Every finding on record at Syracuse Home Association

Based on observations, record review, and interviews during the recertification survey, the facility failed to review the risks and benefits of bed rails with the resident or resident representative, obtain informed consent, and assess the resident for ability to safely use the rails prior to installation of bed rails for one (1) of one (1) (Resident #15) reviewed. Specifically, Resident #15 had bilateral enabler bars/side rails, and there was no documented evidence informed consent was obtained, education was provided, or an assessment was completed for the use of the enabler bars/siderails. Findings include:The facility policy Transfer Bar Policy, last reviewed 10/2025 documented the purpose of the transfer bar was to assist with mobility. A comprehensive assessment must be completed by nursing and/or therapy prior to use. The assessment must evaluate cognitive status, physical strength and mobility, risk of entrapment, ability to use the device safety, and history of falls or injuries. The maintenance staff must inspect the device prior to use and routinely. The residents must be reassessed at least quarterly, with any change in condition, and after a fall safety incident. Resident #15 had diagnoses including Alzheimer's Disease, spinal stenosis (narrowing of spinal canal) and epilepsy (seizure disorder). The 01/13/2026 Minimum Data Set assessment documented the residents had severe cognitive impairment; had functional limitation in range of motion to both arms and legs; was dependent on staff for all activities of daily living; and did not use bed rails. The 10/04/2023 at 1:52 PM Work Order #7462 documented Resident #15 would like a right-side transfer bar on their bed. The request was completed 10/04/2023 at 2:04 PM. There was no documented evidence informed consent was obtained prior to 10/04/2023 when the first enabler bar was placed on the resident's bed. There was no documentation that an assessment was completed to ensure the residents' ability to safely use the transfer bars. The 11/15/2023 at 1:45 PM Work Order #7920 documented the bed in Resident #15's needed the other side rail on for the resident to use. The request was completed on 11/15/2023 at 2:05 PM. There was no documented evidence informed consent was obtained from the resident or the resident's representative related to the use of bed enabler bars/ transfer bars. The 06/17/2024 Comprehensive Care Plan documented the resident required total assistance with activity of daily living tasks. On 10/10/2025, updated interventions included bilateral transfer bars for repositioning. The 01/22/2026 at 6:26 PM Pocket Care Plan documented bilateral transfer bars for safety. There were no documented physician or nursing orders for the bilateral enabler bars. The following observations were made of Resident #15:-on 01/20/2026 at 2:14 PM, in bed with two bilateral enabler bars.-on 01/21/2026 at 1:33 PM, in bed with the two bilateral enabler bars.-on 01/22/2026 at 10:39 AM, sitting in their wheelchair next to their bed with the bilateral enabler bars. During an observation and interview on 01/23/2026 at 1:21 PM, Certified Nurse Aide #1 and Certified Nurse Aide #2 stated the resident required total assistance with their care and could not roll themselves in bed. Staff placed the resident in bed with a Hoyer lift and rolled the resident to their right side. Resident #15 was able to reach the right-side enabler bar with their left hand. When the staff rolled the resident to the left side, the resident could not reach the left enabler bar with their right hand. During an interview on 01/23/2026 at 1:30 PM, Certified Nurse Aide #1 stated Resident #15 required total care. The resident was fearful during repositioning in the bed, so they had transfers bars placed on the bed about three years ago. The bars were placed on the bed by maintenance. The resident did not roll in the bed independently and required two staff for repositioning. The resident did not use the enabler bar on the left side very well During an interview on 01/26/2026 at 3:25 PM, Registered Nurse Unit Manager #3 stated Resident #15 had transfer bars/enabler bars to hold onto when staff repositioned the resident in the bed. They stated the enabler bars were put on the bed a while ago. The resident was skittish and afraid of rolling out of the bed when being repositioned. They were not sure who ordered the enabler bars for Resident #15's bed. Every quarter the interdisciplinary team met and went over the resident's need for the bars. They did not document the assessments; it was just discussed. They did not have any documentation for education about the risk of the bars or consent for the enabler bars. Maintenance staff placed the enabler bars on the beds when nursing placed a work order notification. During a telephone interview on 01/26/2026 at 12:28 PM, Physical Therapist #4 stated they had not recently evaluated Resident #15 for enabler bars. The last annual screen was 07/2025 and that was a hands-off screen, meaning they received most of the information from the certified nurse aide and licensed practical nurse and documented the resident required total assistance of two staff. They were made aware today, the resident was using enabler bars when in the side lying position to assist with repositioning. They had not evaluated the resident for the use of the enabler bars. Nursing usually made the request for side rails/enabler bars. Therapy would make a formal assessment of the residents for the safe use of the side rails/ enabler bars. Resident #15 had enabler bars since 2023, and the request came from nursing. They were not sure if the consent was completed at that time. Residents with cognitive issues should have their contact person/representative consent to the bars and be educated on the risks and benefits of the bars. During a telephone interview on 01/26/2026 at 12:45 PM, the Director of Maintenance stated Resident #15 had enabler bars placed on their bed on 10/04/2023 and on 11/15/2023. If nursing puts the work order in for the bars, they put them on. They do room inspections annually and those room inspections would include reviewing the resident bed enabler bars for stability and ensuring there were no gaps between the bar and the mattress. During a telephone interview on 01/26/2026 at 12:55 PM, the Director of Nursing stated nursing staff and physical therapy staff worked together to evaluate for the safe use of enabler bars. They were not sure where this was documented. Physical therapy would do most of the documentation because they were responsible for the assessment of the residents' ability to use the bars safely. There should be a referral form in the record, and the interdisciplinary team would meet to discuss the need for the enabler bars. The consent and education for the residents or their contact person should be completed as soon as possible after it was determined the enabler bars were required. They were aware Resident #15 had enabler bars. There were no incidents with Resident #15 related to the enabler bars. 415.12(h)(1)(2)

48895 Based on record review and interview during the recertification survey conducted 2/5/2024 to 2/9/2024, the facility did not complete or electronically submit encoded, accurate and complete Minimum Data Set (MDS) data to the Centers for Medicare and Medicaid Services System for 65 of 69 residents (Resident #1, 6, 7, 9-11, 13-18, 20-24, 27, 28, 30-39, 41, 43-45, 50-53, 55-59, 61, 62, 64, 66, 67, 70, 176, 182, 183, 186-188, and 373-383) reviewed. Specifically: - Residents #1, 6, 7, 9-11, 13-18, 20-24, 27, 28, 30-39, 41, 43-45, 50-53, 55-59, 62, 64, 66, 67, 70, 176, 182, 183, 186, 373-375, and 377-383 had Minimum Data Set assessments that were electronically submitted greater than 14 days following the completion of the assessment, or not submitted at all. - Residents #23 and #61 had Minimum Data Set (MDS) assessments that were completed later than 14 days following the Assessment Reference Date (ARD). - Residents #187, #188, and #376 had Minimum Data Set (MDS) assessments that were completed later than 14 days following their admitted . Findings include: The 10/2020 facility policy Documentation 9.3 documented that the resident assessment instrument would be completed according to the regulation of Centers for Medicare/Medicaid Services as outlined in [Centers for Medicare/Medicaid Services' Resident Assessment Instrument] Version 3.0 Manual. The most current Minimum Data Set Assessment 3.0 and active Medicare Minimum Data Set Assessment 3.0 for each resident would be filed in the resident record. A written assessment via progress notes by all disciplines (nursing, dietary, activities, resident services, and physical therapy) would be completed on admission, quarterly, annually after three quarterly assessments, and when a significant change was identified. The assessment progress notes should have included information necessary for the completion of the Minimum Data Set 3.0 assessment questions. All assessment progress notes were to be completed by or on the assessment reference date for each Minimum Data Set 3.0 assessment. The schedule for all assessments was created by the Minimum Data Set assessment coordinator. Section Z (Z0500) was signed by the Minimum Data Set assessment coordinator or nurse manager. The completed and locked Minimum Data Set assessment was then submitted to the state by the nursing administrative assistant or Minimum Data Set assessment coordinator. The facility did not have a policy that outlined the minimum data set submission requirements. The Centers for Medicare/Medicaid Services Minimum Data Set Resident Assessment Instrument Version 3.0 Manual documented that comprehensive assessments must be transmitted electronically to the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system using the Centers for Medicare/Medicaid Services wide area network within 14 days of the care plan completion date and all other Minimum Data Set assessments must be submitted within 14 days of the Minimum Data Set completion date. For the admission assessment, the Minimum Data Set assessment completion date must be not later than 13 days after the Entry Date. An Omnibus Budget Reconciliation Act assessment (comprehensive or quarterly) was due every quarter unless the resident was no longer in the facility. There must be no more than 92 days between Omnibus Budget Reconciliation Act assessments. During the entrance conference on 2/5/2024 at 9:23 AM, the Administrator stated the facility had a census of 94 with 24 new admissions in the last 60 days. During an interview on 2/6/2024 at 1:29 PM, registered nurse Unit Manager #11, stated if a resident was missing a Minimum Data Set assessment in the electronic record it was because they were on paper in registered nurse/Minimum Data Set Assessment Coordinator #6's office. COMPREHENSIVE ASSESSMENTS: 1) Resident #187 was admitted to the facility on [DATE]. The undated Minimum Data Set assessment, section Z documented verified completion by registered nurse/Minimum Data Set Assessment Coordinator #6 on 2/9/2024 (32 days after admission). 