Every finding on record at Salamanca Rehabilitation & Nursing Center

Based on interview and record review conducted during a complaint investigation (NY00370043- 694884) completed during the standard survey completed on 12/05/2025, the facility did not ensure that all alleged violations involving abuse were reported immediately, but not later than two (2) hours after the allegation was made, to the administrator and to the state survey agency for two (2) (Residents #10 and #120) of three (3) residents reviewed. Specifically, facility staff did not report alleged sexual abuse to the administrator immediately which resulted in not reporting to the state survey agency within the required time frames.The findings are:The policy titled Abuse- Investigation, Protection and Reporting, dated 10/24/2022, documented that abuse will be thoroughly investigated and promptly reported to local, state and federal agencies. All reports of an alleged violation of abuse will be reported immediately, but not later than (2) two hours after the allegation.Resident #10 had diagnoses including Wernicke's encephalopathy (a severe brain disorder caused from lack of thiamine, causing confusion, unsteady walking, and vision issues), history of alcohol abuse and generalized anxiety. The Minimum Data Set, dated [DATE] documented they were severely cognitively impaired, usually understood and usually understands others. Resident #10 was independent with mobility and required partial/moderate assistance from staff for dressing.The comprehensive care plan dated 07/22/2020 documented Resident #10 had a self-care performance deficit related to a history of alcohol abuse. They were independent for mobility but required limited assistance from one (1) staff for lower body dressing. They had impaired cognitive function related to dementia and staff should ask yes or no questions.Resident #120 had diagnoses including dementia, chronic obstructive pulmonary disease (lung disease that makes it difficult to breath), and heart failure. The Minimum Data Set, dated [DATE] documented Resident #120 was cognitively intact, always understood and always understands others, and were independent with mobility.The comprehensive care plan dated 01/01/2025 documented a behavior problem of making exaggerated, off-colored, provocative statements to elicit reactions from staff. Also embellishes stories for comedic effect, staff were to reinforce why the behavior was inappropriate and educate that making jokes about events could lead to consequences.The facility Investigation, completed on 01/31/2025, included staff and resident interviews . The investigation documented on 01/26/2025 Certified Nurse Aide #1 reported the allegation of sexual abuse, that occurred on 01/24/2025, to Registered Nurse #3. Registered Nurse #3 reported the incident to the Director of Nursing immediately and assessed both residents. The investigation revealed Certified Nurse Aide #1 stated, while doing rounds, they knocked on Resident #10's doorframe and entered the room. The room was dark with the TV on, they thought they saw Resident #10 lying flat on the bed with their pants down and Resident #120 laying on their side, fully clothed, with their back to the door and their head near Resident #10's pelvic area. They were uncomfortable so they left the room to get another certified nurse aide to help get Resident #120 out of the room. When they returned with another certified nurse aide, both residents were fully clothed and sitting upright on the bed. Neither resident appeared distressed. The two residents were close friends, but staff had never witnessed anything sexual prior to the incident. Resident #10 denied anything inappropriate occurred. Resident #120 initially made comments about inappropriate behavior but then immediately changed their story. When the staff made them leave the room, they stated that you people can't take a joke, nothing happened.Review of Resident #10's progress notes dated 01/24/2025-1/25/2025 revealed there was no documented evidence of alleged sexual abuse with Resident #120.Resident #120's progress notes dated 01/24/2025 - 01/25/2025 revealed there was no documented evidence of alleged sexual abuse with Resident #10.The 24-Hour Nursing Services Reports dated 01/24/2025 - 01/25/2025 did not document the alleged abuse between Resident #10 and Resident #120. The 24-hour report sheet dated 01/26/2025 documented that Resident #10 and Resident #120 were not allowed in rooms alone- use public space for visits.During an interview on 12/02/2025 at 12:00 PM, Resident #120 stated they did have a friendship with Resident #10, but they had never had any sexual contact with them. They went down to sit in the hall with them occasionally.During an interview on 12/03/2025 at 9:43 AM, Resident #10 stated they did not recall an incident with Resident #120. They did not recall having a friendship with Resident #120. They did recall that they were not allowed to have female residents in their room. Resident #10 stated they had never been intimate with anyone in the facility.During a telephone interview on 12/04/2025 at 1:00 PM, Certified Nurse Aide #1 stated they were not really sure what they saw on 01/24/2025. They recalled they knocked and walked into Resident #10's room. It was dark, with just the TV on. At the time they thought they saw Resident #10 laying on their back with their pants down and Resident #120 laying on their side, with their head near Resident 10's groin. Their back was to the door. Neither resident was moving. They felt uncomfortable with what they saw so they stepped back out of the room and went to tell Licensed Practical Nurse #1 and get help from Certified Nurse Aide #2. Licensed Practical Nurse #1 did not really respond to what they told them, they did not know if they reported it to the supervisor at that time. Within a few minutes, Certified Nurse Aide #1 & Certified Nurse Aide #2 went into Resident #10's room. When they entered the room both residents were fully clothed and sitting on opposite sides of the bed. Resident #120 was escorted out of Resident #10's room. Certified Nurse Aide #1 stated they were talking about what they thought they saw to another staff member when the supervisor overheard them, on 01/26/2025, and that was when they changed their care plans to not allow them in each other's rooms.12/04/2025 at 10:53 AM, a telephone interview was attempted with Certified Nurse Aide #2 without success.12/04/2025 at 10:54 AM a telephone interview was attempted with Licensed Practical Nurse #1 without success.12/04/2025 at 11:00 AM a telephone interview was attempted with Registered Nurse #3 without success.During an interview on 12/04/2025 at 11:40 AM, the Assistant Director of Nursing (previous unit coordinator on 1 WEST) stated they were made aware of the alleged incident on Monday 01/27/2025 during morning report. They stated Licensed Practical Nurse #1 should have reported the allegation to the supervisor immediately and they would have called the Director of Nursing to start the investigation. During an interview on 12/05/2025 at 9:59 AM, Registered Nurse #1 stated they were the supervisor on the evening of 01/24/2025. They stated they were not notified of any alleged inappropriate behavior between Resident #10 and Resident #120. Registered Nurse #1 stated that they would have immediately notified the Director of Nursing so the allegation could have been investigated and reported to the state. Registered Nurse #1 stated allegations of abuse should be reported within two (2) hours.During an interview on 12/05/2025 at 10:07 AM, the Director of Nursing stated they expected all staff to report inappropriate behavior between residents immediately. They were educated on abuse reporting when they were hired and at least annually. They were notified by Registered Nurse #3 on 01/26/2025, they started the investigation and reported the allegation to the state. The Director of Nursing stated Licensed Practical Nurse #1 should have reported the allegation to the supervisor immediately.During an interview on 12/05/2025 at 10:24 AM, the Administrator stated they expected their staff to report any allegations of abuse immediately. Certified nurse aides should report to the nurse, and the nurse should report to the supervisor. They were made aware of the allegation on 01/26/2025 by the Director of Nursing who reported it to the state. The Administrator stated allegations of abuse should have been reported immediately because they only had two (2) hours to report it to the state.10 NYCRR 415.4 (b) (2 )

Based on observations, interviews, and record review conducted during a Standard Survey completed on 12/05/2025, the facility did not ensure that each resident who was unable to carry out Activities of Daily Living received the necessary services to maintain grooming and personal hygiene for 1 (one) (Resident #8) of five (5) residents who were reviewed for activities of daily living. Specifically, Resident #8 who was dependent on staff for all Activities of Daily Living was not provided with timely incontinent care. Additionally, infection control practices were not maintained during care.The finding is:The policy and procedure titled Toileting, dated 03/07/2022 documented it is the policy of the facility to provide all residents with timely, person centered assistance for toileting that maintain dignity, promotes independence, and supports continence to the greatest extent possible. Residents are to be assessed for voiding patterns and care planned appropriately. Timely Response: answer call lights promptly, anticipate needs at predictable times (e.g., wake-up, after meals, bedtime). Based on intervals on diary (e.g., every 2-4 hours). Infection prevention: Hand hygiene before and after toilet assist. Cleanse gently after episodes of incontinence. Appropriate use of gloves and PPE, clean disinfect toilet equipment and surfaces per protocol.Resident #8 had diagnoses of hemiplegia (paralysis of one side of the body) multiple sclerosis (an autoimmune disease of the central nervous system), diabetes mellitus, and osteomyelitis (an infection of the bone). The Minimum Data Set (a resident assessment tool) dated 07/04/2025 documented the resident was severely cognitively impaired, sometimes understands and was sometimes understood by others. The Minimum Data Set documented the resident was non-ambulatory, required total dependence on staff for toileting and hygiene; and was always incontinent of bowel and bladder.The Comprehensive Care Plan dated 07/03/2025 documented Resident #8 had bowel and bladder incontinence related to impaired mobility. Interventions included but not limited to, were to use disposable briefs, change as needed, clean peri area with each incontinence's episode.Review of a Kardex (a guide used by staff to provide care) dated 10/01/2025 documented to maintain enhanced Barrier precautions at all times, clean peri area with each incontinence episode, resident uses disposable briefs, change resident as needed. Resident #8 was a total assist of two staff members.During a continual observation on 09/30/2025 from 9:04 AM - 11:00 AM Resident #8 was seated in a Geri chair in their room near the nurse's station. The resident repeatedly called out for assistance with incontinence care. Staff did not respond.At 11:21 AM Certified Nurse Aide # 5 entered the resident's room. Resident #8 was saturated with urine, and their clothes were visibly wet.During an interview on 09/30/2025 at 11:55 AM, Certified Nurse Aide #5 stated Resident #8 was a heavy wetter and that was why they were so wet.Observation on 10/01/2025 at 11:21 AM Resident #8 called out they needed to be changed.During an observation on 10/01/2025 at 11:28 AM Certified Nurse Aide #5 and Certified Nursing Aide #6 entered Resident #8 room and mechanically lifted the resident into their bed. Resident #8 was saturated with urine. The resident's clothing and chair cushion were visibly wet; and a puddle of urine was noted on floor beneath the resident. Staff completed incontinent care, without changing their gloves Certified Nurse Aide #5 handled the residents' oxygen tubing and resident's personal items.During an interview on 10/01/2025 at 11:04 AM, Resident #8 stated they were wet, and they did not feel clean. Resident #8's stated they did not press their call bell because it does not do any good so they would have to call out. They stated there was enough staff, but they would ignore them.During an interview on 10/01/2025 at 11:48 AM, Certified Nurse Aide #5 stated residents were to be changed every two hours and/or as needed. They stated Resident #8 was a part of their rounds that morning, but when they went to check on resident earlier, they were tired so decided to come back later. They stated a lapse in glove change after peri-care created infection risks when the oxygen tubing was touched with dirty gloves. They stated Resident #8 should have been checked and changed earlier. That would have avoided the resident being saturated with urine through their brief, clothing, chair cushion and onto the floor.During an interview on 10/01/2025 at 11:55 AM, Certified Nurse Aide #6 stated Certified Nurse Aide #5 forgot to change their gloves after incontinent and peri-care and could have caused cross contamination when they touched Resident #8's oxygen tubing. They stated residents were to be changed every two hours per facility policy and as needed. They stated that this was important to make sure the resident skin did not breakdown. They stated Resident #8 was a heavy wetter but felt that the resident must have waited over two hours by evidence of the puddle of urine on the floor and saturated brief, pants and wheelchair cushion.During an interview on 12/05/2025 at 8:55 AM, Certified Nursing Aide #4 stated the policy for incontinent care was to check residents every two hours or as needed. They stated it was unacceptable for a resident to have their wheelchair and clothing soaked with urine.During an interview on 12/05/2025 at 9:48 AM, Licensed Practical Nurse #2 Supervisor, stated the certified nurse aides were to physically check residents for incontinence every two hours. They stated this was important to maintain skin from breakdown, for residents' dignity, and their general wellbeing. They stated Certified Nurse Aide #5 should have changed their gloves after incontinent care and after performing peri care due to infection control measures.During an interview on 12/05/2025 at 10:22 AM PM, the Director of Nursing stated their expectation was for staff to address residents that were calling out right away. They stated staff were to make their rounds for incontinent care every two to four hours. They stated their expectation would be for the staff to look on the Kardex to see how frequently incontinent care was to be performed, since it varied resident to resident. They stated no resident should be left in urine-soaked clothing, wheelchair cushions, or have urine puddles on their floor. They stated when the Certified Nursing Aide #5 completed Resident #8's peri care they should had changed their gloves to reduce the risk of cross contamination. They stated Certified Nursing Aide #5 should have not touched the tubing with the dirty gloves and Certified Nursing Aide #6 should have stopped them immediately, corrected them, and told them to get a new nasal canal and replace it. 10 NYCRR 415.12 (a) (3)

