Every finding on record at St Mary's D'Youville Pavilion

Based on facility policy, record reviews, and interviews, the facility failed to thoroughly investigate a resident-to-resident altercation, ensure that the facility's investigation was completed, and failed to send the investigation to the State Agency within 5 business days of the incident for 2 of 3 facility reported incidents investigated on 1 of 5 units (Resident #35, Resident #39, Resident #59, and Resident #186).Findings:Review of the facility Freedom from Abuse, Neglect, & Exploitation policy last revised 01/2025 under Investigation Procedures states, Report of potential abuse can be received from any source and will be investigated. The investigation will be conducted by any of the following: nursing, social services, administration. Immediate medical attention for the resident/patient will be obtained as needed. The reporter, witnesses, alleged abuser and resident/patient will be interviewed. The results of investigations must be reported immediately to the administrator or designee and to other officials in accordance with State law (including to the state survey and certification agency). If the alleged violation is verified, appropriate corrective action is taken. Within 5 working days of reporting suspected/alleged abuse, the administrator or designee will submit a written report to division of licensing and certification.1. On 2/13/26 at 3:29 p.m. the Department of Licensing and Certification received a Facility Reported Incident indicating that on 2/13/26 at 2:30 p.m. Resident #39 slapped Resident #35 with open hand and then picked up a slipper and hit her on the left side of her face with the slipper. The reported incident identified witnesses to be a family member of another resident not involved in the incident.Review of Resident #39's clinical record revealed a nursing note on 2/13/26 at 12:42 a.m. stating that this resident was found sitting in another resident's room, then at 11:11 a.m., a nursing note stated a resident-to-resident incident happened yesterday at 12:00 p.m. when Resident #39 wandered into another resident's room. When the resident asked him/her to leave Resident #39 hit their left hand, and then another nursing noted on 3:01 p.m., states a call was made to a family member regarding Resident #39 standing up in the sensory room and hit Resident #35 in his/her face and picked up a slipper and hit the resident with the slipper in the face.On 6/22/26 a 5-day follow-up investigation was requested by the survey team, and the facility presented the initial Facility Reported Incident that was submitted on 2/13/26 stating this is the facility's investigation. On 6/23/26 a surveyor requested from the Director of Nursing (DON) any information gathered during the investigation including interviews with witnesses.On 6/25/26 at 10:17 in an interview with a surveyor the 3 East Unit Manager agreed that there should be a follow-up investigation, confirming it is their policy, and would look to see if they can find any more documentation regarding this incident. On 6/25/26 at 10:45 a.m. in an interview with a surveyor the DON confirmed the missing pieces of the investigation but stated they would look further into it regarding the witness interviews which they stated were not aware of there being any witnesses. There was no follow-up documentation presented to the survey team by the end of the survey on 6/25/26.2. On 1/28/26 at 3:04 p.m. the Department of Licensing and Certification received a Facility Reported Incident indicating that on 1/27/26 at 5:10 p.m. Resident #186 went into Resident #59's room. When Resident #59 saw Resident #186 in their room they became agitated. Resident #186 was overheard stating to Resident #59 I'll cut you in the throat. Resident #59 was seen striking Resident #186 on the right arm, and no injury was noted. On 6/22/26 a 5-day follow-up investigation was requested by the survey team, and the facility presented the initial Facility Reported Incident that was submitted on 1/28/26 stating this is the facility's investigation. On 6/23/26 a surveyor requested from the DON any information gathered during the investigation including interviews with witnesses, possible causes of the altercation, and interventions implemented to maintain the safety of the residents.On 6/25/26 at 10:17 in an interview with a surveyor the 3 East Unit Manager agreed that there should be a follow-up investigation, confirming it is their policy, and would look to see if they can find any more documentation regarding this incident. On 6/25/26 at 10:45 a.m. in an interview with a surveyor the DON confirmed the missing pieces of the investigation but stated they would look further into it but felt they had done everything they could with the investigation. There was no follow-up documentation presented to the survey team by the end of the survey on 6/25/26.

Based on record review, review of the facility internal investigation, interviews, and video surveillance, the facility failed to ensure a resident was free from an avoidable accident and environmental hazards. Specifically, Resident #1 [R1] exited their assigned unit onto an exterior courtyard/patio area without staff knowledge. The resident remained outdoors, inadequately dressed for the weather, for approximately 30 minutes before being discovered face down on the snow-covered ground. This failure created an immediate jeopardy situation.Findings: The Department of Licensing and Certification [State Agency] received an anonymous complaint which stated R1 was found outside on the ground in wet/snowy conditions in the early morning hours of March 21, 2026. A review of R1's clinical records stated R1 was admitted in March 2026 following an evaluation in the emergency department after a fall at home resulting in fractured ribs. Diagnoses included Alzheimer's disease and dementia complicated by psychosis. During the emergency department evaluation, the resident's family expressed concerns regarding increased confusion, sundowning behaviors, agitation, hallucinations, delusional thoughts, memory thoughts, mobility limitations, and falls. A review of a Late Entry note for March 21, 2026, stated R1 had went out of [his/her] room into the stairwell . [he/she] was observed by staff and brought back to [his/her] room, and states that R1 continued to be restless. A review of a Fall/Details note stated on March 21, 2026, R1 was in bed at 5:00 a.m., and at 5:30 a.m. R1 was noted to not be in [his/her] room, at 5:40 a.m., R1 was found outside lying on the grass. A review of the nursing admission assessment identified a Brief Interview for Mental Status (BIMS) score of 8 out of 15 indicating severe cognitive impairment. The assessment identified chronic confusion, short term memory loss, and need for cues. Additional findings included history of falls, mobility limitations, need for assistance with personal care, and dementia with psychotic disturbance. An elopement risk assessment was conducted upon admission, which indicated R1 had a score of zero, identifying the resident as not at risk for elopement despite a history of Alzheimer's disease and dementia. A review of the facility's investigation revealed a Sentinel Event Root Cause Analysis ( SERCA) which states R1 was found outside in the patio space at 5:38 a.m. wearing a flannel shirt and jeans.the SERCA states contributing factor and root causes as, staff did not re-evaluate resident when [his/her] behaviors change, Roam alert not implemented by nurse on duty with first wandering incident and stated that the facility .did not have an elopement policy in place at the time. A review of written statements from staff obtained was completed, revealing the following: -The Unit secretary stated concerns with placing R1 in room [ROOM NUMBER] because there is no lock on the door (referring to the exit door across the hallway from room [ROOM NUMBER]). -The CNA on duty at the time of admission stated that she expressed concerns to the unit secretary placing R1 in room [ROOM NUMBER] the door across from patients did not lock. and stated that R1s [family member] reported R1 might try to get up.and [he/she] might forget where [he/she] is going and stated I assured [family member] that I would pass along to the night CNA and states that she did pass along this information. -The Clincal Resource Nurse ( CRN) stated that the unit secretary did contact them reporting concerns with R1 being placed in room [ROOM NUMBER] at the end of the hall because of R1s diagnoses. The CRN states that they came down to the unit and found R1 to be lying in bed and answering questions appropriately with bouts of confusion and there were no signs of R1 wanting to leave the unit. -The Registered Nurse ( RN) stated she admitted R1 to the facility and to the unit, she states assessments were completed including an elopement assessment. This resident did not trigger as an elopement risk -The Licensed Practical Nurse ( LPN) on duty the night/early morning of the incident stated R1 sat with nursing staff most of the night., and for most of the night R1 was very insistent on going to move [his/her] truck off the street she describes R1 as hallucinating throughout the shift, taking to people who were not there. At 5:30 a.m. staff begin looking for R1 and at approximately 0540 [5:40 a.m.] the resident was observed out in the courtyard. she describes that R1 was face down on the ground. -The CNA on duty the night/early morning of the incident stated that R1 kept getting out of bed, so confused, and that she went to check on him at about 0535 (5:35 a.m.) and [he/she] was not in [his/her] room or bathroom Surveyor reviewed the unit video surveillance dated 3/20/26 at approximately 8:00 p.m. to 3/21/26 at approximately 5:56 a.m., with the Administrator and Director of Nursing (DON). The following was observed:-On 3/20/26 at approximately 11:02 p.m. through 3:32 a.m. on 3/21/26, R1 can be seen several times wandering in the hallway. -At approximately 5:02 a.m., R1 is observed opening the exit door across from his/her room and exiting through the door. R1 was not seen for several minutes but does return and goes back into his/her room. Staff were not observed to be in the area or having knowledge that R1 had exited through the door. -At approximately 5:08 a.m., R1 is observed opening the exit door across from his/her room, opening the door and exiting the unit. He/She does not return. Staff were not observed to be in the area or having knowledge that R1 had again exited through the door.-At approximately 5:34 a.m., staff identify that R1 is not in his/her room and can be seen looking for him/her.-At approximately 5:38 a.m., video of the courtyard/patio area, staff can be seen outside, and R1 is observed to be lying on the snow-covered ground.-At approximately 5:56 a.m. R1 is seen being transported back into the facility by staff-he/she is noted to be wearing a long sleeve shirt, pants, and socks. Staff do cover the resident with a blanket.Further review of the video surveillance shows that staff placed a rolling linen cart in front of the exit door to prevent R1 from further exiting through the door.A review of archived records from Accu Weather states on March 20, 2026, the overnight temperature was recorded as 20 degrees Fahrenheit.During an interview and environmental tour with the Administrator and Director of Nursing, ( DON) surveyor observed room [ROOM NUMBER] located directly across from the exit door. The Administrator stated that a resident wearing a wander guard would not be able to exit through the first door. R1 had not been identified as an elopement risk and was not wearing a wander guard. R1 was able to open the first exit door and proceed through the second exit door into an enclosed outdoor courtyard/patio which locked after exit and prevented reentry. After the incident both the first and second exit doors had been configured to alarm when opened. During an interview with the DON on 4/8/26 at 1:52 p.m., she stated the incident was not reported to the State Agency because the resident was found on facility property and the facility did not consider the event and elopement. During a later interview the DON stated the incident was initially treated as a fall. The DON stated that the resident received an immediate assessment, vital signs were obtained, telehealth was contacted, and the resident was not sent to the emergency department due to no apparent injuries at that time. The DON further stated the facility did not have a formal elopement policy or procedure at the time. Based on the above information, Immediate Jeopardy (IJ) was called on 4/9/26 for the facility's failure to ensure a resident who was known to be wandering and had exited through an unsecure door was monitored and supervised. The facility's failure to provide these services constituted an immediate jeopardy situation Please see F-0000 Initial Comments related to the IJ removal plan.

