " in it) Potassium Chloride 10 mEq two capsules by mouth three times a day at 9:00 am, 1:00 pm, and 5:00 pm (the 7/22/13 5:00 pm dose signature box had an " X " in it) [MEDICATION NAME] 40 mg by mouth two times a day (the 7/22/13 5:00 pm dose signature box had an " X " in it) [MEDICATION NAME] 75 mg by mouth daily at 5:00 pm (the 7/22/13 5:00 pm dose signature box was blank) [MEDICATION NAME] Diskus 250/50 mcg one inhalation by mouth two times a day (the 7/22/13 5:00 pm dose signature box was blank) [MEDICATION NAME] 2.5 mg via nebulizer four times a day (the 7/22/13 5:00 pm and 9:00 pm dose signature boxes were blank) During an interview on 7/31/13 at 10:00 am LPN # 5 stated the time orders are placed in the computer depends on when the physician returns the call to the facility, and it could be hours. LPN stated that a line is drawn on the MAR over the times that medications are not available, and they would start administration of the medication on the next time documented on the MAR. New admission orders [REDACTED]. The physicians are not made aware of this because they know this is the process. While LPN reviewed Resident # 4 records she stated that the Resident was readmitted at 4:10 pm, nurse notes documented at 10:00 pm that the orders were verified with the physician and the orders were entered into the computer at 8:22 pm. LPN stated that the medications would not be administered until the physician verified the orders and that the medications that were due prior to the physician calling back would have a line written through those times and the Resident would only receive those medications that were due after the physician gave the orders. Technically, orders do not start until orders are received by physician. There is no P&P to clarify medication times that were missed and not given. During an interview on 7/31/13 at 1:30 pm LPN # 6 stated that the orders are sent to the pharmacy after the orders are received by the physician. The medications are usually received on the last run and medications that are in the emergency kit can be used if needed. If the time a medication is to be administered has passed when the medications arrive a line is put through that time and the medication is started on the next time documented. LPN # 6 was working on the night of the readmission of Resident # 4 and he received his HS (at bedtime) medications and anything due after the physician verified the orders sometime around 9:00 pm. Medications that were due prior to obtaining the physician orders were not given to Resident # 4, those included medications that were due at 4:00 pm and 5:00 pm. LPN did not know why she did not sign for any of the medications. During an interview on 8/1/13 at 12:15 pm ADON reviewed Resident # 4 readmission records and stated that the time of the orders should have been earlier than it was, that the MD should be contacted within the first hour. The physicians all take their own calls unless covering for vacation and other time off. If the physician does not call back within an hour the nurses should place a second call to them. The ADON was not aware of Resident # 4 not receiving his medications on the day of his readmission. Resident #12: The resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The MDS dated [DATE], assessed the resident as having severe cognitive impairment. The 24 Hour Resident Care Report dated 7/27/13, documented that on the 7-3 shift the resident was noted with three 1 cm vesicles to the left buttock and a call was made out to the physician. The Nursing Progress Note dated 7/27/13 and timed 2:40 pm, documented a call was made to the resident's physician regarding areas to the resident's left buttock. The note further stated they were awaiting a return phone call from the physician. The Physician's Order Form dated 7/27/13 and timed 7:07 pm, documented an order for [REDACTED]. The Nursing Progress Note dated 7/27/13 and timed 10:00 pm, documented the physician was updated regarding the areas on the resident's left buttock, and a new order for [MEDICATION NAME] 800 mg by mouth three times a day for seven days was obtained. The MAR dated July 9, 2013 through August 8, 2013 documented the first dose of [MEDICATION NAME] 800 mg was given on 7/28/13 at 4:00 pm. The Nursing Progress Note dated 7/28/13 and timed 9:00 pm, documented the area to the resident's left buttock remained and that the [MEDICATION NAME] treatment was started tonight. During an interview on 7/31/13 at 10:00 am LPN # 5 stated the time that medications are put into the computer depends on when the physician calls back. Physician # 1 takes the longest to call back and also physician also will not call the pharmacy for narcotic orders. If a narcotic is ordered by Physician # 1 the facility has to send someone to his office to pick up the paper script, adding more time to the delay. The doctor is very difficult to deal with. LPN stated there is no back-up pharmacy, delivery times are 3:30 pm and between 10:00 pm and 11:00 pm and it is common for residents not to receive their new medications until the following day. Pharmacy does not call the facility to notify if a medication will not be delivered on the next run. During an interview on 7/31/13 at 2:00 pm, Physician #1 stated that he visits the facility one time per week. Physician #1 stated that nursing staff calls him when a new admission or a re-admission comes into the facility to obtain orders. Physician #1 stated that the nursing staff either contact his office during business hours (9 am - 5:00 pm, Monday through Friday) or call the answering service after hours. Physician #1 stated that the time it takes him to return the call to the facility "depends on how busy I am, it's quicker when I am not busy but if I am busy it may take a while, it all depends on how busy I am." Physician #1 stated that for residents requiring narcotics, facility staff need to come to his office during normal business hours to pick up the prescription to be sent to the pharmacy. Physician #1 stated that after hours, staff use the facility emergency kit to obtain certain medications or they have to get it another way, and stated "you'd have to talk to administration about that." Physician #1 stated that nursing staff will call if a resident has missed their medications and that he will call back but "8 to 12 hours without medications is okay." During an interview on 8/1/13 at 11:10 am, the Registered Nurse Manager (RNM) #2 stated that the [MEDICATION NAME] order was obtained on a Saturday night and therefore the facility would not obtain the drug until Sunday. She stated that on the weekends the pharmacy only makes one run to the facility each day. She further stated that the physician should have been made aware that the drug was not available and that there was a delay in treatment. She further stated the facility has an emergency medication kit with other anti-[MEDICAL CONDITION] medications, and they could have asked the physician if he would have wanted to substitute the [MEDICATION NAME] with an anti-[MEDICAL CONDITION] they had on hand in the facility. During an interview on 8/1/13 at 11:45 am RNS # 3 stated that new admission orders [REDACTED]. Medications would come in partial or full