2) Resident #376 was admitted to the facility on [DATE]. The 1/20/2024 Minimum Data Set assessment, section Z documented verified completion by registered nurse/ Minimum Data Set Assessment Coordinator #6 on 2/9/2024 (20 days after admission). 3) Resident #188 was admitted to the facility on [DATE]. The 1/21/2024 Minimum Data Set assessment, section Z documented verified completion by registered nurse/ Minimum Data Set Assessment Coordinator #6 on 2/1/2024 (16 days after admission). QUARTERLY ASSESSMENTS: 1) Resident #23's 1/24/2024 Minimum Data Set assessment, Section Z documented registered nurse Minimum Data Set Assessment Coordinator #6 completed all sections of the assessment and signed the document on 2/9/2024. 2) Resident #61's Minimum Data Set assessment, Section Z was not provided by the facility. MINIMUM DATA SET ELECTRONIC SUBMISSION: During an interview on 2/8/2024 at 3:44 PM, registered nurse/Minimum Data Set Assessment Coordinator #6 stated there had been problems with the computer system, and the Infection Control nurse had been assisting them with Minimum Data Set Assessments since November 2023. The facility software had been problematic since the Centers for Medicare/Medicaid Services update in October 2023. The facility software was not able to comply with the new assessment requirements. Due to the errors in the facility software, they started completing the Minimum Data Set assessments on paper. There was a specific timeline and due dates for new admissions. The admission assessment would open for entries on day one, they would review clinical data from the hospital, and the Minimum Data Set assessment would open on days 4 through 8, the Care Area Assessments were due by day 14, and the care plan was due by day 21. Quarterly assessments were due minimally every 92 days. The purpose of the Minimum Data Set assessment was to develop the care plan, monitor progress, and meet the needs of the resident. The assessment must be completed within 2 weeks of the Assessment Reference Date or the open date of the assessment. They could not submit any assessments since 10/1/2023. The first batch of assessments for October 2023, were sent electronically on 1/30/2024. They were trying to submit all assessments for 2023 by next week. The expectation was that assessments be submitted within two weeks of completion. The assessments were submitted in batches. They were responsible for batching and submitting Minimum Data Set assessments. The Centers for Medicare/Medicaid Services would become aware of the facilities census; however, they had not been able to submit assessments. Resident #23 had a quarterly Assessment Reference Date of 1/24/2024, and the assessment was not completed as of 2/8/2024, it should have been completed by 2/7/2024. Resident #61 had a quarterly Minimum Data Set Assessment Reference Date of 12/27/2023, it was completed on paper, but they could not locate the document in their office. During a follow-up interview on 2/9/2024 at 9:20 AM, registered nurse/Minimum Data Set Assessment Coordinator #6 stated they did not have documentation of Resident #61's assessment and had to check with another nurse. Resident #187's admission assessment was partially completed in the computer, was completed on paper, but they could not find the paper copy. Resident #376's admission assessment was completed on paper but was not completed timely. Resident #188's admission assessment was completed on paper but was not completed timely. Residents #1, 6, 7, 9-11, 13-18, 20-24, 27, 28, 30-39, 41, 43-45, 50-53, 55-59, 62, 64, 66, 67, 70, 176, 182, 183, 186, 373-375, and 377-383 all had assessments completed on paper, but they were not submitted timely as required. Residents #9, 11, 20, 23, 27, 34, 36, 70, 176, 373, 375, and 378-382 had assessments completed on paper, and the assessments were submitted electronically greater than 14 days after completion. Residents #1, 6, 7, 10, 13-18, 21, 22, 24, 28, 30-33, 35, 37-39, 41, 43, 44, 45, 50-53, 55-59, 62, 64, 66, 67, 182, 183, 186, 374, 377, and 383 had assessments completed on paper, but the assessments were not submitted electronically. During a follow-up interview on 2/9/2024 at 10:30 AM, registered nurse/Minimum Data Set Assessment Coordinator #6 stated the facility had to train the interdisciplinary teams on the new electronic Minimum Data Set assessment before they could use it completely. The new electronic system was set to start in March 2024. Until then, when a new resident was admitted to the facility, the resident's admission assessment was completed in the old electronic medical record and on paper, the nursing notes were completed in the old electronic medical record, and medical orders were reviewed in the new electronic medical record system. The whole process was very fragmented, but it was what they had to do until the new electronic medical record system was fully operational and everyone was trained. During an interview on 2/9/2024 at 10:55 AM, the Administrator stated the vendor they used for Minimum Data Set assessments was not able to comply with the new Centers for Medicare and Medicaid Services updates. They were in contact with the vendor several times between 10/1/2023 and 11/7/2023 and the vendor could not make the system work. The facility received proposal for a new system that went through the quality assessment team. They signed with the new system on 12/26/2023, with the holidays they were able to train the staff and get the old minimum data sets put into the new system on 1/17/2024. They completed 158 submissions in the last week, and stated they had to have all assessments submitted by 2/14/2024. The Administrator stated to their knowledge all the assessments were on time as scheduled. They were unaware that assessment must be submitted within 14 days of completion. During a follow up interview on 2/9/2024 at 1:18 PM, the Administrator stated they did not have a Minimum Data Set assessment policy, the facility used the Centers for Medicare/Medicaid Services manual for guidance. During an interview on 2/9/2024 at 1:47 PM, registered nurse/Minimum Data Set Assessment Coordinator #6 stated Resident #187's admission assessment and Resident #61's quarterly assessment were completed on paper on 2/9/2024, and they were not completed timely. 640 - 10 NYCRR 415.11(a)(5) 636 - 10 NYCRR 415.11(a)(3)(i) 638 - 10 NYCRR 415.11(a)(4)

Based on observation, record review, and interview during the recertification survey conducted 2/5/2024- 2/9/2024, the facility did not develop and implement a comprehensive person-centered care plan to meet a resident's medical and nursing needs for 1 of 3 residents (Residentv#66) reviewed. Specifically, Resident #66 did not have a comprehensive person-centered care plan that included a safety gate at the doorway to their room. Findings include: The 9/2023 facility policy Comprehensive Care Plan documented a comprehensive, person-centered care plan would be developed and implemented for each resident consistent with resident rights and include measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment. The comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. Resident #66 was admitted to the facility with diagnoses including stroke with hemiplegia (one sided weakness) on the non-dominant side, aphasia (difficulty speaking), and dysphagia (difficulty swallowing). The 9/12/2023 Minimum Data Set assessment documented the resident was cognitively intact, required extensive of assistance of two for most activities of daily livings, was non-ambulatory, and did not use restraints. During observations on 2/5/2024 at 11:24 AM and 11:55 AM; 2/6/2024 at 9:59 AM; and 2/7/2024 at 12:47 PM, there was a wooden safety gate across the doorway, latched into the door frame of Resident #66's room. During observations on 2/6/2024 at 8:42 AM and 12:18 PM, there was a wooden baby gate at the doorway of the resident's room that was not pulled across the opening to the room. The 12/5/2023 comprehensive care plan did not document any safety care plans, or use of locking door or baby gate at the resident's room entrance. The psychosocial well-being care plan initiated on 12/19/23 documented the resident was alert, oriented, and able to make their needs known. The 2/5/2024 at 4:44 PM and 2/6/2024 at 5:23 PM, pocket care plan (care instructions) did not document use of a locking door or safety gate at the resident's room entrance. Nursing progress notes dated 10/5/2023 to 2/6/2024, did not document a reason for the use of a safety gate at the entrance of the resident's room. During an interview and observation on 2/5/2024 at 11:55 AM, Resident #66 and the resident's family stated the safety gate at the entrance of the room was used to discourage wandering residents on the unit from entering. The family stated that the resident could not open the gate at the doorway, but the resident was also non-ambulatory, and they could not propel their wheelchair to the door on their own. During an interview on 2/6/2024 at 12:11 PM, certified nurse aide #2 stated the safety gate had been used for approximately 2 to 3 months. It was used to keep other residents out of the room. The gate was opened by a lift bar in the front, the mechanism pulled upward to unlatch. Resident #66 did not have the strength to open the gate, or ability to reach over the gate to pull up on the bar. During an interview on 2/6/2024 at 12:28 PM, licensed practical nurse #3 stated the pocket care plan was the resident's care plan and was used it to determine the care needs for the residents. They stated the pocket care plan was generated from the computer, but they were not sure how to get to the electronic medical record care plan. They stated it had been a while since they used the electronic medical record care plan. At 12:31 PM, licensed practical nurse #3 stated the safety gate was used keep other residents from going into the room and was provided by the facility. The resident's roommate had an electronic care plan and a paper pocket care plan for the safety gate but Resident #66 did not. During an interview on 2/6/2024 at 1:00 PM, registered nurse #4 stated that other residents wandered into the resident's room, and it upset the resident and their roommate. The resident could not get to the door on their own accord due to their physical limitations. The facility tried to use a stop sign and locking door, without success. The family was very particular about what they wanted for the resident. The safety gate had a bar that lifted on the front and could be pushed in if needed. The unit staff had been trained on using it. Registered nurse #4 stated they were responsible for the nursing portions of the care plans for the residents, but the facility had 2 types of care plans. The main care plan was documented in the electronic medical record, and the pocket care plan was on paper and included basic care required for the resident. The paper care plan could be updated by any licensed staff. Resident #66 did not have a care plan for the safety