Based on record review, review of the facility internal investigation, interviews, and video surveillance, the facility failed to notify the State agency of a resident's elopement within 24 hours of the incident; and failed to provide the State agency with a 5 day follow up report for 1 of 1 investigated incident of neglect. (#1) Finding: The Department of Licensing and Certification [State Agency] received an anonymous complaint which stated R1 was found outside on the ground in wet/snowy conditions in the early morning hours of March 21, 2026. A review of a Late Entry note for March 21, 2026, stated R1 had went out of [his/her] room into the stairwell . [he/she] was observed by staff and brought back to [his/her] room, and states that R1 continued to be restless. A review of a Fall/Details note stated on March 21, 2026, R1 was in bed at 5:00 a.m., and at 5:30 a.m. R1 was noted to not be in [his/her] room, at 5:40 a.m., R1 was found outside lying on the grass. A review of facility records included nursing documentation, video surveillance, written staff statements and interviews confirmed that on March 21st, 2026, R#1 exited the unit through an exit door and was later found outdoors on facility grounds. Documentation and staff interviews confirmed the facility was aware of the incident at the time it occurred. A review of the facility's investigation revealed a Sentinel Event Root Cause Analysis ( SERCA) which states R1 was found outside in the patio space at 5:38 a.m. wearing a flannel shirt and jeans.the SERCA identified contributing factor and root causes as, staff did not re-evaluate resident when [his/her] behaviors change, Roam alert not implemented by nurse on duty with first wandering incident and stated that the facility .did not have an elopement policy in place at the time. On April 8th, 2026, at 1:52 p.m., during an interview, the Administrator and Director of Nursing (DON) confirmed the incident was not reported to the State Agency because the resident was found on facility property and the facility did not consider the event an elopement. The DON stated the incident was initially treated as a fall. The DON further stated the facility did not have a formal elopement policy or procedure at the time. (See F-689 for details)

Based on review of the facility's incident report, record reviews, interviews, and internal investigation, the facility failed to ensure staff spoke to residents in a dignified manner for 2 of 3 residents reviewed for abuse (R1, R2).Findings: On 9/24/25, the facility reported an incident to the Division of Licensing and Certification, which stated on 9/10/25, staff observed CNA1 (Certified Nursing Assistant) shout at R1 and stated Keep your damn hands to yourself, if you hit me, (I) am hitting you back. Later during the shift, the staff reported CNA1 was heard yelling in R2's room. When the staff entered, CNA1 was observed stating to the resident Why don't you just die already. The staff reported having observed CNA1 yell at residents who are wandering during the night to go back to bed, go to your f***ing room, I am sick and tired of you all. Staff stated no attempt was made to determine if residents needed assistance. Due to R1 and R2's level of cognitive impairment, neither demonstrated an awareness of the incidents. A review of R1's clinical record revealed diagnoses including Alzheimer's Dementia, Anxiety disorder, Restlessness, Agitation and Wandering. A review of the Minimum Data Set (MDS) 3.0 Quarterly Assessment, dated 6/29/25, Section C - Cognitive Patterns, indicated R1 had severe cognitive impairment. R1 required substantial/maximum to dependent assistance on staff for activities of daily living. R1 resident on the facility's secure dementia unit. R1's care plan identified the potential for physical aggression. Interventions included anticipate needs: food, thirst, toileting, comfort (pain); Keep a calm voice, adjust approach if R1 is becoming increasingly agitated. Keep enough distance to not allow R1 to grab, punch, or corner you. You may need to seek another staff for redirection. A review of R2's clinical record revealed diagnoses including Alzheimer's Disease, Dementia with Behavioral Disorder, Bipolar Disorder, Anxiety Disorder, and Insomnia. A review of the Minimum Data Set (MDS) 3.0 Significant Change Assessment, dated 7/17/25, Section C - Cognitive Patterns, indicated R2 had severe cognitive impairment. R2 was totally dependent on staff for assistance with all activities of daily living. R2 resident on the facility's secure dementia unit. R2's care plan identified the potential for physical aggression. Interventions included anticipate needs: food, thirst, toileting, comfort (pain); provide physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of source of agitation, encourage seeking out of staff member when agitated, engage calmly in conversation. On 9/25/25 at 12:45, in an interview with a surveyor, the unit manager stated CNA1 had been previously coached for unprofessional conduct, including reports of using profanity and an abrasive tone with others. The unit manager stated CNA1 had been receptive to the feedback and coaching. No reports of verbal or physical abuse had been received. A review of the facility's internal investigation noted that the incidents previously occurred on 9/10/25. The correct date of the incidents was 9/12/25. Upon learning of the incidents, the facility immediately suspended CNA1 pending the outcome of the investigation. Providers and family members were notified of the incidents. Multiple staff were interviewed. The facility's investigation identified a pattern that CNA1's behavior seems that he/she gets frustrated with certain residents and yells at them, instead of seeking to understand what the residents need.As a result of the facility's investigation the following corrective actions were taken:Incident reported to the appropriate State AgenciesEducation on resident rights, abuse, neglect, and reporting requirements for staff was initiated to be conducted on 9/26 and 9/29the CNA was terminated from the facility