order and there was not notification from the pharmacy that a medication would not be sent with the first delivery. If the medication did not arrive on time for a documented delivery time the physician should be notified and a notation should be made on the back of the MAR. RNS never saw a delivery from the back-up pharmacy. RNS was not aware of nurse putting lines or arrows through administration times if the medication would not be available. During an interview on 8/1/13 at 12:15 pm ADON stated that the pharmacy will generally call to see if admissions are coming in that day. The cut-off times to get orders into the pharmacy to be delivered the next run are around 10:00 am to receive at 1:30 pm and 5:00 pm to receive at 10:30 pm. The admission and readmission discharge summary arrives on the unit, the unit manager, charge nurse and supervisor gets a copy. When the resident arrives they are assessed and a review of the medications is done from the hospital discharge list. The physician is then contacted; orders are transcribed and sent to pharmacy. ADON was not aware of arrows being placed on the MAR for a medication to start the following day or after the orders are received. She stated that the physician should be asked when to start an unavailable medication, or if it was not in the emergency kit would they like to order a substitution. The nurses could also request the pharmacy use the local back-up pharmacy. ADON was not made aware of admission or readmission residents not receiving their medications until the following day. During an interview on 8/1/13 at 9:00 am Physician # 3 stated he had only received one call from the facility in regards to medications not available. The one call he received was in the last two weeks asking for a substitute of a medication that was available in the emergency kit. Physician stated that he and Physician # 2 took call for one another, Physician # 3 took call after 8:00 pm Monday through Friday and Physician # 2 took call during the day and weekends. Physician stated he would always return calls to the facility right away unless he was in a dead zone with his cell phone and then would call as soon as possible. The physician should always be notified to make the judgment whether a medication could be held, LPNs should not be making judgment calls for medications not available. The Medical Director would call the other physicians when there was a problem, he had not received a call in some time and was not aware of any problems. During an interview on 8/1/13 at 11:00 am Physician # 2 stated that it was not frequent that she was notified of medications not being available. They cannot give medications if it does not arrive, if the hospital does not send the resident until late, the pharmacy does not deliver until midnight, it is the hospital ' s fault. Physician stated it is absolutely fine to X out a medication time, that the nurses can make common sense decisions. The Registered Nurse (RN) can use their own discretion with medications that will be two hours late. Medications like antibiotics and pain medications should not wait, but we do the best that we can. There is an emergency pharmacy that could be used. Physician stated she was aware of the rules pertaining to nurses not notifying the physician of unavailable medications and they do notify her. During an interview on 8/1/13 at 12:45pm the Administrator stated he was not aware of a delay in medication administration of new medications. Medication audits had been done in the past but was not sure when. The Nurse Managers should be checking the medication administrations and the physicians should be notified when a medication is unavailable. Administrator stated that the facility has used the present pharmacy for five years. During an interview on 8/1/13 at 1:00 pm the DON stated that the Social Work Department was responsible for admissions, they would receive patient information and it would be reviewed by the DON and ADON for approval. DON was not aware of a problem with admissions, readmissions and residents with new orders not receiving their medications. She did not think about the late delivery from the pharmacy causing medication administration delays. The Nurse Managers are responsible for reviewing the MARS for blanks, they did not notice an issue with admissions and readmissions not receiving their medications on the day of admission. During an interview on 8/1/13 at 3:45 pm the Registered Nurse Supervisor # 1(RNS) stated that the pharmacy delivered the medications late on the evening shift. Normally the facility would try to contact the physician as soon as the discharge summary arrived. She stated that sometimes waiting for the physician to return a call to the facility could be hours, and Physician # 1 could sometimes take three to four hours. The Medical Director had been contacted once or twice in the past for orders, but not for new admissions. The supervisor would sometimes make a call to the physicians herself when the wait became too long. During an interview on 8/2/13 at 8:45 am the ADON stated that last summer it was noted that unavailable medications were occurring due to refill orders of medications. This followed the change in the pharmacy ordering system to be done in the computers. Memos were sent to staff by the ADON because she wanted to make sure everyone knew the new process. In the summer of 2012 an interdisciplinary meeting took place with a pharmacy representative present to address the issue of unavailable medications and a new tracking system was developed for the refill ordered medications. ADON was not aware of new admission and readmission's not receiving their medications as ordered by physician. 10 NYCRR 415.12(m)(2)

Based on record review and staff interviews during an abbreviated partial extended survey, (#NY 689) the Medical Director failed to coordinate medical care in the facility and failed to provide clinical guidance and oversight regarding the implementation of resident care policies. Specifically, for 11(1, 2, 4, 5, 6, 7, 8, 9, 10, 11 and 12) of 25 newly admitted or readmitted residents and for 1 (# 12) of 11 residents with new orders. The Medical Director failed to ensure that policies and procedures were operationalized, failed to monitor and oversee attending physicians to ensure that medical orders were given for a resident's immediate care when admitted or readmitted and failed to ensure that physician ordered medications were available. This resulted in no actual harm and had the potential for serious harm that is Immediate Jeopardy to the health and safety of all residents. The facility was able to remove the immediacy prior to exit by implementing the following: 1. Revision of the Policy and Procedures regarding medication, transcription of MD orders, medication error reporting, emergency kit, admission review, and medication administration. 2. Review and audit all new orders given by attending physicians for accuracy and timeliness. The facility's pharmacy has increased its twice daily delivery schedule to three times daily on Monday through Friday. 