Based on observation, interview and record review during a Standard Survey completed on 12/05/2025, the facility did not ensure that all residents remained free of accident hazards as is possible, and each resident received adequate supervision to prevent accidents for one (1) (Resident #19) of five (5) residents observed for accidents. Specifically, the facility did not identify a potential hazard that Resident #19 had an e-cigarette/vape device stored in their room. Additionally, there was no order for use of an e-cigarette/vape, no care plan interventions for its use, and no assessment by the interdisciplinary team to ensure safe storage of the device. The finding is:The policy titled Resident Safety and Accident Prevention dated 03/2025, documented the facility is committed to providing a safe and supportive environment for all residents by implementing a structured, proactive accident prevention program. The program focuses on identifying and addressing both individual and environmental factors that could contribute to resident injury or illness. The facility routinely evaluates all resident accessible areas for potential hazards and promptly implements corrective actions as necessary to reduce risk. Residents and or their designated representatives will be educated on identified risks, expectations for safe behavior and any interactions in place.The policy titled Smoking Policy dated 10/23/2025, documented the facility protects the rights and safety of the residents, staff members and visitors, and a restricted smoking policy has been adopted by the facility. Smoking (including e-cigarettes) is forbidden in all indoor and outdoor areas of the facility for residents. Residents will be educated upon admission regarding the facility smoking policy. All residents that express a desire to smoke will have smoking assessment completed to determine their safety and physical ability to smoke. Smoking privileges will be granted based on the smoking assessment. Residents who are determined to be safe to smoke independently, will be required to surrender all smoking materials to staff. They must be able to go outside of facility property to smoke.Resident #19 had diagnoses of chronic obstructive pulmonary disease ( lung and airway disease that restricts breathing), type 2 diabetes mellitus, and bipolar disorder (a brain disorder causing extreme shifts in mood, energy and activity levels). The Minimum Data Set (a resident assessment tool) dated 09/26/2025, documented that Resident #19 was cognitively intact, able to understand others and could be understood by others. Resident #19 had no upper or lower extremity impairments, utilized a walker and wheelchair for mobility, was independent with all activities of daily living, and had no behavioral issues.Review of a Comprehensive Care Plan dated 10/06/2025, documented Resident #19 was able to smoke while out of the facility on pass. Interventions included cigarettes and lighter must be kept in a secure place with the nurse, the resident may sign themselves out of the facility daily to smoke off the property, educate the resident on the effects of smoking verses nonsmoking, and offer other options to refrain from smoking. Resident #19 was at risk for actual falls due to history of falls and interventions included safety monitoring at the beginning and end of the shift and with all rounds every shift. There were no interventions regarding the use of an e-cigarette/vape device.Review of a Kardex (a guide used by staff to provide care) dated 12/05/2025, documented Resident #19 preferred eating meals in their room, resident preferred to have several items on their bed at all times, and refused to declutter their room and bed area. The Kardex did not address the use of an e-cigarette/vape device.Review of a Smoking and Safety assessment dated [DATE], documented Resident #19 was assessed for smoking and safety with the use of tobacco products. Resident #19 safely demonstrated ability to use lighter, hold cigarette and extinguish appropriately. Resident #19 was independently safe to smoke outside of the facility. The assessment did not include use of an e-cigarette/vape or that the resident knew where smoking materials were supposed to be stored. During an observation on 12/03/2025 at 12:03 PM, Resident #19 was in bed resting. There were two brown bags full of snacks on the floor and one brown bag full of garbage. Resident had many items on their tray table and on their bed.During an observation and interview on 12/04/2025 at 11:48 AM, Resident#19 was lying in bed, they moved their blanket partially off them exposing an e-cigarette on the mattress, next to them. Resident #19 immediately tried to cover it back up with the blanket. They stated their family member took them to the store around Thanksgiving and they purchased it then. They stated they did not know they were not allowed to have it in their room. They stated they did not smoke in the facility only when out on pass. During an interview on 12/04/2025 at 11:50 AM, Licensed Practical Nursing Supervisor #2 stated they were unaware that Resident #19 had an e-cigarette and would address the issue right away.During an interview on 12/04/2025 at 11:52 AM with Licensed Practical Nursing Supervisor #2 they stated they retrieved the e-cigarette/vape from Resident #19, secured it in a safe location, educated resident, notified administration and attempted to contact residents' health care proxy. They stated the resident would be able to ask for it when they went out on pass and would have to give back to the nurse when they returned. They stated Resident #19 told them they go out on pass three times a week for lunch and only smoked their e-cigarette then.During an interview on 12/04/2025 at 1:15 PM with Certified Nursing Aide #7 they stated they never witnessed Resident #19 with an e-cigarette but if they did, they would report it to the nurse and let them handle it. They stated this was important because e-cigarettes could be dangerous in the hands of the wrong person.During an interview at 12/05/2025 at 9:33 AM, with Licensed Practical Nursing Supervisor #2 they stated Resident #19 had not had any cigarettes in the facility for months, but when they did, they would retrieve them from the nursing station and were always compliant with being 100 feet away from the building when they smoked. They stated the resident was compliant with giving them to staff to secure in a safe place. They stated when their family member would bring a new pack in, they would always bring them to the desk to be stored safely. During an interview on 12/05/2025 at 10:17 AM, Certified Nursing Aide #4 stated they had never witnessed Resident #19 using an e-cigarette or vape in their room. They stated if they did, they would make the resident aware they could not have that in their room and notify their supervisor.During an interview on 12/05/2025 at 10:18 AM with Certified Nursing Aide #8 they stated they never saw Resident #19 smoke an e-cigarette/ vape in their room. They stated if they did, they would notify the supervisor because it could be a fire hazard. During an interview 12/05/2025 at 10:25 AM with the Director of Rehab, they stated the assessment for an e-cigarette or vape would be the same assessment for a regular cigarette because it would require no additional dexterity (performing tasks with the hands). They stated Resident #19 was independent and would have the dexterity to utilize a lighter and an e-cigarette/vape. They stated Resident #19 was assessed as independently safe to smoke outside of the facility quarterly and they were never alerted the resident no longer utilized cigarettes. During an interview on 12/05/2025 at 10:30 AM with the Director of Nursing and the Administrator, they both stated Resident #19 knew they were not supposed to have the e-cigarette in their room and must have hidden it from staff. They stated if a staff member observed any smoking devices, they should notify their supervisor immediately and the items should be stored at the nursing station. They stated Resident #19, and their health care proxy were educated on this when the facility became non-smoking years ago. They stated all residents were educated on the smoking policy when admitted and this information was available in the welcome packet for new admissions. They stated when the policy for smoking went from a smoking facility to a non-smoking facility, Resident #19 was grandfathered in and was re-educated on when and where they could smoke moving forward. Resident #19 was compliant with all aspects of the smoking policy prior to this incident.10 NYCRR 415.12(h)(2)

Based on observation, interview, and record review conducted during a Standard survey completed 12/05/2025, the facility did not store all drugs and biologicals in locked compartments for one (1) unit (2 West) of three (3) units reviewed for medication storage. Specifically, medications for Resident #21 were left unattended and unsecured on an over the bed table in their room. The finding is: The policy titled Self-Administer of Medications reviewed 03/2025 documented staff shall identify and give to the Charge Nurse any medications found at the bedside that are not authorized for self-administration. Resident #21 had diagnoses including hypertension (high blood pressure), congestive heart failure (a chronic condition where the heart is too weak to pump blood), and anxiety disorder. The Minimum Data Set (resident assessment tool) dated 09/05/2025 documented Resident #21 was understood, understands and was cognitively intact. The comprehensive care plan dated 05/09/2025 documented Resident #21 would make choices as able. The care plan lacked documented evidence that Resident #21 had the ability to self-administer any medications. Review of the Medication Review Report dated 10/01/2025 revealed there was no physician's order for Resident #21 to self-administer the medication or to leave medications at the bedside. Review of the Self-Administration of Medication form dated 12/18/2024 documented Resident #21 was not approved for self-administration of medications and may not keep medications at their bedside. During an observation on 09/29/2025 at 11:14 AM, Resident #21 was not in their room. There was a medication bottle that was approximately half filled and labeled Gas-X Total Relief simethicone/calcium carbonate, a nasal spray bottle labeled Mucinex Sinus-Max, a nasal spray bottle labeled allergy-flo nasal spray, and a bottle of pain-relieving liquid 4% lidocaine on their over the bed table in their room.During an observation and interview on 09/30/2025 at 10:36 AM, the same medications were on Resident #21's over the bed table. Resident #21 stated they were allowed to have the medications, and they think that the ones they had in their room were on their medication list at the facility.During an observation and interview on 10/01/2025 at 10:50 AM, with Licensed Practical Nurse #4 present, the same medications were on Resident #21's over the bed table in their room. Licensed Practical Nurse #4 stated the medications should not have been in Resident #21's room. They stated that the medications should have been brought to their attention sooner and removed from the room. They were unsure if Resident #21 had orders for any of the medications and they would have to check.During an interview on 10/01/2025 at 10:52 AM, the Assistant Director of Nursing stated all of the medications that were found needed to be removed immediately. The Assistant Director of Nursing reviewed the medication list in Resident #21's electronic medical record and stated Resident #21 had an order for simethicone but it was not ordered to keep the medication at the bedside or to self-administer. The Assistant Director of Nursing stated there was no order for lidocaine, Mucinex nasal spray, or allergy-flo nasal spray. The Assistant Director of Nursing stated the medications were all sitting in the open and any staff member who had been in the room should have been able to see them. The medications at the bedside should have been brought to their attention sooner.During an interview on 10/01/2025 at 11:07 AM, Certified Nurse Aide #4 stated they had seen the medications on Resident #21's on the over the bed tray table in their room for a couple weeks. They stated they did not realize that they should have brought it to the nurse's attention.During an interview on 12/04/2025 at 10:40 AM, Nurse Practitioner #1 stated they would never expect that volume of over the counter medications in Resident #21's room. Nurse Practitioner #1 stated it would have been common sense for anybody who had seen the medications at Resident #21's bedside to bring it to the nurse's attention and notify Nurse Practitioner #1. They stated they needed to know what Resident #21 was taking to make sure there were no interactions between the medications.During an interview on 12/04/2025 at 12:58 PM, Registered Nurse #1 Resident Care Coordinator stated the only residents who should have medications at their bedside would have been assessed to self-administer medications and have an order to keep the medication at their bedside to self-administer. Registered Nurse #1 Resident Care Coordinator stated their expectation of the certified nurse aides was to report any medications that were found in a resident's room to the nurse, resident care coordinator, or nursing supervisor. They stated it was important for staff to communicate any medications found in a resident room because then education would be provided to the resident or their family.During an interview on 12/05/2025 at 8:46 AM, the Director of Nursing stated there should never have been any medications left at any of the residents' bedsides unless it was approved. The stated it was expected that residents who wanted to self-administer medications to be assessed by nursing and by the nurse practitioner and there needed to be an order in place. The Director of Nursing stated, Certified Nurse Aide #4 should have let either the nurse on the medication cart, the resident care coordinator, or the nursing supervisor know about the medications in Resident #21's room.10 NYCRR 415.18(e)(1)

Based on interview and record review during the Standard survey completed on 12/05/2025, the facility did not implement written policies and procedures for screening employees, that would prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, five (5) employees (Certified Nursing Assistant #10, Housekeeper#1, Certified Nursing Assistant #11, Licensed Practical Nurse #5, and Certified Nursing Assistant #12) of ten (10) employees that were subject to the New York State Nurse Aide Registry Verification, were not reviewed through the New York State Nurse Aide Registry prior to their employment as required.The findings are:The policy and procedure titled Registry For Nurse Aides dated 01/17/2025 documented all certified nurse aides applying for a nurse aide position must present the Human Resources Director, or other designee, a copy of his/ her registration number. The Human Resources Director, or other designee, is responsible for contacting the State Nurse Aide Registry to determine the validity of the individual's certification status upon hire.1a. Review of Certified Nursing Assistant #10's personnel file revealed the employee was hired on 06/10/2025 and the file contained a New York State Nurse Aide Registry Verification Report for the employee dated 08/19/2025.Review of the electronic timecard information provided by the facility revealed Certified Nursing Assistant #10 had worked in the facility for 35 days from 06/16/2025 through 08/18/2025.During an interview on 09/30/2025 at 1:50 PM, the Human Resources Director stated Certified Nursing Assistant #10 was hired on 06/10/2025 to be a Resident Assistant and now the employee was a Certified Nursing Assistant. The Human Resources Director further stated the New York State Nurse Aide Registry Verification Report dated 08/19/2025 was the only report the facility had for the employee. 1b. Review of Housekeeper #1's personnel file revealed the employee was hired on 06/24/2025 and the file contained a New York State Nurse Aide Registry Verification Report for the employee dated 08/19/2025.Review of the electronic timecard information provided by the facility revealed Housekeeper #1 had worked in the facility for 37 days from 06/24/2025 through 08/18/2025.During an interview on 09/30/2025 at 1:56 PM, the Human Resources Director stated Housekeeper #1's was hired on 06/24/2025 to be a Housekeeper. The Human Resources Director further stated the New York State Nurse Aide Registry Verification Report dated 08/19/2025 was the only report the facility had for the employee.1c. Review of Certified Nursing Assistant #11's personnel file revealed the employee was hired on 09/15/2025 and the file contained a New York State Nurse Aide Registry Verification Report for the employee dated 09/29/2025.Review of the electronic timecard information provided by the facility revealed Certified Nursing Assistant #11 had worked in the facility for four (4) days from 09/15/2025 through 09/25/2025.During an interview on 09/30/2025 at 2:02 PM, the Human Resources Director stated Certified Nursing Assistant #11 was hired on 09/15/2025 to be a Certified Nursing Assistant. The Human Resources Director stated the New York State Nurse Aide Registry Verification Report dated 09/29/2025 was the only report the facility had for the employee.1d. Review of Licensed Practical Nurse #5's personnel file revealed the employee was hired on 08/15/2025 as an agency Licensed Practical Nurse and the file contained a New York State Nurse Aide Registry Verification Report for the employee dated 09/29/2025.Review of the electronic timecard information provided by the facility revealed Licensed Practical Nurse #5's had worked in the facility for nine (9) days from 08/15/2025 through 09/29/2025.During an interview on 09/30/2025 at 2:13 PM, the Human Resources Director stated Licensed Practical Nurse #5 was hired on 08/15/2025 to be a Licensed Practical Nurse and the employee was an agency Licensed Practical Nurse. The Human Resources Director further stated the New York State Nurse Aide Registry Verification Reports dated 09/29/2025 was the only report the facility had for the employee. 1e. Review of Certified Nursing Assistant #12's personnel file revealed the employee was hired on 10/01/2024 and the file contained a New York State Nurse Aide Registry Verification Report for the employee dated 01/16/2025.Review of the electronic timecard information provided by the facility revealed Certified Nursing Assistant #12 had worked in the facility for 70 days from 10/01/2024 through 01/16/2025.During an interview on 09/30/2025 at 2:49 PM, the Human Resources Director stated Certified Nursing Assistant #12 was hired on 10/01/2024 to be a Certified Nursing Assistant. The Human Resources Director further stated the New York State Nurse Aide Registry Verification Report dated 01/16/2025 was the only report the facility had for the employee.During an interview on 09/30/2025 at 3:00 PM, the Human Resources Director stated that New York State Nurse Aide Registry Verification Reports were conducted on all employees and that the reports were usually completed prior to an employee being hired at the facility. The Human Resources Director further stated they were not sure why the New York State Nurse Aide Registry Verification reports were not completed for the employees prior to the employees being hired.10 NYCRR 415.4(b)