Based on observations, record reviews, and interviews, the facility failed to provide a sanitary environment to help prevent the development and transmission of disease and infection related to respiratory care on 3 of 4 days of survey (3/25/25, 3/26/25 and 3/27/25) for 9 of 13 residents reviewed for respiratory care. (#40, #52, #153, #370, #366, #42, #24, #468 and #472) Findings: 1. On 3/25/25 from 9:24 a.m. to 10:23 a.m., and again on 3/26/25 at 7:25 a.m., the following was observed: > Resident #40 had an unlabeled/dated nebulizer pipe stored on the bedside dresser. In a brief interview, the resident stated he/she hasn't had to use the nebulizer in a week. > Resident #52 room had an unlabeled/dated oxygen nasal cannula tubing with the nasal prongs lying on the floor. > Resident #153 room had an unlabeled/dated oxygen nasal cannula tubing wrapped up under the concentrator handle. > Resident #370 room had an unlabeled/dated nebulizer tubing with the open tubing end hanging over the nebulizer handle. 2. On 3/25/25 at 10:29 a.m., Resident #366 had an oxygen concentrator running, with the open end of the tubing hanging off machine. No one was in the room. 3. On 3/25/25 at 10:43 a.m., observation of Resident #42 receiving oxygen via an unlabeled/dated nasal cannula tubing. On the bedside dresser was a nebulizer machine with an unlabeled/dated mask stored on the back of the machine. Review of Resident #42's medical record lacked evidence of the nebulizer mask, or the nasal cannula tubing changed weekly. On 3/26/25 at 11:07 a.m., during an interview with the Registered Nurse (RN) unit manager, the above observations were discussed. She stated she had just gone around and removed the concentrators that were not in use and provided bags etc. The Surveyor asked how often O2 tubing and nebulizer masks are changed and how they are stored when not in use. The RN unit manager stated that the facility was in transition with the respiratory therapist leaving and she had been the one changing them. She then stated, you will not find the nebulizer and oxygen tubing changing in the Treatment Administration Record (TAR) and no documentation of changing the tubing weekly is available. The oxygen tubing, nasal cannula, nebulizer tubing and pipe/mask should be changed every week. Nebulizers should be cleansed with water and allowed to dry on a paper towel, then placed in an open plastic bag. 51331 4. On 3/25/25 at 9:03 a.m. Resident #24 had an unlabeled oxygen tubing/nasal cannula hanging off the bedside table. At this time, the resident stated he/she only needs to use oxygen at night. On 3/26/25 at 8:06 a.m., an additional observation of the unlabeled oxygen tubing/nasal cannula hanging off the bedside table. On 3/26/25 at 11:44 a.m., the above information was discussed with the RN Unit Manager. On 3/27/25 at 12:20 p.m., Resident #24's oxygen nasal cannula tubing was coiled up and stored under the handle of the oxygen concentrator. 5. On 3/25/25 at approx. 8:44 a.m. and on 3/26/25 at 8:07 a.m., observation of Resident #468's and resident #472's unlabeled nebulizer pipe stored in their bedside table drawers. On 3/26/25 at 11:44 a.m., the above information was discussed with the RN Unit Manager. On 3/27/25 at 12:20 p.m., an additional observation of Resident #472's unlabeled nebulizer pipe stored in the bedside drawer. On 3/27/25 at 1:28 p.m., the above information was discussed with the Director of Nursing.

Based on observations and interviews, the facility failed to adequately maintain maintenance and housekeeping services necessary to maintain the facility in good repair and sanitary conditions for 2 of 3 units (3rd floor unit and 4th floor unit) and the laundry rooms for 1 of 1 environmental tour (3/28/25). Findings: On 3/28/25 from 8:20 a.m. to 8:45 a.m., an Environmental Tour was conducted with the Administrator, the Quality Assurance and Performance Improvement Program (QAPI) Manager and the 3rd Floor Unit Manager in which the following findings were observed: Laundry rooms >Clean Linen Area: There were 4 wall mounted fans that were dusty/dirty. There were 2 wall mounted air conditioning units that were dusty/dirty. > Soiled Linen Area: There were 2 wall mounted fans that were dusty/dirty. The ceiling air system, just inside the entrance door, had dusty/dirty filters. 3rd Floor Units (East and West) > The hallway walls were marred with black marks. >Resident room [ROOM NUMBER] - The privacy curtains were missing hooks, hanging down and in disrepair. The baseboard heater unit was broken apart in the front and was marred with black marks. > Resident room [ROOM NUMBER] - The privacy curtains were missing hooks, hanging down and in disrepair. There was a commode bucket on the bathroom floor. The room base board heating unit was marred with black marks. > Resident room [ROOM NUMBER] - The base board heating unit had chipped/missing paint and was marred with black marks. The walls around the room were marked with black marks. > Resident room [ROOM NUMBER] - The base board heating unit had chipped/missing paint and was marred with black marks. > Resident room [ROOM NUMBER]- The base board heating unit had chipped/missing paint and was marred with black marks. > Resident room [ROOM NUMBER] - There were black scuff marks all over the room floor. 4th Floor Units(East and West) > The East Unit and [NAME] Unit hallway walls were marred with black marks. > Resident room [ROOM NUMBER] - There was an unbagged commode bucket on the floor in the bathroom. On 3/28/25 at 8:45 a.m., in an interview, the Administrator, the Quality Assurance and Performance Improvement Program (QAPI) Manager and the 3rd Floor Unit Manager confirmed the findings.

Based on record reviews and interviews, the facility failed to assess resident's current diagnosis of Post-Traumatic Stress Disorder (PTSD)/trauma to determine what trigger(s) might cause re-traumatization for 2 of 3 sampled residents reviewed with a current diagnosis of PTSD (Resident #39 and #110). Findings: 1. A review of Resident #39's Annual Minimum Data Set (MDS) 3.0, dated 2/18/25, Section I, Active Diagnoses, Psychiatric/Mood Disorder, I6100 was coded to indicate Resident #39 has an active diagnosis for PTSD. The surveyor was unable to find information in the clinical record that indicates what Resident #39's PTSD was caused by, what trigger(s) might cause re-traumatization, and measures to avoid trigger(s) that might cause re-traumatization. In addition, Resident #39's care plan lacked evidence of a trauma informed care plan with identified triggers and interventions to prevent re-traumatization. On 3/26/25 at 3:12 p.m., the surveyor confirmed the finding above with the Administrator and the Director of Social Services. 37440 2. A review of Resident #110 's clinical record, in the Minimum Data Set (MDS) 3.0, Section I, Active Diagnoses, Psychiatric/Mood Disorder, I6100 was coded to indicate Resident #110 has an active diagnosis for PTSD. The surveyor was unable to find information in the clinical record that indicates what Resident #110 's PTSD was caused by, what trigger(s) might cause re-traumatization, and measures to avoid trigger(s) that might cause re-traumatization. On 3/26/25 at 1:15 p.m., in an interview with a surveyor, the Unit Manager confirmed that Resident #110 did not have a care plan (goal, triggers and trauma interventions) for PTSD, other than it being mentioned as one of the problems under focus in the care plan. On 3/26/25 at 2:20 p.m., in an interview, a Licensed Social Worker(LSW) confirmed that Resident #110 did not receive a Psych/PTSD/Trauma Screening/Assessment.

