Every finding on record at Slate Valley Center for Rehabilitation and Nursing

Based on observation, record review, and interview conducted during the recertification survey, the facility did not ensure the provision of sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, residents reported during interviews that the facility was short-staffed at times, which resulted d in call bells not being answered in a timely manner with long wait times for care to be provided. An analysis of the actual staffing schedule showed that on 10 occasions from 2/15/2025 to 4/13/2025, the facility did not meet their facility assessment for staffing needs. This is evidenced by: Upon entrance to the facility on [DATE] at approximately 10:00 AM, 86 residents resided in two (2) units. Upon observing and reviewing the Facility Staffing Sheet, nine (9) Licensed Nurses and ten (10) Certified Nurse Aides were on duty. The Facility Assessment, last reviewed on 10/07/2024, documented that the facility's bed capacity was 88. The section titled, Staffing Plan, documented the following: - Day shift required three (3) Registered Nurses, four (4) Licensed Practical Nurses, and 12 Certified Nurse Aides - Evening shift required two (2) Registered Nurses, four (4) Licensed Practical Nurses, and 12 Certified Nurse Aides - Night shift required one (1) Registered Nurse, two (2) Licensed Practical Nurses, and four (4) Certified Nurse Aides - A complete census would require the facility to provide 215.6 hours of direct Certified Nurse Aide care for all residents on that day. A review of staffing sheets provided by the facility from 2/15/2025 through 4/13/2025 documented that they did not meet their assessed minimum staffing on most day and evening shifts, for the following: - On 2/15/2025, the facility census was 83 residents, which required 203.35 hours of direct Certified Nurse Aide care. The facility schedule had 152 hours of direct Certified Nurse Aide care. - On 2/16/2025, the facility census was 83 residents, which required 203.35 hours of direct Certified Nurse Aide care. The facility schedule had 160 hours of direct Certified Nurse Aide care. - On 2/26/2025, the facility census was 87 residents, which required 213.15 hours of direct Certified Nurse Aide care. The facility schedule had 144 hours of direct Certified Nurse Aide care. - On 3/07/2025, the facility census was 88 residents, which required 215.6 hours of direct Certified Nurse Aide care. The facility schedule had 152 hours of direct Certified Nurse Aide care. - On 3/11/2025, the facility census was 88 residents, which required 215.6 hours of direct Certified Nurse Aide care. The facility schedule had 136 hours of direct Certified Nurse Aide care. - On 3/17/2025, the facility census was 88 residents, which required 215.6 hours of direct Certified Nurse Aide care. The facility schedule had 152 hours of direct Certified Nurse Aide care. - On 3/26/2025, the facility census was 85 residents, which required 208.25 hours of direct Certified Nurse Aide care. The facility schedule had 152 hours of direct Certified Nurse Aide care. - On 4/1/2025, the facility census was 85 residents, which required 208.25 hours of direct Certified Nurse Aide care. The facility schedule had 160 hours of direct Certified Nurse Aide care. - On 4/07/2025, the facility census was 84 residents, which required 205.8 hours of direct Certified Nurse Aide care. The facility schedule had 144 hours of direct Certified Nurse Aide care. - On 4/11/2025, the facility census was 83 residents, which required 203.35 hours of direct Certified Nurse Aide care. The facility schedule had 120 hours of direct Certified Nurse Aide care. During a surveyor-led group resident meeting on 4/15/2025 at 10:30 AM, the 7 residents attending the meeting reported insufficient staffing to meet their needs. They often had to wait an extended period of time to get care. They stated staffing was extremely low on weekends when only one (1) or two (2) aides per unit. During an interview on 4/18/2024 at 10:45 AM, Staffing Coordinator #1 stated that a program created the daily schedule via a spreadsheet, created by corporate, that allocated the number of staff personnel per the daily census. They stated that the program does not change, and all they are required to do is input the daily census, and the program would provide the number of Certified Nurse Aides and nursing personnel required. 51317 During an interview on 4/18/2025 at 10:45 AM, Director of Nursing #1 stated that they were aware of the federal regulation regarding required hours for Certified Nurse Aides per the census. They stated that the schedule was done by a program created by corporate to determine the number of staff they would require per the daily census. They stated that according to a complete census of 88 residents, the facility was budgeted for six (6) Certified Nurse Aides during the day, six (6) Certified Nurse Aides for the evening, and four (4) Certified Nurse Aides for the night shift. They stated that the staffing would be adjusted when there are call-ins, and they made every attempt to fill in with additional staff. They stated that the pool for additional staffing was relatively small due to their remote location. 10 New York Code Rules and Regulations 415.13(a)(1)(i-iii)

Based on observation, record review, and interview conducted during the recertification survey, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the main kitchen and two (2) of the two (2) resident unit nourishment rooms. Specifically, in the main kitchen, the dishwashing machine temperature display panel and floors under the dishwashing machine were soiled with food particles or dirt; the storage area for clean pots, pans, and food containers had multiple containers stacked together that were not thoroughly dried and contained moisture. In the A-Unit nourishment room, the refrigerator door gaskets were soiled with food particles, and in the B-Unit nourishment room, the refrigerator and floor were soiled with food particles or dirt. This is evidenced by: The following items were noted during observations on 4/17/2025 at 11:15 AM in the main kitchen and unit nourishment rooms. In the main kitchen, the dishwashing machine temperature display panel and floors under the dishwashing machine were soiled with food particles or dirt; the storage area for clean pots, pans, and food containers had multiple containers stacked together that were not thoroughly dried and contained moisture. The refrigerator door gaskets in the A-Unit nourishment room and the floor in the B-Unit nourishment room were soiled with food particles or dirt. During interviews on 04/17/2025 at 1:23 PM, Food Service Director #1 stated that it is a joint effort between nursing staff on the unit and the kitchen staff to keep the areas clean. They indicated they had placed a cleaning schedule and checklist for the unit's nourishment areas. They stated they did not have the gasket area on the checklist and would need to add it. They stated that the staff will need to be more diligent in placing the pots and pans away to make sure they are completely dry before doing so. They stated that the dishwasher was not getting to the proper temperature for sanitizing and had to be repaired. They stated that the maintenance director had repaired the dishwasher but needed to clean the area after they had finished. They stated that staff would clean the area and instructed the staff to make sure the dishwasher area was clean after each use. 10 New York Code of Rules and Regulations 415.14(h)

Based on record review and interview conducted during the recertification and abbreviated (Case #NY00338414) survey, the facility did not ensure residents were provided the proper treatment and assistive devices to maintain vision for one (1) (Resident #86) of one (1) resident reviewed for vision. Specifically, for Resident #86, the facility did not ensure that the resident ' s glasses were replaced and follow up appointments for optometry were obtained. This is evidenced by: Resident #86 Resident #86 was admitted to the facility with diagnoses of polyneuropathy (multiple peripheral nerves are damaged or diseased, leading to symptoms like weakness, numbness, and burning pain), type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). The Minimum Data Set (an assessment tool) dated 3/30/2024 documented the resident usually understood others, sometimes was understood by others, and was severely cognitively impaired. The Minimum Data Set documented the resident had moderately impaired vision and used corrective lenses. A Consult Form dated 5/18/2023 documented the resident had been seen by the optometrist with the next follow-up scheduled for 11/2023. A handwritten note at the bottom of the consult dated 12/5/2023 documented the resident would be seen because their glasses were broken. There was no documented evidence of any other consult forms for optometry services. Record review of an email provided by the facility from the optometry service dated 4/18/2025 documented the resident was not seen by the optometrist following the 5/18/2023 visit. During an interview on 4/18/2025 at 11:15 AM, Director of Nursing #1 did not recall this issue with the resident and stated the resident should have had a follow up appointment and should have received new glasses. 10 New York Codes, Rules, and Regulations 415.12(2)(b)

Based on observation, record review, and interview during the recertification survey, the facility did not ensure food brought for residents by family or visitors (food) was discarded when expired and other foods were stored in a way that is either separate or easily distinguishable from facility food. Specifically, a restaurant sandwich and restaurant prepared chicken wings were not labeled with resident names and dated; and one expired restaurant entre labeled with a resident name was not discarded. This is evidenced is as follows: During observations on [DATE] at 10:58 AM, in the A-Unit nourishment room refrigerator, a restaurant sandwich and restaurant prepared chicken were not labeled with resident names and were not dated; and one restaurant entre labeled with a resident name was dated [DATE] (5 days earlier than survey observations). A document titled Food From Outside and dated ,d+[DATE], documents that food brought by family/visitors that is left with the resident to consume later will be labeled with the resident name, room number, item, date received and discard date to clearly distinguish the item from facility-prepared food; and refrigerated foods brought to residents will be discarded in 48 hours. During interviews on [DATE] at 12:33 PM, the Administrator and Food Service Director stated that nursing is responsible to label food brought in for residents with the resident name and date, and the dietary staff are responsible daily to discard any food brought in to residents that are not labeled properly and discard food dated more than 48 hours prior.

Based on record reviews and interviews during a recertification survey, the facility did not ensure the Minimum Data Set (MDS - an assessment tool) was encoded and transmitted to the Centers for Medicare and Medicaid Services (CMS) system for 1 (Resident #2) of 3 residents reviewed. Specifically, for Resident #2 the facility did not ensure the Discharge - Return Not Anticipated MDS was encoded and transmitted to the CMS system within 14 days. Resident #2 Resident #2 was admitted to the facility with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . dementia and adult failure to thrive. The MDS dated [DATE] documented the resident had severely impaired cognition, could understand others and could make themselves understood. The Discharge - Return Not Anticipated MDS had not been encoded and transmitted at the time of the recertification survey which occurred beyond 14 days of Resident #2's discharge. During an interview on 7/28/22 at 1:13 PM the Director of Nursing stated that MDS completion and transmission was not handled on site in the facility but off site. During a telephone interview on 7/28/22 at 1:53 PM, the Vice President of Clinical Reimbursement stated the MDS scheduling, completion and transmission was done off site from the facility. Resident #2's Discharge - Return Not Anticipated MDS should have been transmitted within the federal guidelines. The Vice President of Clinical Reimbursement stated completion and transmission was often done in batches and this specific MDS may have been missed.

Based on observation, record review, and interviews during the recertification survey, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety in the main kitchen and two (2) of 2 resident unit nourishment rooms. Specifically, cans of sweet potatoes and tuna had unacceptable dents exposing the food to adulteration; ground sausage was not cooled to 41 degrees Fahrenheit (F) within 6 hours; one spray bottle was not labeled; and the concentration of quaternary ammonium compound chemical sanitizing rinse (QAC) was less than that required by the manufacturer. In the main kitchen, the shelf under the window air conditioning unit had raw, unsealed wood; the table mixer, slicer, shelving, dishwashing machine temperature display panel, ventilation duct grate over the dishwashing machine, and floors under the dishwashing machine and stoves were soiled with food particles or dirt; the paper towel dispenser by handwashing sink in dishwashing machine room was empty; and the wall behind preparation table had holes and peeled paint. In the A Unit nourishment room, the refrigerator door gaskets were soiled with food particles, and in the B Unit nourishment room, the refrigerator and floor were soiled with food particles or dirt. This is evidenced as follows: During observations on 07/25/22 at 10:58 AM, in the main kitchen and unit nourishment rooms, the following items were noted. Finding #1 Dented Cans, Cooling Food, and Spray Bottle V-shaped dents were found in the top seams of two #10 cans of sweet potatoes and one can of tuna; all cans were found in the common stock; cooked ground sausage located in the walk-in refrigerator was 52F; and one spray bottle located in dishwashing machine room contained a clear liquid, and the bottle was not labeled. During interviews on 07/25/2022 at 10:58 AM and on 07/26/22 at 11:58 AM, the Food Service Director (FSD) stated the sausage was prepared on 07/24/22, and the spray bottle contained sanitizing solution. Finding #2 Sanitizing Solution The concentration of QAC used to sanitize food contact equipment in the 3-compartment sink was found to be zero (0) parts per million (ppm) when measured at 68 F; when checked after testing the sanitizing solution, the reservoir of QAC concentrate was empty. The document titled Santec eight (not dated), documented that for food contact surfaces sanitization, the sanitizing solution is to be between 200 and 400 ppm. The document titled Greenex Quaternary Sanitizer (the wall poster for sanitizing and solution testing directions; not dated), documents that the sanitizing solution is to be between 150 and 400 ppm; the directions and manufacturer are inconsistent with the Santec eight bottle directions. Finding #3 Cleanliness and Other Concerns In the main kitchen, the shelf under the window air conditioning unit had raw, unsealed wood; the table mixer, slicer, shelving, dishwashing machine temperature display panel, ventilation duct grate over the dishwashing machine, and floors under the dishwashing machine and under stoves were soiled with food particles or dirt; the paper towel dispenser by the handwashing sink in dishwashing machine room was empty; and the wall behind preparation table had holes and peeled paint. In the A-Unit nourishment room, the refrigerator door gaskets were soiled with food particles; and in the B-Unit nourishment room, the refrigerator and floor were soiled with food particles or dirt. During interviews on 07/25/22 at 12:23 PM, the Administrator and FSD stated that in the future staff will be more closely monitored for proper cooling of foods and the cleaning items found; staff will be re-educated on unacceptable dents in cans, checking whether the sanitizer concentrate bottle is full, and on the cleaning items found; the sanitizer concentrate chemical vendor will be contacted to get the correct directions and test kit; all spray bottles will be labeled; and work orders will be submitted to seal the raw wood and repair the wall. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.32, 14-1.40(b), 14-1.60, 14-1.90, 14-112(c), 14-1.110, 14-1.143(c), 14-1.170, 14-1.171