Based on observation, interview, and record review conducted during a Standard survey completed on 9/1/23, it was determined that the facility did not ensure that the resident environment remains as free of accident hazards as is possible. Specifically, three (1 West, 2 East, 2 West) of three resident units had water temperatures that exceeded 120 degrees Fahrenheit ( F). The findings are: The policy and procedure titled Daily Domestic Hot Water Testing effective date 2017, with a reviewed date of 8/2023 documented this policy outlines the daily testing of the domestic hot water supply to ensure it is regulated within 90 - 120 F. Maintenance staff shall perform daily testing at all floors using a correctly calibrated thermometer. This gauge may be a digital or dial type and shall be tested weekly by comparison to other known correctly calibrated gauges. Water temperatures are to be taken on each resident unit daily, at varying times, at two separate locations. One at the beginning of the hot water circuit and one at the end of the circuit. Turn on hot water faucet and let the water run for approximately 10 seconds. Grasp the thermometer by the gauge ensuring that you are not touching the probe and insert the probe on the thermometer into the water stream. Keep the probe immersed in the water for 10 - 15 seconds. Record temperature at this time on a log sheet. Allow water to run for an additional 2 to 2 1/2 minutes (3 minutes total) and retest the water temperature by inserting the thermometer probe into the water for 10 - 15 seconds. Record this temperature on the log sheet. Temperature on mixing valve should be checked and adjusted as needed if water temperatures fall marginally outside the parameters during tests. Thermometers can be checked for calibration using the following method: Calibration in ice water. 1. Add crushed ice and cold tap water to a clean container to form a watery slush. 2. Place thermometer probe into slush for at least one minute taking care to not let the probe contact the container. 3. If the thermometer does not read 30 F to 34 F adjust to 32 F. Non-adjustable thermometers should be removed from use until they have been professionally serviced. Temperatures exceeding 120 degrees F: If a component of the domestic hot water system fails allowing unsafe hot water temperatures; the following procedure will remove the risk to residents, staff, and visitors. Activation Protocol: In the even that water supply temperature(s) are found to be excessively hot; notify a department manager or nursing supervisor on duty immediately. Review the following plan and start the initiate. Plan of Action: Department Manager or Nursing Supervisor will be notified to direct staff to shut off all water supplies at the bathrooms and dining rooms on the resident units. Staff shall utilize the under-sink supply valves, turning them slowly so as not to damage the valve assembly or cause possible injury. Maintenance staff will coordinate this effort. Water shall remain off until corrective action has been taken and maintenance staff confirm that water temperatures are safe. Observation in the Basement in the Boiler room on 8/28/23 at 12:58 PM revealed the building had two hot water tanks that supplied water to the building's domestic hot water system. The thermometer for one of the hot water tanks read 110 F and the thermometer for the second hot water tank read 130 F. The domestic hot water system also had a mixing valve (mechanical device that mixes cold water with hot water to deliver mixed, or tempered, water downstream in the system) and the thermometer for the mixing valve read 118 F. During an interview at the time of the observation on 8/28/23 the Environmental Services Director stated the building's domestic hot water system had two hot water tanks and a mixing valve. The hot water tanks for the building's domestic hot water system were not labeled or identified other than the tanks for the building's domestic hot water system. They also stated the thermometer for one of the hot water tanks read 110 F, the thermometer for the second hot water tank read 130 degrees F and the thermometer for the mixing vale read 118 F. The Environmental Services Director stated the thermometers for the two hot water tanks and the mixing valve, and the mixing valve were in place since they started working at the facility in 2019 and the thermometers and mixing valve had not been recalibrated or replaced since 2019. The Environmental Services Director stated they had noticed the temperature of the domestic hot water in the building creeping up close to 120 F over the last couple of months, so they adjusted the mixing valve to lower the temperature. They also stated a contractor had worked on the mixing valve a year ago and the facility did not have any documentation for the work that was completed. The Environmental Services Director stated the facility took random daily water temperatures Monday through Friday in resident rooms, shower rooms, and the Kitchen and the temperatures were recorded on the Water Temperature logs. The water temperatures for resident rooms were taken from the room of the day and a random resident room. The room of the day was chosen for water temperatures checks because this room was a resident room that the facility chose daily to conduct extra cleaning and checks in. During an interview on 8/29/23 at 2:11 PM, the Environmental Services Director stated that they or the Maintenance Assistant took the daily water temperatures in the building. They stated water temperatures in resident rooms and shower rooms cannot be higher than 120 F. The Environmental Services Director stated they and the Maintenance Assistant used the Eco Lab CDN Model Q2-450X digital thermometer to take water temperatures in the building. This was the thermometer the facility was using to take water temperatures when they started working at the facility in 2019 and this thermometer had never been recalibrated or replaced since 2019. During an interview on 8/29/23 at 2:14 PM, the Maintenance Assistant stated that they or the Environmental Services Director took the daily water temperatures in the building. They stated water temperature in resident rooms and shower rooms cannot be higher than 120 F. The Maintenance Assistant also stated the thermometer they used to take water temperatures in the building was the same thermometer that the Environmental Services Director used, and they had not recalibrated it. Review of water temperature logs from March 2023 through August 2023 revealed the highest temperatures recorded on the resident units ranged from 117 F to 119 F. Further review of the logs revealed water temperatures were taken on the 1 [NAME] Unit, 1 [NAME] Unit Tub room, 2 [NAME] Unit, 2 [NAME] Tub room, 2 East Unit, 2 East Tub room, and the Kitchen. The resident room(s) where water temperatures were taken were not listed on the logs. Review of the Company Design Northwest, CDN Model Q2-450X Pro Accurate Pocket Thermometer instructions documented, Self- Calibration, 1. Place the stem into a mix of 3 parts ice and 1 part water. 2. Press the CAL button for 2 seconds. The display will be blank for 2 seconds. Release the CAL button and a 32.0 F/ 0 C appears. Note to avoid accidental recalibration, this function only works when the water temperature is 30 to 34 F/ -1 to +1 C. ERR will appear for 2 seconds if the water is not within this range and then return to the temperature display mode. Important: Do not immerse thermometer head in water. 2. Observations on 8/28/23 between 1:00 PM and 2:00 PM with calibrated thermometers, [NAME] Model 9840N and [NAME] Model 3519T21 on Unit 1 West; [NAME] Model 9840N and [NAME] Model 9842 on Unit 2 [NAME] and Unit 2 East; and [NAME] Model 9842 on Unit 2 West: Unit 1 West Resident room [ROOM NUMBER] - 122.3 F Resident room [ROOM NUMBER] - 123.3 F Resident room [ROOM NUMBER] - 121.6 F Resident room [ROOM NUMBER] - 122.0 F Resident room [ROOM NUMBER] - 122.4 F Resident room [ROOM NUMBER] - 122.1 F Resident room [ROOM NUMBER] - 122.3 F Unit 2 [NAME] Resident room [ROOM NUMBER] - 123.1 F Resident room [ROOM NUMBER] - 124.7 F Resident room [ROOM NUMBER] - 123.3 F Resident room [ROOM NUMBER] - 121.3 F Resident room [ROOM NUMBER] - 122.0 F Resident room [ROOM NUMBER] - 124.9 F Resident room [ROOM NUMBER] - 123.9 F Resident room [ROOM NUMBER] - 124.5 F Unit 2 East Resident room [ROOM NUMBER] - 122.3 F Resident room [ROOM NUMBER] - 123.5 F Resident room [ROOM NUMBER] - 123.3 F Resident room [ROOM NUMBER] - 124.3 F Resident room [ROOM NUMBER] - 124.6 F Observations on 8/28/23 between 2:30 PM and 3:30 PM with a calibrated thermometer [NAME] Model 9842 with the Director of Environmental Services: Unit 1 West Resident room [ROOM NUMBER] - 127.0 F Resident room [ROOM NUMBER] - 125.2 F Resident room [ROOM NUMBER] - 123.8 F Resident room [ROOM NUMBER] - 123.4 F Unit 2 [NAME] Resident room [ROOM NUMBER] - 124.0 F Resident room [ROOM NUMBER] - 124.0 F Resident room [ROOM NUMBER] - 124.1 F Resident room [ROOM NUMBER] - 125.3 F Resident room [ROOM NUMBER] - 122.4 F Resident room [ROOM NUMBER] - 121.5 F Unit 2 East Resident room [ROOM NUMBER] - 121.3 F Resident room [ROOM NUMBER] - 120.6 F Resident room [ROOM NUMBER] - 122.4 F Resident room [ROOM NUMBER] - 122.0 F Resident room [ROOM NUMBER] - 121.5 F During an interview on 8/28/23 at 3:27 PM, the Environmental Services Director stated they had no idea what would make the water temperatures vary. They stated that if they turn down the temperature of the water then the shower temperature would become cold. During an interview on 8/31/23 at 7:58 AM, Licensed Practical Nurse (LPN) #1 stated that if the temperature of the hot water seemed to hot, they would contact maintenance and would turn on the cold water to lower the temperature, so the resident would not get scalded. During an interview on 8/31/23 at 12:03 PM, the Director of Nursing (DON) stated they were not aware that hot water temperatures were over 120 F. The DON stated they would expect staff to lower the water temperature by mixing in the cold water and for staff to contact maintenance for any issues concerning hot water. During an interview on 9/1/23 at 11:00 AM, the Administrator stated that they expected maintenance to do regular temping of the hot water. The Administrator stated that Maintenance was on call 24 hours a day, 7 days a week so they can be contacted any time for water temperature issues. 10 NYCCR 415.12(h)(1)

Based on observation, interview, and record review conducted during a Standard survey completed on 9/1/23, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one Main Kitchen. Specifically, the dishwasher was not functioning properly and there was a lack of proper hand hygiene. The policy and procedure titled FOOD PREPARATION AND SERVICE dated 5/2/23 documented that appropriate measures were used to avoid cross contamination, including cleaning and sanitizing food-contact equipment between uses, and that food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illnesses. The policy and procedure also documented that bare hand contact with food was prohibited. Gloves were worn when handling food directly and changed between tasks. Disposable gloves were single-use items and discarded after each use. The policy and procedure PREVENTATIVE MAINTENANCE dated 6/2022 documented only routine maintenance safety inspections to ensure resident safety and to check work order books on units and in the kitchen daily. An observation of the main kitchen and dish washing area adjacent to the kitchen on 8/28/23 at 9:57 AM revealed the dish machine which was running at the time of observation, was not displaying temperatures for the wash and rinse cycles. The gages did not move during the observation. There was no sanitizer connected to the dishwasher. During an interview on 8/28/23 at 10:00 AM, the Food Service Director (FSD) #1 stated the temperature gages on the dish machine had just been looked at by maintenance and they were not aware the gages were still not working correctly. During an interview on 8/28/23 at 3:00 PM, FSD #1 stated they had hooked up the sanitizer to the dish machine, to use the dish machine for low temperature operations. During an observation on 8/28/23 at 3:00 PM, FSD #1 ran three separate items through the dish machine and used test strips to test for sufficient levels of sanitization. The test strips did not detect sufficient sanitizer levels. During an interview on 8/28/23 at 3:03 PM, Dietary Aide #1 stated they would call maintenance when there were issues with the dish machine and maintenance would fix when they had time. Dietary Aide #1 stated there had been issues with the dish machine for a while and there was a red light blinking that they had told maintenance about. During an observation of the lunch service on 8/30/23 from 12:02 PM to 1:31 PM in the main dining room/servery, the following observations were made: -Cook #1 was wearing one blue disposable glove on their left hand for the and no glove on their right hand for the entire meal service. Cook #1 used both hands to periodically look through meal tickets, to grab plates, to tear open a bag of prepared lettuce, and to adjust to adjust their personal clothing. Cook #1 also on two occasions placed fabric oven mitts on both hands during meal service to change serving pans on the steam table. Cook #1 used the gloved left hand to grab lettuce and shredded lettuce by hand and placed it into bowls, used the left gloved hand to place cucumber pieces and other cut up items on the salads, then continued to use the soiled left gloved hand to serve/plate food. Cook #1 did not change their glove or wash hands during the meal service. During an interview on 8/30/23 at 1:32 PM, Cook #1 stated they had received all their food service training from FSD #1 and DT #1. When asked about their glove use, Cook #1 stated they were instructed to put on gloves and rotate them between stuff and to wash their hands. They stated wearing only one glove was the way they do it and that the ungloved hand did not touch food and the ungloved hand made it easier to look through meal tickets. During an interview on 8/30/23 at 4:04 PM, Registered Dietician (RD) #1 stated their expectations for hand hygiene and infection control during meal service was for the cook to wear gloves on both hands, wash both hands when soiled, change the gloves frequently, and when visibly soiled. The RD stated when the cooks touch other items, and inside the oven mitts, they should also change their gloves. During an interview on 8/31/23 at 8:00 AM, the ADON (Assistant Director of Nursing)/ IP (Infection Preventionist) stated salads should not be plated by hand, but using utensils, as there was a possibility of cross contamination if gloves were not changed, and food was touched. 10 NYCCR 415.14 (h) 14-1.80, 14-1.31 (a) and (b), 14-1.110 (b), 14-1.116, 14-1.171, 14-1.113 (a) and (b)