gate at the door. The roommate did have a care plan for the safety gate, and the 2 residents shared the same doorway. Registered nurse #4 stated Resident #66 should have an electronic care plan and a paper pocket care plan for the safety gate. During an interview on 2/8/2024 at 8:54 AM, social worker #5 stated the Unit Manager and the social worker were responsible for the resident's care plan. The social worker was responsible for the sections in the care plan that included psychosocial needs, mood, and behaviors. There was no care plan area for safety related to the residents. They could include a care plan for safety within any area of the care plan. The safety gate was kept in the common doorway for the resident and their roommate. Resident #66 did not have a care plan for the safety gate and should have. They stated the electronic care plan could not be viewed by certified nurse aides, and frequently froze which made it no longer viewable by anyone. The facility created the paper pocket care plan for ease of access to information that was reviewed daily by nursing. During an interview on 2/8/2024 at 11:43 AM, the Director of Nursing stated they expected a resident's care to have all required components and be updated by the interdisciplinary team. The registered Nurse Manager was responsible for the main care plan. The Director of Nursing stated both residents should have been care planned for the safety gate. The lack of a care plan for Resident #66 was an oversight. The safety gate should have been electronically care planned and added to the paper pocket care plan. The electronic care plan and paper pocket care plan did not interface with each other and needed to be updated separately. The current electronic care plan system used was very difficult to navigate and utilize, so the facility developed its own paper pocket care plan. There was a possibility that information went into the electronic care plan but not the paper pocket care plan, and vice versa. The paper pocket care plan was a shortened version of the electronic care plan. The resident's information should be on the electronic care plan first and then moved to the paper pocket care plan. 10NYCRR 415.11(c)(1) 48895

Based on observation and interview during the recertification survey conducted 02/5/24-02/9/2024, the facility did not ensure the results of the most recent Federal/State survey were posted in a place readily accessible to residents, family members, and legal representatives of residents. Specifically, the results of the most recent Federal health recertification survey conducted 11/4/2021 were located within a chest of drawers that was not accessible to all residents without asking for assistance. Findings include: The facility policy Resident Rights, reviewed by the facility 10/2023, documented all residents of the facility would have their rights protected and promoted. Every resident would be encouraged and assisted to exercise their rights. The facility policy did not include documentation residents' rights to review the results of the most recent Federal/State survey or that they were posted in an accessible location. During the resident council meeting on 02/05/2024 at 2:18 PM, there were 9 residents present. An anonymous resident stated they knew where the previous survey results were located. However, due to the location they needed to ask for staff assistance to view them. The remaining 8 anonymous residents agreed that staff assistance was required to review the survey results. During an observation and interview on 02/06/2024 at 10:07 AM, a small sign was located at the bottom of the hanging locked glass case that stated, The New York State Department of Health survey results can be found in the chest in the front lobby. Administrative Assistant #7 stated the chest was the drawer set underneath the glass case. The survey results were in a bent folded over plastic dust cover in the top drawer, underneath a cane and two gavels. It was not accessible to residents without requesting assistance. During a follow up interview on 02/8/2024 on 11:18 AM, Administrative Assistant #7 stated the survey book was kept in the chest of drawers and there was a sign in the hanging glass case that indicated to look in the chest for the survey results. They were not aware of any issues of residents not being able to access the drawers, but they would assist residents if needed. They stated they were previously asked for assistance to locate the survey book and were not able to recall if they were asked by residents or visitors. During an interview on 02/08/2024 at 11:33 AM, the Social Services Director stated they reviewed where the survey results book was located during every Resident Council meeting. They stated they were not aware of residents having stated they had trouble accessing the survey book. They stated it was understandable that a resident may have difficulty to access to the survey book without assistance because it was in a drawer which could be difficult for some residents to pull open. During an interview on 02/09/2024 10:55 AM, the Administrator stated the summaries of the previous survey results were in the glass case above the chest. The chest contained the actual results of the survey. They believed the results were easily accessible but stated it was subjective. They were not aware residents stated they had to ask for assistance with the drawer to access the survey results. 10NYCRR 415.3(c)(v)

Based on observation, interview, and record review during the recertification survey conducted 2/05/2024-2/09/2024, the facility did not ensure a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion for 1 of 1 resident (Resident #33) reviewed. Specifically, Resident #33 did not have their resting hand splint applied appropriately as ordered. Findings include: The facility policy Orthopedic Devices, Care of the Resident With reviewed by the facility 10/2023, documented the nursing staff would apply splints and braces according to the physician's order and under the direction of physical or occupational therapy. The application and removal of the orthopedic device would be monitored by the licensed nurse. Resident #33 had diagnoses including unspecified severe dementia with mood disturbances, personal history of traumatic brain injury, and muscle weakness. The 6/14/2023 Minimum Data Set assessment dated documented the resident had severely impaired cognition, was totally dependent for activities of daily living, and had functional limitation in range of motion in both arms. A 9/22/2023 occupational therapist #16 Therapy Communication Form documented resting hand splint to be donned (applied) after AM self-care and doffed (removed) and doffed at HS (bedtime) and replaced with a palmar pose (hand splint) as tolerated for bedtime. There was a photo that included instructions of how to apply the splint. A physician #15 order dated 11/9/2022 and renewed 12/18/2023 documented left-hand splint on during daytime every day 7:00 AM-3:00 PM. The 12/18/2023 comprehensive care plan documented the resident was at risk for impaired skin integrity and had a left hand contracture. Interventions included a left hand blue palmar posy (hand-splint) on at all times and remove for care. The 2/5/2024 to 2/07/2024 pocket care plans (care instructions) documented a left hand splint was to be applied in the morning. The February 2024 treatment administration record documented the left-hand splint was in place every day. The February 2024 certified nurse aide treatment sheet documented the resident had a left-hand splint applied every day shift from 2/01/2024 to 2/8/2024 except for 2/04/2024 where there was nothing documented. The resident was observed without a left-hand resting hand splint applied or applied inappropriately: - On 2/05/2024 at 10:46 AM, sitting in their room in a wheelchair with their left arm curled over their chest and their fingers curled into the palm. The resting hand splint was on the resident's bed, away from the resident. - On 2/07/2024 at 9:14 AM, sitting in their room in their wheelchair with the resting hand splint on their left arm with the straps very loose. Their thumb was off the bracing and curled under. - On 2/08/2024 at 8:53 AM, the resting hand splint was on the resident's lap without the straps on tightly. The resident's forearm and hand were curled into the resident's lap, not on the resting hand splint. During an interview on 2/08/2024 at 9:14 AM, certified nurse aide #12 stated if a resident was gotten up by the night shift, they applied the resident's splint. The day shift certified nurse aide verified it was applied correctly. Therapy educated the certified nurse aides on the splints and there were pictures of how the splint was applied in the certified nurse aide documentation book. They also signed a treatment sheet indicating the splint was applied. Certified nurse aide #12 stated Resident #33's splint was applied by the night shift regularly. They stated the straps on the splint were labeled to ensure correct position and the goal was to keep the left hand open. They stated the resident was unable to remove the resting hand splint themselves. The resident was able to move the splint around slightly by moving around their arm, but the splint should not be completely off the resident. Staff should check the splint periodically to ensure correct positioning. During an interview on 2/08/2024 at 10:24 AM, registered nurse Unit Manager #13 stated splints and contracture management braces were placed on the resident per the physician order. They stated some braces were more complicated than others so therapy would provide education to the staff on how to don and doff the braces. There was a picture of the splint applied to the resident in the certified nurse aide documentation book. The licensed nurses also had a treatment order to check the splints as part of a double check system. Resident #33 could shift their splint with arm movement and the staff should fix it. The straps of the splint should not have been loose enough for their arm or hand to come completely out of the splint when applied appropriately. During an interview on 2/08/2024 at 10:57 AM, licensed practical nurse #14 stated the splints were applied as ordered and licensed nurses documented the splint was applied on the resident in the treatment administration record. They stated Resident #33 could shift the splint. If a certified nurse aide or other staff saw the splint was not on correctly and did not know how to reapply the splint, they should come to them or contact therapy. Therapy would come down and look at the splint. If a resident did not have their splint on, they could become more contracted. During an interview on 2/08/2024 at 11:10 AM, occupational therapist #16 stated if a resident had a specialized splint or if there were questions from the nursing staff, they would provide education. They provided nursing staff a picture of the splint on the resident for reference. They stated Resident #33 had a resting hand splint which should be applied during the day. The resident sometimes maneuvered the brace out of the correct position. The splint would not have been applied appropriately if the straps of the splint were loose enough to still be connected and the resident's hand/arm was not in the splint. If the splint was not applied correctly, the resident could have an increase in tone (increased tension in the muscles which makes it difficult for them to relax). If the splint was being dislodged or taken off a lot, they should be notified so an assessment could be conducted on the continued use of the splint or re-education could be provided to the nursing staff. During an interview on 2/08/2024 11:43, the Director of Nursing stated the splint devices should be care planned and include directions on how to apply the splint was applied. They stated there was a picture available to the certified nursing aides. The staff should keep track of the splints and have them replaced when dirty. They expected the splints to be applied as care planned per the occupational or physical therapy determination and orders. The nursing staff should notify therapy if the resident was slipping out of their splint so a reassessment could be conducted. Improper placement or application of a splint could cause skin breakdown. 10NYCRR 415.12(e)(2)