Based on observations, interviews and record reviews, the facility failed to ensure that a resident who requires Hemodialysis receives such services, consistent with the professional standards of practice and failed to ensure the care plan contained the needed information, including emergency interventions necessary to properly care for 2 of 2 residents reviewed for Hemodialysis. (#105 and #32) Findings: 1. On 3/26/25 at 8:32 a.m., the surveyor observed Resident #105 with a bandage to the upper arm. At this time, during an interview, Resident #105 stated he/she has an AVF (Arteriovenous Fistula) and has been going to dialysis for a couple of years. He/she then stated, Next Friday they are going to do something with my site, the past couple times they couldn't stop me from bleeding and I had to go to the hospital. The surveyor asked if and when the nurses assess and how they monitor his/her AVF site. He/she stated, They have never touched it and no monitoring. Review of the medical record states Resident #105 was admitted to the facility with a diagnosis of End-Stage Renal Disease with an AVF requiring Hemodialysis three times a week. A current physician order states he/she has a Right Arm AVF revision at [hospital] Day Surgery on 4/4/25. No orders were located to address assessment and monitoring of the dialysis access site. Review of the current care plan lacked interventions for monitoring the AVF site for Bruit and Thrill and emergency interventions if bleeding at the site were observed. Further review of the medication and treatment administration record lacked evidence of nursing care/assessment and monitoring for the AVF access site. On 3/26/25 at 4:39 p.m., during an interview with the Director of Nursing (DON) the surveyor discussed the lack of monitoring and emergency interventions in the care plan and treatment record. The DON confirmed the above and was unable to provide a policy and procedure for nursing caring and/or monitoring for a Hemodialysis resident, however, she did provide the surveyor with the Clinical Nursing Skills, basics to advanced skills 9th Edition and stated nursing would follow this book for nursing practice. Review of the Clinical Nursing Skills book, section: Hemodialysis (Renal Replacement Therapy). providing ongoing care of Hemodialysis Client: Procedure . assess the AV Fistula . Assessing the Arteriovenous Fistula. Perform hand hygiene. Position clients arm, so fistula is easily accessed. Palpate the area to feel for thrill (vibration). This indicates arterial to venous blood flow in fistula patency. Auscultate with a stethoscope to detect a bruit (swishing noise). This indicates a patent fistula .Safety alert precautions for fistula or graft . post safety precautions at head of bed . regularly feel for vibration thrill over access site. Do not measure blood pressure on the affected extremity. Do not perform venipuncture in the affected extremity. Counsel the client: avoid lying on the affected extremity. Avoid carrying heavy loads with access extremity. Do not wear constrictive clothing on the affected extremity. Immediately report swelling, discoloration, drainage, or coldness, numbness, or weakness of hand. On 3/27/25 at 1:04 p.m., during an interview with 4 surveyors present, the surveyor asked the DON how often nurses should be monitoring AVF for bruit and thrill, she stated, it should be every shift. 37015 2. On 03/25/25 at 9:51 a.m., in an interview with a surveyor, Resident #32 stated he/she has a catheter site in the right upper chest area used for dialysis access. The surveyor asked how often the staff monitor the site. Resident #32 stated staff look at it on the day of dialysis, and dialysis center staff manage the dressing. The surveyor asked how the catheter is monitored upon return from dialysis, and Resident #32 stated facility staff does not check the catheter site upon return. Clinical record review noted current physician orders for dialysis on Tuesdays, Thursdays, and Saturdays. No orders were located to address assessment and monitoring of the dialysis access site. A hospice physician's note, dated 2/11/25, noted that Resident #32 has in the right upper extremity, an AV fistula with intact bruit and thrill. Resident #32's care plan, last revised 2/17/25, includes the following interventions to address dialysis: Do not draw blood or take B/P in arm with graft. Monitor/document/report as needed any s/sx of infection to access site: redness, swelling, warmth or drainage. A review of Resident #32's current medication and treatment administration records did not address monitoring of the dialysis access site (AVF or catheter). On 3/27/25 at 1:10 .m., in an interview with a surveyor, the charge nurse stated Resident #32's dialysis access site was a hemodialysis catheter on the right chest which was completely covered by 2 Mepilex dressings that staff send with him/her for every dialysis treatment. Regarding the access site, the charge nurse stated we do not look at it and do not touch it. The charge nurse stated Resident #32 has an AVF site in the right upper arm which is not used. On 3/27/25 at 1:25 p.m., in an interview with the Nurse Manager, the surveyor discussed that Resident #32's care plan does not indicate that the resident has a catheter for dialysis, does not include regular monitoring of either the AVF or the catheter site (including after hemodialysis treatments), and does not specify emergency procedures to take for complications. On 3/27/25 at 2:00 p.m., the Nurse Manager stated she had called the dialysis center and was advised that only dialysis staff are to maintain the central line catheter and that the AVF was permanently not to be used. There was no further need for monitoring or checking of the fistula site required. In the event of an emergency, staff were to call the dialysis center for instructions. The nurse manager had updated the care plan to include this information.

Based on observation and interview, the facility failed to ensure that medications were stored properly by having an unlocked, unattended medication cart allowing residents and unauthorized persons access to medications on 1 of 4 survey days. (3/25/25) Finding: On 3/25/25 at 9:15 a.m., a surveyor observed 2 unlocked medication carts located in the hall across from the nurses station on the 3 [NAME] Unit. Two staff were observed in an area behind the nurses station and one staff was seated at the nurses station. The surveyor asked the staff seated at the nurses station who the charge nurse was and the staff person pointed to the two staff seated behind her and stated they both are. At this time, the surveyor opened both medication carts and went through each drawer. No one responded to this. One of the identified nurses got up and walked away. Finally, the surveyor walked over to the remaining nurse and informed her that both medication carts were unlocked. The nurse immediately got up, locked the carts and confirmed the finding.

Based on an interview and review of the facility's Quality Assurance and Performance Improvement (QAPI), the facility failed to present evidence that the required members attended 2 of 4 quarters provided (April 2024 and July 2024). Finding: On 3/25/25 at 2:43 p.m., a surveyor requested a copy of the attendance sheets for the QAPI quarterly meetings. The Quality Assurance and Performance Improvement Manager provided the surveyor with the meeting attendance sheets. A review of the April 2024 QAPI attendance sheet lacked evidence that the Medical Director attended the meeting. The July 2024 QAPI attendance sheet lacked evidence that the Administrator, Director of Nursing and the Infection Preventionists attended the meeting. On 3/27/25 at 9:19 a.m., during an interview, the above was confirmed with the Quality Assurance and Performance Improvement Manager.

Based on observations, interviews, and record reviews, the facility failed to ensure a smoking assessment of resident capabilities and deficits to determine resident safety was completed for 1 of 1 resident reviewed for smoking (105). Finding: On 3/26/25 at 8:44 a.m., during an interview with Resident #105, a Registered Nurse (RN) entered the resident's room and removed a lighter from the open nightstand drawer and explained to the resident that having the lighter in his/her room is a hazard and he/she can obtain the lighter prior to going out to smoke. The resident stated he/she is going outside to smoke after breakfast. Review of Resident #105's Smoking Safety Interaction dated 3/18/25, states he/she uses tobacco products, has Poor vision or blindness and Unable to extinguish tobacco or marijuana safely. The rest of the form includes the section Clinical Suggestions which has; Apply smoking apron, Set up cigarette holder, Staff to extinguish cigarette, Refer to interdisciplinary Team, if Resident deemed unsafe to smoke and Ensure eyeglasses are on, was not completed. On 3/26/25 at 10:43 a.m., during an interview with the RN unit manager, the incomplete Smoking Safety Interaction was reviewed, showing he/she was unable to extinguish tobacco safely. The surveyor asked how the facility knows if the resident is safe to smoke or requires supervision. The RN stated, We don't go out and observe them. We are a non-smoking facility, but residents have rights and They are educated that this is a non-smoking facility. The facilities Tobacco - and Smoke - Free Policy approved 2/2022 states, specific to patients and residents of d'Youville Pavilion: Patients and residents are highly encouraged not to smoke or use tobacco products. They are also educated on the risks of use and strategies to help quit. Due to Patients' Rights in skilled facilities and Long-term care facilities, patients have the right to smoke if they desire to in a safe area. A designated smoking area is available outside at d'Youville Pavilion only to be used by d'Youville Pavilion patients and residents. On 3/26/25 at 4:39 p.m., during an interview with the Director of Nursing, the surveyor discussed the lack of a safety assessment of the resident's capabilities, deficits and whether or not supervision is required.

Based on observations, interviews and record reviews, the facility failed to ensure a physician's order and care plan was followed for 1 of 11 residents reviewed for oxygen therapy (#42). Finding: On 3/25/25 at 10:43 a.m., observation of Resident #42 receiving oxygen (O2) via nasal cannula with the oxygen concentrator set at 3 Liters Per Minute (LPM). At this time, the resident stated he/she is on 3 LPM of oxygen. On 3/26/25 at 7:29 a.m., an additional observation of Resident #42 receiving oxygen via a nasal cannula with the oxygen concentrator set at 3 LPM. Review of the medical record contained a Provider order dated 3/7/25 for Apply O2 at 4L to keep sats at 93 at rest and 88 with activity. every shift. The resident care plan for oxygen therapy r/t CHF (congestive heart Failure), Respiratory illness initiated: 2/28/25. Has interventions of oxygen settings: O2 via nasal cannula @ 4 L continuous. Further review of the nursing documentation states on 3/10/25, 3/11/25 and 3/15/25 he/she was on 3 LPM of oxygen via nasal cannula. On 3/26/25 at 11:07 a.m., during an interview, both the Registered Nurse (RN) unit manager and the surveyor observed Resident #42's oxygen set at 3 LPM via nasal cannula. The RN unit manager stated sometimes the O2 orders will say titrate to keep sats at a particular percentage. At this time, both the surveyor and the RN unit manager confirmed the order for O2 therapy was 4 LPM.

Based on interview and record review, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to properly care for 1 of 8 sampled residents reviewed for new admissions (Resident #36). Finding: Resident #36 was admitted in early March of 2025 with a primary diagnosis of fall with right ankle fracture requiring a Lovenox (anticoagulant) injection daily. As of 3/26/25 Resident #36's medical record lacked evidence of a baseline care plan that included the instructions necessary to properly care for him/her, in the area above. On 3/26/25 at 4:39 p.m., the above was discussed with the Director of Nursing.