Based on observation, interview, and record review conducted during the Standard survey completed on 9/1/23, the facility did not ensure that a resident, with an indwelling suprapubic catheter (tube inserted into the bladder, through the abdomen, to drain urine), received appropriate care and services to prevent urinary tract infections (UTIs) to the extent possible for one (Resident #69) of two residents reviewed for catheter care. Specifically, there was no documented evidence that the catheter was irrigated when the resident had little to no output and the physician/provider was not notified of complications with catheter and low urinary outputs. The finding is: The policy and procedure (P&P) titled Change in Status Notification effective 6/15/21 documented, the resident's attending physician will be notified by the Nurse Manager/Nursing Supervisor/Designee when: any situation which requires a change in the resident's plan of care, medication, or treatment regimen; including the following - intake and output (I&O). The P&P titled Catheter Care - Male/Female Urinary & suprapubic effective 6/2022 did not include procedures for irrigating the catheter or additional interventions for catheter care. 1. Resident #69 was admitted with diagnoses which included Parkinson's disease, obstructive uropathy (obstruction in the urinary tract), and dementia. The Minimum Data Set (MDS- a resident assessment tool) dated 8/18/23 documented Resident #69 had moderately impaired cognition, required extensive assistance of staff for personal hygiene and toileting and had an indwelling catheter. The comprehensive care plan (CCP) revised on 2/2/23 documented Resident #69 had urinary retention, utilized an indwelling catheter due to bladder outlet obstruction and was at risk for recurrent infection. The CCP documented interventions: monitor intake and output and monitor, document, report to MD as needed for signs and symptoms of UTI: frequency, urgency, malaise, foul smelling urine, suprapubic pain, hematuria (blood in urine), cloudy urine, altered mental status, loss of appetite, behavioral changes. Review of the Kardex report (a guide used by staff to provide care) dated 8/31/23 documented Resident #69 required extensive assistance with toileting. Additionally, the Kardex report documented to check catheter tubing for kinks when providing care. There was no documentation on the Kardex report to monitor output or to notify the nurse. Review of the physician's order and Medication Review Report dated 8/31/23 documented irrigate suprapubic catheter with 120 cc (cubic centimeters) for patency as needed every one hour as needed for suprapubic patency. Review of the Treatment Administration Record (TAR) between dates 8/22/23 and 8/30/23, documented six shifts without any urinary output, five shifts with an output of 10-50 cc, and six shifts without any documentation of output. Additional review of the TAR revealed no documented evidence of irrigation of the indwelling catheter throughout August 2023. Review of the nursing progress note dated 8/25/23 at 3:10 PM, Licensed Practical Nurse (LPN) #3, documented resident continues to have no output noted in tubing or urinal bag from suprapubic catheter site. Noted incontinent of urine from genital region and around stoma site or suprapubic. No hematuria was noted. Will continue to monitor. Review of the nursing progress note dated 8/28/23 at 2:55 AM, documented resident with no complaints of pain/discomfort. Suprapubic leakage continues. Review of the nursing progress note written by Licensed Practical Nurse (LPN) #3, dated 8/28/23 at 4:50 PM, documented suprapubic continues to leak around stoma. Catheter irrigated by writer with no effect. Review of the nursing progress note dated 8/28/23 at 11:41 PM written by Registered Nurse Supervisor (RNS) #1, documented suprapubic continues to leak. There was no further documentation in the nursing progress notes from 8/22/23 to 8/30/23 regarding catheter output or interventions to address the low urinary output/leakage. The 24- Hour Nursing Services Report dated 8/22/23-8/30/23 lacked documentation regarding low to no urinary output and interventions for Resident #69's suprapubic catheter. The Nurse Practitioner (NP) note dated 8/10/23 documented resident had a past medical history of frequent UTIs, acute kidney injury, benign prostatic hypertrophy (enlarged prostate gland), and hydronephrosis (excess fluid in a kidney due to a backup of urine). Additionally, the 8/10/23 NP note documented the suprapubic catheter was functioning well, draining yellow urine. The Nurse Practitioner (NP) notes dated 8/11/23-8/30/23 lacked documentation addressing Resident #69's suprapubic catheter. During a personal care observation on 8/31/23 at 1:06 PM, Certified Nursing Aide (CNA) #1 washed their hands and donned (put on) gloves. CNA #1 placed a barrier on the floor and a clean cylinder on top of the barrier. CNA #1 used an alcohol wipe to wipe the spigot of the urine collection bag prior to opening the spigot. CNA #1 emptied approximately 10 cc of dark colored urine into collection bag and wiped the spigot with an alcohol wipe prior to closing it and placing it back into the holder. During an interview on 8/31/23 at 1:09 PM, CNA #1 stated there was 10 cc of urine collected. CNA #1 stated they knew nobody else had emptied the collection bag. CNA #1 stated Resident #69's catheter was not working, and the brief was saturated with urine earlier in the shift. CNA #1 stated they would tell the nurse when the urine output was low. During a catheter flush observation on 8/31/23 at 1:22 PM, LPN #2 performed hand hygiene and donned gloves. LPN #2 used a large piston syringe filled with normal saline and attempted to flush the catheter. LPN #2 stated there was resistance and the catheter was not flushing. LPN #2 stated they were not told anything in report about catheter issues for Resident #69. LPN #2 stated they were going to tell the Resident Care Coordinator (RCC) that the catheter was not flushing. During an observation on 8/31/23 at 1:26 PM, Registered Nurse (RN) #1 and NP were both at the nurse's station. LPN #2 told both RN #1 and NP Resident #69's catheter was unable to be flushed. RN #1 stated they would change the catheter. NP agreed with RN #1 that the catheter needed to be changed. During an interview on 8/31/23 at 1:29 PM, NP stated they were not aware Resident #69 had little to no output prior to LPN #2 telling them today. NP stated they expected the nursing staff to flush the catheter and if that was unsuccessful then the staff should have notified the physician. NP stated since the brief was saturated there was a problem with the catheter and there would be a potential for infection. During a telephone interview on 8/31/23 at 2:43 PM, LPN #3 stated Resident #69 was at the urologist on 8/1/23 and the catheter was working for while after that appointment. LPN #3 stated they reported to RN #1 that Resident #69's catheter was not draining again on Monday 8/28. LPN #3 stated they had tried to irrigate the catheter and there was resistance. LPN #3 stated they could not remember if they documented the irrigation attempt and that they notified RN #1 in the nursing progress notes. During a telephone interview on 8/31/23 at 2:45 PM, LPN #4 stated Resident #69's catheter has not been working for a while. LPN #4 stated there was a lot of sediment in the catheter and that caused it to occlude. LPN #4 stated they tried to flush it on 8/26/23 but nothing happened. LPN #4 stated RN #1 was aware that it was not working. During an interview on 8/31/23 at 3:13 PM, Registered Nurse Supervisor (RNS) #1 stated Resident #69's catheter constantly clogged. RNS #1 stated they attempted flushing it and sometimes it flushed, sometimes it did not. RNS #1 stated nurses should sign they flushed the catheter in the TAR, but they do not always do that. RNS #1 stated during evening and night shift, they have not notified the on-call physician. RNS #1 stated instead of notifying the on-call physician, they would leave a message for RN #1 on the report sheets, for it to be addressed the next day. During an interview on 9/1/23 at 9:48 AM, RN #1 stated they expected the nurses to follow the orders and to irrigate the catheter when there was little to no output. RN #1 stated the nurses should have signed the TAR and should have written a nursing progress note to indicate the catheter was flushed. RN #1 stated if the TAR was not signed out and there was no nursing progress note, that indicated interventions were not done. RN #1 stated they were not aware there was little to no output from Resident #69's catheter since 8/22/23. RN #1 stated when Resident #69's catheter was not working, they would notify the urologist. During a telephone interview on 9/1/23 at 10:15 AM, Medical Director (MD) stated Resident #69 had a history of problems with their catheter. MD stated they have not been notified by nursing staff within the past couple of weeks regarding low to no output. MD stated they expected the staff to notify the physician when there was no output from the catheter, even if the brief was saturated with urine. MD stated they expected a notification if the catheter was not irrigating, as well. MD stated there was a potential for the resident to go into renal (kidney) failure or heart failure. During an interview on 9/1/23 at 10:54 AM, Director of Nursing (DON) stated they expected the CNAs to report little to no urinary outputs to the LPN, even when the brief was saturated. DON stated the LPN should let the RCC or Supervisor know there was a problem and catheter should have been irrigated. DON stated if the nurses were unable to irrigate the catheter, that should have been reported to the RCC or Supervisor. DON stated they expected the RN to follow up and do an assessment of the resident. DON stated their assessment should have included checking for bladder extension and signs of infection. DON stated they expected the irrigation to be documented and signed out in the TAR and the nurse should have written a nursing progress note also. DON stated if the irrigation and follow up assessments were not documented, that means they were not done. DON stated the physician should have been made aware. DON stated when there was little to no catheter output, that would identify a problem such as an occlusion. DON stated an occlusion in a catheter could mean an infection was brewing. 10NYCRR 415.12 (d)(1)

Based on observation, interview, and record review conducted during a Standard survey completed 9/1/23, the facility did not provide food and drink that were prepared by methods that conserved flavor, and appearance, were palatable and at a safe and appetizing temperature, for two (Units 2 [NAME] and 2 East) of two test trays. Specifically, food and beverages were served at suboptimal temperatures and were not palatable. Residents #26, #52, #72, and #91 were involved. The findings are: The policy and procedure titled Food Preparation and Service dated 5/2/23 documented that the danger zone for food temperatures is between 41 degrees ( ) Fahrenheit (F) and 135 F. Therefore, foods must be maintained below 41 F or above 135 F. The policy and procedure further documented the temperatures of foods held in steam tables were monitored throughout the meal. The facility Recipe Card for Macaroni Salad documented to chill the macaroni in a 2 (inch) deep container to 41 F or below. The recipe card then documented to hold on ice for service, maintaining temperature at 41 F or below for up to 1 hour and to discard any product that exceeded 41 F during service. During an interview on 8/28/23 at 11:30 AM, Resident #26 stated that sometimes the food was just thrown together and one had to guess what it was. Resident #26 also stated that sometimes hot food was not hot enough and that trays never arrived on the unit at a consistent time. During an interview on 8/28/23 at 12:03 PM, Resident #72 stated that the food at the facility was not good. They stated that the food was bland, and the hot foods were served cold. 1.During a continuous lunch meal observation the main dining room (MDR) on 8/30/23 at 12:02 PM to 1:31 PM, revealed at 12:02 PM, the steam table contained a serving pan with broccoli with cheese sauce and at 12:18 PM the remainder of the hot food items arrived from the kitchen. Tray line service began at 12:29 PM. Cook #1 pulled plates from the plate warmer to serve food. The plate warmer was not warm. During an interview at the time of the observation the Food Service Director (FSD) #1 stated the plate warmer had not worked in a long time. The second 2 [NAME] dietary cart left the MDR at 1:13 PM and the 2 East dietary cart left at 1:26 PM. During a lunch meal observation on 8/30/23 at 1:09 PM, the first dietary cart for 2 [NAME] arrived, and the second dietary cart arrived at 1:18 PM. All residents on 2 [NAME] were served their meals by 1:28 PM. The test tray temperatures were taken by Diet Tech #1 at 1:29 PM using the facility's digital thermometer. The results were as follows: -BBQ chicken breast 123.1 F, tasted dry, bland, and lukewarm -Baked Beans 119.3 F, tasted lukewarm -Broccoli with cheese sauce 122.3 F, tasted mushy, bland, and lukewarm -Milk 52.2 F, tasted warm and was not palatable -Apple juice 55.8 F, tasted warm and was not palatable During an interview on 8/30/23 at 1:39 PM, Diet Tech #1 stated that hot foods should be served above 130 F, and cold foods should be served below 45 F. During a lunch meal observation on 8/30/23 at 1:30 PM, the 2 East unit dietary cart arrived on the unit. Staff completed the tray pass at 1:40 PM. The test tray temperatures were obtained at 1:40 PM with the FSD #1 using the facility's thermometer. The FSD #1 stated that the hot food temperatures should be above 145 F and the cold food temperatures should be below 41 F. The results were as follows: -BBQ chicken breast 120 F, the chicken tasted dry, the barbeque sauce tasted watery, and it was cold -Baked Beans 127 F, were cool to taste -Broccoli with cheese 128 F, tasted mushy and cool -Canned pears 66.4 F, tasted warm and bitter -Apple juice 59.2 F, tasted warm and unappetizing -Milk 55.6 F, tasted warm and unappetizing During an interview at 8/30/23 at 1:50 PM, Resident #91 stated the chicken was dry and did not taste good. Resident #91 stated their food was cold and their drinks were warm. During an interview at 8/30/23 at 1:55 PM, Resident #52 stated they were served barbeque chicken, baked beans and sauerkraut for their lunch meal and it was an odd combination of food items. Resident #52 stated their hot food items tasted cold. During an interview on 8/31/23 at 7:24 AM, Resident #72 stated that on 8/30/23 they had the alternate meal for lunch. It was cabbage and it did not taste good. They stated that the cabbage was bland, and they only ate about half of it. 2.During an observation of the MDR on 8/31/23 at 12:27 PM, an uncovered, clear plastic full size 4 (Inch) deep food service pan containing macaroni salad was on a cart in the servery. Cook #2 was just beginning to plate the meals and the macaroni salad was part of the lunch meal to be served. When the FSD #1 took the temperature of the macaroni salad, it was 60 F. During an interview on 8/31/23 at 12:30 PM, FSD #1 stated the macaroni salad could not be served, as it was too warm and should have been kept on ice. During an interview on 9/1/23 at 11:15 AM, Cook #2 stated they should have taken the macaroni salad temperature before beginning meal service and they should have kept the macaroni salad on ice when setting up for meal service. 10 NYCCR 415.14(d)(2)

Based on observation, interview and record review conducted during the Standard survey completed on 9/1/23, the facility did not post on a daily basis the staff total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift. Specifically, the facility's Report of Nursing Staff Directly Responsible for Resident Care form did not include the total actual hours worked for Registered Nurses (RN), Licensed Practical Nurses (LPN) and Certified Nursing Aides (CNA) for each shift. The finding is: The policy and procedure (P&P) titled Posting Direct Care Daily Staffing Numbers effective 2/11/2017 documented shift staffing information shall be recorded on the Nursing Staff Directly Responsible for Resident Care form for each shift. The information recorded on the form shall include: the actual time worked during that shift for each category and type of nursing staff. During an observation on 8/28/23 at 11:33 AM, the form Report of Nursing Staff Directly Responsible for Resident Care was completed with the date 8/28/23, day shift census: 105, total number of nursing staff scheduled for day shift as follows: RN 2, LPN 3, CNA 9, and actual hours worked for day shift as follows: RN 3, LPN 3, CNA 10. During an observation on 8/29/23 at 8:49 AM, the form Report of Nursing Staff Directly Responsible for Resident Care was completed with the date 8/29/23, day shift census 105, total number of nursing staff scheduled for day shift as follows: RN 5, LPN 4, CNA 14, and actual hours worked for day shift as follows: RN 4, LPN 4, CNA 12. Review of the Report of Nursing Staff Directly Responsible for Resident Care form dated 8/1/23-8/30/23 documented the total number of nursing staff scheduled for each shift. The form did not list the actual hours worked, for each type of nursing staff, accurately completed for each shift. During an interview on 8/31/23 at 11:34 AM, Human Resource Manager (HR) stated they were responsible for filling out the Report of Nursing Staff Directly Responsible for Resident Care form. HR stated they completed the form based on the number of staff in the building for each category and they were never trained to include the actual hours worked during the shift for each type of nursing staff. HR stated they filled out the total number of nursing staff scheduled column based on the Daily Schedule staffing sheets. HR stated after they checked to see which staff were in the building, they then put the updated number of staff under the actual hours worked column of the form. HR stated they have completed the form that way since they started working in March 2023. HR stated the form was intended for families to see how many of each nursing staff were in the building. During an interview on 8/31/23 at 11:46 AM, the Administrator stated it was expected for the actual hours worked by each type of nursing staff to be included on the Report of Nursing Staff Directly Responsible for Resident Care, not only the total number of nursing staff scheduled. 10NYCRR 415.13