Based on observation and interview during the recertification survey conducted 11/2/21-11/4/21, the facility failed to label drugs and biologicals in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 3 of 3 nursing units (Units 1, 2 and 3) reviewed. Specifically, the facility did not dispose of expired medications and biologicals in the medication storage area on Units 1, 2 and 3. Findings Include: The facility policy General Medication Administration updated 3/2015 documented before administering the medication, check for irregularities such as expiration date. During a Unit 2 cart A medication storage observation on 11/2/21 at 1:42 PM with licensed practical nurse (LPN) #3, there was a tube of Ben Gay ([MEDICATION(S)] rub) with a manufacturer expiration date of 9/2021 and a handwritten opened expiration date of 7/2020. The LPN stated it was expired as it was opened over a year ago. The LPN stated the resident was to use the medication as needed but was unaware if it was recently used. During a Unit 2 medication storage room and refrigerator observation on 11/2/21 at 1:49 PM with LPN #3, the following was observed: - 3 unopened single use vials of [MEDICATION(S)] (flu vaccine) 0.5 milliliters (ml) syringes with a manufacturer expiration date of 6/15/21; - 1 opened stock vial of [MEDICATION(S)] (flu vaccines) 5 ml that was half filled and had no opened date; - 2 unopened stock bottles of [MEDICATION(S)] (eye drops) solution with a manufacturer expiration date of 10/2021; and - an opened bottle of Scalpicin (scalp anti itch medicine) solution with a manufacturer expiration date of 10/20 and opened date of 9/12/19 handwritten on the tube. When interviewed on 11/2/21 at 2:00 PM, LPN #3 stated all of the Unit 2 medications observed were expired. The 5 ml flu vial had no handwritten date on it to determine when it had been opened and was considered expired as it was only good for 30 days once opened. The LPN stated the nurse opening a vial was supposed to write the open date on the vial. The LPN stated there was no specific shift assigned to check medication storage areas for expired medications, but all nurses were to check each medication prior to administration. The LPN stated they were unaware of any resident receiving any of the expired medications. During a Unit 1 cart B medication storage observation on 11/2/21 at 2:22 PM with licensed practical nurse (LPN) #4, the following was observed: - an opened bottle of colbetasol shampoo 0.05% with a manufacturer expiration date of 9/21; - an opened bottle of [MEDICATION(S)] (nasal) spray 50 micrograms (mcg) with a manufacturer expiration date of 8/2021; - an opened container of [MEDICATION(S)] 12% (facial cream) with a manufacturer expiration date of 10/4/05; and - 2 tubes of stock [MEDICATION(S)] 2% (antifungal) with a manufacturer expiration date of 8/2021. During a Unit 1 medication room storage observation on 11/2/21 at 2:24 PM with LPN #4, the following were observed: - an unopened stock bottle of aspirin 81 milligrams (mg) with a manufacturer expiration date of 4/21; and - an unopened stock bottle of [MEDICATION(S)] (cough syrup) 100 mg/5 milliliters (ml) 16 ounce (oz) with a manufacturer expiration date of 10/21. During a Unit 1 medication room refrigerator observation on 11/2/21 at 2:24 PM with LPN #4, the following were observed: - an opened stock vial of [MEDICATION(S)] (insulin) 100 units/ml with no written date of when it had been opened; and - an opened vial of [MEDICATION(S)] ([MEDICATION(S)] test) 1 ml vial with a manufacturer with no written date of when it had been opened. During a Unit 3 short hall' cart medication storage observation on 11/2/21 at 2:02 PM with LPN #5, there was a resident specific ear drop container that had a manufacturer expiration of 2021 and the month was faded so that it was unreadable. The LPN stated they were unable to read the expiration month, the bottle was received at 8:30 PM on an evening shift and the resident still had an active order for the medication. The LPN was unaware if the resident received the drops recently. When interviewed on 11/2/21 at 2:26 PM, LPN #4 stated the observed medications on Unit 1 were past the manufacturer expiration date and the vials with no written opened date were considered expired. Vials were good for 28 days once opened and since there was no open date, there was no way to know how long they were there. LPN #4 stated all nurses should check expiration dates prior to administering medications. The LPN stated there was no specific shift assigned to check the medication storage areas for expired medications and treatment supplies. The LPN was unaware of any resident receiving any of the expired medications. When interviewed on 11/2/21 at 2:38 PM, registered nurse (RN) Unit Manager #6 stated all nurses were to check for expiration dates of medications or treatments prior to administering them. The pharmacy consultant came in occasionally to check for expired medications. The Unit Manager did not know if those checks were random regarding treatments or medications. The Unit Manager stated the expiration checks were not assigned to a specific shift and were not documented. The Unit Manager stated medications were to be discarded once expired and the nurse opening a vial should date the vial with the open date. If the vial was not dated with an open date, it was considered expired. When interviewed on 11/3/21 at 3:52 PM, the Director of Nursing (DON) stated expired medications should be checked every so often and the consulting pharmacist checked for them quarterly. There was no specific shift assigned to check for expired medications, but it was usually the midnight shift nurse who was asked to check. Those checks were not documented. The person checking for expired medications should check the medication room, medication refrigerator and medication carts. The nurse should also check the expiration dates of any treatments and creams. When a nurse opened a vial, they should date the vial or the box with the open date. Any opened vial was good for 28 days. 10NYCRR 415.18(d)(e)(2-4)

Based on observation, record review, and interview during the recertification survey conducted 11/2/21-11/4/21, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 2 kitchenettes (main dining room). Specifically, a food service worker (dietary aide #7) did not change gloves after handling raw eggs and before serving residents breakfast, and unlabeled and undated soups were observed in a hot box (insulated food storage system) after a breakfast meal. Findings include: The undated facility policy General Food Preparation and Handling documented food is covered for storage. Leftovers were to be dated, labeled, covered, cooled, and stored in a refrigerator. Bare hands should never touch raw food directly. During an observation on 11/3/21 at 8:31 AM, dietary aide #7 was at the stove in the main kitchenette area in the main dining room. The dietary aide was making a fried egg for a resident. At 8:33 AM, the dietary aide cracked a raw egg while wearing gloves. The dietary aide did not change their gloves, touched the clean plate being used for the resident, and touched the spatula to flip the egg. At 8:35 AM, the dietary aide plated 2 resident meals wearing the same gloves they had worn to crack the raw egg. The dietary aide then touched French toast and a ham steak with the same hand. The plate was then removed from the serving table and served to a resident. During an interview with dietary aide #7 on 11/3/21 at 8:43 AM, they stated they should wash their hands between glove changes. The gloves should be changed between cooking items and touching raw meats. They stated they should have changed their gloves after cracking the egg(s). During an observation on 11/3/21 at 8:48 AM, there were 6 trays at the bottom of the hot box located in the main dining room kitchenette. One of them was labeled chicken noodle and one of them was rice. The remaining trays were marked in illegible black marker. The lids were bent in/warped allowing air flow and food to be visible. There were no dates on the trays. During an interview with the Director of Food Service on 11/4/21 at 9:56 AM, they stated staff should wash their hands before moving to a different task, when changing gloves, or anytime they were going from raw to ready to serve food. The Food Service Director stated this was important to prevent cross contamination and foodborne illness. They stated the staff should not have touched the raw egg then utensils, plates, and food items. The staff should have changed their gloves after cracking the egg. They stated staff did not usually put any foods into the hot box. The hot box was used to keep plates hot. Anything not being used for that meal service should have been labeled and should not have been stored in the hot box overnight. Soup was not served for breakfast and should have not been in the kitchenette. The hot box should have been cleaned before the end of the shift the night before. If the hot box had been turned off and back on, the food left inside could cause foodborne illness. That food would not be able to be reused and would have to be discarded. 10NYCRR 415.14(h)