Based on record review and interviews during an abbreviated survey (Case # NY 874), the facility did not ensure that all alleged violations of abuse, neglect, or mistreatment were reported immediately, but no later than 2 hours after becoming aware of the allegation for 1 (Resident #1) of 3 residents reviewed. Specifically, on 9/24/2021 the facility became aware of an allegation of abuse involving Resident #1 and reported the allegation to the New York State Department of Health (NYSDOH) on 9/27/2021. This was evidenced by: The Policy and Procedure on Abuse dated 9/2012 and last revised 2/2019 documented the Administrator (ADM) and the Director of Nursing were responsible for investigating and reporting allegations. Resident #1: Resident #1 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (an assessment tool) dated 9/27/2021 documented the resident had moderately impaired cognition and could usually make themselves understood and could usually understand others. An Investigation Form dated 9/29/2021 documented that on 9/24/2021, Resident #1 reported to the Psychologist that they may have been sexually assaulted. The Psychologist reported the allegation to the ADM after the appointment with the resident. The form the facility used to notify the NYSDOH of the allegation documented the incident occurred on 9/24/2021 and was reported to the NYSDOH on 9/27/2021. During an interview on 9/29/2021 at 2:24 PM the ADM stated they became aware of Resident #1's allegation on 9/24/2021 and did not report the allegation until 9/27/2021. The ADM stated the resident's family member called on 9/27/2021 and said they wanted a full investigation of the allegation and called the police. The ADM stated that at that point they thought they should report the allegation to the NYSOH. 10 NYCRR 415.4(b)(2)

Based on record review and interview the facility did not refer residents with newly evident mental illness for a level II review for one (Resident #80) of two residents reviewed for Pre-Admission Screening and Resident Review (PASRR). Specifically, the facility did not ensure for Resident #80, who was newly diagnosed with [REDACTED]. This is evidenced by: Resident #80: The resident was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - an assessment tool) dated 10/31/19, documented the resident had severe impairment for cognition, was able to sometimes understand others, and sometimes able to be understood by others. The MDS documented the resident had [DIAGNOSES REDACTED]. The facility's Policy and Procedure for Screen/PASRR revised 6/2019, documented: - to identify if a Level II PASRR evaluation is required for a resident who has a newly diagnosed mental illness or mental [MEDICAL CONDITION]/developmental disability, a Level 1 screen will be completed by a qualified screener. A new Screen and Level II PASRR Evaluation (if required) must be completed within the required timeframe according to state regulations. - to identify if a Level II PASRR evaluation is required for a resident who has a serious mental illness and/or mental [MEDICAL CONDITION]/developmental disability and is identified as having a significant change in physical or mental condition, a Level 1 screen will be completed by a qualified screener. A new Screen and Level II PASARR Evaluation (if required) must be completed within the required timeframe according to state regulations. The Screen Form dated 4/14/14, Level 1 Review for Possible Mental Illness (question #23) documented the resident did not have a serious mental illness. The Resident's [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. physician's orders [REDACTED]. - [MEDICATION NAME] 100 mg (along with 25 mg) to equal 125 mg every day at 12:00 PM for [MEDICAL CONDITION] and [MEDICAL CONDITION]. - [MEDICATION NAME] 25 mg (along with 100 mg to equal 125 mg every day at 12:00 PM for [MEDICAL CONDITION] and [MEDICAL CONDITION]. - [MEDICATION NAME] XR 150 mg, give one tablet every day at 6:00 PM for [MEDICAL CONDITION] and [MEDICAL CONDITION]. - [MEDICATION NAME] 100 mg every day at 12:00 PM for depressive episodes. - [MEDICATION NAME] 0.5 mg twice daily at 6:00 AM and 6:00 PM for generalized anxiety disorder. - [MEDICATION NAME] 60 mg every day at 12:00 PM for [MEDICAL CONDITION]. A physician's orders [REDACTED]. A Careplan for Psychosocial-Alteration dated 1/31/17, documented for annual review on 10/29/19, that the resident shows she had difficulty meeting her psychosocial goals due to [DIAGNOSES REDACTED]. Her mood state shows some improvement but she still experiences episodes of weeping and continues to be withdrawn. The resident is maintained on [MEDICATION NAME] and [MEDICATION NAME] for her mental wellbeing but has experienced hallucinations and times of crying out for her mother over the quarter. The medications are proving beneficial and she continues to require psychiatric evaluation. At times she refuses care and becomes confused. There are no new behaviors over review period. A psychiatric note dated 8/09/19, documented the resident has [DIAGNOSES REDACTED]. Patient isolated in room and has little engagement with others or in pleasurable activities. During an interview on 11/21/19 at 09:32 AM, Social Worker #2 stated the resident should definitely have had a new level 1 screen to include new [DIAGNOSES REDACTED]. SW #2 did not realize the resident did not have a new screen. 10NYCRR 145.11(e)

Based on record review and interview conducted during the recertification survey, the facility did not ensure an Infection Prevention and Control Program was maintained. Specifically, the facility did not ensure Infection Control Policy and Procedures were reviewed and/or revised on a yearly basis. This is evidenced by: During an observation on 11/25/19: - Infection Control Program did not include the date it was originated or the date it was updated. - Pneumococcal Vaccine for Residents Policy was dated 10/2016. - Antibiotic Stewardship Policy was dated 10/2017. During an interview on 11/25/19 at 12:01 PM, the Infection Control Coordinator stated she did not know if the Infection Control Policies were reviewed and revised at the corporate level since she noted the dates documented on the Infection Control, Pneumococcal Vaccine and Antibiotic Stewardship Policies were not current. She had previously questioned this herself and stated the policies should be looked at annually. 10NYCRR415.19(a)(1-3)

Based on observation, record review and interviews during an abbreviated survey (Case #NY 938), the facility did not ensure each resident was free from abuse for 1 (Resident #1) of 3 residents reviewed. Specifically, the facility did not ensure Resident #1, who had severe cognitive impairment, was free from psychological abuse when he was made to take a shower with his clothes on. This is evidenced by: Resident #1: Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) (a standardized assessment tool) dated 9/5/19 documented Resident #1 was severely cognitively impaired, could usually able to make self-understood and usually able to understand others. The Accident and Incident Policy and Procedure (P&P) last revised 8/2019 documented each resident was to be free from abuse. Abuse could include verbal, mental or physical abuse. Additionally, residents were to be protected from abuse. A Physician Admission Progress note dated 8/29/19 documented Resident #1 had been admitted to the facility with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Nurse Progress notes dated 9/1/19 through 9/11/19 documented Resident #1 had been resistive to care delivery on 9/1/19, 9/4/19, and on 9/8/19. The Behavioral Symptoms Comprehensive Care Plan (CCP) dated 9/10/19 documented Resident #1 displayed physical symptoms directed toward others, verbal symptoms directed towards others, rejection of the evaluation or care, and wandered. The CCP documented for staff to use a calm, slow approach when interacting with residents and to redirect from inappropriate behavior. The CNA Assignment Summary (care delivery instructions) (printed 9/12/19) did not document evidence Resident #1 displayed resistance to care behaviors and did not document interventions to address the behavior. A Facility Investigation Form signed by the Director of Nursing (DON), documented that on 9/11/19 Certified Nurse Aide (CNA) #1, gave Resident #1 a shower while he was fully dressed and while he was in his wheelchair despite Resident #1's protest of not wanting a shower. CNA #1 stated to Resident #1 that his hair was dirty and that he smelled. It was documented that there was no [MEDICATION(S)] harm to Resident #1, as he was diagnosed with Wernicke's [CONDITION(S)] and did not remember the incident. In a written statement dated 9/12/19 CNA #1 documented Resident #1 agreed to take a shower but did not want to take off his pants. She removed Resident #1's shirt and told him that his hair was dirty. She did not remove his pants but explained to Resident #1 that more pants were available. After CNA #1 started getting Resident #1's hair wet, he became agitated because his pants got wet, and he calmed down after he found out there were more pants and the shower was finished. In a written statement dated 9/11/19 RNS #1 documented that CNA #2 reported that CNA #1 had grabbed Resident #1 and pushed him (in his wheelchair) into the shower fully dressed. In a written statement dated 9/11/19, CNA #2 documented she witnessed CNA #1 grab Resident #1's wheelchair, hold down his arms, and force the resident into the shower room. CNA #2 went into the shower room and CNA #1 was observed spraying Resident #1 with water while being fully clothed. CNA #2 instructed CNA #1 to stop and allow Resident #1 to remove his clothes and CNA #1 replied No, I don't care he needs his hair washed, it is disgusting, and he smells. In a written statement dated 9/11/19 Licensed Practical Nurse (LPN) #5 documented she was unaware of Resident #1 having a shower until she noticed his hair wet after dinner, when she went to the resident's room. During an interview on 10/9/19 at 11:20 AM, the DON stated RNS #1 notified her of the event at about 6:00 PM and the DON advised RNS #1 to escort CNA #1 from the facility and start an investigation. RNS #1 had assessed Resident #1 but there was no documentation of the assessment. During an interview on 10/9/19 at 2:51 PM CNA #2 stated she witnessed CNA #1 hold Resident #1's arms down, while CNA #1 was standing behind his wheelchair, then push the wheelchair forward with Resident #1 in the wheelchair. CNA #1 held the hand-held shower attachment and sprayed Resident #1 while he had on his pants, socks, and short sleeved shirt. CNA #2 was able to get Resident #1's socks and shirt off, but not his pants. After Resident #1 was wheeled back to his room and dressed for bed. CNA #2 reported to RNS #1 what had happened. During an interview on 10/9/19 at 3:30 PM, RNS #1 stated CNA #2 reported the event, RNS #1 then called the DON, as CNA #1 was off the unit on break. When CNA #1 returned, she was escorted out of the building. RNS #1 stated that CNA #1 told her she had washed Resident #1's hair because it needed to be done. RNS #1 stated she felt CNA #1 did not recognize the event as abuse. RNS #1 also stated that she had seen that Resident #1's wheelchair was wet when she went to assess the resident. During an interview on 10/15/19 at 12:30 PM, CNA #1 stated that on 9/11/19, Resident #1 had agreed to have a shower but then did not want a shower. CNA #1 stated Resident #1 said no, no, I don't need a shower. She stated the shower was started in Resident #1's wheelchair but then the resident was transferred to a shower chair. CNA #1 stated she removed Resident #1's clothes, except his pants. Resident #1 began to swing his arms in the shower, but she continued the shower, and did not notify a nurse of the resident's behavior until after the shower was completed. Additionally, CNA#1 stated that CNA #2 was present during the entire interaction with Resident #1. 10 NYCRR 483.12(a)(1)

Based on observation, interview and record review during the recertification survey it was determined the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, foods time/temperature controlled for safety (TCS foods), formerly identified as potentially hazardous foods, are to be cooled to 41 degrees Fahrenheit (F) within 4 hours if prepared from ingredients at ambient temperature, such as canned foods. Soiled food service gloves (gloves) may not be used to prepare food. Adequate handwashing facilities are to be provided in food preparation areas; food contact surfaces shall be cleaned after use; and walls, floors, and ceiling are to be kept clean. Specifically, the facility did not ensure that TCS foods were cooled safely and food contact and non-food contact surfaces and floors were clean. Also, the facility did not ensure that the Dietary Server in the Main Dining Room (MDR), stationed behind the steam table, did not place multiple gloves on his hands, did not remove and replace gloves and did not perform hand hygiene in between. This was evidenced by: Finding #1: The facility did not ensure that TCS foods were cooled safely and food contact and non-food contact surfaces and floors were clean. The main kitchen was inspected on 07/30/2018 at 9:14 AM. The handwashing sink was blocked with a sheet pan rack. The microwave oven, table mixer, slicer, door to the walk-in refrigerator, shelving, K-fire extinguisher, tape dispenser, window sills, ceiling fan, wall behind prep table, ceiling, and the floor in corners and under equipment. The Food Service Director stated in an interview conducted on 07/30/2018 at 9:14 AM, that he is working on revising and updating the cleaning job procedures, and he will train staff to keep the handwashing sink access clear. Cook #1 stated in an interview conducted on 07/30/2018 at 9:14 AM, that she opened and reconstituted (ambient temperature) cans of soup at 9:05 AM this morning and placed the soup in the walk-in refrigerator to cool for later use. The temperature of the reconstituted soup was 64 F when checked on 07/30/2018 at 1:10 PM. The Food Service Director immediately discarded the soup. The Food Service Director stated in an interview conducted on 07/30/2018 at 1:10 PM, that TCS food is not monitored while cooling, and he will discuss with staff safe food cooling procedures. Observations on 08/01/2018 at 8:59 AM, revealed that the fronts of the cabinets, cupboards, drawers; cabinet below sink; and refrigerator door gaskets were sticky and soiled with food particles. 10 NYCRR415.14(h); State Sanitary Code Subpart 14-1.40(b), 14-1.71, 14-1.80, 14-1.110, 14-1.170 Finding #2: In the Main Dining Room (MDR), the Dietary Server stationed behind the steam table was observed placing multiple gloves on his hands and removing and replacing gloves without hand hygiene in between. The following was an observation on 7/30/18 at 11:32 in the Main Dining Room during the lunch meal. The Dietary Server (DS) placed four gloves on each hand. DS picked up the telephone, after hanging the phone up he removed cleaned gloves from the glove box and set them on the counter. He then removed the contaminated gloves from his hands and placed the clean gloves over the remaining gloves on his hands. DS then opened the refrigerator and removed a crate filled with milk cartons and set the crate on the counter. DS removed several milk cartons from the crate and filled a plastic bin with them, he then returned the crate to the refrigerator. He then took two gloves from the glove box and placed another glove on each hand over the contaminated gloves. DS then turned to the steam table, picked up a serving utensil and filled a plate with food from the steam table. DS then placed his fingers on the mask covering his beard, touched his beard and repositioned the mask. DS went to the phone, after hanging up he removed the gloves, washed his hands and left the MDR. DS returned to the MDR and placed two gloves over each hand. Using his right hand he removed soda cans from the refrigerator, then removed one glove from that hand. He turned to the steam table, picked up a serving utensil and filled a plate then placed the plate on the top shelf of the steam table. DS then scratched his exposed hair not covered with the hair net with his right hand, then turned back to steam table, picked up the serving utensil and filled a plate. DS then opened and closed the refrigerator, turned back to the steam table and picked up a piece of chicken with his right gloved hand, placed it on a plate then put the plate on the steam table. DS opened a cabinet door below the steam table, removed a cardboard box filled with non-food items, removed items and placed the box back into the cabinet. He removed the top gloves and put another glove over the remaining gloves on his hands. During an interview on 07/30/18 at 12:16 PM the Dietary Server stated my glove use during the meal is my way of doing it, as I touch dirty stuff I remove a glove. My old boss said that was OK if I put multiple gloves on and when I touch something I should take that glove off. I did not realize that taking a dirty glove off and putting a new glove on was wrong. During an interview on 7/31/18 at 3:15 PM, the Administrator stated that she was not aware of the practice of multi-glove use, did not think it was allowed in the facility. The Dietary department does their own handwashing audits, did not think it was a consistent routine. The Server should not have been using a multiple glove practice. During an interview on 7/31/18 at 3:47 PM, the Infection Control Nurse (ICN) stated that multi-glove use was not OK. ICN is new in the facility and will be doing environmental rounds that will include watching the meal serving in the Dining Rooms. She will be looking into that use and will be doing hand-washing audits with all staff. During an interview on 7/31/18 at 3:47 PM, the Dietary Director stated he was fairly new working in the facility. He was not aware of the Server using multiple gloves, and it did not sound like it would be an OK practice. I will be looking into that, and will be doing audits as well. 10NYCRR415.19(a)(1-3)