Based on interview and record review conducted during an Abbreviated survey (NY00310681) completed on 6/14/23, the facility did not ensure that they immediately inform the resident's representative when there is a significant change in the resident's health, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening changes or clinical complications) for one (Resident #1) of three residents. Specifically, Resident #1's representative was not notified regarding the resident's hyperglycemia (high blood sugar levels) and new physician orders for insulin (a hormone that helps regulate blood sugar levels) injections subcutaneously (injections underneath the skin). The finding is: The policy and procedure titled Change in Status Notification dated 11/8/23 documented the resident's responsible party will be notified by the nurse manager, nursing supervisor, or designee when there is a sudden or unexpected change or deterioration in the resident's physical, mental, or psychosocial/emotional status; or any situation which requires a change in the resident's plan of care, medication, or treatment regimen. 1. Resident #1 was admitted with diagnoses of diabetes mellitus (a disorder where there are high blood sugar levels for prolonged periods of time), cerebral infarction (a stroke), and dementia. The Minimum Data Set (MDS - a resident assessment tool) dated 5/4/23 documented Resident #1 was severely cognitively impaired, understood, and usually understands. The MDS documented the resident received insulin injections. Resident #1's Comprehensive Care Plan (CCP) dated 8/21/2020 documented the resident had diabetes mellitus, was to use diabetic medication as ordered. Additionally, the resident had impaired cognitive function and impaired thought processes due to their dementia and stroke. The physician's orders dated 2/5/23 documented an order for subcutaneous injection of insulin of 20 units at 3:00 PM and an additional injection of 30 units at 5:30 PM. The physician's orders also documented a one-time order for a blood sugar check at 5:00 PM. During an observation on 6/14/23 at 9:30 AM, Resident #1's glucometer (a device that measures a person's blood sugar level through a test strip) was an (Brand Name) glucometer. Review of the undated owner's guide to the (Brand Name) glucometer documented the glucometer measured blood sugar from a value of 20 to 600 (normal blood sugar levels are from 70 to 100). Additionally, the owner's guide documented that if the glucometer reads high, the person's blood sugar was over 600. An Order Note dated 2/5/23 at 2:52 PM documented that Resident #1's blood sugar was running high, the physician was notified, and new orders were received to give 20 units of lispro insulin now and check blood sugar in two hours. The Order Note revealed no there was no documented evidence that Resident #1's responsible party was notified about the new order or the high blood sugar. A Nurses Note dated 2/5/23 at 5:57 PM documented that Resident #1's blood sugar was high, the physician was notified, and new orders to give 30 units of Humalog insulin subcutaneously now. Further review of the Nurses Note documented the resident was responsive but lethargic, and that the resident's blood sugar will be rechecked at 7:30 PM. There was no documentation the resident's responsible party was notified of the new orders or change in condition. During an interview on 6/13/23 at 1:00 PM, Registered Nurse (RN) #1 stated that if they didn't write in in a progress note, then they did not notify the responsible party of the resident's changes. RN #1 recalled notifying the physician concerning Resident #1's blood sugar after the glucometer was read high. RN #1 stated they should have let the nursing supervisor know and called the resident's responsible party. During an interview on 6/13/23 at 1:16 PM, RN #2 Nursing Supervisor stated that they did not recall notifying the responsible party concerning a change of condition. RN #2 Nursing Supervisor stated that if there was a change of condition or a problem, they should notify the physician and the resident's responsible party. RN #2 stated the person notifying the responsible party should document it in the progress notes. During an interview on 6/14/23 at 10:00 AM, the Director of Nursing (DON) stated the process was that if there was a new order, a change of condition, or an incident, the resident's physician, or responsible party was to be notified right away. They stated they expected the nurses to document in the progress notes the notification of family, physician, or responsible parties. The DON stated they expected nurses to do a follow up for any change of condition or anything else concerning the residents. During an interview on 6/14/23 at 10:07 AM, the Administrator stated they expected staff to notify the resident's responsible party if there was a change of condition with the resident and staff to document in the progress notes that the family and the physician were notified about a change in condition. 10 NYCRR 415.3(f)(2)(ii)(b)

Based on observation, interview, and record review during an Abbreviated survey (Complaint #'s NY00297795 and NY00298518) completed on 6/14/23, the facility did not ensure that each resident receives adequate supervision to prevent accidents for two (Resident #11 and #12) of three residents reviewed. Specifically, the facility did not provide adequate supervision to prevent the residents from eloping from the facility. Resident #11 eloped from the facility on 7/5/22 and was found by staff off facility grounds and Resident #12 eloped from the facility on 6/21/22 and was found outside by a family member on the front patio. The findings are: The policy and procedure (P&P) titled, Elopement Prevention and Search for Missing Resident, dated 3/10/21, documented the purpose is to safeguard the health and welfare of those residents who are cognitively impaired, wander, have emotional disturbances, or any resident who leaves the facility without notification/ approval of the staff and the physician. Residents will be assessed for potential for elopement on admission, re-admission, quarterly and upon significant change, adhering to the MDS (minimum data set - a resident assessment tool) assessment process, and if an attempted elopement occurs. If residents are identified as being a wanderer and/ or exhibit the potential for elopement, a behavior management plan shall be developed by the interdisciplinary team. Additionally, the facility utilizes environmental strategies to prevent/ deter elopement, including a code system on exit doors, stairwells, and elevators. The P&P titled, Security Considerations, effective 4/21/22, documented physical and/ or electronic security is essential in providing security, access, and protection to residents, personnel, equipment, buildings, and resources. Diligent control of electronic access devices (keypads) and building keys will help provide a safe and secure environment. Only authorized individuals will be provided with door/ elevator keypad codes and building keys. In the event of an electronic device breech (unauthorized individual has accessed the code), the code will be changed immediately, and an investigation will be implemented to determine how/ why the breech occurred. 1. Resident #11 had diagnoses which included secondary Parkinsonism, anxiety disorder, schizophrenia, major depressive disorder, and obsessive-compulsive disorder. The MDS dated [DATE] documented Resident #11 was moderately cognitively impaired, was usually understood. The Elopement Evaluation dated 4/7/22 documented the resident had a score of one, which was categorized as At Risk. Additionally, it documented Resident #11 had a history of or attempted leaving the facility without informing staff. The clinical suggestions were to apply an identification bracelet and notify staff of elopement risk. The comprehensive care plan dated 6/7/22 documented Resident #11 was at risk for elopement, and an orange wrist band was utilized, and their photo was placed by main entrance. The resident ambulated independently to all destinations. The electronic medical record (EMR) Progress Notes for Resident #11 documented the following: - 1/14/22 1:43 PM - Resident is telling staff that their sister is coming to pick them up this morning and take them home, repeatedly asking for backpack. - 2/24/22 10:53 AM - On 2/23/22, resident's sister signed resident out of the facility at 12:45 PM. At approximately 1:15 PM, sister came back into facility and stated resident was attempting to get out of car. Sister pulled into facility parking lot and resident refused to get out of car. Sister came into facility to ask for help. While sister was in facility, resident got out of car and walked toward street. Social Worker and other staff members followed resident and got into their car and brought resident back. - 7/5/22 6:00 PM - a CNA (Certified Nurse Aide) had come through the interior locked doors into the hallway when they saw a shadow. The CNA turned back to look, and the resident was running though the outer doors and could not be persuaded to come back inside and continued to run away from the building. Based on the CNA's description, the resident was in the lobby out of sight when the CNA entered. There was no receptionist on duty at that time. - 7/6/22 8:58 PM - Resident has attempted to leave many times, stands near door to Solarium watching the stairway and elevator. Watches for someone to put the code in. - 7/8/22 11:13 AM - Activities Aide got into elevator and resident swiftly got in as the door was starting to close. Resident angrily mumbled for about three minutes, but finally got out of the elevator. Resident then swiftly turned and tried to rush into the elevator but was blocked by staff member. - 7/8/22 8:17 PM - When dinner carts were being delivered to units, resident attempted to get onto elevator numerous times, but was blocked by staff members. - 7/9/22 9:09 PM - Resident attempted to force way onto elevator by pushing past staff members. Resident finally turned around and began pushing elevator code buttons after door had closed. The Investigation Summary dated 7/5/22, completed by the Former Director of Nursing (DON), documented Resident #11 was hiding around the corner in the front lobby area when a staff member came back into the building, the resident ran through the locked door and out of the building, running away from the facility. Upon completion of interviews of all staff members, none brought the resident down the elevator, opened the elevator door for the resident, or gave the resident the code to use. It is believed that the resident did have the code and used the code to let themselves down the elevator. The resident may have received the code from another resident who frequently goes outside to water flowers and feed the birds. Staff does not give residents the codes, but this resident sees the codes being inputted at times. This resident was able to get themselves to the lobby, lookout the front window and see when staff was coming up the sidewalk to re-enter the building. There was no Receptionist on duty that evening to monitor the front entryway. The staff member who entered the building saw a shadow out of the corner of their eye and turned to see the resident run out the door and was unable to persuade the resident to come back into building. The resident was located and returned to facility. The facility's investigation documented Resident #11 resided on the facility's second floor at the time of the elopement, in the 2 [NAME] Unit. During a telephone interview on 6/14/23 at 1:45 PM, CNA #3 stated on the date of Resident #11's elopement, they were just coming into work at the main entrance, and they did not see anyone inside until they turned to go down the hall toward Dietary, they thought they saw a shadow out of the corner of their eye. CNA #3 stated they turned around and saw Resident #11 exiting out of the main entrance doors and tried to stop them and coax them back in. At that time, Resident #11 had just passed through the outer door and pushed CNA #3. CNA #3 stated they did not want anyone to get hurt, so they immediately went to find a supervisor, and at that time, they saw Resident #11 run away from the building. CNA #3 stated the front doors had an approximate five to ten second delay in closing, and they believed Resident #11 could have been waiting in the cubby corner of the lobby until the doors opened and they had that long to get out of the front doors before they closed. They further stated they believed no one else was nearby at the time and no one was sitting at the front reception desk. There was usually someone at the front desk until 8 PM and they were not sure why no one was at the desk at the time of the incident. CNA #3 further stated they believed the Receptionist was in the building, but not sitting at the desk at that time. CNA #3 also stated orange wrist bands were for elopement risk, but they could not remember if Resident #11 wore an orange band at the time. During a telephone interview on 6/14/23 at 2:00 PM, Dietary Employee #1 stated they were working in the kitchen when a Dr. Wander (code for a resident elopement) was called. They further stated upon hearing Dr. Wander, they jumped in their car, cruised a couple of close streets, and found Resident #11 one or two streets over from the facility. Dietary Employee #1 also stated Resident #11 kind of knew them, so they were able to get Resident #11 to come into their car, and they drove Resident #11 back to the facility. They further stated Resident #11 did not say much of anything while in the car and was annoyed at the fact that they were found. After Dr. Wander was called, Dietary Employee #1 stated it was about 15 minutes or less before Resident #11 was returned to the facility. They stated they did not recall if Resident #11 was wearing an orange bracelet at the time of the elopement. We are not citing the issue about the orange wrist band. During an interview on 6/13/23 at 12:06 PM, Registered Nurse (RN) #4 stated prior to the 7/5/22 incident, in April 2022, Resident #11 scored a one on the Elopement Evaluation and a score of greater than one was classified as At Risk. They stated Resident #11 would not have had an orange bracelet at the time of their elopement on 7/5/22. During an interview on 6/14/23 at 10:25 AM, Licensed Practical Nurse (LPN) #2 stated Resident #11's mobility had declined since July 2022, but they were still an elopement risk. Observations on 6/12/23 through 6/14/23 revealed there were no locked or access-controlled doors between the 2 [NAME] Unit and the elevator and multiple stairways on the second floor. The elevator door and all stairway doors on the second floor were access-controlled by electronic keypads that required a numeric code. Observation at the main front entrance on 6/14/23 at 3:00 PM revealed the main entrance consisted of two sets of double doors. At this time, the front desk Receptionist hit the button located behind the desk to release the main entrance doors' magnetic door lock, the front inner door opened electronically, and the front outer door opened electronically five seconds later. Twenty- five seconds after the button was pushed, the inner door closed electronically and 30 seconds after the button was pushed, the outer door closed electronically. During an interview on 6/13/23 at 11:25 AM, the Environmental Services Director stated the facility's lockdown system consisted of key coded locked doors. The exterior doors and stairway doors had magnetic locks that were controlled by numeric codes and a numeric code was needed to get in or out of the building. The Environmental Services Director also stated a numeric code was also needed to access the elevator, and different doors had different codes. The codes were changed periodically and in case someone happened to catch the code being used. The Environmental Services Director stated the Receptionist could buzz people in or out of the main entrance and the facility had a full time Receptionist from 7:00 AM - 3:30 PM daily Monday through Friday and part-time people who worked reception in the evenings. When no one was at the reception desk, the 1 [NAME] Nurses' Station had a monitor that was linked to a camera at the main entrance. The camera activated when the facility's doorbell was rung. This monitor was the same camera feed that the front reception desk had on their monitor. Additionally, on 6/14/23 at 9:15 AM, the Environmental Services Director stated the doors equipped with magnetic locks and keypad codes were checked by maintenance staff daily and there were no malfunctions with the system in June or July of 2022. Review of front reception desk coverage schedule revealed the schedule for 7/5/22 (Tuesday) indicated the reception desk would be covered from 7:00 AM to 3:00 PM. Review of the Receptionist job description called, Administrative Assistant, dated 4/1/98, revealed the Administrative Assistant assumed responsibility for the clerical operations of the facility, which included overseeing front desk operations. The job description did not address security items such as the key coded locked door system or access into and out of the building. During an interview on 6/13/23 at 9:20 AM, CNA #1 stated the were working at the front desk at this time because the front desk Receptionist, who usually worked 7 AM to 3 PM, was on vacation this week. CNA #1 stated the front reception desk was occupied usually until 8 PM. When the usual Receptionist went on break, they would sit at the reception desk until the Receptionist returned from break if they were working that day, and if they weren't working that day, CNA #1 stated they did not know who covered the Receptionists' breaks. CNA #1 also stated the Explorers Club poster was at the front door and there were currently seven residents' pictures there. The purpose of the poster was to alert people to which residents were an elopement risk. CNA #1 stated the keypads on the exterior doors, stairway doors, and the elevator kept doors locked and they had to buzz people in and out. Employees knew the codes, which were different at each door, and they could let themselves in and out by entering the numeric code into the keypad. Additionally, at this time, CNA #1 stated they were going to leave the facility momentarily and an Activities Assistant would take over for them while they were out. Continual observation on 6/13/23 between 10:00 AM - 10:10 AM revealed the front reception desk was unoccupied. Additionally, the front reception desk was observed to be unoccupied on 6/13/23 at 10:39 AM and 11:15 AM. During an interview on 6/13/23 at 11:18 AM, Activities Assistant #1 stated they started covering the front reception desk today at around 10:45 AM or 11:00 AM because they were told to come to reception at that time. During an interview on 6/14/23 at 9:20 AM, the Administrator stated the hours of front reception desk coverage were 7 AM to 3 PM and 3 PM to 8 PM on Mondays through Fridays. There was also weekend front desk coverage from 8 AM to 4 PM and 4 PM to 8 PM. The Administrator also stated the usual Receptionist was on vacation this week, and when that happens, a light duty CNA or Activities staff or others as needed could cover the front reception desk. During the Receptionist's breaks, the facilities outside phone line was forwarded to all other office phones. The Administrator also stated there was a doorbell system with a camera that turned on when doorbell was rung. If anyone other than a staff member wanted to get out of the facility, such as residents' family members, and no one was at the front reception desk, they are told to go to the 1 [NAME] Nurses' Station and a staff member there will assist them. Residents' family members never get the keypad codes for doors. They must be walked to the elevator and let in and let out of the front entrance by staff. 2. Resident #12 had diagnoses which included Alzheimer's Disease. The MDS dated [DATE] documented Resident #12 was severely cognitively impaired, sometimes understood others, and was sometimes understood by others. The Elopement Evaluation dated 6/15/22 documented Resident #12 had a score of two, which was categorized as At Risk. The evaluation documented the resident wandered and the wandering behavior was likely to affect the privacy of others. There were no clinical suggestions check marked on the evaluation. Resident #12's comprehensive care plan dated 6/16/22 documented resident's ambulation was limited assist of one staff member with gait belt and rolling walker to all destinations. This version of the care plan did not mention a risk for elopement. The focus of Resident is at risk for elopement related to cognitive impairment was initiated on the care plan on 6/22/22. The EMR Progress Notes for Resident #12 documented the following: - 6/15/22 6:38 PM - Resident just admitted , wanders to door and out in hall in evening, but unsure of during night. - 6/17/22 3:50 PM - Orange elopement band applied to resident's wrist and DON made aware of possible elopement risk. Resident was with a visitor and stated they were leaving the facility. It was explained to resident that they needed to stay at the facility. Resident seemed to think they were at a hotel and for the remainder of the shift, they tried to turn in keys and packed things over and over throughout the shift. - 6/17/22 8:10 PM - Resident wandered out of room and down to the other end of the unit before staff found resident attempting to enter another resident's room. - 6/18/22 1:09 PM - Resident alert with some confusion, ambulating in room and within the unit. - 6/18/22 8:26 PM - Resident alert with some confusion, continues to ambulate unassisted in the halls and attempts to go into other residents' rooms at times. - 6/19/22 1:00 PM - Resident alert with confusion, wandering halls today looking for son to take them home. Review of the facility's Investigation Summary, written by the Former DON, dated 6/21/23 documented the resident used a rolling walker to ambulate to all destinations on care plan, but frequently ambulated out of room without assistance and without roller walker and had to be assisted back to room. Resident was well-groomed and can speak, although unable to carry on a normal conversation due to deteriorating mentation. On the date of the incident, the resident was last seen sitting across from the Nurses' Station at 10:50 AM and ten minutes later, resident's sister reported resident was seen on the patio outside of the front of the building. Between 10:50 AM and 11:00 AM, no staff was around to let the resident out of the building. There was a resident that was transferring to another facility leaving at that time with family. It is suspected that the family member had the code to the front door and let themselves and the resident out the front door. At time of admission, because of the Elopement Evaluation, an orange band was placed on the resident's wrist, to denote elopement risk. Staff were alerted to elopement status. The resident resided on 1 West, which was ground level of the building, no second-floor rooms were available, and resident needed to be on quarantine upon admission and the only rooms available for quarantine were on the 1 [NAME] Unit. The resident was reportedly wearing an orange bracelet at the time of the elopement, but a long sleeve shirt covered it. The written Employee Statement signed by the Assistant Director of Nursing (ADON), dated 6/21/22, documented they observed the resident sitting in a chair in the hallway at 10:50 AM and at that time, they informed staff that the resident should be in their room, and they went to their break. The written Employee Statement signed by RN #5, dated 6/21/22, documented they were notified by the resident's sister that the resident was on the front patio walking away from facility still on the patio. The resident's sister stated someone was at the front desk who let the resident out of the facility but was unclear who exactly let the resident out. Resident did have an orange elopement band on. The written Employee Statement signed by the Receptionist, dated 6/21/22, documented the resident's sister came inside to get someone to get the resident off the front porch. Review of the Visitor Sign In log dated 6/21/22 revealed it did not have a separate column for time in and time out, but only one column labeled Time. There were eleven entries on the log, and only the first entry was highlighted. The column labeled Time for the first entry was 9:17. Review of front reception desk coverage schedule revealed the schedule for 6/21/22 (Tuesday) indicated the reception desk would be covered from 7:00 AM to 3:00 PM and 3:00 PM to 8:00 PM. Observations made on 6/12/23 and 6/13/23 revealed numeric code access keypads were located at the elevator and stairway at the front/ center of the building as well as exit doors on the first floor. A numeric code access keypad was also observed at the main entrance and at all second- floor stairway doors and elevator. During a telephone interview on 6/14/23 at 3:20 PM, the former DON stated they were the DON at the time of the elopements of Residents #11 and #12. They stated an elopement investigation always started with interviews with all staff to find out how the person got out of the building. The former DON also stated some residents did not look like residents and another residents' family members could let a resident out of the building thinking they were not a resident. The former DON also stated the facility got rid of cameras during the remodeling about two years ago and because there were no cameras left in the facility, it would be hard to know who would have let Resident #12 out. The front main doors close slowly, which could allow enough time for someone to possibly get out. Family members are not supposed to get the door codes, but some family members hear or see staff members punch in the door codes. The staff are asked to block the view of the keypad while they are punching in the codes as much as possible. Families may overhear staff saying door codes out loud to each other. If the facility knows that a family has a code, we will change codes. The former DON also stated the potential safety concerns related to elopement of a resident with limited capacity included the busy road out front of the facility and the nearby creek. The Former DON also stated new interventions should have been put in place for Resident #12 when they were observed to be packing on 6/17/22 and if they personally didn't know about it, the Resident Care Coordinator should have been notified. Resident #12 should have been moved upstairs, but at that time, there was no room upstairs as this resident was under quarantine for COVID-19 as a new admission. Orange bracelets alert everyone that that resident is an elopement risk, so they are aware to monitor closely. 10 NYCRR 415.12(h)(2)