Based on observation, record review and interview during the recertification survey conducted from 11/2/21-11/4/21 the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice for 1 of 2 residents (Resident #67) reviewed. Specifically, Resident #67 had an order to receive oxygen therapy at all times and was observed with an empty oxygen tank. Findings include: The facility policy Oxygen Therapy updated 6/2019, documented oxygen must be administered safely and properly in an effort to help the resident with a respiratory impairment breathe easier. It is administered and monitored by licensed nursing staff. All residents using oxygen must have a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #67 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 9/29/21 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, required extensive assistance with most activity of daily living (ADLs) and required oxygen. The 10/10/21 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The comprehensive care plan (CCP), updated 10/13/21, documented the resident was at risk for respiratory distress related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff were to apply oxygen as ordered daily and monitor oxygen saturation (amount of oxygen in the blood stream) as needed for shortness of breath. The 11/2021 treatment administration record (TAR) documented oxygen at 2-3 liters AAT to keep oxygen saturations equal to or greater than 90%. Nursing staff signed the oxygen was administered as ordered on 11/2/21 and 11/3/21. There was no documentation if the resident was on 2 or 3 liters or what their oxygen saturations were. The resident was observed on 11/2/21 at 12:42 PM, seated in the dining room eating lunch. The resident's portable oxygen tank was hanging on the back of their wheelchair and was observed to be empty. The resident did not exhibit signs or symptoms of respiratory distress. The resident remained seated in the dining room with an empty portable oxygen tank at 1:24 PM. At 3:12 PM, the resident was seated in the activity room with an empty portable oxygen tank with no visible signs of respiratory distress. During an interview on 11/2/21 at 3:20 PM, licensed practical nurse (LPN) #10 stated it was the responsibility of the nurses and the certified nurse aides (CNA) to check that portable liquid oxygen tanks were full or empty. The LPN stated residents that had oxygen tanks should be checked every shift especially before the resident went to meals. The LPN stated they had not yet checked the resident's oxygen tank that shift. During the interview at 3:24 PM, the LPN walked over to the resident to check the oxygen tank. They lifted the tank by the handle, and it was light-weight and the LPN stated the tank was empty. An 11/3/21 registered nurse (RN) #6 progress note documented a late entry for 11/2/21 at 3:30 PM, the resident was seated in the lounge with an empty portable oxygen tank. The resident's oxygen tank was replaced by the nurse. On 11/3/21 at 9:04 AM, the resident was observed in the TV room with an empty oxygen tank. The resident had no visible signs and symptoms of respiratory distress. During an interview on 11/3/21 at 9:13 AM, CNA #9 stated they would check the resident's oxygen tank after meals and on rounds. The CNA stated that they did not check the tank that morning because the LPN student was assigned to the resident. The CNA stated the student should have checked to make sure that the oxygen tank was full. The CNA stated they did check the tank at some point between 1:00 PM-1:30 PM on 11/2/21, and there was oxygen in the tank at that time. During an observation on 11/3/21 at 9:17 AM CNA #9 checked the resident's portable oxygen tank by pulling the strap by the dial and CNA #9 stated the tank was empty. During an interview on 11/3/21 at 9:20 AM, LPN student #13 stated when they got a resident up, they were to make sure the oxygen was on and working properly. The LPN student stated to make sure the tank was full they held the tank by the handle and read the gauge. The LPN student stated they got the resident out of bed about 2-2.5 hours before and the tank was half empty at that time and the tank was now empty. During an interview on 11/3/21 at 9:22 AM, LPN #11 stated resident's that were on oxygen therapy usually had their oxygen saturation checked once a day. They stated the resident usually ran a lower oxygen saturation level, and their saturation level was 91% yesterday. They stated that the goal was to have a resident's oxygen saturation level be greater than 90 %. The LPN stated that since the resident had an oxygen saturation level above 90% the resident was doing good. They stated that a nursing student was assigned to the resident on 11/2/21 and as far as they knew the resident had oxygen in their tank and they were not aware the resident had an empty tank. The LPN recalled that the resident was brought to the dining room in the morning and the tank was not empty. They stated that it was the responsibility of the nurses and CNAs to make sure that the resident's oxygen tank was checked and was not empty. During an interview on 11/4/21 at 10:19 AM, RN Unit Manager #12 stated that it was the responsibility of the nurse to fill the oxygen tank, set the flow, and make sure there was oxygen in the tank. They stated the CNA was only responsible to assist in getting a new tank. The RN stated the only time the resident was using the portable oxygen tank was when they were attending activities outside of their room. When in their room they would use wall unit oxygen. The resident required oxygen therapy due to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A resident could last through a meal with a partial oxygen tank, but ideally the resident should have been provided a full tank before the meal. The resident should have been brought back to their room to use their wall unit oxygen at some point. The RN stated the resident had a routine that they liked to go back to their room and sit in the recliner. They believed on 11/2 a newer CNA cared for the resident and was not used to the resident's routine. On 11/3/21, the assigned staff and the LPN instructor should have checked the resident's oxygen and not relied on the student. 10NYCRR 415.12(k)(6)

Based on observation, interview and record review during the recertification survey, the facility did not ensure a resident who needed respiratory care was provided such care consistent with professional standards of practice and the comprehensive person-centered care plan for 1 of 3 residents (Resident #101) reviewed for respiratory care. Specifically, Resident #101 was receiving supplemental oxygen without a physician's order and indications for use. Findings include: The 4/2019 Oxygen Therapy policy documented a resident would be administered oxygen in accordance with the physician's order and monitored by the licensed practical nurse (LPN). Resident #101 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 4/29/19 Minimum Data Set (MDS) assessment documented the resident's cognition was intact, she required extensive assistance of one staff for transfers and dressing, and she received oxygen therapy. The 4/15/19 hospital discharge instructions did not include oxygen use. The 4/15/19 Nursing Admission Data Collection form documented the resident used oxygen, was not having respiratory difficulties and her lung sounds were clear. The 4/2019 and 5/2019 physician's orders did not document an order for [REDACTED]. Physician and nurse practitioner (NP) progress notes from 4/15 - 5/10/19, documented the resident experienced shortness of breath relieved with rest. The progress notes did not document the resident required the use of oxygen. The 4/2019 and 5/2019 medication and treatment administration records (MAR and TAR), did not document the resident used oxygen. The 5/2/19 comprehensive care plan (CCP) did not document the resident used oxygen. The 5/9/19 Pocket Care Plan (direct care instructions) did not document the resident used oxygen. The resident was observed: - On 5/8/19 at 10:22 AM, in her room wearing oxygen via nasal cannula at 2 liters (L) per minute. - On 5/8/19 at 3:23 PM, 5/9/19 at 12:11 PM, 5/10/19 at 11:54 AM and 5/14/19 at 9:49 AM, in her room without the nasal cannula in her nose. The piped wall oxygen regulator above the resident's arm chair was set to 2 L and the humidifier bottle was visibly bubbling. During an interview on 5/10/19 at 1:09 PM, the resident stated that she had not used supplemental oxygen before being admitted to the hospital, used it intermittently when hospitalized , and had used supplemental oxygen intermittently since she was admitted to the facility. During an interview on 5/14/19 at 10:09 AM, LPN #1 stated if she knew a resident was using oxygen and did not see an order for [REDACTED]. During a telephone interview on 5/14/19 at 11:03 AM, physician #6 stated each resident was reviewed on an individual basis, and if a resident was receiving oxygen, nursing staff would contact a provider to get an order. He could not recall if he had been contacted about Resident #101 using oxygen. During an interview on 5/14/19 at 11:15 AM, registered nurse (RN) #2 Unit Manager stated if there was an episode where a resident required oxygen who previously was not ordered oxygen, the physician should have been contacted for an order. It was an oversight that Resident #101 did not have an order. 10NYCRR #415.12 (k)(6)

Based on record review and interview during the recertification survey the facility did not ensure residents who enter the facility with an indwelling catheter (a tube which drains urine from the bladder) or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary for 1 of 2 residents (Resident #59) reviewed for urinary catheters. Specifically, Resident #59 had a urinary catheter placed without valid medical justification. The facility's Use of Urinary Catheterization policy reviewed 5/2012 documented: - A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization is necessary. - The facility will assess all resident's at risk for urinary catheterization and assess any resident currently with a catheter on an ongoing basis. - The comprehensive assessment will include underlying factors supporting the medical justification for the initiation and continuing need for catheter use and development of a plan for removal. - If the physician/NP decides to use an indwelling catheter, it must be based on valid clinical indicators. Resident #59 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The 3/14/19 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment, required extensive assistance of two persons for toileting and hygiene, did not have a catheter, was frequently incontinent, and had a toileting program or trial. The resident had no pressure ulcers/injuries, and no other wounds or skin problems. The physician's progress note dated 12/18/18, documented the resident was admitted to the facility from the hospital following a UTI. She had acute [MEDICAL CONDITION], a urinary catheter was placed, and arrangements were made for urology follow-up. The Medical Referral for Consultation form dated 1/7/19, documented the resident was referred to a urologist for trial of voiding due to [MEDICAL CONDITION]. Treatment recommendations completed by the urologist included: - The resident passed the voiding trial; - Keep the catheter out and monitor for retention; - If 350 milliliters (ml) of post void residual (PVR, amount of urine remaining in bladder after voiding), replace indwelling catheter, and complete bladder scans as necessary; - Continue weekly oral antibiotics; and - Follow up appointment in three months with a bladder scan. A nursing progress note dated 1/8/19 at 2:41 PM documented the