3. All licensed staff were educated on the areas of concern noted in the deficiencies, including admission/readmission procedure, timely medication administration, unavailable medication policy, transcription of MD orders, medication error reporting, emergency kit, medication administration, and licensed practical nurses will be inserviced on their scope of practice regarding physicians' orders. 4. The Administrator and Director of Nurses met with the physicians to review timely responses to calls from the facility, phoning required scripts to the pharmacy when necessary, and timely response when addressing any nursing, resident or designated representative concern. The findings are: Responsibilities of Staff/Consulting/Attending Physicians dated 3/10/05 documented that the physician in charge must give medical orders for the resident's immediate care upon admission. The policy further documented that if a physician does not adhere to these provisions, privileges will be withdrawn and the Medical Director will care for the patient/resident. Unavailable Medication Policy and Procedure dated 11/1/05 documented that the policy is set forth to ensure the availability of medications necessary for resident health. The policy documented that if a medication is not available for the resident in the medication cart, the following steps must be taken: A. inform the pharmacy of the missing medication, B. if medication cannot be made available in a timely manner by the pharmacy, the physician is to be notified for any new orders. C. The use of "unavailable" is not acceptable for nursing to write in the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The physician also needs to give a telephone order stating the medication is on hold until available from the pharmacy or use an alternative medication. During an interview on 7/31/13 at 1:20 pm, the Medical Director stated that he visits the facility for a couple of hours every two to three weeks to work on policies and to attend Quality Assurance (QA) meetings. The Medical Director stated that he was unaware that there were delays in getting newly admitted or readmitted residents their medications. The Medical Director stated that upon arrival of a new admission or readmission, nursing staff should contact the attending physician, the attending physician should order medications, and if necessary, the physician should call the pharmacy and the pharmacy should deliver the medications to the facility to be administered to the resident. The Medical Director stated that he was not aware that there were delays in physicians responding to nursing staff but on a few occasions, he has been contacted to authorize medications. The Medical Director stated "however, I don't take care of residents or back up for physicians (MDs)". The Medical Director stated that the facility staff could contact him for assistance in obtaining medication orders, however, "I'm not on call and there is no guarantee they are going to get me." During a follow-up interview on 8/1/13 at 2:30 pm, the Medical Director stated that he was in the facility on 7/25/13 for a QA Meeting however no specific issues were brought to his attention and there were no policy issues discussed. When asked for clarification of his role in the facility, the Medical Director stated that when he visits the facility he usually reviews infection control issues and will attend the morning meeting. The Medical Director stated that he does not routinely communicate with the attending physicians and communicates with them only when there is an issue and "if a medication nurse doesn't bring an issue to my attention, I can't address it." The Medical Director stated that he dictated a letter to one of the physicians last week (7/25/13) for inattentiveness. The Medical Director stated there has been an on-going issue with one of the physicians who has "issues with compliance". The Medical Director stated that nursing staff have reported that they call out to the physician, and the physician will not call the pharmacy. The Medical Director stated, "If he doesn't call it (medication) in, the resident doesn't get it." The Medical Director stated "I can't fire the physician, so I dictated a letter last Thursday and I wanted to let the physician know, "your job is at stake." The Medical Director stated the issue was discussed with the Administrator, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 7/25/13 and that he dictated a letter, gave it to the ADON and she put it in the physician's mailbox. The Medical Director stated he was concerned that the physician was not addressing the immediate needs of residents, he stated "its a quality of care issue, not acting in the best interests of the residents." He further stated, "nursing staff are trying to call the physician with a pharmacy/medication issue, if its a new admission, the physician has to call the pharmacy and nursing staff are being told "I can't do it, I won't do it." The Medical Director stated he thought that the DON and/or ADON had called the physician in to talk with him because these issues could go to the Medical Director, "it is not a preferred practice but we made accommodations for him." 10 NYCRR 415.15 (a)

Based on record review and interview the facility did not identify issues with respect to which quality assessment and assurance (QA) activities are necessary; and did not develop and implement appropriate plans of action to correct identified quality deficiencies. Specifically: for 5 of 12 residents reviewed for weight loss the facility did not recognize areas of concern related to significant weight loss and progressive weight loss. Resident weights were not documented and monitored, there was no effective system in place to alert interdisciplinary team members of a weight loss, comprehensive care plans were not developed, nutritional assessments were not completed timely, dietary interventions were not initiated, not ordered and/or not implemented when ordered and physicians were not notified of weightloss concerns. This resulted in actual harm to three residents and the potential for more than minimal harm to two other resident which was Substandard Quality of Care. This is evidenced by: Refer to F 325 Nutrition scope and severity -G During interview on 1/7/13 at 12:15 pm the Administrator stated that the contracted food company provided the dietary services for the facility. He stated there was no specific contract on how many hours of Registered Dietician (RD) service would be provided. He stated the facility has had a contract with the food service company for over a year. He stated the facility was not doing any QA on weights. He stated the RD would give him a monthly report and never let him know of any findings with weights. He stated he had no indication there was a problem with weights. During interview on 1/7/13 at 1:41 pm the Regional Manager for the contracted company stated that the previous RD was only working 24 hours a week so did not do any QA. He stated that in or about August the former RD was bumped up to 30 hours a week. He stated that 24 hours a week for RD services was not enough and that is why the new RD will be working full time. 10NYCRR 415.27(a-c)