Based on interview and record review during a recertification survey the facility did not establish and maintain an infection prevention and control program (IPCP) designed to help prevent the development and transmission of communicable diseases and infection. Specifically, the facility did not develop a Water Management Plan (WMP) in accordance with adopted regulations. Also, the facility did not establish and maintain an infection control program to prevent the development and transmission of disease and infection determined for 3 of 3 dressing changes observed for one (1) (Resident # 42) of one (1) resident reviewed. Also, the facility did not ensure foley catheter tubings were maintained in a manner to prevent the development of transmission of disease and infection for two (2) (Residents # 19 and #32). Specifically for Resident #42, the facility did not ensure standard precautions were maintained during dressing changes to the resident's wounds to his right medial malleolus, left knee and right thigh. Specifically, for Residents #19 and #32, their foley catheter tubings were touching the floor when the residents were seated in their wheelchairs. This is evidenced as follows: Finding #1: The facility did not develop a Water Management Plan (WMP) in accordance with adopted regulations The WMP was reviewed on 07/31/2018. The WMP documentation provided was a generic template, was not facility-specific, and did not describe the Legionella growth control measures and actions to be taken if the control measures are not followed. The Administrator and the Environmental Services Manager stated in an interview conducted on 07/31/2018 that the WMP will be modified, specific to this facility, to include a description of the Legionella growth control measures and actions to be taken when the measures are not followed. 10 NYCRR 483.80(a)(1)(2)(4)(e)(f) Finding #2: The facility did not ensure standard precautions were maintained for Resident #42, during dressing changes to the resident's wounds. Resident #42: This resident was admitted on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had no cognitive impairment and was able to understand others and was able to be understood. The Policy and Procedure for Dressing Changes, with a revision date of 9/2013, documented the purpose of this procedure is to provide guidelines for the application of dry, clean dressings. Steps in the procedure were to clean the bedside stand to establish a clean field. Place the clean equipment on the clean field. Wash and dry hands and put on clean gloves. Loosen tape and remove soiled dressing. Pull glove over dressing and discard into bag. Wash and dry hands. Open dry, clean dressings by pulling corners of the exterior wrapping outward, touching only the exterior surface. Using clean technique, open the other dressing supplies and place on clean field. Wash and dry hands. Put on clean gloves. A Physicians's Order dated 7/16/18, documented the resident was to receive acetic acid 0.25% irrigation solution to all wounds beds every day. A physician's orders [REDACTED]. A physician's orders [REDACTED]. During an observation on 8/02/18 at 1:40 PM, LPN #1 was observed to be preparing to do a dressing change to the resident's left inner ankle, left knee and right thigh. In the treatment room, she opened dressing supplies and touched a 4 x 4 gauze with her ungloved hands. She placed all supplies on piece of wax paper and brought the supplies into the hall. She placed the supplies on the wax paper on an overbed table in the hallway. She did not cleanse the overbed table prior to placing the supplies on it. Left inner ankle wound: LPN #1 did not place a barrier under the resident's left foot. She cleansed the wound, opened a border foam dressing, touched the dressing, opened the xeroform, and cut it to size with scissors. She did not clean the scissors before using them. She opened the kling wrap and applied the border foam dressing to the wound. She opened and touched the ABD pad and applied it to the wound. She wrapped and secured the kling around the resident's ankle and foot. She did not remove her gloves, wash her hands and donn a new pair of gloves after touching the outside of the dressing packages. She did not avoid touching dressing supplies while opening the packages. Left knee wound: LPN #1 washed the wound, opened the [MEDICATION NAME], opened the dressing supplies and applied the [MEDICATION NAME]. She did not remove gloves, wash her hands and donn a new pair of gloves after touching the outside of [MEDICATION NAME]. Right outer thigh wound: LPN #1 removed the dressing, washed her hands and changed gloves. She then moved the overbed table to the right side of the resident's bed. She did not remove her gloves, wash her hands and donn a new pair of gloves after touching the overbed table, and proceeded with the dressing change. LPN #1 did not place a barrier under the resident's right leg. She cleansed the wound and applied [MEDICATION NAME]. She opened the skin prep, opened the package containing the [MEDICATION NAME] and cut it to size. She did not wipe the scissors before using them. She did not remove her gloves, wash her hands and donn a new pair of gloves after touching the outside of the dressing packages. She did not avoid touching dressing supplies while opening the packages. During an interview on 08/02/18 at 10:28 AM, LPN #1 stated she knew she was supposed to wipe the overbed table prior to placing dressing supplies on it. She did not realize she had not done so. She did not know she was not supposed to touch the dressing supplies when opening the packages. She did not realize she would need to remove her gloves, wash her hands and donn a new pair of gloves after she touched the outside of the packages containing the dressing supplies. During an interview on 08/02/18 at 11:13 AM, Registered Nurse Manager (RNM) #1 stated the nurses should be using a clean technique during a dressing change. The dressing materials should not be touched and hands should be washed and gloves changed when the outside of the dressing packages had been touched. A barrier should also have been placed under the resident's foot prior to start of the dressing change. During an interview on 08/02/18 at 01:40 PM, the Assistant Director of Nursing/Infection Control Nurse stated, during a clean dressing change, the nurses carry the treatment cart supplies together in the wax paper which is used as a barrier. The table is to be washed prior to putting the barrier down. She stated usually the nurses will need three pairs of gloves during a dressing change. She stated the nurse probably did not realize the table was dirty as waxpaper was being used. Finding #3: The facility did not ensure that Resident #19's and Resident #32's foley catheter tubings did not touch the floor when the residents were seated in their wheelchairs. Resident #19: This resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had severe cognitive impairment and was able to sometimes understand others and was sometimes able to be understood. Policy and Procedure for Urinary Catheter Care dated 7/2016, documented a general guideline for infection control is to be sure the catheter tubing and drainage bag are kept off the floor. The electronic Treatment Administration Record (eTAR) dated 8/2018, documented the resident's foley catheter size 18 Fr, with 10 millileters (ml) balloon, was to be changed as needed. During an observation on 07/31/18 at 01:45 PM, the resident was observed to be in front of the nurses station on B Unit, sitting in his wheelchair with his urinary catheter tubing touching the floor. Resident #32: This resident was admitted on [DATE] and re-admitted on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident had moderate cognitive impairment, usually was understood by others and usually understood others. The eTAR for 8/2018, documented the resident's foley catheter size was 16 fr with a 10 ml balloon, was to be changed every 6 weeks and as needed. During an observation on 07/30/18 at 10:20 AM, the resident was seated in her wheelchair in her room with her urinary catheter tubing touching the floor. During an observation on 07/31/18 at 01:44 PM, the resident was in the hallway seated in her in wheelchair with the urinary catheter tubing touching the floor. During an interview on 8/02/18 at 11:19 AM, RNM #1 stated the residents have pockets on their wheelchairs for the foley bags. The tubing needs to be below the resident and secured to keep it from kinking and is never to be touching the floor. She stated she did not understand why the tubing was not secured for the residents. During an interview on 08/02/18 at 01:40 PM, the ADON/ Infection Control Nurse stated she was pretty sure the urinary catheter tubing was not to be touching the floor. 10NYCRR415.19(a)(1-3)

Based on staff interview and record review during the recertification survey, it was determined that the environment was not free from accident hazards over which the facility has control. The resident environment is to remain as free from accident hazards as is possible. Specifically, unprotected metal brackets and sharp edges were exposed in resident areas. This is evidenced as follows. Observations on 07/30/2018 at 11:10 AM, revealed a hard-edged metal bathroom tissue holder bracket attached to the wall near the commode in the resident bathroom for resident room A-15. Further, in the corridor immediately outside resident room A-15, the inside of the handrail had a very sharp jagged metal projection; when the surveyor placed his hand in the handrail the projection pierced the pad of his finger and discovered the hazard. Observations on 08/02/2018 at 10:00 AM, revealed sharp frayed wooden or plastic edges on the following resident area doors: A-17 restroom, B-35 restroom, B-Wing long hall shower room, three A-Wing shower rooms. The Environmental Services Manager stated in an interview conducted on 07/30/2018 at 11:10 AM and again on 08/02/2018 at 11:30 AM, that he will immediately repair the bathroom tissue holder and assess all handrails for sharp projections. Record review on 07/30/2018 revealed that a work order for repair of the bathroom tissue holder in resident room A-15 was submitted on 07/29/2018, one day prior to survey observations. 10 NYCRR 415.12(h)(1)

Based on observation and staff interview during the recertification survey, the facility did not dispose of garbage and refuse properly. Specifically, the trash compactor was leaking waste. This is evidenced as follows. The trash compactor area was inspected on 07/30/2018 at 1:30 PM. The trash compactor was leaking a yellowish fluid from seams in the front, and the ground below the front was soiled with a black build-up. The Food Service Director stated in an interview conducted on 07/30/2018 at 1:30 PM, that he first noticed the compactor leaking last Friday, (MONTH) 27, (YEAR). The Environmental Services Manager stated in an interview conducted on 07/30/2018 at 1:30 PM, that he was notified today the compactor was leaking and has contacted the vendor for repairs. 10 NYCRR 415.14(h)

Based on observation, record review and interview during a recertification survey, the facility did not ensure a comprehensive care plan was reviewed and revised after each assessment for one (1) (Resident #67) of nineteen (19) residents reviewed. Specifically, for Resident #67, the Pain Careplan evaluations did not reveal documentation regarding the resident's pain. This was evidenced by: Resident #67: This resident was admitted on [DATE] and re-admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had no cognitive impairment and was able to understand others and was able to be understood. Policy and Procedure for the Care Planning Process revised on 11/2016, documented a policy statement, the comprehensive care plan includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs that are developed for each resident. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans at least quarterly. Review of resident's Pain Care Plan for quarterly evaluations, did not reveal documentation regarding the resident's pain. The electronic Medication Administration Record [REDACTED]. During an interview on 07/30/18 at 01:53 PM, the resident stated she recently twisted her knee and she reported it to the nurse. During an interview on 08/01/18 at 01:29 PM, Certified Nursing Assistant (CNA) #1 stated the resident's legs are very stiff. She will provide assistance when the resident is transferred on and off toilet. Resident had no complaints of pain. During an interview on 08/01/18 at 01:35 PM, LPN #1 stated the resident had no complaints of pain. A pain scale is done every shift and resident will respond she has no pain. During an interview on 08/02/18 at 01:33 PM, RNM #1 stated the pain careplan should mention an evaluation if the resident is or is not having pain. The RNM reviewed the Pain Careplan evaluation notes and stated there is no documentation regarding the resident's comfort level. no mention of pain level or lack of pain. She stated it should have been documented. 10NYCRR415.11(c)(2)(i-iii)