resident was voiding well. The comprehensive care plan (CCP) dated 1/8/19, documented the resident's catheter was removed and she was voiding well. Orders were in place to bladder scan as needed and reinsert the catheter if PVR was greater than 350 ml. The resident required staff support for all aspects of toileting, was taking diuretic and blood pressure medication that effected urine output, and the resident was at risk for recurrent UTIs. Approaches included a bladder scan as needed and assess for signs of UTI and [MEDICAL CONDITION]. A bladder scan dated 1/26/19, documented the PVR was 217 ml. A nursing progress note dated 2/24/19 at 2:56 PM, documented a family member stated she wanted the resident's catheter back in and the family had spoken with the urologist. A nursing progress note dated 3/10/19 at 2:45 PM, documented the resident had no complaints of urinary symptoms. The urologist visit summary dated 3/18/19, documented the resident was seen for follow-up for [MEDICAL CONDITION] and was accompanied by her family member. The resident had a history of [REDACTED]. The resident had persistent incontinence. A bladder scan showed the PVR was 122 ml. Persistent incontinence and skin breakdown had been affecting the resident's quality of life and a catheter was placed during the visit. A nursing progress note dated 3/18/19 at 10:29 PM, documented the resident returned to the facility from her urology appointment with a urinary catheter. Consultation paperwork was left in the NP communication book. The CCP updated 3/28/19, documented the resident had a catheter in place due to [MEDICAL CONDITION], had a history of [REDACTED]. The goal was the resident would be free from UTIs and did not include a plan to remove the catheter. Approaches included to monitor for signs of UTI, urology consult as needed, and catheter care. The NP progress note dated 4/1/19, documented the resident had a history of [REDACTED]. During an interview on 5/8/19 at 2:30 PM, Resident #59 stated she had a catheter and she was not sure why she had a catheter, she was able to use the bathroom, she had a history of [REDACTED]. She stated the catheter had at one point been out for a while and she was able to go to the bathroom without difficulty. The physician was interviewed on 5/10/19 at 3:40 PM and stated indications for an indwelling catheter included [MEDICAL CONDITION], skin issues, wound healing, and comfort care. He stated there had to be a medical indication for use of an indwelling catheter. He stated urinary incontinence and/or family request was not a valid reason for reinsertion of the resident's catheter. The resident had a history of [REDACTED]. He was unaware of any recent concerns with [MEDICAL CONDITION] or skin breakdown which would justify catheter use for the resident. A PVR of 122 ml would not indicate [MEDICAL CONDITION], and he would look for a PVR of 350 ml or greater to indicate the need for the catheter. The physician stated he was unaware of the urologist's documentation regarding the reasons for the replacement of the catheter and if he had seen it, he would have had a conversation with the urologist and the family. The physician stated based on the low PVR, lack of ongoing urinary issues, and no skin issues, there was not a valid medical justification for the resident to have the catheter. Registered nurse (RN) Unit Manger #2 was interviewed on 5/10/19 at 4:35 PM and stated she recalled the family member asking about having the catheter replaced. The RN stated an appointment was set for the resident to see the urologist and she deferred to the urologist to help the family member understand there was no medical need for the catheter to be replaced. The resident was voiding well since the catheter was removed in early 1/2019, had no signs of retention, and no complaints of urinary difficulties. She stated the resident returned from the urology appointment with the catheter already in place, which was unusual, as typically residents returned with orders and the catheter insertion would be completed at the facility. If the resident returned with an order for [REDACTED]. 10 NYCRR 415.12 (d)(2)

Based on record review and interviews conducted during the recertification and abbreviated surveys (NY 799) the facility did not ensure residents were free of significant medication errors for 1 of 6 residents (Resident #99) reviewed for medications. Specifically, Resident #99 had a [MEDICAL CONDITION] medication discontinued in error on 8/8/2017 and the error was not discovered until 8/29/2017. Findings include: Resident #99 was admitted to the facility on [DATE], and re-admitted to the facility on [DATE] following hospitalization . She had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was severely impaired cognitively and required extensive assistance to total dependence for activities of daily living (ADLs). The physician's orders [REDACTED]. The 8/2017 electronic Medication Administration Record [REDACTED] - On 8/8/2017 the resident received the medication at 6 AM and 9 AM only. - From 8/8/2017 at 12 PM to 8/30/2017 at 9 AM the resident did not receive any [MEDICATION NAME]-[MEDICATION NAME]. Nursing progress notes documented: - On 8/8/2017 at 9:25 AM, the resident was seen by the physician with no new orders. - On 8/21/2017 at 2:04 PM, the resident was observed with a tremor of her right hand throughout the day. - On 8/29/2017 at 2:30 PM, the resident's appetite and fluid intake remained poor and labs were ordered. - On 8/30/2017 at 2:11 PM, the resident's [MEDICATION NAME]-[MEDICATION NAME] was restarted. - On 8/31/2017 at 9:47 AM, the resident was seen by the physician for the recent restart of [MEDICATION NAME]-[MEDICATION NAME]. physician progress notes [REDACTED]. The medication was restarted and the resident was alert. The facility investigation dated 9/2/2017 documented: - On 8/8/2017 the MEDICATION ORDERS FOR [REDACTED] - On 8/28/2017 the resident was noted to have a 17-pound weight loss over the past two weeks and her fluid intake had significantly declined. - On 8/29/2017 the nurse updated the family on the resident's condition and it was discovered at that time the [MEDICATION NAME]-[MEDICATION NAME] was discontinued. - On 8/30/2017 the [MEDICATION NAME]-[MEDICATION NAME] was restarted and the discontinued order was reviewed by Administration and NP #2. When interviewed on 1/18/2018 at 2:30 PM, registered nurse (RN) Unit Manager #1 stated the resident seemed to be declining towards the end of August 2017. They gave her a work-up and discovered her [MEDICATION NAME] had been discontinued by the nurse practitioner in early August, so she had not been receiving the [MEDICATION NAME] for about 3 weeks. She went to the hospital 9/1/17 because the family wanted her evaluated and was diagnosed with [REDACTED]. Nurse practitioner (NP) #2 did not recall discontinuing the medication. During an interview on 1/18/18 at 3:05 PM, NP #2 stated the [MEDICATION NAME] error was discovered 20 days after it was discontinued. RN #1 discussed the resident's health concerns with the family and mentioned the [MEDICATION NAME] had been discontinued. The resident had been declining overall and the family wanted her sent to the hospital. The NP stated she unintentionally discontinued the [MEDICATION NAME] and did not know how it happened in the electronic system. On 1/18/18 at 3:15 PM, the Director of Nursing (DON) stated during an interview the [MEDICATION NAME] error began 8/8/2017, and we discovered it 9/1/2017. Since the [MEDICATION NAME] order had been discontinued by medical, it did not appear on the computer screen/eMAR as viewed by the nurses who administer medication. On 1/19/18 at 10:15 AM, the Administrator stated an investigation was completed when the medication error was discovered. The software for the eMAR was checked, nothing was found to be wrong, and it was determined to be human error. NP #2 and the resident's physician were counseled on the error. 10NYCRR 415.12(m)(2)

Based on observation, interview, and record review conducted during the recertification survey, it was determined the facility did not ensure snacks were routinely provided between supper and bedtime related to time lapse between meals for 5 of 21 sampled residents (Residents #8, 9, 10, 20, and 21) and for 6 anonymous residents in attendance at the resident group meeting. Specifically, the meal times exceeded 14 hours between a substantial evening meal and breakfast the following day, and nourishing snacks were not consistently provided as required. Findings include: The facility's 5/2011 Snack Pass policy documented a nourishing snack pass is provided to each unit by dietary for bedtime snacks. A nourishing snack is an offering of items from 2 of the basic food groups (single or in combination). This nourishing snack will be verbally offered to all residents at bedtime. Once the bedtime snacks have been offered to all residents, the licensed nurse will initial the snack tray book under offered, under the appropriate date. This one initial will represent completion of the entire snack pass. The evening snack pass record did not document residents were offered evening snack passes: - for Unit 1 on 7/4, 7/9, 7/12, 7/23, 7/24, and 7/28/2016; and - for Unit 2 on 7/9, 7/16 - 7/18, 7/22, 7/28, 7/29, and 7/31/2016. The evening snack pass record did not document residents were offered evening snack passes: - for Unit 1 on 8/13, 8/14, 8/18, and 8/22/2016; and - for Unit 2 on 8/2, 8/6, 8/7, 8/11, 8/15, and 8/29/2016. The evening snack pass record did not document residents were offered evening snack passes: - for Unit 1 on 9/6, 9/12 - 9/14, 9/16, and 9/18/2016; and - for Unit 2 on 9/3, 9/4, 9/6 - 9/18, and 9/20/2016. The resident meal times provided by the facility on 9/20/2016 documented supper started at 5:00 PM for the (tray) line, 5:30 PM for dining rooms, and breakfast started at 8:00 AM. During the resident group meeting on 9/20/2016 at 3:30 PM, 6 anonymous residents stated they were not offered a bedtime/evening snack. During a follow-up interview with certified nurse aide (CNA) #11 on 9/21/2016 at 3:55 PM, she stated if a resident did not have planned evening drinks or snack, she would not provide them. She stated if the resident wanted something/asked for something, she would provide it. She stated Resident #10 did not have a planned evening snack/drink. During an interview with CNA #1 on 9/22/2016 at 4:00 PM, she stated Residents #9 and 21 did not receive scheduled HS (bedtime) snacks. Resident #21 would sometimes request a snack, and she did not always document if a snack was offered to her. She would provide Resident #9 with a tea if requested, or if her throat was dry she may offer her a water, otherwise she would not provide an HS snack or drink. During an interview with CNA #2 on 9/22/2016 at 4:16 PM, she stated Resident #20 did not receive scheduled HS snacks. She stated she would offer a resident an HS snack or drink if they were on the nourishment list. If they were not on a scheduled nourishment, she would not offer a resident an HS snack or drink. During an interview with