Based on medical record review and resident and staff interview the facility did not maintain acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrated that this was not possible for 5 (#s- 2, 33, 46, 73 and 94) of 12 residents reviewed for weight loss during the recertification survey. Specifically, the facility did not have effective systems in place for documentation and monitoring residents weight, developing timely Comprehensive Care Plans for nutrition, completion of timely nutritional assessments, initiation and implementation of dietary intervention and notification to the physician of residents weight loss.This resulted in actual harm for Residents # 2, 33 and 46 and had the potential for more than minimal harm for Residents # 73 and 94 which resulted in Substandard Quality of Care that is not immediate jeopardy. This is evidenced by the following: Resident #2: The resident was initially admitted to the facility on [DATE] with readmissions to the facility on [DATE] and on 10/10/12. The resident was readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 10/23/12 assessed the resident was understood and was able to understand with moderate impairment in cognitive skills for daily decision making. The resident was assessed as having little energy and a poor appetite on half or more of the days, and had other behavioral symptoms not directed toward others. The resident measured 68 inches in height and weighed 157 pounds (lbs), had a weight loss of 5 percent or more in the last month or 10 percent or more in the last six months, was not on a physician prescribed weight loss program, on a mechanically altered, therapeutic diet and it was documented the resident received an antipsychotic medication on seven days for the seven days prior to the assessment. The resident's monthly weights were recorded in the unit weight book as follows: November 2012 was 151 lbs and for December 2012 the weight was documented as 151.4 lbs. The resident's weekly weights were recorded in the unit weight book as follows: on 10/10/12 -174.0 lbs (readmission weight), 10/19/12 -157.6 lbs (16.4 lb weight loss, 9.4% loss in one week with no reweight completed). On 10/25/12 - 157.4 lbs, 11/02/12- 151.0 lbs, on 11/9/12 - 153.8 lbs, 11/15/12 - 152.6 lbs (21.4 lbs weight loss, 12.2% loss in approximately one month), 11/22/12 - 151.4 lbs, undated December weight of 151.4 lbs, undated December weight of 147.6 lbs, on 12/13/12 -149.6 lbs, 12/20/12- 147.6 lbs, 1/2/13 -146.3 lbs (27.7 lbs weight loss, 15.9 % loss in approximately 90 days). The Comprehensive Care Plan (CCP) for Nutrition dated 9/21/12, and updated on 9/25/12 and 10/10/12 noted a goal for the resident was to maintain a weight of 170 lbs plus or minus five lbs for thirty days. It documented that the resident's intake and appetite was poor with a three day intake study completed on 10/12/12. It documented that the resident was on a Regular with no added salt and fat controlled diet that was changed to Mechanical Soft on 10/26/12. There were no new interventions or evaluations added to the care plan. The resident was seen by Psychology numerous times for identified behaviors. There was no documentation in the psychology notes regarding the residentss significant weight loss. The resident's Food Preference Record dated 10/1/12 showed that these were obtained at the time of the resident's initial admission to the facility. It documented that the resident loved peanut butter, was agreeable to sandwiches and casseroles, liked salads and desserts, tuna and ham cold cuts, and grapes. It noted that the resident was to receive a small tossed salad at lunch, 4 ounces of 2% milk and two of any type of cookies at dinner. The resident's Food Preferences were not readdressed with the resident and/or resident's family on the readmission on 10/10/12. The resident was readmitted on [DATE] with physician (MD) orders for a Regular no added salt, fat controlled diet. The Intake Sheet for Fluids and Solids documented for solids: For October 10-31 2012 : Breakfast 0-25% 10 times, 26-50% 6 times, 51-75% 1 time, 76-100% 1 time; Lunch 0-25% 11 times, 26-50% 6 times, 51-75% 2 times, 76-100% 1 time; Supper 0-25% 18 times, 26-50% 1 time, 51-75% none, 76-100% none. There were no nourishments recorded ; For November 2012, Breakfast 0-25% 16 times, 26-50% 7 times, 51-75% 5 times, 76-100% 2 times, Lunch 0-25% 8 times, 26-50% 12 times, 51-75% 2 times, 76-100% 8 times, Supper 0-25% 9 times, 26-50% 16 times, 51-75% 3 times, 76-100% 2 times, no nourishment were recorded; For December 2012, Breakfast 0-25% 15 times, 26-50% 11 times, 51-75% 1 time, 76-100% 4 times; Lunch 0-25% 16 times, 26-50% 6 times, 51-75% 5 times, 76-100% 3 times; Supper 0-25% 15 times, 26-50% 10 times, 51-75% 5 times, 76-100% none were recorded, no nourishments recorded. MD's progress note dated 10/11/12 documented the resident was not eating or drinking, that the resident refused tube feedings, and that the resident's niece suggested trialing [MEDICATION NAME] with the resident for his agitation. It was noted that the facility would trial [MEDICATION NAME] 25 mg every night and every day as needed. The Initial Nutrition Risk Assessment for Short-Term Stay was dated 10/12/12 and documented that the resident's height was 68 inches and that the residents weight was 174 lbs. The resident's usual body weight was in the 180's and that his Body Mass Index (BMI)was 25.85, which was noted to be in the healthy range for the resident's age. The resident was on a no added salt, fat controlled diet The resident was independent with eating his meals in his room after set up, the resident's estimated nutrient needs were 1728 calories per day, 75 grams of protein per day, 2100 cubic centimeters (cc) of fluid per day, and the resident's food and fluid intake was fair to poor and approximately 25 percent for solids. It noted that the resident was at risk for unintended weight loss because he was forgetful, a "fussy" eater, demanding and agitated. The weight goal on this assessment was for the resident to maintain a weight of 170 lbs plus or minus 5 lbs for 30 days and interventions were to provide the resident with his diet as prescribed, honor his food preferences, provision of necessary assistance at meals and in between, and monitoring of weekly weights, oral intake, and labs. A Nutrition Care Progress Note (NCPN) dated 10/12/12 documented that the resident was hospitalized from [DATE] to 10/10/12 for dehydration and acute [MEDICAL CONDITION] and noted that the resident continued on the same diet of no added salt, fat controlled, and continued with a poor appetite and fluid intake. It documented that the resident was frequently agitated and refused medication. It was noted that a food intake study was to begin. The facility policy for "3-Day Food and Fluid Intake" effective January 2008 and revised on 9/24/12 documented that the RD would record a summary of the nutrient intake analysis for fluids, protein and calories in the medical record following the completion of the 3 day fluid and food intake study and that the dietician would make appropriate recommendations for dietary changes to the MD. A Food Intake Study completed 10/13/12 to 10/15/12 documented that the daily total of the residents intake was well below his daily need. There was no documented evidence of recommendations having been made by the registered