Based on observation, interview and record review during a recertification survey the facility did not ensure the development and implementation of a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care for one (Resident #380) of 19 residents reviewed. Specifically, for Resident #380, the facility did not ensure the care plan developed for pain was resident centered and did not ensure non-pharmaceutical interventions for pain and a care plan for diuretic were developed. This is evidenced by: A Policy & Procedure (P&P) dated (MONTH) (YEAR), documented a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy interpretation and implementation documented, the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The care planning process will facilitate resident involvement. The comprehensive person-centered care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and incorporate identified problem areas. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. Resident #380: The resident was admitted to the facility on [DATE], with the [DIAGNOSES REDACTED]. Resident is alert and oriented according to the Nursing Admission assessment dated [DATE]. The comprehensive care plan (CCP) dated 7/17/18 titled Comfort/Pain, Potential for alteration in comfort/pain documented related to, however the reason was not included. Barriers to managing pain documented (the resident had) high tolerance to pain meds. The goal documented that the resident will experience a decrease in pain daily after pain reducing measures are implemented through next review. Interventions included: Identify, evaluate, and document presence of pain or discomfort as indicated; medicate per physician's orders [REDACTED]. The Pain assessment dated [DATE], documented the resident was currently having pain, was receiving pain medication and the resident's acceptable level of pain was 6/10. A Physician order [REDACTED]. [MEDICATION NAME] 100 micrograms (mcg)/hr [MEDICATION NAME] (A strong prescription pain medicine that contains an opioid (narcotic) that is used to manage pain severe enough to require daily around-the-clock, long-term treatment with an opioid). Apply 1 patch every 72 hours, for pain. Tylenol (treats pain or fever) 650 mg every 4 hours as needed (prn) for pain. A Physician order [REDACTED]. The electronic Medication Administration Record [REDACTED]. The Nursing progress note dated 7/17/18, documented the resident's abdomen was distented and there was tenderness upon palpation. The resident was incontinent of bladder, states because of diuretics he cannot hold it. A review of the CCP dated 7/17/18, did not include a care plan to address the use of the diuretic [MEDICATION NAME]. The physician progress notes [REDACTED]. He is admitted for rehab (rehabilitation) and strengthening possible placement to a more supportive environment. Past medical history included chronic low back pain. During an interview dated 8/6/18 at 12:37 pm, the Director of Nursing (DON) stated that the Therapy Department does most of the non-pharmaceutical interventions, and they should be care planned if nursing is doing them. The care plan should not document non-pharmaceutical interventions and not list them. The care plan for Resident #380 should include one for [MEDICATION NAME] if the resident is receiving it. During an interview on 8/6/18 at 2:00 pm the Registered Nurse Manager (RNM) stated she was still new in her position and was still in training with the care plans. RNM had not yet done her own care plans, but they will be part of her duty. RNM had not talked to Resident #380 about his pain management. RNM did know that they do turn and position him every 2 hours, did not know if that was documented anywhere. During an interview on 8/6/18 at 2:26 pm the MDS (minimum data set) Coordinator stated the care plans are done by the Nurse Managers and the other disciplines. The MDS Coordinator attends the care conferences and reviews the care plans. She was on vacation the week Resident #380 was admitted , when she returned she pulled his old care plans from previous admissions. Non-Pharmaceutical interventions should have been documented in his care plan. The diuretics are usually care planned with the urinary incontinence care plans. 10NYCRR415.11

Based on observation and interview during the recertification survey, the facility did not ensure the management corporation used its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This is evidenced as follows. Refer to F584 Safe/Clean/Comfortable/Homelike environment During a resident meeting on 07/31/18 at 1:45 PM, seven out of seven residents that met with surveyors reported the condition of the carpeting (odors and stains) in the facility was unacceptable and they have complained frequently during Resident Council meetings. During an interview with the Activities Director on 7/31/18 at 2:45pm, it was reported that residents speak about carpets being dirty and in need of replacement in Resident Council meetings a lot. During an interview with the facility Administrator on 08/06/18 at 2:00 PM, it was reported that maintenance and cleanliness is on the Quality Assurance and Performance Improvement (QAPI) Tracker (a form used to track and monitor issues in need of improvement). The condition of the carpets, including odor, stains, fraying and buckling have been reported on the Tracker for the past year. The QAPI Tracker is reviewed at Quality Assurance quarterly meetings which are attended by Centers regional administrator and clinical coordinator. Centers took over ownership of the facility in (MONTH) (YEAR) and corporate staff told the residents they would replace the carpets. It has been reported by the Administrator to Centers' corporate staff, that the residents are very unhappy with the carpets. Centers corporate activities staff review the Resident Council meeting minutes and the carpeting is discussed regularly by residents. Centers representatives have toured the building and voiced the need to replace the carpeting. The Administrator has been told by corporate staff that the carpets will be replaced in late (YEAR) or early 2019, but there is no plan in place to ensure this. 10 NYCRR 415.26

Based on observation and staff interview during the recertification survey, the facility did not provide effective housekeeping and maintenance services. Specifically, durable medical equipment and floors were not clean on 2 of 2 resident units. This is evidenced as follows. The resident area floors and equipment were spot checked on 07/30/2018 at 9:30 AM and again on 08/02/2018 at 10:00 AM. A strong odor of stale urine and all corridor carpeting throughout the facility on both the A-Wing unit and B-Wing unit and the common areas were heavily soiled with a dark black build-up. Four wheelchairs and one lift were soiled with dried food, dusty, grime, and an indistinguishable substance on the resident contact areas. The Environmental Services Manager stated in an interview conducted on 08/02/2018 at 11:30 AM, that the odor was reduced by cleaning the carpet. The Regional Register Nurse stated in an interview conducted on 08/02/2018 at 1:40 PM, that the wheelchairs and lifts will be placed on a cleaning schedule and that though no vendors have yet been contracted, the carpeting will be replaced during the last quarter of (YEAR). 483.10(i)(2) 483.10(i)(2)

Based on observation, record review and interviews during a recertification survey the facility did not ensure that it maintained an Infection Control Program designed to prevent the development and transmission of disease and infection for one (1) (Resident #11) of eighteen (18) resident's reviewed. Specifically: for Resident #11, the facility did not ensure that infection control practice was maintained during administration of an Intravenous (IV) medication through a residents peripherally inserted central catheter (PICC line) (A peripherally inserted central catheter ( PICC Line), less commonly called a percutaneous indwelling central catheter, is a form of intravenous access that can be used for a prolonged period of time (e.g., for long chemotherapy regimens, extended antibiotic therapy, or total [MEDICATION NAME] nutrition). This is evidenced by: Resident #11: The resident was admitted on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident was understood and could understand, with a Brief Interview of Mental Status (BIMS) score of 15/15 and with no decision making impairment. A Physician order [REDACTED]. A Physician order [REDACTED]. A Physician order [REDACTED]. The electronic Medication Administration Record (eMAR) documented an order for [REDACTED]. Times of administration documented were 6:00 am, 2:00 pm and 10:00 pm. The eMAR documented Right Upper Extremity (RUE) PICC line to be flushed with 10 mL normal saline (NS) prior to infusion of medication. every 8 hours. A facility document titled Policy and Procedures for Central Venous Catheters revised on 10/17/16, documented the following: Non-valve PICC lines will be administered by initially verifying the order, performing hand hygiene, preparing the equipment, donning gloves, cleaning the injecion cap with an alcohol prep pad, allowing the cap to dry, attach the 10 cc syringe (prefilled with 10 mL NS) to cleansed port, gently pull back on the plunger while observing for a blood return to confirm placement. (If resistance is met and no blood returned, reposition resident with head turned, If no blood return notify physician for further orders.) It is further documented to flush the PICC slowly with 10 mL NS, then to connect IV to the port, discard syringes in sharps container, discard gloves, and perform hand hygiene. During observation on 11/30/16 at 2:15 pm, the Registered Nurse Unit Manager (RNUM) for Unit A was observed administering the IV medication for Resident #11. The RNUM did not perform hand washing upon entering the residents room, did not clean the area to place supplies or use a barrier for the supplies. During observation of the cleaning of the PICC line port (connection at the end of the PICC line) the RNUM was observed to wipe the end of the port with alcohol wipes and did not allow the end of port to dry. (The importance of allowing the port to dry is significant when a port has not been handled properly to prevent any contamination when the IV is connected allowing germs to the inner port). Prior to connecting the IV to the PICC line port the RNUM was observed touching the IV pole and bedside table with ungloved hands and did not perform handwashing prior to connecting the IV to the residents port. Also, the RNUM did not don gloves prior to performing a PICC line flush and connection to the IV. The RNUM did not wash her hands prior to leaving the room and carried the syringe used to flush the port out of the room into the hall. During an interview on 11/30/16 at 2:40 pm, the RNUM stated she was aware that she should have washed her hands prior to entering the resident's room and after the completing the care before leaving the room. She further stated that she was not aware that she should have applied gloves to perform the PICC Line flush and to connect the IV line to the the resident port. She stated she was not aware of any policy that the facility had for care of a PICC line. She further stated that she wasn't sure if the procedure was a clean or sterile procedure, but thought that she should have cleaned the area where she had to place her supplies prior to beginning the procedure. She stated she was given yearly inservices on infectious control by the staff development educator and stated this would include care of PICC lines. During an interview on 11/30/16 at 3:00 pm, the Director of Nursing (DON)stated that the RNUM should have washed her hands and donned gloves prior to giving care to the residents PICC line. She stated that staff should wash and dry their hands prior to care and after care is completed. She stated they were going to have the staff development nurse work with the RNUM and that there was a policy and procedure available to the RNUM. She further stated that the RNUM should have reviewed the policy for care of central lines if she was unsure about any part of the procedure. She stated that the RNUM would be observed and assisted with the PICC line when the IV was finished. She also stated that the way the RNUM performed the PICC line procedure, while administering the IV antibiotic, was not in compliance with the facilities infection control practices. The DON stated that the facilitiy expects the Registered Nurses to know how to follow the procedure when caring for a central line. She stated the RNUM would need further reeducation. 10NYCRR415.19

Based on record review and interview during a recertification survey the facility did not ensure that the Pre-Admission Screening and Resident Review (PASSR) was completed prior to admission for 2 (Residents #'s 8,and 32) of eighteen (18) residents reviewed. Specifically, for Resident #'s 8 and 32 the facility did not complete a New York State (NYS) PASSR using the required Department of Health (DOH) Screen Form DOH-695 (2/2009) prior to the residents' admission to the facility. This is evidenced by: Resident #8: The resident was admitted on [DATE], with the [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident as usually understands, usually understood with a Brief Interview of Mental Status (BIMS) score of 2/15 with decision making impairment. It also documented the resident received antipsychotic medication. During record review there was no documented evidence of a NYS PASSR. A neighboring states PASSR dated 12/07/16, was observed in the residents medical records Resident #32: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed the resident was understood and could understand. A Brief Interview of Mental Status (BIMS) of 15/15, with no decision making impairment. During record review there was no documented evidence of a NYS PASSR. However, a neighboring states PASSR was found in the residents medical record dated 10/31/16 During an interview on 11/29/16 at 11:15 am, the Registered Nurse Unit Manager (RNUM) stated the Social Worker (SW) is responsible for the PASSR's and that she was not sure why there was no PASSR available for the Residents #'s 8 and #32. She stated that she was not sure of the significance of the PASSR. During an interview on 11/29/16 at 1:50 pm, the Administrator stated that she was unclear as to what was needed to satisfy the NYS PASSR requirement for the out of state admissions. She further stated they frequently had problems getting PASSR's from Vermont for admissions. She stated that the neighboring states admissions are about 10% of the facilities census and that currently she had no one to perform the NYS PASSRs. She stated the facility liaison in the hospital, where most of her admissions come from, does not go to the neighboring state to perform the screens. She also stated that she understood that the PASSR needed to be done prior to the residents admission. She stated she would like clarification on what was needed and stated that no one from the facility had contacted NYS DOH to check if the neighboring states PASSR satisfied the requirements needed, before a resident was admitted to the facility. She further stated that there is a resident admission checklist that needs to be completed when a resident is admitted to the unit and that verification of a completed PASSR is one of the items that is on the checklist. The Administrator stated that the RNUM should be familiar with the documentation needed and should be reviewing the chart to make sure all needed documents are completed. During interview on 11/29/16 at 2:25 pm, the SW for the facility stated she was not PASSR certified as yet. She stated she had performed an on-line course and was not sure if the neighboring states PASSR was enough to fulfill the NYS DOH requirement. She stated the facility needed clarification on whether the NYS DOH-695 was required prior to the admissions of the residents. She further stated that there was no documented evidence that a NYS PASSR for Resident #8 or Resident #32 had been completed prior to admission. NY-10 CRR 415.11(e)