Based on observations and interviews, the facility failed to maintain and implement an infection control program to help prevent the development and transmission of disease and infection for 1 of 7 residents on contact precautions (Resident #6). Findings: On 1/2/25 at 8:00 a.m., a surveyor observed a contact precaution sign on Resident #6's door instructing all staff to wear the following Personal Protective Equipment (PPE) for all direct care; gown, gloves and goggles (if there is high chance of liquid exposure). Hanging on the outside of the door was a yellow precaution bag containing the PPE required for Resident #6's direct care. At this time, 2 Certified Nursing Assistants (CNA#1 and CNA#2) entered Resident #6's room wearing only a mask. CNA#1 began preparing the resident for the transfer. The surveyor intervened, and asked CNA #1 if Resident #6 is on contact precautions and what should be worn. CNA #1 stated a gown, and gloves are to be worn with direct patient care and if there is high change of liquid exposure to wear goggles, then closed the door on the surveyor. At this time, the surveyor alerted the Licensed Practical Nurse (LPN), who immediately instructed both CNA #1 and CNA #2, to don the appropriate PPE. The LPN confirmed all staff providing direct care for a resident on contact precautions are required to wear gloves and gowns. On 1/2/25 at 8:10 a.m., during an interview, the Registered Nurse for Resident #6's confirmed he/she is on contact precautions for Extended-Spectrum Beat-Lactamase (ESBL). On 1/2/25 at 8:19 a.m., during an interview, the above was discussed with the LPN Unit Manager of the 3 West. On 1/2/25 at 10:16 a.m., during an interview, the Director of Nursing stated she educated CNA #1 and CNA #2 on PPE requirements.

37648 Based on observations, interviews, record review and facility policy, the facility failed to maintain and implement an infection control program to help prevent the development and transmission of disease and infection related to Methicillin Resistant Staphylococcus Aureus (MRSA- a Multidrug-Resistant Organism) colonized in sputum and urine for a 2 of 2 sampled residents (Resident #20 and #148) diagnosed MRSA for 1 of 5 days of survey (1/22/24). This has the potential to affect all 39 residents on the 4 East unit. Findings: 1. Resident #20's clinical record was reviewed and revealed a diagnosis of Quadriplegia, tracheostomy, a carrier of MRSA in his/her sputum and chronic respiratory failure with Oxygen supplement. Physician order dated 7/23/23 for Tobramycin (antibiotic) inhalation nebulization solution, 3ml (milliliters) inhale orally via nebulizer two times a day 28 days on and 28 days off for respiratory MRSA. The care plan for MRSA - colonization (respiratory) revised on 10/11/21, instructs staff to wear Mask /face shield to be worn during procedures with risk of splashes or droplet contamination of bodily fluids. In addition, the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #20 had a Brief Interview for Mental Status (BIMS) of 15 of 15, indicating he/she is cognitively intact. On 1/22/24 at approx. 9:30 a.m., 2 surveyors observed 4 East unit having 2 rooms with Transmission Based Precautions (TBP) in place; room [ROOM NUMBER] and 407. room [ROOM NUMBER] had with a free standing Personal Protective Equipment (PPE) bag indicating B bed was on Precautions, instructions stating As a caregiver when entering this room, please wear the following: Gloves, Gown, Mask were checked off. On 1/22/24 at 9:48 a.m., 2 surveyors observed Certified Nurses Aid (CNA) #7 and CNA #8 don PPE (gown, gloves and mask) and begin to enter room [ROOM NUMBER]. At this time, surveyor interviewed CNA #7, who stated, Resident #20 has MRSA (Methicillin Resistant Staphylococcus Aureus) in his/her trach/respiratory and she is going into provide care for Resident #20, wash his/her body, apply cream etc. Surveyor questioned whether eye protection is used while providing care for Resident #20. CNA #7 stated, she doesn't wear eye protection because [Resident #20] has the trach covered with plastic and she would only wear eye protection if [he/she] was getting a nebulizer treatment. CNA #7 and CNA #8 entered the room and began providing care to Resident #20 without the use of eye protection. At this time, Surveyor entered the room and observed Resident #20 to have a tracheostomy mask with visible yellow sputum noted in the mask. On 1/22/24 at 9:55 a.m., During an interview with the Registered Nurse (RN) Manager of 4 East unit, surveyor questioned the lack of eye protection while providing care for resident #20, if there is a diagnosis of respiratory MRSA. RN Manager stated she would get back to the surveyor shortly. At 10:16 a.m., RN Manager reapproached the surveyor and stated, [Resident #20] is colonized, has been colonized for about 6 years and the TBP are up because [resident #20] does get a mist (nebulizer) by the nurse. At this time, the surveyor observed room [ROOM NUMBER]'s free standing PPE bag indicating caregivers are now to wear goggles, in addition to the gloves, mask and gown when entering the room. On 1/22/24 at 1:17 p.m., during an interview, Resident #20 was asked if staff wear eye protection while providing care, he/she stated, mostly no, only when there COVID on the unit. Surveyor asked about the diagnosis of respiratory MRSA, he/she stated, I did, they haven't tested me in a year and half. I would think it would be colonized by now. At this time resident #20 stated he receives an Antibiotic nebulizer every other month for 28 days and regular nebulizers 3x day. On 1/23/24 approx. 10:15 a.m., observation of 2 CNA's transferring Resident #20 from the shower chair to the bed for tracheostomy care, both wearing PPE including eye protection. On 1/25/24 at 12:11 p.m., during an interview with Assistant Director of Nursing (ADON), surveyor discussed the lack of eye protection use and the TBP PPE stand without instructions for eye protection during the observations on 1/22/24. The ADON stated it's colonized. Both the Surveyor and ADON reviewed the Infection Prevention and Control Plan revised 1/2024, Under section Precautions: stating, Transmission-based Precautions. The Centers for Disease Control and Prevention Guidelines for Transmission-based Precautions will be follow. Transmission-based Precautions are designed for residents known or suspected to be infected or colonized with highly transmissible or epidemiologically important pathogens for which additional precautions beyond Standard Precautions are needed to interrupt transmission within the facility. Transmission-based Precautions will be followed by all employees per policy. 2. On 1/22/24 at approx. 9:30 a.m., 2 surveyors observed 4 East unit having 2 rooms with Transmission Based Precaution (TBP) in place; room [ROOM NUMBER] with free standing bag indicating B bed and 407 with cart outside door for A Bed, this was again observed later in the day at 3:30 p.m. On 1/23/24 at 7:34 a.m., a surveyor entered 4 East unit and observed a 3rd room now on TBP, room [ROOM NUMBER] with a cart outside of the door and a sign to see nurse before entering on the door frame. On 1/23/24 at 7:39 a.m., during a brief interview with the Certified Medication Technician (CNA-M #5), she stated room [ROOM NUMBER], bed one (resident #148) has MRSA (Methicillin Resistant Staphylococcus Aureus), not sure where but knows it's not respiratory. On 1/23/24 at 7:43 a.m., during a brief interview with Certified Nursing Assistant (CNA #6) stated room [ROOM NUMBER], bed one (resident #148) has MRSA urine I believe, it's new last couple of weeks. On 1/23/23 at approx. 7:45 a.m., during an interview with the RN Manager on 4 East, surveyor asked why TBP were now in place for room [ROOM NUMBER]. RN stated [Resident #148] had a [NAME] (on the door), the roommate has an electric wheelchair, hits it and it fell off. She then stated, she had noticed it yesterday afternoon and placed the cart by the door. At this time, the Surveyor informed the RN that there was no TBP in place yesterday (1/22/23), either by cart or caddy from approx. 9:30 a.m. to 3:30 p.m. RN then stated, I know there was one, it must have fallen down. On 1/23/24 at 8:06 a.m., during a brief interview with the RN Manager on 4 [NAME] unit. Surveyor asked why there wasn't a TBP cart for room [ROOM NUMBER] yesterday. RN Stated, That's probably true, only in [his/her] urine, VRE (Vancomycin-resistant Enterococcus) I believe. I think [heshe] brought it back from the hospital last or week before. Surveyor then asked why a TBP cart was now in place, RN stated I'm not sure. Review of resident #148's clinical record indicated he/she was readmitted to the facility on [DATE] with the hospital discharge diagnosis of, Developed positive MRSA in urine and a provider order dated 12/29/23 for, contact precaution MRSA urine. On 1/25/24 at 12:11 p.m., during an interview with Assistant Director of Nursing, the surveyor discussed the above concerns of, on 1/22/24 from approx. 9:30 a.m. to 3:30 p.m. 2 surveyors observed Resident #148 without TBP in place, with MRSA urine.