dietician (RD), the nursing staff, or the medical doctor after completion of this food intake study which reflected the resident as having had poor intake of meals and having had refusals of meals at times. A Nurse's Note dated 10/16/12 documented that the resident refused to eat lunch stating "I don't want it, I'm not hungry". It documented that the resident's lunch was saved in case the resident's wife came in and could talk him into eating. A MD progress note dated 10/18/12 documented that resident was alert, but confused. It documented that the resident was still refusing meals and fluids at times, yelled out at times, and did not sleep well. It documented that the resident was advised to eat and drink and that the resident expressed understanding. A facility Weight Change Memo dated 10/19/12 forwarded to the RD, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) documented that the resident's previous weight was 174 lbs on 10/10/12 and current weight was 158 lbs on 10/18/12. . A NCPN dated 10/23/12 documented that the resident's weekly weight was 158 lbs on 10/18/12 and was down 16 lbs in two weeks, that the food intake study of 10/13/12 to 10/15/12 showed that the resident had an intake of 400 calories, 25 grams of protein, and 260 cc of fluids with meals, that the resident continued to refuse food/meals, that per CNA intake records, the resident consumed approximately 5 to 50 percent of meals and less than 500 cc of fluids. It noted that substitutions at meals were provided as the resident requested. The RD did not address the residents significant weight loss of 16 lbs (nine percent) in two weeks. A Nurse's Note dated 10/26/12 documented that the family requested a decrease in the resident's diet and then noted that the resident's diet was changed to mechanical soft. A MD order dated 10/26/12, documented to change the resident's diet from Regular consistency to to Mechanical Soft. A NCPN dated 11/1/12 documented that the resident's weight was 147.4 lbs on 11/1/12 and the resident's intake continued to be poor at approximately 25 to 50 % at meals. It documented that the resident was then eating with assistance, had a urinary tract infection, was on an antibiotic and that nursing staff was providing requests as the resident initiated (e.g. peanut butter and jelly or soft salad sandwiches on white bread with each lunch and dinner meal). It documented that the resident was eating a mechanical soft diet better than a regular diet. The RD did not address the residents significant weight loss of 26.6 lbs (fifteen percent) since admission. A MD progress note dated 11/8/12 documented that the resident remained alert, but confused. It noted that the resident's weight was 151 lbs (minus 36 lbs) at the time of the note. There was no documented evidence that the resident's poor appetite and intake and continued weight loss was addressed by the MD, other than notation of his recommending that the resident continue to be encouraged to eat and drink at meal times. A NCPN dated 1/3/13 documented that the resident's weight on 1/2/12 was 146.3 lbs and indicated a 1.1 lb weight loss from 12/20/12. The resident continued with poor oral intake, was consuming 0 to 50 % of meals and foods were provided as requested. It was documented on this date recommendations to liberalize the resident's diet to Mechanical Soft with discontinuation of the fat control and no added salt to allow more choices and to start 60 cc of 2Cal HN (calorie and protein dense nutritional supplement) three times a day with medication pass to provide 360 calories, and 15 grams of protein. The MD order dated 1/3/13, documented an order for [REDACTED]. Additionally, it documented an order for [REDACTED]. During an interview on 1/3/13 at approximately 12:00 pm, the resident's wife mentioned to the surveyor that the resident was going out to the dentist on this date for new denture impressions. She stated that this was because his dentures had been lost at the hospital in October 2012. A speech therapy plan of treatment signed on 10/23/12 documented that the resident had no dentures in his mouth because the upper dentures were lost. It then documented that the resident's ordered diet was for no added salt, fat controlled, regular consistency diet. The speech therapist's diet recommendation was for the diet to continue as ordered. It noted that the resident was cooperative and had no difficulties. The resident was noted to have refused a dental evaluation on 10/25/12 after being readmitted and it was documented that he would be rescheduled if he needed to be seen. During an interview on 1/4/13 at 10:10 am, the part time RD consultant stated that the previous part time RD consultant left her position at the facility on 11/28/12 and then stated that she started working at the facility on 12/1/12. She stated that she was slated to work at the facility for 20 hours a week and typically came to the facility every Saturday. She stated that there had never been any diet technicians working at the facility before and that the facility never had a full time RD. She stated she only addressed this resident's weight loss after some one at the facility gave her heads up to look at him. She stated she didn't know which residents were on weekly weights and which ones were not and was unsure if the facility had a system for this. She stated that normally she would get a memo from nursing if there was a weight change from week to week or month to month. She stated that she did not know about this resident's significant weight loss since admission because when she started in December she only looked back to the November weight and since there was not much of a change, she just thought this was the resident's normal weight and that he was stable. She stated because of this she had not put any new interventions in place. She stated it was when the resident had a five pound weight loss from December to January, that she thought something wasn't right and then made recommendations to address the loss sooner. She stated that if she had been working at the facility and did know the whole history for the resident, then she would have probably placed other nutritional interventions in place to address the resident's weight loss. She stated that ideally the RDs working at the facility are supposed to review resident intake records to assess if residents are meeting their needs, but then stated that they just could not do this daily being employed as a part time consultant and stated that they relied on nursing staff to communicate with them about resident intake if there were problems. During an interview on 1/4/13 at 11:10 am, the RNUM stated that if they see that a resident is not eating or having a problem with weight loss, then she puts the resident on weekly weights and would send a memo to the dietary department. She stated that they tried to get the family involved, but then stated that this resident is a hard sell. She stated the resident was initially asked about his favorite foods, and asked during meal times about substitutions for food from the kitchen, but that he often refuses. She stated that when this resident did have occurrences of weight losses of three lbs or more, a reweight should have been