licensed practical nurse (LPN) #3 on 9/22/2016 at 4:30 PM, she stated not all residents received scheduled fluids at medication passes. She stated Resident #21 would use the call bell for a drink if she wanted something, and she was not on a scheduled pass. She stated Resident #8 was not on a scheduled snack pass; she offered her cookies as she was familiar with her and she accepted them around 8:00 PM. LPN #3 stated she did not document when she offered this snack. She stated Resident #8 may have had a drink of water with medication pass and she did not document this. LPN #3 stated if a resident was ordered to receive a nourishment, she would provide the nourishment during her medication pass. She stated she would not offer drinks or snacks to residents that did not have ordered nourishments, or did not request them. During an interview with LPN #4 on 9/22/2016 at 4:47 PM, she stated she would not offer a snack or fluid to a resident that did not have an ordered nourishment, outside of the amount of fluid needed to administer medications. She stated she would offer a snack or fluid to a resident if they had an ordered nourishment pass. She stated she did not provide anything to Resident #9 outside of her medications after meal time. In an interview with the Food Service Director on 9/23/2016 at 9:10 AM, she stated dietary was responsible to bring the snack tray to the units at approximately 7:30 PM, and nursing was responsible for passing the snacks. She stated some residents had (pre-printed) snack stickers on specific snacks if they were part of a resident's nourishment plan. During interviews with registered dietitian (RD) #6 on 9/23/2016 at 9:30 AM and 9:40 AM, she stated all residents should be offered an HS snack, as there was more than 14 hours between their evening meal and breakfast meal. She stated the units were stocked with a variety of snack items that staff were able to offer to residents. She stated CNAs or LPNs could pass or offer snacks. She stated a nurse would sign off this had been done. She stated snacks and fluids were not documented in the individual resident records unless they were ordered nourishments. She stated she had not observed an evening snack pass in a while, and was not aware residents were not being offered snacks. During an interview with registered nurse (RN) Manager #8 on 9/23/2016 at 10:40 AM, she stated it had been recently discussed following a resident council meeting that snacks were not being offered. She stated staff should be offering all residents HS snacks and this was part of the facility's policy. She stated a nurse was to sign off snacks were offered. She stated there was not a way to document if a resident declined or was unavailable to offer a snack. RD #6 stated to a surveyor on 9/23/2016 at 10:30 AM, the resident meal period which exceeded 14 hours between the 5:00 PM Dinner and the 8:00 AM Breakfast was discussed with residents on 5/6/2016. She stated residents were in agreement, and it was not documented in the resident meeting minutes. A nourishment snack list provided by the facility on 9/23/2016 at 12:30 PM by the Administrator documented 27 residents received scheduled HS snacks. The list did not include Residents #8, 9, 10, 20, or 21. 10NYCRR 415.14(f)(1)(2)(3)

Based on record review, interview, and observation conducted during the recertification survey, it was determined for 7 of 24 residents (Residents #8, 9, 10, 15, 20, 21, and 23) reviewed for hydration, the facility did not ensure each resident was provided with sufficient fluid intake to maintain proper hydration and health. Specifically, Resident #10 exhibited signs of dehydration, there was no documentation the resident was encouraged to drink and she did not receive straws for all drinks as planned. Residents #8, 9, 15, 20, 21, and 23 were not meeting their daily hydration needs and changes were not made to ensure each resident received sufficient fluid intake. Findings include: 1) Resident #10 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The 8/30/2016 laboratory results documented the resident's blood urea nitrogen (BUN)/creatinine ratio was elevated at 30.9 (normal 10.0-20.0), possibly a sign of dehydration. The 8/30/2016 physician orders [REDACTED]. An 8/30/2016 at 10:09 PM, a nursing progress note documented the resident drank approximately 180 cc with medication pass. An 8/30/2016 registered dietitian (RD) assessment documented the resident required total assistance with meals. The resident's intake had been poor and staff were having a difficult time getting her to eat and drink. Per family, the resident did best with straws and these were provided to help facilitate fluid intake. The resident liked juices, including apple and cranberry. The resident's assessed fluid needs were 2200 cc - 2300 cc daily. The speech-language pathologist would review. Staff continue to offer and encourage intake as best she would accept. It was recommended staff continue to offer and encourage liquids throughout the day in small amounts. The liquid detail report documented the resident accepted 360 cc on 8/30/2016, and 180 cc on 8/31/2016, during meals. The 8/31/2016 medication administration record (MAR) documented the resident received 60 - 120 cc of fluids during the scheduled TID 180 cc fluid pass. The 9/2/2016 laboratory results documented the resident's BUN/creatinine ratio was higher than previously, at 36.4. A 9/2/2016 at 2:29 AM nursing progress note documented the resident did not accept fluids during the night. A 9/2/2016 at 2:02 PM nursing progress note documented fluid intake remained poor. A 9/4/2016 at 10:20 AM nursing progress note documented fluid intake remained poor. The 9/5/2016 Minimum Data Set (MDS) assessment documented the resident was severely cognitively impaired, and required extensive assistance with eating. The 9/7/2016 laboratory results documented the resident's BUN/creatinine ratio was 26.4. A 9/7/2016 registered nurse hydration assessment documented the resident was consuming 46% of her fluid needs. The resident's mucous membranes were slightly dry, and her skin turgor had some tenting noted (can be indicative of dehydration). The note documented she drank minimally, and they recently started a fluid pass. The resident would continue to be monitored. A 9/7/2016 RD progress note documented the resident was placed on a fluid pass secondary to her laboratory results. The staff continued to encourage fluid intake. The resident was accepting nutritious juice well at meals. The 9/13/2016 comprehensive care plan (CCP) documented the resident was at risk for UTIs and dehydration. The resident required assistance with decision making, preferred straws with liquids, and staff were to encourage/assist with fluids. The CCP documented conflicting information on the resident's level of assistance at meals including, generally needs to be fed, set-up assist and encouragement as needed for meals, and required total assist with meals. The MAR documented the resident accepted 60-120 cc of fluids during the TID 180 cc fluid pass from 9/1-9/20/2016. The resident accepted 180 cc of fluid 1 time during this time period. The liquid detail report documented the resident consumed between 45-450 cc during meals, and 750 cc 1 time between 9/1/2016 - 9/20/2016. The liquid detail report included a section to document fluids that were provided outside of meal times. The resident did not consume additional fluids from 9/2 - 9/5/2016 or 9/7/2016. The resident consumed between 25-175 cc on various days and shifts the remainder of 9/2016. The 9/21/2016 certified nurse aide (CNA) care guide (care instructions) documented the resident preferred straws, and needed to be fed/encouraged to eat. The resident was observed on 9/20/2016 at 5:46 PM, 5:52 PM, and 6:10 PM lying in bed with her meal tray on the bed side table in front of her, not eating or drinking. The resident's tray contained an 8 ounce chocolate milk, 6 ounces of water, cranberry juice, and apple juice, 6 ounces of coffee, and a bowl of soup. Only 1 of the 4 cold liquids contained a straw. At 6:28 PM, a CNA offered the resident her sub sandwich and said she would move the tray closer to the resident and left the room. At 6:30 PM, the resident was in her room, holding her silverware, not eating or drinking. At 6:40 PM, the resident's tray was removed and the resident had not eaten her sandwich or had any of her fluids. The resident was observed on 9/21/2016 at 9:00 AM seated in the unit lounge dining area. The resident had her meal tray in front of her, was not eating, and staff were not present. The resident had 6 ounces of tomato juice, 8 full ounces of milk, fiber juice, water, and coffee, and . At 9:10 AM, the staff left the lounge and the resident remained seated alone at the table not eating or drinking. At 9:25 AM, a CNA removed the resident's tray and left the resident with tomato juice, water, and fiber juice. During an interview with CNA #11 on 9/21/2016 at 3:55 PM, she stated the resident was sometimes able to eat a sandwich by herself and staff always needed to be with her to assist at meals. She stated if the resident was not eating, staff was to assist her. CNA #11 stated the resident liked her chocolate milk and occasionally drank her juice. She stated she had delivered the resident's meal tray on the evening of 9/20/2016 and had set the resident up. It depended on the day if the resident would use a straw. She stated left the area to assist in the dining room, and other staff were to check on the resident. CNA #11 stated the resident did not have planned evening drinks or snacks, and she would not provide the resident with an evening drink or snack unless it was scheduled. She stated if the resident wanted something/asked for something, she would provide it to her. During an interview with RD #6 on 9/23/2016 at 9:49 AM, she stated the resident was new to the facility and took several days to adjust to the new environment. She stated the resident required assistance and constant cueing at meals. She stated a staff person should have been seated by the resident to offer cueing and assistance throughout the entire meal. She stated the resident would not initiate eating without staff assistance. RD #6 stated the resident was provided with additional 180 cc on admission during medication pass. She stated she was not aware the resident was not consuming the full 180 cc at medication pass. 2) Resident #15 had [DIAGNOSES REDACTED]. The 5/16/2016 hydration rounds document recorded the resident consumed on average 59% of her estimated fluid needs and was not ordered for daily fluid passes. The 7/21/2016 nursing progress note recorded the resident would take 240 cubic centimeters (cc) of fluids for snack/medication pass. The 7/27/2016 Minimum Data Set (MDS) assessment recorded the resident had severely impaired cognition. She was rarely/never able to understand others or make herself understood, and had total dependence on staff for eating and drinking. The 7/27/2016 Quarterly Nutrition Review recorded the resident was fed by staff for all of her meals and fluids and