Based on medical record review and staff interviews during a recertification survey, the facility failed to ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source were reported immediately to the administrator of the facility. The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. Specifically, for nine (#'s 6, 12, 18, 39, 43, 61, 65, 68, and #83) of eleven residents, the facility failed to ensure there was a system in place for a thorough investigation of falls and other injuries of unknown origin to rule out abuse, neglect and mistreatment. Specifically, for residents who had unwitnessed falls and other injuries of unknown origin, the facility failed to thoroughly investigate to rule out abuse and neglect. Additionally, the facility failed to thoroughly investigate and report an allegation of verbal abuse that was observed by a family member between a nursing supervisor and a resident and prevent further potential abuse as the supervisor continued to work at the facility. This resulted in Immediate Jeopardy and Substandard Quality of Care to resident health and safety and no actual harm with the potential for more than mimimal harm. This is evidenced by: Resident # 12: Resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The resident is alert and oriented with a Brief Interview for Mental Status (BIMS) score of 15 according to the Minimum Data Set ((MDS) dated [DATE]. Finding # 1: Incident & Accident (I&A) dated 12/24/13 at 10:40 am documented, resident had gone outside to smoke, on attempting to re-enter the building she sustained a bruise to the left side of forehead. She was attempting to re-enter at side of doorway and hit shovel that was leaning on the door with the bottom of the wheelchair. The shovel fell , hitting resident ' s head and her ribs on the right side, she rang the elder care system (intercom button outside of the old emergency room (ER) entrance) for help. Immediate care provided was documented, resident was assisted by Certified Nurse Aides (CNA) to sit upright in the chair. Bruise noted to left side of forehead, she refused an icepack and complained of (c/o) pain in right rib area. Resident statement dated 12/24/14 at 10:55 am documented, was attempting to re-enter right hand side door of ER entrance, hit shovel that was leaning on door with bottom of chair, shovel then fell and hit my head on left side and ribs on my right side. Staff statement dated 12/24/14 at 10:40 am documented, went out the door and saw the resident leaning to the right side, she managed to push the intercom button to call for help. Staff statement dated 12/24/14 at 11:22 am documented, resident called us on the intercom so we ran out to see what was wrong. Interdisciplinary Team (IDT) Review dated 12/26/14 documented, Resident was accidently hit by a shovel leaning against the emergency room entrance door when she was re-entering the building. Resident is alert and oriented and per her smoking assessment appropriate to smoke on her own. There was no statement from maintenance staff in regards to the shovel being left by the outside door, or a plan to ensure the shovel would not be left in that area in the future. The IDT review made no mention of the resident requiring supervision when going outside per the Activity of Daily Living (ADL)/Mobility Comprehensive Care Plan (CCP). There was no revision to the Smoking or the ADL/Mobility CCP to prevent future incidents with resident going outside of the facility without supervision. Assessment titled Supervision of Smoking dated 10/04/13 documented under the heading " resident requires following smoking interventions, " to smoke unsupervised, and use smokers apron. Assessment titled Supervision of Smoking dated 12/26/13 documented under the heading " Resident requires following smoking interventions " was not completed. CCP titled, ADL/Mobility and dated 9/22/13 documented for intervention; Wheelchair, Independent in motorized wheelchair on and off unit "*must be supervised by CNA or nurse when going outside of building*." Pillow on left side for trunk position, seat belt. CCP titled Resident Smoking and dated 9/22/13 documented, resident is independent with smoking-no supervision needed. Documented for intervention; resident is independent with smoking. The CCP made no mention of the supervision required when going outside, per the ADL/Mobility CCP. Documented under " Notes " and dated 12/2/13, she is following facility smoking policy. No issues. No changes in care plan. During an interview on 9/17/14 at 8:00 am the Acting Administrator stated the Registered Nurse (RN) or Registered Nurse Unit Manager (RNUM) usually does Smoking Supervision Assessment anytime there is a change and quarterly. Many things come into play when deciding whether someone requires supervision with smoking. Someone probably left the shovel as they were using it for snow. It does not appear that anyone was spoken to from environmental services and an onsite education was probably not done but should have been. During an interview on 9/17/14 at 7:30 am the Maintenance Manager stated that in the winter they try to leave shovel outside the door leaning on the building and she had to hit it coming in. We left it there for convenience during winter. Finding # 2: I&A dated 1/19/14 at 10:00 am documented, Maintenance manager was exiting the building through the ER entrance and came upon resident on the ground with her arm against his car tire. Resident went outside to smoke per her usual routine at 10:25 am. Resident was in her motorized wheelchair per her norm. Per resident she was trying to reposition herself in her wheelchair when she slid out of her wheelchair onto the ground. Statement from staff member with no title written, documented the resident found lying face down with right arm up in the air on tire. Seat belt was buckled when last seen, not fastened when found. Statement from Maintenance Manager documented he saw resident five minutes before the incident riding in her wheelchair. Resident found face first lying on her stomach with arm against my car tire. Investigation Summary documented, last smoking assessment done 11/14/13 indicates resident is safe to smoke independently in designated smoking area. Smoking care plan reflects independence with smoking and was last updated 12/2/13. IDT Review dated 1/20/14 documented, resident is alert and oriented and is care planned to be able to go outside to smoke independently in her power chair. On 1/19/14 resident went outside to smoke at approximately 10:30 am. The resident while outside made the decision to try to reposition herself in her power wheelchair. It appears as though resident had unbuckled her seatbelt in the power chair and was attempting to use a parked vehicle to hold on to. This fall was unobserved, resident found out of her power chair lying face down on the ground. Right arm was stabilized, 911 called immediately, resident transported to hospital for evaluation. CCP followed. Resident statement dated 1/19/14 at 10:35 am documented resident was going to smoke, trying to reposition herself in the chair, and that she slid. There was no documentation in regards to whether the seat belt was unbuckled by the resident or some other means to determine whether the buckle was possibly faulty. There was no documentation in regards to the conflicting information of the resident ' s CCP for ADL/Mobility and must be supervised outside; the CCP for smoking and no supervision needed; and the smoking assessment dated [DATE] that was not completed with parameters for required interventions and assistive devices needed, to prevent further incidents of resident going outside without supervision. X-ray (An x-ray machine sends individual x-ray particles through the body. The images are recorded on a computer or film) report dated 1/19/14 documented, spiral fracture (type of fracture caused by a twisting force) to distal diaphysis of the right humerus (area of the elbow), with mild displacement. Supervision of Smoking assessment dated [DATE] was not completed with the instructions for " Resident requires following smoking interventions: and " Assistive devices needed. " CNA Assignment Summary (instructions of the level of care required for a resident) undated documented for locomotion; resident independent with own power chair, has a seat belt that she uses. Written on the bottom of the form; 1/19/14 Care plan OK, resident is independent with smoking. CCP titled, ADL/Mobility and dated 9/22/13 documented for intervention; Wheelchair, Independent in motorized wheelchair on and off unit *must be supervised by CNA or nurse when going outside of building*. Pillow on left side for trunk position, seat belt. CCP titled Resident Smoking and dated 9/22/13 documented, resident is independent with smoking-no supervision needed. Documented for intervention; resident is independent with smoking. The CCP made no mention of the supervision required when going outside, per the ADL/Mobility CCP. Documented under " Notes " and dated 12/2/13, she is following facility smoking policy. No issues. No changes in care plan. During an interview on 9/17/14 at 8:00 am the Acting Administrator stated the RN or RNUM usually does the Smoking Supervision Assessment anytime there is a change. Acting Administrator did not finish the assessment after resident had incident outside while smoking on 12/24/13, but was aware that resident was going out alone and even if the assessment was completed the care plan said she could go out alone. The RNUM should check assessment when updating care plan. During an interview on 9/17/14 at 2:15 pm the Director of Nursing (DON) stated they should have seen the incomplete Smoking assessment dated [DATE]. During the investigation she used the prior assessment of 11/29/13 which documented that the resident was unsupervised to smoke. DON further stated that there should have been an update to the CCP after the incident outside on 12/24/13. Finding # 3: A progress note dated 8/26/14 at 6:01 pm by the LPN, documented that at 6:15 pm the resident left the unit and did not tell staff where she was going. It documented that the resident was found wheeling around with another resident and their family and that the resident had been told many times that she had to go out with staff. It documented that the resident returned to the unit and was crying in her room. There was no further documentation in the progress notes related to this incident. An investigation Complaint Summary dated 8/28/14 documented, a search of the grounds was initiated on 8/27/14 at 6:15 pm because staff were unable to locate the resident, and that the resident came in through the front entrance in her wheel chair at 6:38pm. Summary of incident dated 8/27/14 and signed by the Acting Administrator documented, on Tuesday 8/26/14 Resident # 12 went outside with another resident ' s family member. Resident is allowed to go out of the facility if accompanied by staff, family or other responsible adult. When the Registered Nurse Supervisor (RNS) #1 saw the resident return to the facility she became upset and stated to the resident that she had been looking for her and was worried about her. The family member with Resident # 12 thought that the RNS#1 was unduly rude to the resident. The next day I met with the RNS#1 and the resident to discuss the situation, the resident did not feel that she had done anything wrong. Resident felt that she was being treated as a child. We agreed to a plan that included resident letting someone know when the resident was going outside. This was done on 8/27/14 at 3:00 pm. There was no statement from the family member that thought the RNS#1 was unduly rude to the resident. There was no statement from the resident in regards to the RNS#1's behavior towards her, or that the resident returned to the unit and was crying in her room. There was no evidence that the Resident was protected from interaction with the RNS#1 until it was determined that abuse, neglect or mistreatment had not occurred. In fact, the Acting Administrator held a meeting the day after the incident with the RNS#1 and Resident # 12 to discuss the incident. Evidence revealed there were no statements obtained to determine if abuse, neglect or mistreatment had occurred until day three following the incident of alleged verbal abuse. Statement attached to the investigation and dated 8/29/14 and signed by the Acting Administrator documented, on 8/29/14 the Ombudsman called and spoke to this writer. Ombudsman stated that an anonymous family member had called her and stated that the RNS#1 had spoken inappropriately to Resident # 12. The family member wished not to be named and did not want the DOH called. They (anonymous caller) stated to the Ombudsman that they wanted someone in authority at the nursing home to know and speak to the RNS#1. I explained to the Ombudsman that we had already had a meeting with the RNS#1 and Resident # 12 and we had come up with a plan. Statement attached to investigation and dated 8/29/14 at 4:45 pm and signed by a Licensed Practical Nurse (LPN, who wrote the note dated 8/26/14 at 6:01 pm) documented, on August 27th Resident # 12 left the floor without notification to the staff where she was going. I informed the RNS#1 , I walked completely around building and found resident on the far end of building with a family member and their resident. Resident # 12 wheeled inside and was met by the RNS#1. The RNS#1 told her we need to know where she is for her safety. The RNS#1 spoke to resident with firm tone stating DON would be notified. The other resident she had been out with and family were in entryway to observe event. Statement attached to investigation and dated 8/29/14 at 6:30 pm and signed by RNS#1 documented, observed another resident in wheelchair being pushed by her daughter coming in the front entrance with Resident # 12 behind them in her electric chair. I simply stated the DON would be immediately notified as this was a very serious situation, she knows she is not allowed outside unaccompanied by staff due to past history with past injuries. Going along with another resident and their family is unacceptable. On-site In-service dated 8/29/14 documented the incident as 8/26/14. The in-service outline documented: "Inappropriate verbal response to resident 's behavior. This incident was overheard by a family member and in their perception bordered on verbal abuse. This was reported by the Ombudsman." The Goal was documented, "RNS#1 will be aware that speaking to this resident in a harsh tone of voice and by the nature of her remarks could be considered verbal abuse." The In-service was signed by the RNS#1 and dated 8/29/14. Investigation conclusion dated 9/2/14 and signed by the Acting Administrator documented, on 8/27/14 Resident # 12 went outside accompanied by another resident ' s family member. Resident # 12 who is allowed to go outside with staff or responsible adults did not inform staff. Staff were sent to search facility and grounds, in process of search resident # 12 returned into the facility with another resident and family member. RNS#1 was upset, worried and spoke with Resident # 12 in a very determined voice stating that she needed to know where residents are for their safety. Resident was unhappy with being told what to do. Between the RNS#1, the resident and myself as intermediary we came to the conclusion that Resident # 12 would let the supervisor know by means of nurse or supervisor when going outside of facility to smoke or get fresh air. I received a call from the Ombudsman who stated that someone had reported to her that the RNS#1 spoke inappropriately to Resident # 12, and the reporter did not want to be named. I told the Ombudsman about the meeting and that an in-service had been done with the RNS#1 outlining the definition of verbal abuse, and the Ombudsman agreed that at this time it was a sufficient plan of correction. There was no evidence that following the report from the Ombudsman on 8/29/14 that Resident # 12 was protected from interaction with the RNS#1 until it was determined that abuse, neglect or mistreatment had or had not occurred. There was no evidence that the Resident was interviewed in regards to the alleged verbal abuse and how it affected her. There was no evidence that statements were obtained from all persons who witnessed the incident on 8/26/14 to rule out abuse, neglect or mistreatment. There was no evidence that the incident was reported to the DOH. During an interview on 9/18/14 at 9:15 am the Registered Nurse Manager stated that any accusations of abuse or neglect get left for the Administrator or Director of Nursing (DON) to contact the Department of Health (DOH) and that if there is no harm they do not need to notify the DOH. During an interview on 9/18/14 at 11:30 am the DON stated that she had already spoken to the resident and the RNS#1 about the incident on 8/27/14 and felt it was handled before she got the call from the Ombudsman. She further stated that she thought that she spoke to the resident alone but did not document it. During an interview on 9/16/14 at 2:00 pm the Supervising Administrator stated that during the course of an abuse investigation they usually did not check the personnel file of the involved staff to see if they had history. She stated that they would do a re-education and give the sheet which went to the In-service Coordinator (IC) and that the IC would let them know if there was history. During an interview on 9/18/14 at 2:55 pm the IC stated that she did not always check to if staff involved in incidents had a history. During an interview on 9/18/14 at 3:00 pm the Ombudsman stated that she had received a call on 8/29/14 from a visitor (who wished to remain anonymous) who reported that while at the facility on 8/26/14 witnessed a verbal altercation between the resident and the RNS#1. The caller stated that the resident had been visiting out in the garden and when she came back in the building the RNS#1 was at the door with her hands on her hips, and told the resident that she had to make out a missing person report and she was going to call the DON. The Caller stated that this RNS #1 always belittled this resident, talked down, and was sarcastic to the resident. The Ombudsman stated that she spoke to the DON about there being other people who must have witnessed the interactions between the RNS #1 and the resident. During an interview on 9/18/14 at 3:15 pm Resident # 12 regarding this incident she stated that she had gone outside with another resident's family and went out back to look at the garden. The resident stated that when she came back in accompanied by this family and with another family in close proximity, the RNS #1 "chewed her head off ", and said she knew better. The resident further stated that she felt very small and embarrassed and that she just tries to stay out of the RNS #1'S way. The resident stated that the DON met with her and the RNS #1 together on 8/27/14 and told the resident that she had to try to get along with the RNS #1. She stated that she just tries to stay out of the RNS #1'S way and that the RNS #1 told her that she was not there to be the resident's friend. The resident further stated that the DON never talked to her alone after the meeting with her and the RNS #1 together. When further information regarding the incident was provided via the Ombudsman no effort was made to re-examine the incident. Resident # 61: Resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident had moderate cognitive impairment with a BIMS score of 10 according to the MDS dated [DATE]. I&A (Incident and Accident) form dated 8/31/14 at 1:00 pm documented, noted on left foot great toe, bruise (yellowish) with redness going down lateral part of foot. Immediate care documented, assess area for pain and discomfort, slightly tender, slightly warm to the touch. Immediate actions documented, to monitor area. Statements included; Resident statement documented, "I think I hit it on table." LPN statement (who was working at time of discovery of bruise) documented, did not see incident occur. Staff member with no title documented, "did not see anything". Certified Nurse Aide (CNA) #2 assigned to Resident # 61 on 8/31/14 and who reported the injury documented, "does not know when the incident happened." "I reported the foot the day before and it looked worse today." Three employee interview forms documented staff member names and were not completed. Interdisciplinary Team (IDT) Review documented, resident noted to have a bruise to her left great toe. X-ray obtained after resident complained of pain upon palpitation, x-ray showed no acute fracture. No changes at this time, resident denies anyone hurting her. IDT conclusion documented unavoidable, and initialed by members of the IDT. There was no documented evidence in the IDT review that identified or addressed that the employee interview forms documenting staff names were incomplete. There was no documented evidence in facility records that indicated or determined other factors that may have contributed to this resident's injury or the documentation to address or investigate CNA #2's statement that the bruise was reported the day before. Review of nursing progress notes dated 8/30/14 (day before discovery of bruise) revealed there was no documentation in regards to the bruise to the left great toe. Review of nursing progress notes dated 8/31/14 revealed there was documentation at 2:19 pm describing the discovery of the bruise to the left great toe, and at 4:05 pm documentation, assess left foot great toe. Looks like old bruise with slight redness to the toe, slightly warm and tender, will monitor. Per resident stated "I think I hit it on the table in dining room a few days ago." Subsequent progress notes made no mention of the left great toe bruise until 9/3/14 at 1:09 pm which documented, physician (MD) contacted, resident has a bruise to her left great toe, she is able to move it but complained of pain upon palpation, new order for x-ray of left great toe. CNA Assignment Summary of Resident #61 documented the assistance for locomotion on unit as total assist of one person with bilateral leg rests to wheelchair. During an interview on 9/16/14 at 3:00 pm Registered Nurse Unit Manager (RNUM) stated the discovery of Resident #61 bruise occurred on a weekend and the investigation was started by the Registered Nurse Supervisor (RNS). If pieces were missing from an investigation the RNUM would look into it. There was no documentation that CNA #2 told the nurse about reporting the bruise to another nurse the day before. RNUM #1 stated LPN #1 said she did not know about the bruise prior to 8/31/14. RNUM stated that Resident #61 had short term memory loss and that her statement would not be reliable. The investigation was not a reliable investigation, not at all. During an interview on 9/16/14 at 2:55 pm the Acting Administrator (former Director of Nursing) stated the RNUM and MD looked at Resident #61's bruise and it was investigated. Resident was asked if it hurt and how did it happen. There was no evidence that anything deliberately was done to her. Investigations should have interviews with all staff that worked on the unit for 48 hours, unless what happened could be figured out without statements. The investigation with Resident #61 was concluded unavoidable because we got an x-ray, talked to Resident #61 and assessed her, did not think there was any harm, abuse or neglect. Resident is not mobile without assistance and probably hit her foot on the dining room table. CNA #2 alleged she told the nurse the day before 8/31/14 and nothing was done. During an interview on 9/18/14 at 8:25 am the DON stated she asked CNA #1 if she reported the bruise to a nurse on 8/30/14 (day before incident report) and CNA #1 said nurse looked at it. DON did not find an incident report for 8/30/14, and the nurse should have started one. During an interview on 9/17/14 at approximately 2:00 pm CNA #1 stated she reported Resident #61 left great toe bruise to LPN # 1 on 8/30/14 (day before incident report). The bruise looked worse 08/31/14, the day the incident report was initiated. CNA #1 said LPN #1 looked at the bruise and the RNS was made aware of the bruise on 08/30/14. CNA #1 said she did not know when the incident occurred. CNA #1 stated 09/17/14 was the first time she had ever been questioned by anyone regarding the incident report documentation that she had reported the bruise on Resident #61 the day before the incident report was initiated. Resident # 68: Resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Resident had severe cognitive impairment with long and short term memory problem according to the MDS dated [DATE]. I&A form dated 5/16/14 at 1:45 pm documented, Activities Director was walking past Resident #68 and noted his right hand bleeding. I&A documented CNA instructions was not followed for the resident. Contributing factors documented; staff had to keep repositioning resident in his wheelchair because he continually was bent over and fiddling with the wheel on his wheelchair. Also, his geri-sleeves were not on. Area was cleansed with normal saline, patted dry, and steri-strips applied. Description of injury documented 2 areas at 0.5 centimeter in size. Immediate action were documented as, staff were educated on the importance of reading each resident's care card. Statements included; Resident statement documented, "I was just fixing my car." Staff member statement with no title documented, the resident was toileted and that the resident was provided ADL care on the 11:00 pm to 7:00am (night) shift. For the question "is there anything that may be helpful" was documented, protective arm sleeves, I saw resident leaning over in chair repeatedly, had to adjust him in chair. Interdisciplinary Team (IDT) Review documented, Resident noted to have a skin tear on his right hand. Staff has noted that resident continues to lean forward in his wheelchair and tries to adjust or pick up something on or near the wheel of his wheelchair. Resident has severe cognitive deficits and is nearly always unaware of his surroundings, no change to CCP per IDT. IDT conclusion documented unavoidable, and initialed by members of the IDT. There was no documented evidence that the facility had identified or addressed the failure to follow care plan, that the resident received care on the night shift and at 1:45 pm he still did not have geri sleeves on. There was no documented evidence that facility staff identified or addressed that the I&A form listed that the resident was not wearing the geri sleeves as indicated on his careplan and that the resident may have incurred injury as he was not wearing the geri sleeves. I&A dated 7/21/14 at 3:45 am documented, the LPN heard a trash can being moved and found resident on the floor on door side of room crawling to the door. Resident was last seen on rounds at midnight in bed. Bed alarm was not sounding, CNA forgot to turn it on. Resident statement documented, "I heard some noises and I wondered what was going on. They told me it was snowing hard out." Staff member statement with no title documented, this writer heard a trash can being moved, went into resident room and found resident on the floor. Bed alarm did not sound nor call light. On-site Inservice (attached to investigation) documented an inservice provided to CNA for "bed and chair alarms found in the off position". The IDT Review documented, Resident found out of bed on the floor on the door side of room. Resident had no injuries, however bed alarm was not on and that is why resident was not identified as being out of his bed. On site inservice done with CNA caring for resident. No other changes at this time as resident is in low to floor bed with bilateral safety mats and bed alarms. IDT conclusion documented unavoidable, and initialed by members of the IDT. There was no statement from the assigned CNA in regards to not turning the alarm on, or why the resident had not been seen from 12:00 am till 3:45 am. There was no mention within the investigation in regards to the resident not being seen for three hours and forty five minutes. During an interview on 9/16/14 at 1:30 pm CNA #2 stated she often works with Resident # 68, he is usually up and dressed when she arrives on the day shift. When he is not up she lets him up as soon as she notices he is awake. During an interview on 9/17/14 at 11:30 am RNUM #2 stated they usually only get statements from person finding the person who fell , not the CNA assigned to the resident. Resident #68 sleeps at two hour intervals most of the time, thinks the only way to stop his falls is one on one supervision. The 7/21/14 incident should have a statement from the CNA, resident should have been changed no later than 2:00 am. The CNA did not follow the care plan for rounds every two hours and for not turning the bed alarm on. During an interview on 9/17/14 at 1:30 pm the Acting Administrator stated that everyone in the facility is checked on a minimum of every two hours. There should be a statement from the last person that saw him on 7/2/14. It is not acceptable if he was not checked from midnight to 3:45 am. During an interview on 9/16/14 at 12:45 pm the Activity Director stated when there is a resident incident we ask the resident what happened. In morning report we review all incidents as a team and we don't initial as member of the IDT until all statements are obtained. During an interview on 9/16/14 at 12:45 pm the RNUM stated when an incident occurs with a resident a statement is obtained from the person who finds the resident. The I&A should state when the resident is last toileted or last seen. The resident is also asked about what happened. During an interview on 9/16/14 at 12:45 pm the Social Worker stated that in morning meeting the Nurse Manager reads the incident reports and the statements out loud. The IDT then decides together to conclude the investigation. The facility's resident Incident and Accident Reporting and Follow-up policy revised 06/24/14, documented Incidents and Accidents will be reported and report forms completed in a timely manner consistent with federal regulations and facility guidelines. Reports will be reviewed by the Interdisciplinary Team during morning meeting. When an incident or accident occurs when indicated, immediate action(s) must be taken at the time of the incident to keep the resident in the safest environment. The resident's Care Plan will be updated by The Team at this time. The Nursing Supervisor/Administrative Representative will interview direct care givers to determine the cause of the incident. This may require obtaining statements from each direct caregiver over the past 24 hours or more. The Nurse Manager will present The Incident to the Interdisciplinary Team during morning meeting. All areas of the Incident/Accident Form and the Incident/Accident Follow-up must be completed except for those areas designated for Interdisciplinary Team Review. Reports completed on weekends will be reviewed at the next regularly scheduled morning meeting. Changes in a resident care plan of care will be noted on the care plan and the CNA Resident Nursing Instructions during the morning meeting after review by the Interdisciplinary Team. An Unavoidable Accident despite facility efforts to identify environmental hazards and individual resident risk of an accident. These include the