completed, but that these were not completed according to the resident's weight record. She stated that a designated Licensed Practical Nurse (LPN) transcribed all resident weights down on the monthly weight record and then gave this information to the RD. She stated this did not capture weekly weights. She stated that the resident's weekly weights were documented on a separate sheet and that whenever there was a change of three or more lbs, the same designated LPN that transcribed the monthly weights was responsible for sending a memo to the RD if this was identified from week to week. The RNUM was only able to locate the one weight change memo that was dated 10/19/12. She stated after the memo was sent, the RD usually came up with recommendations on how to address the weight loss. She stated that she didn't know what to say because she was surprised that the previous part time RD consultant who had worked at the facility had not documented new interventions. She stated that the staff tried Ensure in the past with the resident and he refused, but there was no evidence of this having been trialed for any period of time documented in the nutrition or nurse's notes. She stated that the attending MD was made aware of the resident's poor appetite and he spoke to the wife about encouraging the resident to eat. She stated the staff kept telling the doctor, and he stated to just keep telling the family and trying to encourage the resident to eat. During an interview on 1/4/13 at 1:10 pm, the attending MD stated he knew the resident was not eating or drinking. He stated the resident was very difficult and that if the he continued to lose weight, the facility would have to talk with the family about a plan to address this. During an interview on 1/7/13 at 9:00 am, the Social Worker stated that since the hospital lost the resident's dentures, the family had gone back and forth with the hospital for payment of a new set of dentures. She stated that this had been out of the hands of the facility for replacement of the dentures. She stated that the resident was to be seen on 1/7/13 denture impressions. She stated that the psychologist at the facility addressed this resident's mood and behavior and if he recommended anything, then he would have let the facility know. She stated she did know that the antidepressant [MEDICATION NAME] is sometimes used for mood and appetite stimulation, but that this had never been recommended by the psychologist and never came up in team discussions. She stated that the psychologist was primarily addressing this resident from a behavioral standpoint. During an interview on 1/7/12 at 9:30 am, the DON stated that they did a lot for this resident's behaviors through medication management and that the resident was now smiling and participating more. The DON stated she could see where there was a lack of interventions put in place. She stated she was surprised the previous RD had not put nutritional interventions into place. She stated that hindsight is always 20/20 and could see they could have done better with addressing this resident's weight loss as a team. Resident #33 The resident was admitted to the facility February 2011 he was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's weight in June 2012 was documented as 135.6 lb. His height was documented to be 67 inches. The resident's weight from January 2012 was documented to be 159.7lb. His current weight for January 2013 is documented to be 113.7. The current physicians orders resident 's diet consisted of No Added Salt (NAS),Fat Controlled pureed, Honey thickened Liquids, Pro Stat 64 2x a day. The resident was to receive A Magic Cup at lunch. The Comprehensive Care Plan for Nutrition dated August and December 2012, documented the resident was a total assist for eating and drinking due to the resident being unable to make needs known. The dietary Quarterly Nutrition Review dated 8/31/12 documented the residents BMI was at 19.03, or low end of the healthy range. The resident's weight at that time was 121.5lb. Three months prior the resident's weight was 139.2lb, and at that time it was documented that the resident had a significant weight loss from 3 months prior (12.93 %). The dietary recommendation at that time was to give 2 additional margarine at every meal for increased calories, and a request was made for 2 Cal HN 4 ounces (oz) three times a day at 10:00 am, 2:00 pm and 8:00 pm. The weight goal was documented to maintain weight at 121 +/- 4 lbs for 90 days. A new nutrition [DIAGNOSES REDACTED]. A dietary note dated 10/11/12 documented the October 2012 weight was 115.2 lb, weight now down 9 lbs/7% in 3 months. Nursing stated intake was very good at 100%. The intake record at dinner documented the resident consumes 50-75% of the meal. 2 Cal HN 4 oz at 10:00 am,2:00 pm and 8:00 pm sent daily. There is no documentation of intake. RD to request 2Cal HN to be increased from 4 oz to 8 oz three times a day. The dietary record Quarterly Nutrition Review, dated 12/11/12, documented the resident's BMI at 17.10%, underweight with a significant weight loss. The resident continues to tolerate diet well, consuming 50-100% of meals and supplements. No labs are available for review. The resident was noted to have a 22 lb weight loss, 16% in 6 months. Recommend that 4 oz of 2Cal HN be increased from three times a day to four times a day. Continue to monitor weight and food intake. The weight goal documented was to maintain weight of 115lb =/- 3 lbs x 90 days. The new Nutrition [DIAGNOSES REDACTED]. The Intake sheet for Fluids and Solids for October 2012, November 2012, December 2012 and January 2013 were reviewed and there was no documentation for the amount consumed for the 10:00 am, 2:00 pm and 8:00 pm nourishments. The Medication Administration Records (MAR) for October 2012, November 2012, and December 1 through 18 2012, did not include 2Cal HN to be administered at 10:00 am, 2:00 pm, and 8:00 pm. The December 2012 /January 2013 MARs had documented an order for [REDACTED]. There was no documentation the 2Cal HN was administered. There was no documented MD order for the 2Cal HN until December 11, 2012. During an interview on 1/7/13 at approximately 10:00am the LPN stated the 2Cal HN 4 times a day was documented on the MAR from December 19, 2012 through January 7, 2013. The 2CalHN was not documented as administered 4 times a day as there were no signature in any of the boxes during this time frame. The LPN stated that they only give 2Cal HN if it is handwritten on the MAR, and not printed from the pharmacy. During an interview on 1/7/13 at 2:30 pm the residents' CNA stated that the CNA's and sometimes the LPN's pass the nourishments. The CNA stated the it was the responsibility of the person who passed them to document. During an interview on 1/7/13 at 3:00pm with the DON and ADON, the DON stated that she was unaware of the weight loss for this resident. She stated that the ADON, is responsible for compiling this data. Additionally the DON stated that weight loss is discussed at morning meeting. The ADON stated that she receives the information of weight loss from the units and compiles it for the morning meetings. She stated that the resident was not on the list she