Based on observation, interview, and record review conducted during an Abbreviated survey (Complaint #NY00313271) completed on 3/29/23, the facility did not ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, and the comprehensive person-centered care plan for one (Resident #1) of three residents reviewed. Specifically, the facility inaccurately documented the use of a non- invasive mechanical ventilator as a CPAP (continuous positive airway pressure) machine and on 3/22/23 the non-invasive mechanical ventilator was removed from Resident #1's use. The finding is: The facility provided a policy for CPAP (machine that uses mild air pressure to keep breathing airways open while you sleep) and did not have a policy specifically for the (brand name) Ventilator (a non-invasive mechanical ventilator). The (brand name) 100 Clinical Manual provided to the facility by the vendor on 3/28/23 documented the machine was a (brand name)100 system that provided continuous or intermittent ventilatory support for the care of individuals who require mechanical ventilation. This ventilator provides both pressure control and volume modes of therapy. The device can provide non-invasive or invasive ventilation. It can be used to provide total therapy to patients as they progress from non-invasive to invasive ventilation. Resident #1 was admitted with diagnoses including chronic obstructive pulmonary disease (COPD), anxiety disorder and depression. The Minimum Data Set (MDS - a resident assessment tool) dated 2/20/23 documented Resident #1 was cognitively intact. The undated Comprehensive Care Plan (CCP) documented Resident #1 had COPD, chronic respiratory failure with hypoxia (low oxygen levels in the blood). The CCP inaccurately documented the use of a CPAP versus the non-invasive mechanical ventilator. The undated Closet Care Plan (a guide used by staff to provide care) documented oxygen (O2) at 3 liters continuous via nasal canula. The Hospital Discharge Summary dated 1/12/22 documented Resident #1 used a nighttime Trilogy in ventilator mode and was encouraged to use the machine during daytime naps. The Nursing Comprehensive assessment dated [DATE] documented acute and chronic respiratory failure with hypoxia, and COPD exacerbation. Respiratory treatments and devices included a ventilator and continuous oxygen. The resident has own ventilator type machine they take care of. The Physician's Orders dated 1/14/22 revealed an order for a CPAP. The physician's order documented CPAP on at HS (hour of sleep), off in am. There were no settings listed. There was no physician's order for the Non-Invasive Mechanical Ventilator ((brand name) Ventilator) as per the hospital discharge summary and comprehensive nursing assessment. The orders inaccurately documented the use of a CPAP versus the non-invasive mechanical ventilator Review of the Treatment Administration Record (TAR) from 1/14/22 through 3/22/23 documented CPAP on at HS, off in am. Resident does like to place on by themselves, every day and night shift and had a start date of 1/14/22 and discontinued date of 3/22/23. The treatment record inaccurately documented the use of a CPAP versus the non-invasive mechanical ventilator. The Nursing Progress Notes dated 3/22/23 documented the Administrator informed Registered Nurse (RN) #1 the vendor was picking up Resident #1's machine on 3/22/23. Resident #1 was anxious about the machine being taken. During observation and interview on 3/28/23 at 11:30 AM, Resident #1 was wearing oxygen via a nasal canula, and the liter flow was set at 3. There was no evidence of a non-invasive mechanical ventilator at the bedside. Resident #1 stated the machine was a ventilator which removed carbon dioxide from their lungs and functioned differently than a CPAP or BIPAP. The vendor took the machine on 3/22/23. During a telephone interview on 3/28/23 at 1:05 PM, the Operations Manager/ Respiratory Therapist for the vending company stated the non mechanical ventilator helped with the removal of Carbon Dioxide (CO2) levels. Resident #1 had a ventilation issue, not an oxygenation issue. The Operations Manager/Respiratory Therapist stated they contacted the Administrator to discuss payment on 2/17/23, 2/21/23, 2/28/23, 3/2/23, and 3/15/22 with no response from the facility. On 3/22/23 the Respiratory Therapist came to the facility and spoke with the Administrator. The Administrator instructed the Respiratory Therapist to take the ventilator. During an interview on 3/28/23 at 2:10 PM, the Administrator stated Resident #1 was admitted with a CPAP machine on 1/13/22. The machine was rented prior to admission and the resident brought it with them. Resident #1 insisted that it was a ventilator. Registered Nurse (RN #1), Resident Care Coordinator, (RCC) determined it was a CPAP. Resident #1 would put it on and take it off on their own. Nursing staff would sign off for accountability on the TAR. The Administrator stated the vendor came to the facility on [DATE] and told the vendor to remove the machine. During a telephone interview on 3/28/23 at 2:27 PM, the Corporate Supervising Administrator stated they weren't sure what type of machine Resident #1 used. The machine should not have been removed. The facility was responsible to provide respiratory services for residents. We'll take care of it. During a telephone interview on 3/29/23 at 9:24 AM, RN #1 RCC stated they assumed the machine was a CPAP, until yesterday (3/28). RN#1 stated Resident #1 communicated with the vendor and maintained it on their own. RN# 1 stated they were responsible for inaccurately documenting the CPAP order on 1/14/22. The order should have specified a non-invasive mechanical ventilator. RN #1 stated they should have attempted to contact the vendor on admission and clarified what the machine was but did not. On 3/22/23 the vendor picked up the machine. Resident #1 was anxious and upset the machine was being taken. During a telephone interview on 3/29/23 at 11:05 AM, the Medical Director stated a noninvasive mechanical ventilator provided more inspiratory and expiratory pressure. PCO2 (partial pressure of carbon dioxide- the measure of carbon dioxide within arterial or venous blood) was expelled. The pressure changes on its own and was different from a CPAP/BiPAP (bilevel positive airway pressure). The pressure delivered by the CPAP/BiPAP was much lower. The Medical Director stated they were unaware the machine was a ventilator and had been taken away. Monitoring SPO2 (percentage of oxygen in blood) levels every 4 hours would not be a good indicator for someone with severe COPD. The problem was not getting rid of the CO2. The facility was not capable of monitoring CO2 levels. CO2 levels were obtained through arterial blood gases (ABGs) which the facility was incapable of performing. ABGs were performed in the hospital or emergency room . The Medical Director stated the non-invasive mechanical ventilator prevented further hospitalization s and should have not been taken away. 10 NYCRR 415.12(k)(6)