Based on record review, observations and interview, the facility failed to develop or implement the care plan interventions for the residents' current needs for 6 of 33 sampled residents/care plans reviewed (Resident #2, #20, #52, #101, #166 and #173) Findings: 1. Resident #2's clinical record was reviewed and revealed the resident has muscle weakness, unsteadiness on feet and has had falls. The current care plan noted the following: [Resident #2] requires floor mats when in bed on both sides of bed for fall safety. [Resident #2]will have no injuries if a fall occurs before the review date. Staff to pick up and place mats out of the way from wheelchair accessibility in room when out of bed and will lay them next to bed on both sides when in bed. On 1/24/24 at 2:05 p.m., a surveyor observed Resident #2 in bed with no floor mats placed on the floor on both sides of the bed. On 1/24/24 at 2:10 p.m., in an interview, Registered Nurse, RN. #3 confirmed that Resident #2 was in bed and the floor mats were not put on both sides of the bed. 2. Resident #20's clinical record was reviewed and revealed a diagnosis of Quadriplegia, tracheostomy and carrier of Methicillin Resistant Staphylococcus Aureus (MRSA) in his/her sputum. The care plan for MRSA - colonization (respiratory) revised on 10/11/21, instructs staff to wear Mask /face shield to be worn during procedures with risk of splashes or droplet contamination of bodily fluids. In addition, the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #20 had a Brief Interview for Mental Status (BIMS) of 15 of 15, indicating he/she is cognitively intact. On 1/22/24 at 9:48 a.m., 2 surveyors observed Certified Nurses Aid (CNA) #7 and CNA #8 don PPE (gown, gloves and mask) and begin to enter room [ROOM NUMBER]. At this time, surveyor interviewed CNA #7, who stated, Resident #20 has MRSA (Methicillin Resistant Staphylococcus Aureus) in his/her trach/respiratory and she is going into provide care for Resident #20, wash his/her body, apply cream etc. Surveyor questioned whether eye protection is used while providing care for Resident #20. CNA #7 stated, she doesn't wear eye protection because [Resident #20] has the trach covered with plastic and she would only wear eye protection if [he/she] was getting a nebulizer treatment. CNA #7 and CNA #8 entered the room and began providing care to Resident #20 without the use of eye protection. On 1/22/24 at 1:17 p.m., during an interview, Resident #20 was asked if staff wear eye protection during care, he/she stated, mostly no, only when there COVID on the unit. On 1/25/24 at 12:11 p.m., during an interview, the Director of Nursing confirmed the care plan was not followed for use of eye protection. 3. On 1/23/24 at approximately 11:00 a.m. a surveyor observed Resident #166 on a pressure reducing mattress. The clinical record for Resident #166 was reviewed. The admission Minimum data set (MDS) 3.0 dated 11/16/23, under section M1200 Skin and ulcer/injury treatments found yes was selected for Pressure Reducing device on bed. Review of Resident #166 care plan did not include a pressure reducing device on bed-under interventions. On 1/26/24 24 at 11:41 a.m. during an interview with the rehab unit manager after discussing the missing interventions on the care plans reviewed, I learned he/she thought the MAR and TAR were part of the care plan meaning interventions on the MAR and TAR did not also need to be on the care plan. The MAR and TAR can not be used in lieu of a Care Plan to create the Comprehensive Care Plan. 4. On 1/24/24, during record review of Resident #52 physician orders, it was noted that he/she is receiving the psychotropic medication Quetiapine Fumarate since 11/26/22. The Annual Assessment (MDS) - Version 3.0 dated 10/12/22, Section N indicated Resident #52's use of antipsychotics, in addition the CAA's indicated to proceed to care plan for Psychotropic Drug Use. The medical record lacked evidence of a comprehensive care plan that addressed the use, goals and interventions for the use of Quetiapine Fumarate. The surveyor confirmed this lack of care plan for Psychotropic Drug Use in an interview with the Assistant Director of Nursing, on 1/26/24 at 11:15 a.m. 5. On 1/25/24 at 2:40 p.m. during a clinical record review for Resident #101, a surveyor found under orders, wear heel protectors when in bed dated 10/25/23 and turn patient every 2 hours dated 10/25/23. These interventions were found in Resident #101's Medication Administration Record (MAR) and Treatment Administration Record (TAR) but not on the care plan. On 1/26/24 24 at 11:41 a.m. during an interview with the rehab unit manager after discussing the missing interventions on the care plans reviewed, I learned he/she thought the MAR and TAR were part of the care plan meaning interventions on the MAR and TAR did not also need to be on the care plan. The MAR and TAR can not be used in lieu of a Care Plan to create the Comprehensive Care Plan. 6. Residents #173's clinical record was reviewed and revealed hospice services were initiated on 10/5/23 for terminal diagnosis of Alzheimer's disease with late onset. On further review, Resident #173 passed away on 11/15/23, the medical record lacked evidence of a Hospice care plan being developed with goals and interventions for end of life care from the onset of hospice services on 10/5/23 through to end of life on 11/15/23. On 1/26/24 at 12:45 p.m., the Director of Nursing confirmed a comprehensive assessment should have been completed within 14 days after the resident began hospice services 37440 33639 48648 33640

Based on observations and interview, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and in a sanitary condition for 1 of 3 floors (3rd) and the laundry rooms for 1 of 1 environmental tour. (1/26/24) Findings: On 1/26/24 from 9: 20 a.m. to 10:10 a.m., an Environment tour was conducted with the Plant Operations Manager in which the following findings were observed: Laundry Rooms > The soiled laundry linen room had 1 wall fan that was dusty/dirty. The cement floor had chipped/missing paint and the non-skid floor tape was missing pieces/sections creating uncleanable surfaces. > The clean laundry linen room had 3 wall fans that were dusty/dirty. The cement floor had chipped/missing paint creating an uncleanable surface. > The laundry room had 30 broken/missing floor tiles. The cement floor, behind and under the washing machines, had chipped/missing paint creating uncleanable surfaces. 3rd Floor East > The wheelchair scale had ripped/missing non-skid surface tape creating an uncleanable surface. 3rd Floor West > The two sit-to-stand patient lifts had missing/chipped paint and rusty areas in the foot base areas creating uncleanable surfaces. > Resident room [ROOM NUMBER] - The baseboard heating unit was marred with black marks. The bathroom, which is shared by 4 residents, had an unmarked urinal hanging on the grab bar behind the toilet and the bathroom exhaust fan was dusty/dirty. > Resident room [ROOM NUMBER] - The bathroom had 2 commode buckets sitting on the floor under the sink and a bed pan stored on the hand rail by the toilet. > Resident room [ROOM NUMBER] - The bathroom exhaust vent was dusty/dirty. > There were 2 hallway ceiling vents by Resident room [ROOM NUMBER] that were dusty/dirty. > There was 1 hallway ceiling tile by Resident room [ROOM NUMBER] that had a large brown stain. > Resident room [ROOM NUMBER] - The wall fan was dusty/dirty. There was debris in the shower light lens. The room walls and the bathroom doorframe were heavily marked/marred with blackish marks. 0n 1/26/24 at 10:10 a.m., in an interview, the Plant 0perations Manager confirmed the findings.

Based on record review and interviews, the facility failed to follow a physician order for obtaining daily weights for 1 of 8 sampled residents for rehospitalization (#114) and failed to follow physician orders for making a referral to a specialist for 1 of 5 residents reviewed for unnecessary medications. (#144) Finding: 1. On 1/24/24, Resident #114's clinical record was reviewed and contained a physician order dated 10/12/23, for Daily weight in the morning for edema. Review of Resident #114's weights from 10/13/23 to 1/21/24 revealed that weights were not completed on 10/17/23-10/19/23, 10/21/23, 10/22/23, 10/24/23, 10/25/23, 10/31/23, 11/1/23, 11/5/23, 11/7/23, 11/9/23-11/15/23, 11/18/23-11/20/23, 11/23/23-11/29/23, 12/1/23-12/9/23, 12/11/23-12/16/23, 12/18/23-12/25/23, 12/27/23, 12/28/23, 12/31/23, 1/1/24-1/3/24, 1/6/24, 1/9/24-1/13/24, 1/15/24, 1/17/24, 1/19/24, 1/20/24, 1/22/24 and 1/23/24. On 1/24/24 at 10:05 a.m., during an interview with the Assistant Director of Nursing, she confirmed that Resident #114's weights had not been taken daily between 10/13/23 to 1/21/24 as the current physician's order stated. 2. On 1/23/24, Resident #144's clinical record was reviewed and contained a physician order dated 9/13/23, for a Psych evaluation for depression. A nurses note dated 9/20/23 stated, We are working on [Dr.] referral - per office need a recent note from provider to fax to them to justify referral for depression. All recent notes do not address depression. The surveyor was unable to find evidence that this appointment was made. On 1/24/24 at 8:21 a.m., during an interview with a Registered Nurse Minimum Data Set Coordinator she confirmed a provider order on 9/13/23 for psych eval but was unable to find the psych eval was completed stating, she had let [Registered Nurse] (RN) Manager of 4 East know and it will happen today. On 1/24/24 at 11:00 a.m., during an interview, the RN Manager of 4 East unit stated, My nurse, [RN #2] made an SBAR (Situation, Background, Assessment, and Recommendation, means of communication with provider) in September and nothing happened, no response from the doctor and I spoke with the Doctor today because [he/she] looks the best [he/she] ever looks. She then showed surveyor an order dated 1/24/24 to discontinue the Psych evaluation. 37440