Based on observation, medical record review and interviews during a recertification survey it was determined that the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, for residents who had unwitnessed falls and other injuries of unknown origin, the facility failed to complete thorough investigations to rule out abuse and neglect, and mistreatment and to prevent the recurrence of incidents. Additionally, the facility failed to investigate and report an allegation of verbal abuse that was observed by a family member between a nursing supervisor and a resident. Consequently, the supervisor continued to work at the facility. This was widespread and resulted in no actual harm with potential for more than minimal harm that was Immediate Jeopardy. This is a repeat deficiency from the recertification survey dated 11/12/13. This is evidenced by: Interviews revealed facility staff were unable to identify key staff members to be interviewed in the case of an unwitnessed fall or injury of unknown origin to rule out abuse, neglect or mistreatment and to prevent reoccurrence of falls and/or injuries. Additionally, facility staff did not consider the need for additional interventions to prevent falls in those residents with increase in restlessness and behavior symptoms. Refer to F 225-Scope and Severity-L. During an interview on 9/15/14 at 11:15 am the Supervising Administrator stated that when the former administrator left sometime in June that the Director of Nursing (DON) became the Acting Administrator and the Assistant DON became the Acting DON. The Supervising Administrator comes into the facility two to three times per week and as needed. The Supervising Administrator saw that the facility had many falls and started to look at them. While looking into the falls she also noted that there was a problem with the Incident Reports (I&A). She began reviewing the I&As and sending them back to the units for completion, and did an inservice in August with the Interdisciplinary Team members (IDT). During an interview on 9/18/14 at 8:25 am the Acting Administrator (former DON) stated she thought all was OK with the I&As. Would not sign off on an I&A if we did not think there was no evidence of abuse, neglect or mistreatment. Even without some statements, would be OK to conclude no abuse, neglect or mistreatment. The most important statement would be from the person discovering the incident or injury. The falls, we always hope for no falls, the major thing is to protect from injury. The Supervising Administrator recognized we had a problem with the I&As in August and she inserviced the members of the IDT on how to change things. During an interview on 9/18/14 at 4:40 pm the Medical Director stated he signs the I&A reports. There have been meetings were he has been told of the amount of falls and investigations. Medical Director's understanding is they always do the investigations and talk to the staff. Was not aware of the problem with investigations and falls that DOH has identified. Had not been made aware by the Supervising Administrator that there was a problem with the I&As prior to the DOH survey. 10NYCRR 415.26

Based on medical record review and staff interviews, during a standard recertification survey it was determined that the facility Quality Assurance (QA) Program did not have a process that readily identified issues that had the potential to cause serious harm to residents. The facility failed to ensure that a system is in place for thorough investigation of falls and other injuries of unknown origin to rule out abuse, neglect and mistreatment. Specifically, for residents who had unwitnessed falls the facility failed to complete thorough investigations to rule out abuse and neglect, did not interview and obtain statements from caregivers to determine factors that may have contributed to the falls, and interventions were not personalized to prevent reoccurrence. The facility failed to ensure residents who sustained falls had interventions and supervision in place to prevent further accidents. Additionally, the facility failed to investigate and report an allegation of verbal abuse that was observed by a family member between a nursing supervisor and a resident. Consequently, the supervisor continued to work at the facility. This was widespread and resulted in no actual harm with potential for more than minimal harm that was Immediate Jeopardy. This is a repeat deficiency from the recertification survey dated 11/12/13. This is evidenced by: The IDT review process did not identify and or address factors contributing to I&A's such as incomplete assessments, discrepancies in careplans, and resident care provided as careplanned (rounds q 2h, shin care turn and position). Additionally, facility staff did not consider the need for additional interventions to prevent falls in those residents with increase in restlessness and behavior symptoms. Refer to F 225-Scope and Severity-L. During an interview on 9/15/14 at 11:15 am the Supervising Administrator stated that when the former administrator left sometime in June that the Director of Nursing (DON) became the Acting Administrator and the Assistant DON became the Acting DON. The Supervising Administrator comes into the facility two to three times per week and as needed. When she began coming in as the Supervising Administrator she saw that the facility had many falls and started to look at them. While looking into the falls she noted that there was a problem with the Incident Reports (I&A) as well. She began reviewing the I&As and sending them back to the units for completion, and she did an inservice in August with the Interdisciplinary Team members (IDT). During an interview on 9/16/14 at 10:30 am the Supervising Administrator stated there is a subcommittee of the Quality Assurance Program that is working on falls reduction. This committee began within the last six months. The falls committee meets monthly and does case reviews of falls including the CNA care card and interventions. During an interview on 9/18/14 at 8:25 am the Acting Administrator (former DON) who is the Acting QA Coordinator, stated she thought all was OK with the I&As. Would not sign off on an I&A if we did not think there was no evidence of abuse, neglect or mistreatment. Even without some statements, would be OK to conclude no abuse, neglect or mistreatment. The most important statement would be from the person discovering the incident or injury. The falls, we always hope for no falls, the major thing is to protect from injury. The Supervising Administrator recognized we had a problem with the I&As in August and she inserviced the members of the IDT on how to change things. During an interview on 9/18/14 at 4:40 pm the Medical Director stated he signs the I&A reports. There have been meetings were he has been told of the amount of falls and investigations. Medical Director's understanding is they always do the investigations and talk to the staff. Was not aware of the problem with the investigations and falls that the DOH is finding. Had not been made aware by the Supervising Administrator that there was a problem with the I&As prior to the DOH survey. 10 NYCRR 415.27(a-c)