Based on observation, interview, and record review conducted during the Focused Infection Control Survey completed on 11/5/2021, the facility did not ensure sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility did not have adequate staff based on the facility established assessment. Additionally, for one (1 West) of three resident care units there was a lack of answering resident call lights timely and there was a delay in serving lunch meals. The findings are: The Skilled Nursing Facilities CMS assessment dated [DATE] documented total residents at time of the assessment 81 and list the staffing levels per unit follows: Unit 1W (West)-Day shift: 1 Resident Care Coordinator (RCC), 1 Licensed Practical Nurse (LPN) med nurse, 4 Certified Nursing Assistants (CNAs). Evening shift: 1 LPN, 3 CNA. Night shift: 1 LPN, 2 CNA. Unit 2W-Day shift: 1 nurse manager (NM), 1 LPN, 4 CNAs. Evening shift: 1 LPN, 4 CNAs. Night shift: 1 LPN, 2 CNAs Unit 2E (East)-Day shift: 1 NM, 1 LPN, 4 CNAs. Evening shift: 1 LPN, 4 CNAs. Night shift: 1 LPN, 2 CNAs. The facility policy and procedure (P&P) titled Contingency Staffing Plan dated 6/21/21 documented that they were taking proactive steps by instituting specific measures to ensure the safe and timely delivery of resident care. The policy did not include critical/minimum nursing staff requirements for each shift. The facility P&P titled Resident Call System dated 2/3/2021 documented the facility believed that appropriate services and care should be provided to assist each resident in attaining or maintaining his or her highest level of physical, mental, and psychological well-being. When call system is activated - alarm sounds and light is on, the following should be done: Answer bell/light promptly. The facility P&P titled All Hands-on Deck - Dining Assistance Program dated 9/30/2021 documented that in the event of a disaster or emergency that a contingency plan is in place so that all residents can be provided the necessary assistance during dining to promote adequate nutrition. All Hands-on Deck will be announced during Morning IDT (Interdisciplinary Team) Meeting when applicable or at the beginning of the shift when a situation arises that necessitates additional assistance during meals. During an interview on 11/5/21 at 9:45 AM, the Administrator stated the current facility census was 96. Unit 1 West was the designated COVID-19 positive unit with 35 residents. a.) Review of an undated, untitled document identified by the Director of Nursing (DON) as acuity level for 1 West revealed the current number of residents requiring total assistance with meals was 4 and the total number of residents that required 2 staff assist with transferring was 17. Review of facility document titled Daily Schedule dated Friday, November 5,2021 documented one RCC for facility, 3 LPNs, 5 CNAs scheduled 6AM-2PM, 1 CNA scheduled 6AM-10PM and 1 CNA scheduled 1PM-2PM. Further review revealed 1 West was scheduled with:1 RCC, 1 LPN, 1 CNA 6AM-2PM, 1 CNA 6AM-10AM and 1 CNA 1PM-2PM. Therefore, one CNA for 35 residents for the hours of 10 AM to 1:00 PM. b.) During an observation on Unit 1 West 11/5/21 at 10:45 AM, multiple call lights were luminated (lit up) and sounding. The call light system monitor mounted on wall at Nurses station displayed four rooms and call light times as follows: -Resident #4 for 80 minutes -Resident #1 for 58 minutes -Resident #5 for 56 minutes -Resident #6 for 46 minutes. During an interview on 11/5/21 at 10:49 AM, CNA #1 stated there was one CNA and one nurse on unit. CNA #1 at the time interview observed the call light monitoring system at the nurses' station and stated that the residents listed above call lights were on and sounding for the length of time displayed. CNA #1 stated they were working by themself, doing the best they could, and the nurse had to pass medications. During continual observations on Unit 1 West 11/5/21 from 12:17 PM to 1:18 PM the following was observed: -12:17 PM, two dietary carts (lunch meal trays) were at the entrance of unit 1 West sitting at nurses' station. -12:22 PM, lunch meal tray pass from dietary carts initiated by CNA #1 and RCC #1. -1:10 PM, Multiple call lights luminated and sounding and verified with call light system monitor at nurse's station the following: -Resident #1 for 59 minutes -Resident #7 for 55 minutes -Resident #9 for 37 minutes -Resident #8 for 27 minutes. During an observation and interview on 11/5/21 at 1:15 PM, Resident #1 was in bed with call light in hand and was observed to have a very dry oral cavity (lips, tongue) and had difficulty speaking. Resident #1 stated they had put there call light on over thirty minutes ago for something to drink and stated they were very thirsty. -1:18 PM, tray pass was completed on unit. During the continual observation (12:17 PM - 1:18 PM) CNA #1, LPN #1, RCC #1 passed lunch trays. There was no additional assistance (All hands-on Deck) provided from ancillary staff (therapy, activity, social worker, dietary, etc.) on Unit 1 West. During an interview on 11/5/21 at 2:10 PM, CNA #1 stated the residents should not be waiting a half an hour to an hour for their call lights to be answered. Staffing was critical and there were not enough staff to take care of the residents. Skin breakdown could occur if the residents were not cleaned (provided with incontinent care) and positioned timely. Additionally, CNA #1stated they were unable to get residents out of bed because the facility was short staffed. Leaving the residents in bed makes it easier to ensure they are cleaned up. During an interview on 11/5/21 at 2:30 PM, LPN #1 stated that 5 to 10 minutes was a reasonable time for the residents call lights to be answered. Having to wait a half hour or longer was an excessive time to wait. LPN #1 stated there was not enough staff to answer the call lights timely and more staff was needed so the residents get the care they deserve. During an interview on 11/5/21 at 3:12 PM, HR (Human Resource) Director stated 8.5 CNAs were scheduled for the day shift today but only 5.5 worked. The day shift was typically scheduled with 4 aides on each unit and having one aide on a unit would be a critical staffing level for day shift. During an interview on 11/5/21 at 3:22 PM, the DON stated they were aware of call offs, aware of the schedule for the day shift on 1West and there was no way they could have taken a CNA from another unit to assist on 1 West. Critical staffing levels depend on how many residents are on the unit. Ideally, we would like to have 2 aides on each unit. The expectation for the COVID-19 unit was 2 to 3 aides. The DON stated it was unacceptable for call lights to be on for over a half hour and would like the lights answered within a few minutes. The DON added, it had a lot to do with there being only one full shift aide on 1 West today. The DON stated that it usually takes 15 minutes to pass lunch trays on a unit and on a normal day we would have made an announcement for available staff to assist with feeding. The 1 West staff did not notify the DON of the need for additional assistance during lunch. During an interview on 11/5/21 at 3:38 PM, Administrator stated they have been at a critical staffing level. The facility utilizes an All hands-on deck approach and use department heads to help when they were able. The critical staffing plan was to be implemented when there were less than 2 aides per unit. During an interview on 11/5/21 at 3:49 PM, the RCC #1 (for 1 West) stated they were responsible for 1 West, covering the rest of the facility as a nursing supervisor and that they had been called to other units twice during the day shift. The RCC stated 1 West was understaffed today (11/5/21). Resident call lights should be answered within 15 minutes, if not sooner. Call lights were answered the best they could be with the staff they had. Meal tray pass should have taken 20 minutes had there been adequate staff. The RCC stated that two assist residents only get out of bed if they ask. The RCC added that they were too busy to call for help and that the scheduler knew how much staff the 1 West unit had. During an interview on 11/5/21 at 4:57 PM, the DON stated 1 West did not have enough staff based on acuity. During an interview on 11/5/21 at 5:00 PM, the Administrator stated they were aware of the staffing on 1 West and that they did not have enough staff. At minimum, the lowest number of CNA's would be 2 for each unit and that wasn't even ideal. 415.13(a)(1)(i-iii)

Based on observation, interview, and record review conducted during a Standard survey completed on 7/30/21, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, one of one Main Kitchen had issues with unacceptable dish washer temperatures when cleaning and sanitizing resident dinnerware and flatware, not properly cleaning and sanitizing the food processer equipment in between each food item that was being pureed, and staff not wearing beard guards while prepping and serving food. The findings are: Review of the facility Policy and Procedure (P&P) entitled Food and Nutrition Services dated 3/10/21 documented each resident is provided with a nourishing, palatable, well balanced diet that meets his or her nutritional and specialty dietary needs. All surfaces will be sanitized with approved sanitizing agent between food preparation efforts including sanitizing all small equipment. Review of the facility P&P entitled Dietary Dress Code dated 3/10/21 documented employees of the dietary department will wear professional appearing attire and will maintain appropriate hygiene while on duty. Staff with facial hair must keep the length less than half inch in length or a beard guard will be required. 1. During an observation on 07/28/21 at 10:20 AM in the dish machine room two dietary staff were in the process of cleaning the breakfast dishes for the day. Five racks of juice cups, plates, bowls, coffee cups, and flatware were rinsed and placed into the racks and sent through the conveyor of the high temperature dish machine. Observation of the wash cycle revealed the temperature not going above 141°F (degrees Fahrenheit) with the thermostat instructions revealed the water should be above 150°F. In addition, the rinse cycle instructions revealed the water should be above 180°F and it did not go over 153°F. The juice cups, plates, bowls, coffee cups and flatware were then stacked and stored to dry. These items were observed to be used during that day's lunch tray line. Review of the Dish Machine/Pot Washing Log dated July 2020 documented the wash and rinse cycle temperatures as follows: -7/28/21 at the breakfast meal wash cycle was 140°F and rinse cycle was 160°F. -7/28/21 at the dinner (lunch) meal wash cycle was 140°F and rinse cycle was 175°F. -7/29/21 at the breakfast meal wash cycle was 140°F and rinse cycle was 140°F. -7/29/21 at the dinner (lunch) meal wash cycle was 150°F and rinse cycle was 140°F. There were no documented temperatures for the supper meal for both days During an interview on 07/28/21 at 10:39 AM Dietary Aide #1 stated the dish machine temperatures are checked in the morning, wash cycle should be over 150°F and rinse cycle should be at 200°F but not be low 180°F. The dietary aide further revealed some days the temperatures are up and down, and it takes sometimes 4-5 passes of the dishes to go through to get to the required temperature. Dietary Aide #1 stated they do not rewash the dishes and did not notify anyone of the low temperatures this morning. Further interview at 10:58 AM Dietary Aide #2 informed the surveyor the rinse cycle was now up to 160°F and the dish machine temperatures should be between 160 -180°F for the rinse cycle. During an interview on 7/28/21 at 10:51 AM the Dietary Technician (DT) stated the dish machine temperatures are taken by the staff in the dish room before each meal and logged. Further interview at 11:28 AM the DT informed the surveyor maintenance checked the dish machine and the rinse cycle is now up to 190°F. The rinse cycle should be above 180°F if the temperature was not high enough the staff should have rewashed and sanitized the dishes. During a further observation on 7/28/21 at 2:43 PM two dietary staff were in the process of cleaning the lunch dishes for the day in the dish machine room. Five racks with juice cups, plates, bowls, coffee cups and flatware were rinsed and placed into racks and sent through the conveyor of the high temperature dish machine. Observation of the wash cycle thermostat revealed with instructions of the water should be above 150°F the wash cycle temperature did not go above 141°F and the last rinse cycle with instructions the water should be above 180°F, did not go 161°F. The juice cups, plates, bowels, coffee cups and flatware were then stacked and stored to dry. 2. During an observation on 07/28/21 at 10:41 AM the cook washed their hands donned gloves and added approximately 24 cooked meat balls, approximately eight green handled scoops of cooked macaroni and eight ladles of red sauce into the food processer for that day's lunch meal and pureed to a smooth texture. The cook then went to the manual dish sinks and removed their gloves. Observation of the wash sink revealed the sink was filled to the top with a large strainer and cooking pans soaking in the dirty, milky colored water with floating food debris and a greasy film on top. The cook put the food processer, spatula, and lid in the empty middle sink , turned on the hot water and rinsed each piece, wiping the inside of the processor with their bare hand. The cook then tapped all three pieces of equipment against the side of the sink and brought the equipment back to the processing station. The cook then put approximately ten gray handled scoops of cooked green beans in the un-sanitized food processer and a small amount of chicken broth and processed to a smooth texture. The cook then removed her gloves and took the food processor, spatula, and lid to the manual dish sinks, turned on the hot water, rinsed all three pieces of equipment up and down three times in the wash sink, that still contained the dirty, milky colored water, food debris and the greasy film, large strainer, and cooking pans. The cook then proceeded to rinse the three pieces of equipment under the tap water in the middle sink, tapped the equipment on the side of the sink and brought the three pieces of equipment back to the processing station. The Cook then went on to process the Italian bread in the un-sanitized food processor. During an interview on 7/28/21 at 11:31 AM the Cook stated they were not sure what the process was for cleaning the food processer in between each food item. During an interview on 7/28/21 at 12:20 PM with the DT, the surveyor asks if anything was wrong with the puree process this morning and the DT stated yes. The DT stated the cook did not clean and sanitize the equipment in between the spaghetti and green beans. I told the cook before you came in to watch the puree process and she needed to clean and sanitize the equipment in between each food item and that the pureed food should be thrown away, d/t unsanitized equipment. During an observation on 7/28/21 at 12:26 PM the DT told the Cook to remove all the pureed food from the tray line and warming oven. The observation further revealed the DT taking over the tray line and the Cook pureeing a new batch of spaghetti and meatballs, green beans and Italian bread. 3. During an observation on 7/28/21 at 01:44 PM Dietary Aide #3 began serving lunch to the residents in the main dining room. They were wearing a surgical mask with facial hair protruding from the sides of the mask and below the chin approximately 1/2 to 1 inch of facial hair in length showing. During an interview on 7/28/21 at 2:05 PM Dietary Aide #3 stated they had just started working in the kitchen and was not wearing a beard guard and was unsure if the facility had any beard guards and was never told to wear one. During an interview on 7/28/21 at 3:23 PM the DT and Administrator revealed there were issues in the kitchen at lunch today as the Food Service Director (FSD) was not in the facility. Both the DT and Administrator agreed staff should be wearing beard guards if they have facial hair an inch or more. They were aware of the low temperatures on the dish machine and was working on getting the dish machine fixed and all equipment should be properly cleaned and sanitized. The hot foods should be served no lower than 130°F and cold foods below 40°F. 415.14 14-1.110(a)(c)(e) 14-1.72(c)

Based on observation, interview and record review conducted during an Abbreviated survey (Complaint #NY 897) completed during the Standard survey 7/30/21, the facility did not ensure that each resident received adequate supervision to prevent accidents for one (Resident #5) of four residents reviewed. Specifically, the facility did not identify and reassess a resident with exit seeking behaviors and the resident eloped from the facility. The finding is: A facility policy and procedure titled, Elopement Prevention and Search for Missing Resident revised 3/10/21 documented that residents will be maintained in a safe and secure manner and protected from actual harm while encouraging a restraint free environment. Residents will be assessed for potential elopement on admission, re-admission, quarterly and upon significant change, and if an attempted elopement occurs. If residents were identified as being a wanderer and/or exhibited the potential for elopement, a behavior management plan would be developed. All staff would receive elopement prevention in-service upon hire and annually. Staff would be instructed to immediately alert the licensed nurse of any resident displaying an increased risk for elopement including but not limited to: - Displaying exit seeking behaviors - Wandering behaviors - Verbalizing statements that may indicate potential for elopement 1. Resident #5 had diagnoses including metabolic [CONDITION(S)] (disturbance in brain function due to disease or toxin in the body), dementia, and restlessness and agitation. The Minimum Data Set (MDS-a resident assessment tool) dated 8/12/20 documented Resident #5 had severe cognitive impairment and required limited assistance of staff for ambulation with no assistive devices. The initial Elopement Evaluation dated 8/5/20 documented Resident #5 was not at risk for elopement. The Comprehensive Care Plan (CCP) dated 8/6/20 documented the resident was independent with ambulation to all destinations. Additionally, on 8/17/20 the CCP documented the resident had impaired cognitive function/dementia or impaired thought processes. Interventions included to cue, redirect, and supervise as needed. There was no CCP developed, or interventions implemented for wandering behaviors or elopement risk. Review of Resident #5's electronic medical record (EMR) interdisciplinary team (IDT) Progress Notes dated 8/6/20 through 8/24/20 revealed the following: - 8/11/20 at 2:55 PM Resident alert with periods of confusion and disorientation noted throughout shift. Required occasional redirection during times when they wandered out of their room and was looking to go home or to find some alcohol. - 8/15/20 at 1:31 PM Continued to have periods of confusion/disorientation at times. Resident told writer this morning that they were (leaving) for a few days. - 8/18/20 at 1:39 PM Occasionally wandered out from room and would usually tell staff they were looking to go somewhere to drink. Staff made resident aware of where they were and gently guided resident back to their room. - 8/22/20 1:10 PM After lunch was given to resident it was noted that resident had ambulated independently out of their room and walked down to the end of the hallway and attempted to open the emergency door. - 8/22/20 at 9:51 PM Alert with confusion, continued to come out of room asking for ETOH (alcohol). Resident asked if ride was here, explained no one was here to pick up resident. - 8/24/20 at 7:31 PM Accident & Incident: Elopement was paged overhead for resident. Resident then asked by writer if anyone let them out, resident stated No. Immediately all staff went to search for resident. Resident was noted to be walking toward the apartment buildings next to the facility. Resident's name was called, resident stopped, and calmly walked back to the facility with writer and another staff member. MD was called and notified of incident. Resident's room was changed to the second floor and an elopement band was placed on the resident. When asked how resident got out the resident stated, I went out of the front door. Review of the facility's Investigation Summary dated 8/24/20 at 5:30 PM revealed the resident eloped from the building. Certified Nurse Aide (CNA) went to deliver dinner tray and the resident was not in their room. Resident was found outside of building in grassy area next to the building. The resident returned to the building without incident. Registered Nurse (RN) assessment documented no injury occurred and the resident was not previously identified as an elopement risk. The investigation summary conclusion documented that the investigation supported the allegation of elopement as defined in the regulations. Attempts to interview the CNA involved in the incident were unsuccessful. During an interview on 7/30/21 at 10:18 AM, Licensed Practical Nurse (LPN) #3 stated that RNs were responsible for elopement assessments on admission and if a resident exhibited signs of wandering. LPN #3 stated Resident #5 would sometimes wander in the hall and was down by an exit door but she didn't think the resident was going to leave and couldn't remember if she told anyone. During an interview on 7/30/21 at 10:23 AM, Resident Care Coordinator (RCC) RN #3 stated they didn't remember if Resident #5 exhibited signs of wandering when they were admitted to the facility. If a resident was identified at risk for elopement, they try to transfer the resident to the second floor. RCC RN #3 stated I am not really sure how Resident #5 got out of the building. During an interview on 7/30/21 at 10:39 AM, the facility receptionist stated they usually worked until 3:30 PM and was not on duty when Resident #5 eloped. The receptions stated there nobody worked the front desk after she left. The receptionist stated they were not sure how the resident would have gotten outside because the front door has always been coded. It required a code before it would open. The resident may have followed someone out the door or they somehow knew the code, but they change the door code frequently. During an interview on 7/30/21 at 12:34 PM, the Director of Nursing (DON) stated the expectation for wandering residents was to do the elopement assessment and if risk was determined try not to keep resident's downstairs on the first floor. It's easier to monitor residents upstairs and they can't get on the elevator because a code was needed. Resident #5 was wandering and looking out the door but that doesn't always mean they are trying to get out. During an interview on 7/30/21 at 12:37 PM, the facility Administrator stated they never determined how Resident #5 got out of the building. The expectation was residents should be supervised for the exact reason as what happened with Resident #5. They should be supervised, for safety, so they don't elope from the building. 415.12(h)(2)