Based on observations and interviews, the facility failed to ensure the kitchen was maintained in a clean manner on 1 of 1 days of survey (1/22/24) for ceiling vents, ceiling tiles, and an auto bag machine; failed to ensure the male kitchen staff were wearing facial hair protection, failed to ensure wet sacking of glasses, and failed to ensure foods were dated and/or labeled in freezers and refrigerators. Further, the facility failed to monitor temperatures of the dish washing machine and the refrigerators and freezers. In addition, the facility failed to ensure that proper hand sanitizing and proper food handling, during lunch service, was followed for 1 of 2 lunch observations (1/22/24) on the 3rd floor [NAME] Unit. Findings: Refrigeration Temperature Log(documented at the bottom of the Refrigeration Temperature Log)- This log will be maintained for each refrigerator and freezer(both walk in and reach in units) in the facility. Employee will record the time, air temperature and their initials (preferably upon arrival) once in the morning and once(preferably just before leaving the facility). The food service supervisor for each facility will verify that food service employees have taken their required temperatures by visually monitoring food service employees and reviewing, initially, and dating a sample of logs each month. Record retention requirement one year. If corrective action is required on any day, circle the date in the first column and explain the action taken. Refrigerator should be below 41 Fahrenheit. The facility policy Standards, Food Temperature Controls las revised 10/2023 noted: temperatures of refrigerators and freezers for all patient and resident service are taken and recorded. Dish machine and pot machine temperatures are taken and recorded. The facility policy Pantry Storage and Refrigeration dated as last reviewed on January 2020 noted: Procedure: All perishable food items are covered and labeled with the following, as appropriate; Date delivered, date open, and discard date. All stored items must meet the criteria for storage(covered, labeled, and dated). On 1/22/24 from 9:30 a.m. to 10:30 a.m., during the initial tour of the kitchen with the Food Service Director, the following was observed: > 4 male kitchen staff observed having facial hair were not wearing facial hair protection. > There were 5 ceiling vents, above clean dish storage shelves, that were dusty/dirty and rusty. > There were 30 - eight ounce plastic glasses, on two trays, that were observed to be wet stacked. > The auto bag machine had chipped/missing paint and was rusty creating an uncleanable surface. > The dish room had 2 ceiling tiles with brownish stains on them and 4 ceiling vents that were dusty/dirty. > Refrigerator/Cooler #3 had 3 packages of sub rolls and 3 packages of biscuits that were unlabeled and undated. Additionally, the biscuits had large amounts of ice crystals built up inside the packages. > Freezer #3 had a previously opened bad of french fries that were unsealed, unlabeled and undated. On 1/22/24 at 10:30 a.m., in an interview, the Food Service Director confirmed the findings. 2. On 1/22/24 from 11:32 a.m. to 12:05 p.m., a surveyor observed lunch service on the 3rd floor [NAME] dining room. A surveyor observed the dietary aide/server did not have a hair restraint on while handling and serving food. A surveyor also observed the dietary aide/server had gloved hands and touched a cleaning towel then opened cupboards and removed dishes, then used utensils to serve/plate foods, then he reached into a bag of rolls with his gloved hands and got a roll out and put in on a plate of food. With the same gloved hands, a surveyor observed the dietary aid get a biscuit out of a pan and then use the microwave with same gloved hand. He got rolls out of a bag with the same gloved hands multiple times to serve/plate. He then got two pieces of bread out of bag with same gloved hands, then grabbed meat patties out of freezer with same gloved hands. He held the bread with gloved hands while spreading peanut butter and got a muffin out of bag with same gloved hand and held while cutting. He touched a cheese slice with same gloved hands and then used the phone again with same gloved hands. He never changed gloves or washed and sanitized his hands through the entire meal service. 0n 1/22/24 at 11:59 a.m., in an interview, the dietary aide/server confirmed that his procedure of serving was not preventing possible cross contamination of foods. 0n 1/22/24 at 12:55 p.m., in an interview, a surveyor discussed the finding with the Food Service Director. 3. 0n 1/23/24 at 8:45 a.m., a surveyor reviewed documentation the facility provided for dish machine and refrigerator/freezer temperatures and noted he following: > The main kitchen dish machine wash and rinse temperatures were not monitored and documented on the following dates: Dish Machine Temperature Logs: 0ctober 2023: Main Kitchen - 10/3/23(supper check), 10/16/23(breakfast check), 10/30/23(supper check) Pot Room Dish Machine - 10/23/23 November 2023: 11/8/23(supper check), 11/19/23(breakfast and lunch checks) December 2023: Main Kitchen: 12/15/23(lunch check) and 12/22/23(breakfast check) Pot Room Dish Machine - 12/22/23(breakfast check) and no documentation from 12/1/23 to 12/31/23(supper check) January 2024: Main Kitchen: 1/1/24(supper check) 1/4/24(lunch check) Pot Room Dish Machine - no documentation from 12/1/23 to 12/31/23(supper check) The main kitchen dish machine wash and rinse temperatures were documented below 180 degrees Fahrenheit on the following dates: November 2023: Main Kitchen: 11/1/23 - 11/14/23(breakfast check and lunch check) 11/1/23 - 11/7/23 and 11/9/23 - 11/14/23(supper check) Pot Room Dish Machine: 11/5/23 and 11/8/23 > The facility failed to monitor and document the refrigerator and freezer temperatures on the following dates: December 2023 11/22/23- opening check- 4 East deli refrigerator, 4 East refrigerator, 4 East freezer, 4 East patient refrigerator, 4 East patient freezer, 4 [NAME] deli refrigerator, 4 [NAME] refrigerator, 4 [NAME] freezer, 3 East deli refrigerator, 3 East refrigerator, 3 East freezer, 3 [NAME] patient freezer, 3 [NAME] patient refrigerator, 2 [NAME] deli refrigerator, 2 [NAME] refrigerator, 2 [NAME] freezer, 2 [NAME] patient refrigerator, 2 [NAME] patient freezer, November 2023 11/11/23- opening check- 4 [NAME] patient freezer(also closing check), 4 [NAME] patient refrigerator, 4 [NAME] freezer, 4 [NAME] Refrigerator, 4 [NAME] Deli Refrigerator, 4 East patient freezer, 4 East patient refrigerator, 4 East freezer, 4 East refrigerator, 4 East deli refrigerator, 3 [NAME] patient freezer, 3 [NAME] patient refrigerator, 3 [NAME] freezer, 3 [NAME] refrigerator, 3 [NAME] Deli Refrigerator, 3 East freezer, 3 East refrigerator, 3 East deli refrigerator, 2 [NAME] patient freezer, 2 [NAME] patient refrigerator, 2 [NAME] freezer, 2 [NAME] refrigerator, 2 [NAME] deli refrigerator. Meat prep freezer- opening check- 11/3/23 and 11/5/23. Blast Chiller- opening check- 11/3/23 and 11/5/23. Closing check on 11/9/23, 11/11/23, 11/12/23, 11/16/23/11/23/23, 11/25/23, 11/26/23 and 11/30/23. October 2023 Food Bank Refrigerator- opening check- on 10/7/23, 10/8/23, 10/21/23 and 10/22/23. closing check on 10/25/23 and 10/29/23. Food Bank Freezer- opening check- on 10/7/23, 10/8/23, 10/21/23 and 10/22/23. closing check on 10/25/23 and 10/29/23. Bake Shop Refrigerator- opening check- on 10/7/23, 10/8/23, 10/21/23 and 10/22/23. closing check on 10/25/23 and 10/29/23. Bake Shop Freezer- opening check- on 10/7/23, 10/8/23, 10/21/23 and 10/22/23. closing check on 10/25/23 and 10/29/23. Pizza Refrigerator- opening check- on 10/7/23, 10/8/23, 10/21/23 and 10/22/23. closing check on 10/25/23 and 10/29/23. Blast Chiller- opening check- on 10/7/23, 10/8/23, 10/21/23 and 10/22/23. closing check on 10/1/23, 10/5/23, 10/12/23, 10/19/23, 10/25/23 and 10/26/23. Produce Refrigerator- opening check- on 10/7/23, 10/8/23, 10/21/23 and 10/22/23. closing check on 10/25/23 and 10/29/23. Meat Prep Refrigerator- opening check- on 10/7/23, 10/8/23, 10/21/23 and 10/22/23. closing check on 10/25/23 and 10/29/23. Meat Prep Freezer- opening check- on 10/7/23, 10/8/23, 10/21/23 and 10/22/23. closing check on 10/25/23 and 10/29/23. > The main kitchen dish machine wash and rinse temperatures were not monitored and documented on the following dates: Dish Machine Temperature Logs: 0ctober 2023: Main Kitchen - 10/3/23(supper check), 10/16/23(breakfast check), 10/30/23(supper check) Pot Room Dish Machine - 10/23/23 November 2023: 11/8/23(supper check), 11/19/23(breakfast and lunch checks) December 2023: Main Kitchen: 12/15/23(lunch check) and 12/22/23(breakfast check) Pot Room Dish Machine - 12/22/23(breakfast check) and no documentation from 12/1/23 to 12/31/23(supper check) January 2024: Main Kitchen: 1/1/24(supper check) 1/4/24(lunch check) Pot Room Dish Machine - no documentation from 12/1/23 to 12/31/23(supper check) The main kitchen dish machine wash and rinse temperatures were documented below 180 degrees Fahrenheit on the following dates: November 2023: Main Kitchen: 11/1/23 - 11/14/23(breakfast check and lunch check) 11/1/23 - 11/7/23 and 11/9/23 - 11/14/23(supper check) Pot Room Dish Machine: 11/5/23 and 11/8/23 > The facility failed to monitor and document the refrigerator and freezer temperatures on the following dates: December 2023 11/22/23- opening check- 4 East deli refrigerator, 4 East refrigerator, 4 East freezer, 4 East patient refrigerator, 4 East patient freezer, 4 [NAME] deli refrigerator, 4 [NAME] refrigerator, 4 [NAME] freezer, 3 East deli refrigerator, 3 East refrigerator, 3 East freezer, 3 [NAME] patient freezer, 3 [NAME] patient refrigerator, 2 [NAME] deli refrigerator, 2 [NAME] refrigerator, 2 [NAME] freezer, 2 [NAME] patient refrigerator, 2 [NAME] patient freezer, November 2023 11/11/23- opening check- 4 [NAME] patient freezer(also closing check), 4 [NAME] patient refrigerator, 4 [NAME] freezer, 4 [NAME] Refrigerator, 4 [NAME] Deli Refrigerator, 4 East patient freezer, 4 East patient refrigerator, 4 East freezer, 4 East refrigerator, 4 East deli refrigerator, 3 [NAME] patient freezer, 3 [NAME] patient refrigerator, 3 [NAME] freezer, 3 [NAME] refrigerator, 3 [NAME] Deli Refrigerator, 3 East freezer, 3 East refrigerator, 3 East deli refrigerator, 2 [NAME] patient freezer, 2 [NAME] patient refrigerator, 2 [NAME] freezer, 2 [NAME] refrigerator, 2 [NAME] deli refrigerator. Meat prep freezer- opening check- 11/3/23 and 11/5/23. Blast Chiller- opening check- 11/3/23 and 11/5/23. Closing check on 11/9/23, 11/11/23, 11/12/23, 11/16/23/11/23/23, 11/25/23, 11/26/23 and 11/30/23. October 2023 Food Bank Refrigerator- opening check- on 10/7/23, 10/8/23, 10/21/23 and 10/22/23. closing check on 10/25/23 and 10/29/23. Food Bank Freezer- opening check- on 10/7/23, 10/8/23, 10/21/23 and 10/22/23. closing check on 10/25/23 and 10/29/23. Bake Shop Refrigerator- opening check- on 10/7/23, 10/8/23, 10/21/23 and 10/22/23. closing check on 10/25/23 and 10/29/23. Bake Shop Freezer- opening check- on 10/7/23, 10/8/23, 10/21/23 and 10/22/23. closing check on 10/25/23 and 10/29/23. Pizza Refrigerator- opening check- on 10/7/23, 10/8/23, 10/21/23 and 10/22/23. closing check on 10/25/23 and 10/29/23. Blast Chiller- opening check- on 10/7/23, 10/8/23, 10/21/23 and 10/22/23. closing check on 10/1/23, 10/5/23, 10/12/23, 10/19/23, 10/25/23 and 10/26/23. Produce Refrigerator- opening check- on 10/7/23, 10/8/23, 10/21/23 and 10/22/23. closing check on 10/25/23 and 10/29/23. Meat Prep Refrigerator- opening check- on 10/7/23, 10/8/23, 10/21/23 and 10/22/23. closing check on 10/25/23 and 10/29/23. Meat Prep Freezer- opening check- on 10/7/23, 10/8/23, 10/21/23 and 10/22/23. closing check on 10/25/23 and 10/29/23. 0n 1/23/24 at 9:00 a.m., in an interview, the Food Service Director confirmed the findings.