Based on record review and staff interview the facility was not administrated in a manner that enabled it to use its resources effectively and to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident during the extended recertification survey. Specifically, on 2 of 2 units, 9 residents (#s 4, 25, 30, 34, 50,76, 87, 90 and 91) of 11 residents the Administration failed to ensure that residents were free of significant medication errors. This was widespread and resulted in the potential for serious harm and Immediate Jeopardy to resident health, and safety. This is evidenced by: The facility was able to remove the immediacy prior to exit by implementing the education and investigation of the identified medication error as listed in F520. Refer to Quality of Care - F 333, Residents are Free from Significant Medication Errors, Scope and Severity - L Refer to Administration- F 520, Quality Assessment and Assurance, Scope and Severity- L During an interview on 11/7/13 at approximately 1:30 pm, the Administrator stated that he was not notified and was not aware that the residents were not receiving their medications on the evening and night shifts of their admission and /or readmission. The Administrator stated the omission of medications is a serious concern because it places the resident at risk,and that had he been aware he would have addressed it immediately and directed the committee to implement audits and investigations He stated the facility had only a few Medication Variance Reports which he reviewed and were not related to mediation errors on the day of admission. He also stated the nurses are working out of their nursing scope of practice when they do not call the physician for orders if the medication is to be delivered later than the time the dose is due and doses of the medication are omitted. The Administrator also stated he was surprised to be notified that the nurses were working out of their scope of practice since the facility had an inservice on nursing scope of practice a few months ago. During a later interview on 11/13 /13 at approximately 5:30 pm with the Administrator, Director of Nurses(DON) , Assistant DON, Staff Educator and Corporate staff member present , the Administrator stated that in addition to what he stated in his previous interview on 11/6/13 that he and the DON were not aware of any of the medication errors and that the nurses not following the facility's policies and procedures and the standards of nursing practice as identified by the survey team. He stated that once administration became aware of the medication errors the QA Committee immediately began auditing , interviewing staff and investigating the identified medication errors to determine a root cause analysis immediately began re-educating the staff. The Administrator stated that it would not have mattered whether the facility was using the electronic system or the hand written paper system, because the medication errors would still have occurred because nurses are not following the facility's policies and procedures, are not using their basic nursing knowledge, not following professional standards of practice and are [MEDICATION NAME] outside their scope and practice. The DON who was also present at the interview with the Administrator on 11/13/13 at approximately 5:30 pm stated that she is very upset that residents did not receive their medications as prescribed by the physician and attributes the cause to the nurses not following their professional standards of practice, not following the facility's policies and procedures, not calling the pharmacy when a medication was not available and not calling the physician for further directions. She stated that the Medical Variance Reports have been initiated and she is in the process of obtaining statements from the nurses and then deciding what disciplinary action will be taken on each individual medication error. During an interview via telephone on 11/12/13 at approximately 3:00 pm, the Medical Director stated that he was concerned when informed of the number of residents that did not receive their medications which included insulin, anticonvulsants, antihypertensives, diuretics an antibiotic, and some less significant medications on the evening and night shift on the day of admission. He stated that nurses need to apply professional standards of practice, follow policies and procedures, and work within their scope of practice. He also stated that this is not acceptable and the facility is now going to have to evaluate their audit process to ensure it is effective, re-educate the nursing staff so they follow professional standards of practice and are following the facility's policies and procedures. 10 NYCRR 415.26

Based on record review and interviews during the extended recertification survey ,the facility failed to ensure that resident' s were free from significant medication errors. Specifically for 9 (# 4, 25, 30, 34, 50, 76, 87, 90 and 91) of 11 residents reviewed the facility failed to ensure that newly admitted resident's and readmitted residents received significant medications and treatments. The omission of the medications was not recognized by staff as a medication error and medication error reports were note made out. In addition, figer sticks with sliding scale insulin were not performed to determine if residents required insulin coverage. This resulted in no actual harm with potential for serious harm that was Immediate Jeopardy to the health and safety of the residents and Substandard Quality of Care. This is evidenced by: The facility was able to remove the immediacy prior to exit by implementing the following: The facility educated over 90% of their nursing staff on the admission process including the review of the hospital's Patient Departure Summary, Medication Administration Record (MAR), Hospital's physician's orders [REDACTED]. physicians orders are complete, the transcribing nurse has to call the Pharmacy for medications that are scheduled for that evening or night shift and that some medications are available in the facility's Emergency Kits which contains a supply of frequently prescribed medications such as antibiotics, anticoagulants and [MEDICATION NAME] Insulin, and the nursing staff are to notify the physician when a medication would be delivered late or not be available for administration. The facility initiated the investigations of the transcription and medication errors identified by the New York State Department of Health Survey Team. As part of their investigations, the facility performed a root cause analysis which identified the staff deviations from their policies and procedures and professional standards of practice. RNs will complete the electronic transcription by scheduling the times for medications in the EMAR. Medication Variance Reports were initiated for all the identified medication errors. The facility is conducting daily audits. Finding: A Policy titled Medication and Administration Record dated revised 9/2/11 documented if a medication or treatment supply is not available, the staff must make all attempts to secure the ordered medication and treatment supply and to consult with the Registered Nurse (RN)/Unit Manager and or RN Supervisor. It is unacceptable for the nurse to mark his /or her initials and document that the medication/treatment is not available. If a medication or treatment is held due to unavailability, the physician will be contacted for further instructions. A Policy titled Medication Administration dated revised 1/24/13 documented that the medication and treatment nurse will review the computerized " Dashboard "at the end of each shift to ensure that all items assigned to his or her shift have been completed. The Nursing Supervisor will also ensure all assigned items have been completed. There was no documentation in the Policy and Procedure that specified that the medication /treatment nurse was to check the "Dashboard" of the computer at the beginning of the shift for medications to be scheduled. A Policy titled physician's orders [REDACTED]. The nurse is to select " Reconciliation" in the left column to ensure that all components of the orders were transcribed completely and accurately. When a resident is readmitted from the hospital , the nurse will ' Re-activate' the resident in the electronic medication administration record (EMAR) and all orders must be reviewed with the physician and re-activated as necessary. The policy did not include that the nurse was to transcribe the medication orders as To Be Scheduled ( an area on the dashboard where incompleted work is placed) and was to schedule the times the medications were to be administered. Resident #4 The resident was admitted to the facility on [DATE] at 12:30 pm and also 10/28/13 at 4:00 pm with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented that the resident had moderately impaired cognitive skills for daily decision making. It documented that the resident usually understood and usually understands. A progress note dated 10/16/13 at 2:09 pm by the nurse documented that the resident arrived to the facility by squad and was admitted at 12:30 pm. A Patient Depart Summary from the hospital dated 10/16/13 documented that the resident was discharged on Levetiracetam ([MEDICATION NAME]-an anticonvulsant medication) 500 mg by mouth twice daily. It did not document the last time the medication was administered to the resident. A Physician order [REDACTED]. A Medication Administration Record (MAR) for October 2013 documented initials and a star in the box for 10/16/13 at 4:00 pm. Under comments dated 10/16/13 at 4:00 pm it documented that [MEDICATION NAME] 100 mg/ml give 5 ml (500 mg) twice daily, was not administered. It documented under the comment section, not available-new admit. A progress note dated 10/28/13 at 4:40 pm documented that the resident returned from the hospital after a total hip replacement. A Patient Depart Summary from the hospital dated 10/28/13 documented that the resident was discharged on [MEDICATION NAME] 100 mg/ml oral solution give 2.5 ml (250 mg) every evening. It did not document the last time the medication was administered to the resident. A Physician order [REDACTED]. Give 2.5 ml (250 mg) by oral route every evening at 8:00 pm. A MAR for October 2013 documented initials and a star in the box for 10/28/13. Under comments dated 10/28/13 at 4:30pm it documented that [MEDICATION NAME] 100 mg/ml give 2.5 ml (250 mg) once every evening was not administered. It documented under the comment section that the medication was not available-new admit. There was no documented evidence on 10/16/13 or 10/28/13, that the hospital was contacted for clarification on when the resident was last medicated with [MEDICATION NAME], and there was no documented evidence that the supervisor, pharmacy, or the Medical Doctor (MD) was contacted when the medication was not available. During an interview on 11/11/13 at 11:45am Licensed Practical Nurse (LPN )# 1 stated that sometimes medications are put in the computer and the times are not scheduled. This caused the medications to remain in the dashboard ( an area where incompleted documentation /tasks are stored in the computer) and not show on the MAR as needing to be administered. If the medication is not scheduled until after the time due, the computer would automatically schedule it to start the next day. She further stated that if a medication is scheduled for the evening of admission and the computer puts an "X" in the spot for that day she does not question it, "she just goes with what the computer says." During an interview on 11/8/13 1:15 pm the Nursing Supervisor (NS) stated that medications were routinely left in the dashboard until they are available before scheduling. NS further stated that she had access to the dashboard and could see anything that was left on there. The licensed staff were supposed to make sure that nothing was left on the dashboard at the end of the shift. During an interview on 11/9/13 at 11:50 am the Administrator and the Director of Nurses (DON) stated that they were unaware of the medication errors but that they would expect that if a medication error was discovered that they would have been notified. During a telephone interview on 11/11/13 at 2:30pm the MD for Resident's # 4 stated that the facility sends a fax with orders and someone in his group signs off on it. He stated that he was not aware of problems getting evening medications and that he would expect that residents were receiving them. He further stated that if the nurse had a problem getting medications or a medication was missed that he should be contacted. During an interview on 11/11/13 at 1:50 pm the Staff Development Registered Nurse (SDRN) stated that she gave basic training on the computer system and when an order is put in the computer there are 4 dots signifying different parts of the order. When each portion was completed , it ' s dot would turn from red to green. She further stated that one of the dots was for scheduling the medication and that the medication could still be ordered from pharmacy without the scheduling being completed but she did not know that staff were leaving the medications unscheduled in the dashboard. SDRN stated that the nurse was supposed to look at the departure sheet to find out what medications the resident was on and when the last dose was given. There was a problem with the system because the departure sheet were not always filled out. Resident # 90 The resident was admitted to the facility on [DATE] at 4:15 pm with [DIAGNOSES REDACTED]. The resident was alert and oriented and was able to make her needs known. An admission, transfer, discharge sheet documented that the resident arrived at the facility on 11/5/13 at 4:15 pm. A progress note dated 11/5/13 at 9:23 pm documented that the resident was admitted to the facility at 4:15 pm and that she ate her evening meal at the facility with her family. A Patient Depart Summary from the hospital dated 11/5/13 documented that the resident's discharge medications were [MEDICATION NAME] flex pen 100 units(u)/milliliter (ml) inject 0.1 u per kilogram subcutaneous(sq) twice daily before meals; last dose 11/5/13 at 1:30pm, next dose: meal time, [MEDICATION NAME] inject 6 u daily: The last dose was in the evening and next dose was documented, as directed. [MEDICATION NAME] 250 mg tablets give 2 by mouth( po) twice daily; last dose was 11/5/13 at 9:45am, next dose 11/5/13 in the evening. It documented [MEDICATION NAME] 25 mg 1 po twice daily; Last dose was 11/5/13 in the morning, Next dose: 11/15/13 in the evening, Potassium Chloride 10 milliiequivalents(mEq) give 2 tablets twice daily; Last dose was 11/5/13 in the morning am and next dose due was 11/5/13 in the evening. It documented [MEDICATION NAME] 20 mg give one tablet po twice daily the spaces for last and next dose were blank, and [MEDICATION NAME] topical 100,000 units vaginal tablet; Instill one tablet twice daily, the spaces for last and next dose were blank. A Physician order [REDACTED]. 4:30pm. It documented [MEDICATION NAME] 100 u/ml inject 6 u sq at 8:30pm, [MEDICATION NAME] 250 mg tablets give 2 tablets po twice daily at 8:00 am and 4:30pm, [MEDICATION NAME] 25 mg give 1 tablet po twice daily at 8:00 am and 4:30pm, Potassium Chloride 20 mEq extended tab 1 tab po twice daily at 8:00 am and 4:30pm, [MEDICATION NAME] 20 mg 1 po twice daily at 8:00 am and 4:30pm, and [MEDICATION NAME] 100,000 u vaginal tablet 1 intravaginal twice daily at 6:00 am and 10:30pm. A treatment record for November 2013 documented initials and a star in the box for [MEDICATION NAME] for 11/5/13 at 10: 30pm and 11/6/13 at 6:00 am. Under comments dated 11/5/13 at 10:30pm and 11/6/13 at 6:00 am it documented that the medication was not administered because the pharmacy did not have it . There was no documented evidence on 11/5/13 or 11/6/13, that the hospital was contacted for clarification as to when the resident was last medicated, and there was no documented evidence that the supervisor, pharmacy, or the MD was contacted when the medication was not available. A MAR for November 2013 documented X's in the boxes on 11/5/13 at 4:00 pm under [MEDICATION NAME], Potassium Chloride, and [MEDICATION NAME], at 4:30pm for [MEDICATION NAME], and at 8:00pm for [MEDICATION NAME] indicating that the next dose that was due was not until 11/6/13. There was no documented evidence that the MD was notified of the resident not receiving significant medications. During a telephone interview on 10/8/13 at 12:50am, LPN # 2 stated that they are not allowed to have a red dot indicating a medication was not available so they usually leave the medication order in the dash board and wait for it to come in. If the medication was not in by the time she had to leave she would then schedule the medication and the computer would start the medication the next day putting an "X" in the spot for that medication indicating that it was not due the day of admission. LPN #2 further stated that she reported to the evening supervisor that she did not have Resident #90's medications. During an interview on 11/9/13 at 11:50 am the Administrator and the DON stated that they were unaware of the medication errors but that they would expect that if a medication error was discovered that they would have been notified. During a telephone interview on 11/11/13 at 2:30pm the MD for Resident # 90 stated that the facility sends a fax with orders and someone in his group signs off on it. He stated that he was not aware of problems getting evening medications and that he would expect that residents were receiving them. He further stated that if the nurse had a problem getting medications or a medication was missed that he should be contacted. During an interview on 11/11/13 at 1:50pm the Staff Development Registered Nurse (SDRN) stated that she gave basic training on the computer system and when an order is put in the computer there are 4 dots signifying different parts of the order. When each portion was completed , it ' s dot would turn from red to green. She further stated that one of the dots was for scheduling the medication and that the medication could still be ordered from pharmacy without the scheduling being completed but she did not know that staff were leaving the medications unscheduled in the dashboard. SDRN stated that the nurse was supposed to look at the departure sheet to find out what medications the resident was on and when the last dose was given but that there was a problem with the system because the departure sheet were not always filled out. Resident # 50 The resident was admitted to the facility on [DATE] at 3:30pm with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented that the resident had moderately impaired cognitive skills for daily decision making. It documented that the resident usually understood and usually understands. A progress note dated 10/31/13 at 6:40 pm by a nurse documented that the resident was admitted to the facility at 3:30pm. A Patient Depart Summary from the hospital dated 10/31/13 documented that the resident was on Atorvastatin([MEDICATION NAME]) 40 mg at bedtime ; It documented under last dose: none and next dose: tonight. It documented [MEDICATION NAME]solution 100 u/ml sq before meals and at bedtime using sliding scale as follows: FBS 100-149 give 2 units insulin, FBS 150-199 give 4 units insulin, FBS 200-249 give 6 units insulin, FBS 250-299 give 8 units insulin, FBS 300- 349 give 10 units insulin, and call MD if FBS greater that 400. There was no order documented for FBS of 350-399. It documented the last dose was 4 unit and next dose was due at dinner. It documented [MEDICATION NAME] 100 mg/ml, 18 units sq once daily; last dose 9:00 am, next dose tomorrow. It documented Magnesium Oxide 400 mg 1 tablet twice daily; Last dose: none, next dose: tonight. It documented [MEDICATION NAME] 25 mg 1/2 tablet every 8 hours; last dose 9:30pm, next dose: 9:30pm. It documented [MEDICATION NAME] 50 mg 1 po at bedtime; last dose: none, next dose: tonight. A Physician order [REDACTED]. There was no documented evidence of insulin orders for this date. A physician order [REDACTED]. It documented [MEDICATION NAME] 100 u/ml inject 18 units sq daily at 9:30 am. A MAR for October 2013 documented initials and a star in the boxes on 10/31/13 for the 8pm dose of [MEDICATION NAME], the 4:00 pm dose of Magnesium Oxide, the 8:00pm dose of [MEDICATION NAME], and the 3:30 pm dose of [MEDICATION NAME] . Under comments dated 10/31/13 at 3:30pm, 4:30pm, and 8:30pm it documented that the above medications were not administered because they were new orders and the medications had not arrived yet. The MAR for October 2013 further documented [MEDICATION NAME] 25 mg give 1/2 tablet every 8 hours and was scheduled for twice a day; and Magnesium Oxide 400 mg tablet give 2 po twice daily and was only scheduled for once daily. There was no documented evidence that the hospital was contacted for clarification on when the resident was last medicated or that the supervisor, pharmacy, or the Medical Doctor (MD) were notified when medications were not available for administration or that the resident's insulins were not transcribed until the following day. Also there is no documented evidence that staff informed the MD of the medication errors. During an interview 11/9/13 at 3:30pm the Registered Nurse Manager (RNM #2)stated that she took Resident #50 ' s medication off a medication list she took from the computer from his previous admission. She stated that she did not put in the insulin but delegated it to the evening supervisor. When she was reviewing orders the next morning she noticed the insulin was not put on the MAR and put it on. RNM further stated that she did not report it to anyone at the facility or document that the resident missed 2 doses of insulin. During an interview on 11/11/13 at 11:45am LPN # 1 stated that sometimes medications are put in the computer and the times are not scheduled. This caused the medications to remain in the dashboard and not show in the MAR as needing to be given. If the medication is not scheduled until after the time due, the computer would automatically schedule it to start the next day. She further stated that if a med is scheduled for the evening of admission and the computer puts an x in the spot for that day she does not question it, "she just goes with what the computer says." During an interview on 11/8/13 1:15 pm the Nursing Supervisor (NS) stated that medications were routinely left in the dashboard until they are available before scheduling. NS further stated that she had access to the dashboard and could see anything that was left on there. Nurses were supposed to make sure that nothing was left on the dashboard at the end of the shift. During an interview on 11/9/13 at 11:50 am the Administrator and the DON stated that they were unaware of the medication errors but that they would expect that if a medication error was discovered that they would have been notified. During a telephone interview on 11/11/13 at 2:30pm the MD for Resident # 50 stated that the facility sends a fax with orders and someone in his group signs off on it. He stated that he was not aware of problems getting PM medications and that he would expect that residents were receiving them. He further stated that if the nurse had a problem getting medications or a medication was missed that he should be contacted. During an interview on 11/11/13 at 1:50pm the Staff Development Registered Nurse (SDRN) stated that she gave basic training on the computer system and when an order is put in the computer there are 4 dots signifying different parts of the order. When each portion was completed , it ' s dot would turn from red to green. She further stated that one of the dots was for scheduling the medication and that the medication could still be ordered from pharmacy without the scheduling being completed but she did not know that staff were leaving the medications unscheduled in the dashboard. SDRN stated that the nurse was supposed to look at the departure sheet to find out what medications the resident was on and when the last dose was given but that there was a problem with the system because the departure sheet were not always filled out. 10NYCRR 415.12(m)(2)