Based on observation, record review, and interview conducted during a Standard survey completed on 7/30/21, the facility did not provide food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, two (Main Dining Room Servery and One West) of two test trays completed for food temperatures during meals had issues involving food and beverage items that were not at safe and appetizing temperatures. Residents (#13, 15, 89, and 312) were involved. The findings are: Review of the undated Policy and Procedure (P&P) entitled Food Temperatures dated 3/2021 documented to ensure safety and quality of food items, it is the policy of the facility to obtain and record temperatures of food items prior to serving to residents. Hot foods must reach an internal temperature of 145°F (degrees Fahrenheit) and allowed to rest for at least 3 minutes before consuming. Cold foods should be held below 40°F. During an interview on 7/26/21 at 11:38 AM Resident #312 stated the food usually comes up cold and could be warmer. Trays are late. During an interview on 7/27/21 at 8:52 AM Resident #13 stated the food is bad and it's cold when it comes up. I can't eat it. I make my own sandwich from my refrigerator. Every day the meals are cold, and the cold food is very warm, like room temperature including the milk and juices. During an interview on 7/27/21 at 9:53 AM Resident #15 stated the food is terrible. The food is cold, has no flavor and small portions. There are too many sandwiches on the menu for the supper meal. During an interview on 7/27/21 at 09:54 AM Resident #89 stated the food is terrible, cold, and no flavor. They have to many sandwiches at night. During the Resident Council Meeting on 7/27/21 at 10:06 Residents stated the meals are always late, sometimes two hours late and the food is always cold. During an observation on 07/28/21 at 1:44 PM after all the lunch trays were served to the residents on unit One West, the test tray temperatures were then taken by the facility Registered Dietitian using a facility thermometer. The temperatures obtained were as follows: -Green Beans- 121°F and tasted waxy and rubbery. -Milk- 51°F and tasted cool/ lukewarm, not palatable. -Prune Juice- 52.5°F and tasted cool not cold/ lukewarm, not palatable. During an observation on 7/28/21 at 1:44 PM the Dietary Aide #3 began serving the lunch meal in the Main Dining Room Servery and did not obtain the food temperatures prior to serving. During an observation on 7/28/21 at 01:54 PM after all the lunch trays were served to the residents in the Main Dining Room Servery, the test tray temperatures were then taken by Dietary Aid #3 using a facility thermometer. The temperatures obtained were as follows: -Meatballs- 142°F and tasted lukewarm, bland, and rubbery. -Green Beans- 115°F and tasted cold, bland and were mushy. -Spaghetti- 138°F and tasted lukewarm and the sauce tasted acidic. -Milk- 55°F and tasted lukewarm, not palatable. -Juice- 56° F and tasted lukewarm, not palatable. During an interview on 7/28/21 at 2:05 PM Dietary Aide #3 stated they did not take the food temperatures prior to serving the food to the residents. They thought the food temperatures were already taken in the kitchen but was unsure. During an interview on 7/28/21 at 2:42 PM the Cook stated the food was tempted prior to bringing to it to the Main Dining Room Servery and it was hot. The Cook stated they did not document the temperatures though. The Cook stated the temperatures should be over 140° F for hot items and below 40° F for cold items. They stated the server in the servery should temp the food and document on log prior to serving. During an interview on 7/28/21 at 3:23 PM the Dietary Technician and the Administrator revealed there were issues in the kitchen today at lunch due to the Food Service Director (FSD) being out of the facility. They were aware of the low food temperatures, all foods should be tempted and logged prior to serving. Hot foods should be served no lower than 130°F and cold foods below 40°F. 415.14(d)(1)(2)

Based on observation, interview and record review conducted during a Recertification survey completed on 7/30/21, the facility failed to ensure that infection control practices and procedures were maintained to provide a safe, sanitary, and comfortable environment to help prevent the development of COVID-19 and transmission of communicable diseases and infections. Specifically, staff member Registered Nurse (RN #2) did not wear an N95 mask, gloves, gown, and their surgical mask was below the nares during specimen collection for one Visitor (#1) of three visitors tested for COVID-19. The finding is: A CMS (Centers for Medicare and Medicaid Services) memorandum, revised 4/27/21 (Reference QSO-20-38-NH), documented: during COVID-19 specimen collection, facilities must maintain proper infection control and use recommended personal protective equipment (PPE), which includes an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection, gloves, and a gown when collecting specimens. CDC (Centers for Disease Control and Prevention) guidance, updated 2/26/21, titled Interim Guidelines for Collecting and Handling of Clinical Specimens for COVID-19 Testing documented: For healthcare providers collecting specimens or working within 6 feet of patients suspected to be infected with [CONDITION(S)]-CoV-2, maintain proper infection control and use recommended personal protective equipment (PPE), which includes an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection, gloves, and a gown. Facility policy and procedure titled, COVID-19 Testing Requirements dated 3/22/21, documented: during specimen collection the facility would maintain proper infection control and use recommended personal protective equipment (PPE), which included an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection, gloves, and a gown when collecting specimens. During an observation on 7/26/21 at 4:09 PM, Registered Nurse (RN) #2 was in the parking lot at a car window performing a nares swab without donning gloves, gown, or an N95; RN #2 wore only a surgical mask positioned at the base of the nares, not covering their nose. During an interview on 7/26/21 at 4:12 PM, RN #2 stated a COVID-19 Rapid test swab was performed for a visitor who requested to have a test completed prior to visiting a resident. RN #2 stated the visitor was asymptomatic. RN #2 stated they forgot to put on the N95 mask and should have and the surgical mask should be worn over the nose to cover the nares. RN #2 stated they did not need to wear gloves because the swab was placed into the specimen test card and the specimen was not touched, therefore gloves were not required. RN #2 stated a gown was not worn because the testing was done outside the facility. During an interview on 7/30/21 at 12:09 PM, the Director of Nursing (DON) Infection Preventionist (IP), stated they were not aware RN #2 did not wear gloves and wore a surgical mask below the nares while RN #2 swabbed a visitor for COVID-19. The DON/IP stated staff were expected to wear appropriate PPE during COVID-19 swabbing, which included surgical mask in the correct position over the nose, gloves, gowns, N95, and eye protection when swabbing staff, residents, and visitors, including swabbing outside the facility. The DON/IP stated PPE was used to protect the staff from potential exposure and ultimately protect the residents from potential exposure to COVID-19. During an interview on 7/30/21 at 12:50 PM, the Administrator stated RN #2 didn't think full PPE was required since they were vaccinated for COVID-19 and that RN #2 should have worn full PPE (gown, gloves, N95, eye protection) during the swabbing process. 415.19(a)(1)

Based on observation, interview and record review conducted during an Abbreviated survey (Complaint #NY 318) completed on 11/21/19, the facility did not ensure sufficient staff with the appropriate competencies and skill sets to carry out the necessary functions to safely and effectively carry out the functions of the food and nutrition service. Specifically, the facility did not ensure sufficient dietary support personnel resulting in extended meal wait times, food not palatable and temperatures that were not appetizing. The findings are: Refer to F 803 - Menus Meet Resident Needs/Prep in Advance/Followed - S/S=D Refer to F 804 - Nutritive Value/Appearance, Palatable/Preferred Temperature - S/S=D A facility policy titled Staffing - Dietary dated 9/2017 documented it is the facility's policy to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service taking into consideration resident assessments, individual plans and care and the number, acuity and [DIAGNOSES REDACTED]. Sufficient support personnel means having enough dietary and food and nutrition staff to safely carry out all of the functions of the food and nutrition services. The Food Serviced Director (FSD) must ensure the following: Determine if there are sufficient support personnel to safely and effectively carry out the meal preparation and other food and nutrition services; ensure that the residents' needs and preferences are met and food is palatable, attractive, served at the proper temperatures and at appropriate times; and sufficient staff to prepare and serve meals in a timely manner. Review of Food Service Committee/Food Council meeting minutes revealed residents and staff both attended the meetings and the following concerns were discussed: - 10/16/19 - The Main Points from the Administrator section documented lateness of meal times is still a problem, but is getting better. - toast is often hard, and not buttered to where it should be (suggested to be made last) - 11/13/19 - The Main Points from the Supervisor section documented lateness of mealtimes is still a problem, but is getting better each day. Review of the Dining Schedule dated 7/17 revealed dining hours for lunch begin at 12:15 PM. Interview with the Food Service Director (FSD) on 11/20/19 at 10:00 AM revealed ideally, the tray line starts at 11:45 AM. We serve Unit 1 room trays, then Unit 2 East and West. The Main Dining Room is served last and usually finishes by 12:30 PM. The lunch meal observation on 11/19/19 revealed the following: - 12:00 PM - residents were seated in the Main Dining Room awaiting lunch. - 12:05 PM - meal service started with the Cook and two Dietary Aides plating food in the Servery in the Main Dining Room, which was connected to the Kitchen. Staff were setting up trays and loading them on the dining cart for transport to the respective dining areas. - 12:39 PM - One Certified Nurse Aide (CNA) joined the two Dietary Aides in passing trays to 58 residents in the Main Dining Room. - 1:27 PM - The last resident was served their lunch meal. Confidential interviews with residents on 11/19/19 and 11/20/19 revealed the following food concerns: - Resident A stated the food is awful. It is cold and uneatable. - Resident B stated that meals are always late. We could get lunch anywhere from 12:30 PM to 1:30 PM. Lately it's been more like 1:30 PM. When we do get our meals, they are cold by then. - Resident C stated the food is hot occasionally, but 9 times out of 10 it is cold and it's never on time. - Resident D stated the food is frequently cold. Last time we had lasagna it was burned. It takes a long time for them to pass trays and they waited over an hour plus before they received their lunch yesterday (11/19/19). - Resident [NAME] stated food is cold most of the time. Interview with the FSD on 11/19/19 at 1:45 PM revealed Administration has budgeted the Dietary Department for one Cook and two dietary aides in the AM and in the PM. It is difficult to get meals out on time because of the limited staffing. The FSD stated she helps with cooking and tray line when she can and if there are call-ins, she comes in to fill in. The FSD stated today I had to place food orders and I couldn't help with Lunch preparation. That is why they're running behind. Interview with the FSD on 11/19/19 at 2:30 PM revealed if they had more staff, they could get meals out to the residents faster and improve the temperatures of the food. Interview with the Registered Dietitian (RD) on 11/20/19 at 10:40 AM revealed she has consulted with Administration regarding the staffing needs of the kitchen. The RD stated there is no way two dietary aides can complete all their duties, keep up with sanitation in the kitchen, and serve residents food in a timely manner. A minimum staffing plan would include at least three dietary aides. The RD also stated that the facility never switched over to the Spring/Summer Menu because the old FSD stated they didn't have time to do the change. The residents have been receiving the same Fall/Winter cycle 3 menu for 9 months. 415.14(b)

Based on observation, interview and record review conducted during an Abbreviated survey (Complaint #NY 318) completed on 11/21/19, the facility did not follow the prepared menus on 11/19/19 for one (Lunch) of one meal observed. Specifically, residents on a regular textured diet received 1.5 ounces (oz) of the main entry (Salisbury steak with mushroom gravy) instead of 4oz of protein as planned. There were no mushrooms in the gravy as planned. Residents on a carbohydrate-controlled diet (CCD) received half of a baked potato instead of a whole baked potato as planned. Residents A, B, C, D and [NAME] were involved. Review of an undated facility policy titled Portion Control revealed the facility will serve food and beverage items at the portion size indicated by production documents, menus, recipes, and meal tickets. The findings are: Review of a Dining Manager Menu Diets document dated Fall/Winter (YEAR)-19 revealed the following planned menu items and portion sizes for Day 3 - Tuesday Lunch: - Salisbury steak 4 ounces (oz.) - Mushroom gravy 2oz. - Baked potato - one - Steamed vegetables 4oz Observation of the Lunch meal service in the Main Dining Room on 11/19/19 revealed that residents on a regular diet received a small portion of Salisbury steak with gravy, a whole baked potato and mixed vegetables. Residents on a Consistent Carbohydrate Diet (CCD) received the same meal with half of a baked potato. There were no mushrooms in the gravy. Interview with the Food Service Director (FSD) on 11/19/19 at 2:12 PM stated the Salisbury steak was homemade and mushrooms were available for the gravy, the Cook just didn't add them. Interview with the FSD on 11/21/19 at 3:00 PM revealed she asked the Cook why the Salisbury steaks were only 1.5 oz and the Cook told her that she followed the recipe for meatballs instead of Salisbury steak. It was a mistake. The FSD stated the residents who are on regular diets received a whole baked potato and residents on CCD received half a baked potato like usual. Review of the Day-3 Production Sheet revealed that residents receiving a CCD should have received a whole baked potato. The FSD stated she didn't realize the production sheet stated that CCD residents were to receive a whole baked potato. 415.14(c)3