received from the unit. The DON stated that the process for residents who receive additional nourishments such as 2 Cal HN that the dietitian fills out a form for the MD to review and approve, and that form is then sent to the kitchen where individual labels are made for the resident trays. Additionally,the DON and ADON stated they were not aware the 2Cal HN was not being documented on the MARs or on the intake sheets. They stated that 2Cal HN needed a MD order and it should be documented on the MAR. They were not aware that the 2Cal HN was not ordered from the MD until December 2012, and when it was ordered and placed on the MAR from the pharmacy the staff did not give it because it was not hand written on the MAR. A telephone interview was conducted with the Attending MD on 1/7/13 at approximately 3:30pm. The MD stated that she could not remember this resident and stated "I don't know I cover two nursing homes." During an interview on 1/7/13 at approximately 4:15 pm the Administrator stated he was not aware of the weight problem until yesterday when you (surveyors) started looking into it. He stated he should have been made aware of any problem. The Administrator stated there were no Quality Assurance studies related to weight issues. Resident # 46 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] assessed the resident with no cognitive impairment and able to understand and be understood. The Initial Nutrition Risk assessment dated [DATE] documented the resident's admission weight as 118.6 and the interpretation as the resident is in the healthy range and slightly overweight. The estimated nutrients needs documented the daily caloric need to be [PHONE NUMBER] calories per day and protein needs for the day as 55 Grams. The weight goal documented to maintain weight at 118 lbs +/- 4 lbs for 90 days. Weight records for 2012, titled Weekly/Bi-Weekly Weight Records, documented weight values as: 118.6 on 9/5/12, 117.9 on 9/12/12, 118.8 on 9/19/12, 115.3 on 9/26/12, 116.8 on 10/10/12 and 10/17/12, 117.5 on 10/24/12, 116.4 on 10/31/12, 113.2 on 11/7/12, 112 on 11/21/12, 111 on 11/28/12, and 109.2 on 12/12/12. No weights were recorded on 10/3/12, 11/14/12, 12/5/12, 12/19/12, and 12/26/12. All weights were recorded in pounds(lbs) Weight records, titled Weight Record 2012, found in the miscellaneous section of the resident chart, documented weight values as follows: 9/2012 - 118.6, 10/2012 -118.7, 11/12 - 116.4, and 12/12 - 109.2. Facility staff verified a weight value obtained on 1/7/13 as 105. Weight records for the nursing unit, verified by the Registered Nurse Manager (RNM) as the form utilized to track weight trends on the unit level, documented weight values for 9/2012- 118.6, 10/12 - 118.7, 11/12- 116.4, and 12/12- 109.2. Another weight record, also identified by the RNM as the form utililized to track weight trends on the unit level, documented the same weight values for the time period with the exception of 12/12 the resident's weight was documented as 105.4lb. During an interview on 1/7/13 at 10:30am the RNM stated she could not be sure which of the weight records used to trend weight record for 12/12 was the correct value. The Monthly Weight Changes form, used by the ADON to track facility weight changes, for 9/12, 10/12, and 11/12 did not have documented weights for Resident #46. No Monthly Weight Change for 12/2012 to track resident weight's could be found. The NCPN dated 9/25/12 documented the resident was adjusting to placement, continues on regular diet with small appetite and weight was stable at 118.7 pounds. The NCPN dated 10/16/12 documented a 30 day review, which lacked documentation of a October weight. The NCPN dated 11/5/12 documented the November weight as 116.4 lbs and October weight as 118.7 lbs and intake was 50-75 % at meal times. The Quarterly Nutrition Review dated 12/22/12 documented the resident's current weight as 109.2 with the weight obtained 1 month ago as 116.4 and weight obtained 3 months ago as 118.6. The Review documented a 6.1 % decrease in weight in 30 days and 7.9 % decrease in the last 3 months. The Review documented the weight trend as a weight loss and the current diet order as regular, small portions per request. The Review documented the percentage of meal intake as 25-75% and estimated intake from diet as 1500 calories and 60 Grams per day of protein. A recommendation was made for fortified mashed potatoes with lunch and supper and fortified cereal (oatmeal) every morning. The MD progress notes dated 11/1/12, 11/8/12, and 11/29/12 documented no reference to weight loss. The Nutrition/ Hydration Care Plan dated 12/22/12 documented the resident will maintain weight of 109 lbs +/- 2 lbs by 03/2013 and the resident will maintain weight of 109 lbs with no further loss by 03/2013. No nutrition care plan could be found in place prior to 12/22/12. Intake Sheets for Fluids and Solids dated 11/2012 and 12/2012 documented the resident consumed 0 % of breakfast on 2 occasions, 25 % of breakfast on 9 occasions, 50 % of breakfast on 19 occasions, 75 % of breakfast on 21 occasions and 100% of breakfast on 5 occasions. The Intake sheets for 11/2012 and 12/2012 documented the resident consumed 25 % of lunch on 17 occasions, 50% of lunch on 16 occasions, 75% of lunch on 13 occasions, and 100 % of lunch on 3 occasions. The Intake sheets documented the resident consumed 0 % of dinner on 1 occasion, 25 % of dinner on 22 occasions, 50 % of dinner on 23 occasions, 75% of dinner on 4 occasions, and 100% of dinner on 1 occasion. The Intake sheets had no entry for breakfast 7 occasions and no entry for lunch on 9 occasions. Physician orders [REDACTED]. During an interview on 1/7/13 at 9:30 am the resident stated she has had a fair appetite. The resident stated she does not like to eat too much but she has not been trying to lose weight. The resident stated she was not aware of an 11 lb weight loss between 11/2012 and 01/2013. The resident stated some foods look appetizing and some don't. The resident stated she is not often offered foods she likes to eat but will receive an alternate entree if requested. The resident stated she does receive bread and butter at mealtime and may or may not eat the bread and butter depending on the entree ordered. During an interview on 1/4/13 at 1:30 pm the CNA stated she works with the resident on a regular basis and assists the resident with meal/tray set up. The CNA stated the resident will usually consume 75 % of breakfast and 50 % of lunch. The CNA stated the resident will sometimes ask for an alternate meal selection if she does not like the selection served. During an interview on 1/4/13 at 12:30 pm and reinterview on 1/7/13 at 10:00 am the RNUM stated it is her responsibility to monitor weight losses or gains of residents on her unit. The RNUM stated she reviews weights for gains or losses of 3 or more lbs and will advise staff to reweigh as needed. The RNUM stated that when reweights occur and the loss or gain is again noted she will notify the Registered Dietician (RD) and/or the physician. The RNUM stated there has been a change in RD coverage recently and she was not sure who should have been notified of the resident's weight loss. The RNUM stated she utilizes a weight sheet for monitoring of monthly weights and for the resident there were two copies of the same record that had 2 different weights entered for 12/2012. The RNUM stated one copy had 105. 