Based on medical record reviews and staff interviews during the extended recertification survey, the facility's Quality Assessment and Assurance Program (QA) failed to have a program that readily identified issues that had the potential to cause serious harm to the residents and failed to have an an ongoing evaluation of the admission and readmission process to determine if standards of quality were achieved, to ensure that care practices are consistently applied, and to prevent deviations from the care processes from arising. Specifically, the QA Program failed to have a program in place that readily identified that on 2 of 2 units, 9 residents (#s 4, 25, 30, 34, 50,76, 87, 90 and 91) of 11 residents recently admitted and readmitted did not receive their prescribed medications as ordered by the physician, that nurses called the physician for orders when a medication was not delivered or when it was not available, and that nurses recognized omission of medications as medication errors. There were multiple significant medication errors that were not reported. This deficient practice was widespread and had the potential to affect all the residents in the facility. This resulted in no actual harm with the potential for serious harm, which resulted in Immediate Jeopardy to resident health safety. The facility was able to remove the immediacy prior to exit by implementing the following: The facility educated over 90% of their nursing staff on the admission process including the review of the hospital's Patient Departure Summary, Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s E Kits which contains a supply of some frequently prescribed medications such as antibiotics, anticoagulants and [MEDICATION NAME] Insulin, and the nursing staff are to notify the physician when a medication would be delivered late or not be available for administration. The facility initiated the investigations of the transcription and medication errors identified by the New York State Department of Health Survey Team. As part of their investigations, the facility performed a root cause analysis which identified the staffs deviations from their policies and procedures and professional standards of practice. RNs will complete the electronic transcription by scheduling the times for the medications in the EMAR. Medication Variance Reports were initiated for all the identified medication errors. The facility is conducting daily audits. Refer to Resident Assessment- F 281- Services Provided Meet Professional Standards of Quality - Scope and Severity F Refer to Quality of Care- F 333 - Residents are Free from significant Medication Errors - Scope and Severity L During an interview on 11/ 7/13 at approximately 1:30 pm the Administrator stated that he heads the the QA Committee which consists of himself , the Director of Nursing (DON), the Assistant Director of Nursing (ADON) , the Staff Education Co-coordinator , the Medical Director, and the Directors /Supervisors of the various departments. He also stated that the committee meets quarterly (and more often if there are concerns) to discuss and identify concerns and issues that must be addressed and investigated to determine a root cause analysis and develop a plan of correction to prevent further recurrences. The Administrator stated that he was not notified and was not aware that the residents were not receiving their medications on the evening and night shifts of their admission and /or readmission. He stated he also reviews the Medication Variance Reports but the facility had only a few and that the DON, ADON , RN/UM and RN Supervisors had not discussed any concerns or identified that residents were not receiving their medications as prescribed by the physician in the morning reports. The Administrator stated the omission of medications is a serious concern because it places the resident at risk,and that had he been aware he would have addressed it immediately and directed the committee to implement audits and investigations . He stated that the nurses are working out of their nursing scope of practice when they do not call the physician for orders if the medication is delivered later than the time the dose is due and the dose of medication is omitted. The Administrator also stated he was surprised to be notified that the nurses were working out of their scope of practice since the facility had an inservice on nursing scope of practice a few months ago. During an interview on 11/6/13 at approximately 3:30 pm ,the DON stated that the residents admitted from the hospital have a Patient Departure Summary and a Medical Discharge which are to be reviewed by the nurse and then with the physician when calling the physician for admission orders [REDACTED]'s orders. The DON also stated that the facility often receives residents later in the day and the vendor pharmacy has 2 scheduled deliveries on the evening shifts at approximately 4-5 pm and 9-10 pm and that the facility has the availability of a local pharmacy. The DON also stated that the pharmacy policy is available on both nursing units. During an interview on 11/6/13 at approximately 3:45 pm, the Assistant Director of Nurses (ADON) stated that she had conducted an audit a few months ago regarding medication administration and found no issues or concerns. The ADON also stated that the audit was not done on residents who had been recently admitted or readmitted from the hospital. During an interview on 11/6/13 at approximately 5:00 pm , the Medical Director stated he is not the residents attending physician but oversees the medical staff in the facility. The Medical Director stated that if a resident is admitted or readmitted to the facility even at 5:00 pm he would expect that the residents received the medications as prescribed by their physician on the evening shift and subsequent night shift. In addition, the Medical Director stated that the facility has various options of obtaining medications from the vendor pharmacy or the local contracted pharmacy and availability should not be a problem. The nurse would be expected to call the physician for instructions /orders when a medication is going to be delivered later then the scheduled times. If a nurse does not administer a prescribed medication as ordered, the nurse is working out of the scope of practice and has made a medication error which places the resident at risk. During an interview via telephone on 11/12/13 at approximately 3:00 pm , the Medical Director stated that he was concerned when informed of the number of residents that did not receive their medications which included insulin, anticonvulsants, antihypertensives, diuretics an antibiotic, and some less significant medication on the evening and night shift on the day of admission He stated that nurses need to apply professional standards of practice, follow policies and procedures, and work within their scope of practice. He also stated that this practice is not acceptable and the facility is now going to have to evaluate their audit process to ensure it is effective and re-educate the nursing staff so they are following the professional standards of practice and that they are following the facility's policies and procedures. During a later interview on 11/13/13 at approximately 5:30 pm with the Administrator, DON, ADON , Staff Educator and Corporate staff member present , the Administrator stated that in addition to what he stated in his previous interview on 11/7/13 that he and the DON were not aware of any of the medication errors and that the nurses not following the facility's policies and procedures and the standards of nursing practice as identified by the survey team. He stated that once administration became aware of the medication errors the QA Committee immediately began auditing , interviewing staff and investigating the identified medication errors to determine a root cause analysis and immediately began re-educating the staff . The Administrator stated that it would not have mattered whether the facility was using the electronic system or the hand written paper system, because the medication errors would still have occurred because nurses are not following the facility's policies and procedures, are not using their basic nursing knowledge, not following professional standards of practice and are [MEDICATION NAME] outside their scope. The DON who was also present at the interview with the Administrator on 11/13/13 at approximately 5:30 pm stated that she is very upset that residents did not receive their medications as prescribed by the physician and attributes the cause as to the nurses not following their professional standards of practice, not following the facility's policies and procedures, not calling the pharmacy when a medication was not available and not calling the physician for further directions. She stated that the Medical Variance Reports have been initiated and she is in the process of obtaining statements from the nurses and then deciding what disciplinary action will be taken on each individual medication error. The DON also stated that daily audits have been implemented. 10NYCRR 415.27(a-c)