Based on record review and interview, the facility failed to revise a care plan to reflect the current needs for 3 of 33 sampled residents/care plans reviewed (#104, #135 and #144) Findings: 1. A review of Resident #104's clinical record revealed that Hospice was initiated on 9/2/23 for terminal diagnosis of Parkinson's Disease. A Significant Change in Status Minimum Data Set (MDS) 3.0 assessment was completed on 9/4/23 with the Interdisciplinary Team (IDT) meeting held on 9/22/23 and the most recent Quarterly MDS completed on 12/5/23 with the IDT meeting held on 12/8/23. The most recent care plan revision was completed on 12/12/23. As of 1/26/24 Resident #104's care plan lacked evidence of a revision to reflect Hospice services after both MDS assessments and IDT meetings. On 1/26/24 at 11:24 a.m., during an interview with Assistant Director of Nursing, the above was confirmed. 2. A review of Resident #135's clinical record revealed a progress note dated, 1/9/24 at 12:24. Progress note states resident had a verbal outburst and was yelling out this a.m. for help, and made reference to killing [himself/herself], as [he/she] sat on the side of [his/her] bed, attempting to rise up to a standing position. This writer entered the room and offered assistance with getting out of bed. [He/She] accepted and stated, I need to get up. This writer acknowledged [his/her] feelings and offered assistance, with ADL's. Another progress note dated, 1/11/24 at 12:20 states Resident had a verbal outburst and a crying spell as [he/she] was leaving the dining room, upset that no other residents would talk to [him/her]. [He/She] expressed a feeling of worthlessness, and anxiety, and stated if [he/she] could get out of here and drive away, [he/she] would never come back again. [He/Sh]e also made reference to not wanting to live like this. Other phrases [he/she] used to express [his/her] feelings were, I guess my life is over, and I've never been treated like this before and just want to die. On 1/12/24 Zoloft (antidepressant) was increased from 50 milligrams (mg.) once a day to 100 mg. once a day. Seroquel (antipsychotic) was increased from Seroquel 25 mg. once a day to 25 mg. three times a day. The care plan was initiated on 11/16/23 with a target date of 2/25/24. As of 1/24/24 the care plan lacked evidence of a revision to reflect suicidal ideation. In a meeting with the Licensed Social Worker (LSW) at approximately 8:49 a.m. on 1/24/24 he/she was unaware of the above issue and planned to institute required protocol. On 1/24/24 at approximately 9:45 a.m. during an interview with the Nurse Manager on the Memory Unit, the above was confirmed. 3. A review of Resident #144's clinical record revealed a physician order dated 9/13/23 for Sertraline HCl (antidepressant) Tablet 50 milligrams (MG) Give 1 tablet by mouth one time a day for Depression. The most recent care plan revision was completed on 12/12/23. As of 1/23/24 Resident #144's care plan lacked evidence of a revision to reflect the use of an antidepressant medication. On 1/23/24 at 4:06 p.m., during an interview with two of the facilities MDS coordinators, the above was confirmed. 33640