4 lbs listed and the other copy had 109.2 lbs listed and she could not be sure which copy was correct. The RNUM did not report an 11 lb weight loss if one sheet was accurate or an 7 lb weight loss if the other sheet was accurate to the RD, MD, or nursing administration. The RNUM stated that a CCP was not put in place until 12/22/12 by the RD. During an interview on 1/4/13 at 12:45 pm the RD stated there was a recent change in RD coverage of the facility. The RD stated she completed a Quarterly Nutrition Review on 12/22/12 when it became apparent the resident had experienced a weight loss. The RD stated she was not aware of any weight loss for this resident prior to 12/22/12. The RD stated the resident had experienced a 6.1 % significant weight loss and this weight loss caused the RD to recommend changes to in the resident's diet to the MD. The changes to the resident's diet included recommending a regular diet with smaller portions and fortified cereal (oatmeal) at breakfast and fortified mashed potatoes with lunch and dinner. The RD stated she could not find a CCP for nutrition for the resident prior to 12/22/12 and stated she implemented a CCP at that time. During an interview on 1/7/13 at 2:00 pm the Food Service Director stated the recommendation from the RD to the MD for fortified cereal at breakfast and fortified mashed potatoes at lunch and dinner was not started until 12/26/12. During an interview on 1/7/13 at 2:45 pm the physician stated he was not aware the resident had experienced a weight

Based on medical record review and staff interviews during a complaint investigation (Case #NY 157), the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of two residents reviewed. Specifically, the facility did not ensure that Resident #1 was protected from burns when on 2/29/12 she was served hot soup at dinner and spilled the hot soup into her lap sustaining second degree burns on both thighs. This resulted in actual harm that is not immediate jeopardy. This is evidenced by the following: Resident # 1 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] assessed the resident as having moderately impaired cognitive ability. The MDS further assessed the resident to require extensive assist of one for eating. In a document titled, Resident Incident Event Report, dated 2/29/12 at 6:15pm, the author documented that Resident #1 spilled hot soup on her lap during dinner on 2/29/12. Under the injury section of the form the author documents, right thigh 19 X 6 cm area with intact blisters, left thigh 3 X 2 cm. In the pain level section of the report, the author documented that the resident "did not verbalize actual level of pain and complained of tingling pain, mild" Under the first aide section, the author documented that cool compresses were applied to the reddened areas and Tylenol was given to the resident for tingling pain. In the conclusion section of the report, the author documented "staff to be sure clothing protector in place and covering entire lap area; Resident says "bowl was on the table and next thing it was in my lap." In a nurse's note dated 2/29/12 at 7:55pm, an RN documents that she was called at 6:30pm to assess Resident #1 who reported to her, "I spilled the soup on me." The RN describes an area on the right upper inner thigh, approximately 19cm X 6cm with intact blisters and a reddened area on the left inner upper thigh measuring 3cm X 2.4cm. The RN documents that cool compresses were applied and when the resident complained of pain she was given Tylenol 650mg. The physician was notified and ordered silvadene ointment to be applied to the area, covered by a dry sterile dressing. In a progress note dated 3/7/12, physician (MD #1) wrote in Resident #1's medical record, "Bed/chair bound, moves extremities at will. Tremors both arms, mild." In a second progress note, the facility Medical Director (MD #2) wrote on 3/15/12 that the resident was seen on that day for a history of soup-spill burns to right upper thigh area on 2/29/12, 2cm wide X 10cm long burn. MD #2 wrote checked wound today and it appeared to be healing with medial aspect sloughing. Staff advised to continue treatment with wound evaluation every shift and notify MD #1 with any change. Care plan modification with kitchen staff and long bibs instituted. During an interview on 4/18/12 at approximately 2:30pm, a certified nursing assistant (CNA #1) stated that on 2/29/12 as she was finishing up in the dining room after dinner, Resident # 1 reached out to her and asked for her help as she walked past the resident's table. When the CNA looked, she saw that Resident # 1 was holding an empty bowl of soup and said that she had spilled her soup and could she have help to clean it up. CNA # 1 stated she did not see the resident spill the soup, did not know how long the resident had been sitting with the soup on her lap. CNA#1 cleaned up what she could of the soup in the resident's lap and when she asked if the resident was "okay," the resident replied that she was. CNA #1 recalled that a short time later another CNA (CNA #2), came to the dining room to push Resident # 1 back to her unit. CNA #1 advised CNA #2 that if there was a reddened area on the resident's thighs when they removed her pants as they undressed her for bed, that it should be reported to the charge nurse because the resident had spilled soup in her lap. CNA #1 stated that normally Resident # 1 is "pretty shaky" with tremors when she sees her. CNA # 1 stated that sometimes the soup coming off the food truck in the assist dining room can be "pretty hot." CNA #1 could not recall if the soup was hot on that night (2/29/12). During an interview on 4/18/12 at approximately 10:00am the dining room manager (DRM)stated that temperatures were taken randomly of food items and logged in a log book. The temperature of the food item as it was plated at the tray line was logged in as a "begin temp" on the log sheets; the temperature of the food item as it was ready to be served in the dining rooms or on the food trucks on the units, was referred to as "end time." The DRM stated that the temp of tea and coffee when it was ready to be served, was generally between 185 and 175 degrees, and soup temperature was usually between 185 and 175 degrees as it was ready to be served. The DRM stated that food temperatures were usually taken every day on some food items and a dummy tray (test tray) was checked for quality at lunch time about every two weeks. The DRM stated that the temperatures were documented on a log sheet and kept in his office. A review of the temperatures on the log sheets for soup served at the dinner meal on 3/6/12 revealed a "begin temp" of 180 degrees and an "end temp" of 176 degrees; soup on 3/2/12, "begin temp" 190 and "end temp" 187; soup on 3/1/12, "begin temp" 190 and "end temp" 187; soup on 2/27/12, "begin temp" 190 and "end temp" 188. The DRM stated that he could not find a log sheet for soup temperature checks at dinner on 2/29/12. He was not sure if there was a soup temperature checked on that date. 10NYCRR 5.12(h)(1)(2)