her total daily fluid intake with meals was 720 cc. The resident's assessed fluid needs were 2200 - 2300 cc per day. The resident accepted 87% of nutritious juice at breakfast, and 61% and 98% of shakes provided at lunch and supper respectively. The 7/2016 liquid detail summary recorded the resident consumed 75-100% of nutritious juice 21 of 31 meals, and 75-100% of the shake at 39 of 62 meals. There was no documentation the resident was provided the shake at 13 of 62 meals as scheduled. A physician progress notes [REDACTED]. The 8/8/2016 hydration rounds document recorded the resident consumed on average 50% of her estimated fluid needs and was not ordered to receive daily fluid passes. The 8/10/2016 updated comprehensive care plan (CCP) recorded the resident had impaired ability to understand others and made herself understood and required assistance with activities of daily living (ADLs). It recorded the resident often sat with her eyes closed and required physical assistance at meals, as she no longer attempted to feed herself. The CCP recorded the resident had a history of [REDACTED]. A hydration evaluation was requested on 8/10/2016. The 8/10/2016 hydration evaluation recorded the resident met 50% of her hydration needs. The resident's mucous membranes were slightly dry and skin turgor was sluggish. The 8/23/2016 diet technician progress note recorded the resident was not opening her mouth and could be very difficult to feed at times. The resident received supplemental juice at breakfast, and shakes with lunch and supper, which were all generally well accepted. The 8/2016 liquid intake summary documented the resident consumed 75-100% of the nutritious juice on 24 of 31 meals and 0-50% on 5 out of 31 meals; the resident consumed 75-100% of her shake on 37 out of 62 meals and there was no documentation she received the shake for 7 of the 62 scheduled meals. The 9/2/2016 diet technician progress note recorded the resident had increased constipation, required an enema, and fluid intake at meals continued to decline. The 9/8/2016 registered dietitian (RD) progress note recorded the resident received nutritious juice with good overall acceptance and showed improvement. The 9/19/2016 nutrition report of residents who needed encouragement documented the resident had decreased intake, needed extra calories, needed to be encouraged to drink fluids, and her weight was trending down. On 9/22/2016 at 1:02 PM, the resident was observed sitting in the main dining room with her eyes closed as a certified nurse aide (CNA) fed her lunch. The resident consumed 50% of the solids and 360 cc (50%) of the fluids from the tray. On 9/23/2016 at 11:30 AM during interview, registered nurse (RN) Manager #8 stated the fluid pass schedule included the type and volume of fluid that was offered and was documented on the medication administration record (MAR). A licensed practical nurse (LPN) usually provided the fluids for fluid pass and documented consumption. A nurse or nutrition professional would recommend a resident for fluid pass during a hydration meeting and a physician or nurse practitioner (NP) would sign an order to initiate. Residents who were not ordered for the fluid pass would still be offered drinks by CNAs, and this fluid consumption would not be tracked unless they were on intake and output (I&Os) monitoring. RN Manager #8 stated residents on comfort care measures would not be precluded from receiving additional fluids throughout the day unless it agitated them. She stated she wouldn't advocate for the resident being placed on fluid pass as she was not alert, may have received fluids in between meals, and this was not always documented. On 9/23/2016 at 11:40 AM during an interview with CNA #9, she stated her shift was 7 AM - 3 PM and she often fed the resident lunch. She said the resident used to eat very well, and had declined. The resident would accept foods she liked, especially desserts. She stated the resident opened her eyes once in a while during meals, and most of the time ate with her eyes closed or only slightly open. The CNA stated the resident did well consuming fluids even if she did not eat much, and if the resident was asleep, she would not feed her. The CNA stated she provided water to the resident before mouth care and the resident would drink some of that water, but not all. On 9/23/2016 at 11:55 AM during interview with diet technician #10, she stated during weekly hydration meetings, the RD or diet technician would request fluid pass for a resident if they felt they needed additional fluids. This would include decreased daily/average fluid intake or elevated lab work. The diet technician stated the resident used to eat and drink very well, but had a marked decline in intake. She said the CNAs did well trying to encourage fluids for the resident and the resident's eyes were closed most of the time. The diet technician did not know why the resident was not on a fluid pass. On 9/23/2016 at 12:05 PM during an interview, RD #6 stated fluid pass would be used for residents who were dehydrated, not drinking enough, or had elevated lab work indicating dehydration. The RD stated there were weekly hydration meetings to discuss weights, trends, fluid consumption, or other concerns the team (RD, LPN/RN, NP) may have. She stated there were quarterly hydration evaluations for each resident, and residents who had decreased intake of meals were referred to the occupational therapist (OT) or speech-language pathologist (SLP) to be monitored at meals to determine if a full assessment was warranted. The RD said residents who should be encouraged with extra fluids were added to a list, with items to encourage. The RD stated the resident was on this list and discussed with staff the need to encourage her with meals/fluids. The RD also stated the resident was on the fluid pass schedule up until 11/2015, at which time she was removed. She did not remember why the resident was taken off the fluid pass schedule, and stated that the resident had been declining for some time. There was no evidence the resident was monitored during a meal or assessed by an OT or SLP from 1/2016 through 9/23/2016. 3) Resident #20 had [DIAGNOSES REDACTED]. A 5/9/2016 registered dietitian (RD) progress note documented the resident's fluid intake was good and to continue her nutritional plan. The 5/25/2016 Minimum Data Set (MDS) assessment documented the resident was severely cognitively impaired. She required extensive assistance for eating, and was at risk for skin breakdown. A 5/26/2016 RD nutritional assessment documented the resident's estimated fluid needs were 2100 - 2200 cubic centimeters (cc), her fluid intake was 765 cc, she did not have routine laboratory work completed, and her fluid plan was to monitor. The assessment documented the resident was a hydration risk related to her history. The resident did best with straws in a lid, she was overwhelmed by portion size, and she was at risk for decline in intake as her dementia progressed. A 5/27/2016 at 3:04 PM nursing progress note documented the resident no longer participated in the feeding process and was discontinued from restorative nursing for feeding. A 6/6/2016 hydration rounds sheet documented the resident was not on a fluid pass, and had a goal to consume 2100 - 2200 cc. She consumed a total of 960 cc that date, and consumed 46% of her fluids at lunch. A 6/7/2016 at 2:34 PM hydration assessment, completed by a registered nurse (RN), documented the resident was found to be meeting her fluids at only 46% that review. The resident's mucous membranes were slightly pale and she had dry skin turgor that responded a little slow. The resident was at the facility for comfort care and staff would make reasonable attempts to offer fluids by mouth. The 6/8/2016 comprehensive care plan (CCP) documented the resident was at risk for urinary tract infections, had a history of [REDACTED]. The resident was to be fed by staff at meals, and provided with cups with lids and straws for cold beverages. She was unable to follow verbal cues. She enjoyed sweets, juices, chocolate milks, and diluted cranberry juice. A 6/20/2016 RD progress note documented fluid intake continued to be small and per her usual. The resident was provided with shakes at meals, accepted between 75 - 100%, and to continue her current plan. A 6/21/2016 attending physician progress notes [REDACTED]. The note documented this was expected with her dementia, she had directives not to implement intravenous fluids, and he would not make any further intervention. A 6/27/2016 RD progress note documented the resident's fluid intake showed improvement and to continue with current plan. The 6/2016 liquid detail summary documented the resident was offered between 1020 - 1680 cc at meals, and was consuming between 240 - 900 cc. The summary did not document fluid intake for all meals, including on 6/8, 6/10, 6/14, 6/15, 6/16, 6/19, 6/22, 6/27, and 6/29/2016. Nursing progress notes documented the resident was being monitored for cold symptoms between 7/11/2016 - 7/22/2016. A 7/15/2016 diet technician progress note documented the resident's fluid intake was down, and her needs were assessed at 2100 - 2200 cc. The resident was provided with a 4 ounce shake at breakfast, and a 6 ounce shake at lunch and supper. The 7/2016 liquid detail summary documented the resident was offered between 1020 - 1740 cc at meals, and was consuming between 360 - 870 cc. The liquid detail summary did not document fluid for all meals including on 7/3, 7/6, 7/7, 7/13, 7/14, 7/16, 7/17, and 7/28/2016. An 8/16/2016 attending physician progress notes [REDACTED]. An 8/18/2016 at 10:19 AM nursing progress note documented the resident would drink approximately 60 cc with medications and 120 cc with snack pass. An 8/20/2016 at 3:55 PM nursing progress note documented the resident received 120 cc of fluid at medication and nourishment pass. An 8/24/2016 diet technician assessment documented the resident was eating in the dining room with staff, was provided with a 4 ounce shake at breakfast, lunch, and supper and consumed 42%, 96%, and 71%. Her fluid intake was about 620 cc at meals alone. The resident had a history of [REDACTED]. The 8/2016 liquid detail summary documented the resident was offered between 1020 - 1560 cc at meals, and was consuming between 195 - 1050 cc. An undated hydration rounds sheet documented the care plan was updated on 9/7/2016. The resident was not on a fluid pass, had a goal to consume 2100 - 2200 cc of fluid, and was consuming 950 cc. The resident consumed 45% of her fluids at lunch. A 9/8/2016 RD progress note documented the resident was consuming 45% of her fluids, her fluids continued to be a chronic issue, and no further evaluation regarding hydration for the resident was completed. The 9/1/2016 - 9/19/2016 liquid detail summary documented the resident was offered between 660 - 1560 cc at meals, and was consuming between 225-720 cc. The resident was observed on 9/20/2016 at 12:45 PM, seated at the dining table. The resident had a 4 ounce chocolate shake and a 4 ounce water. A hot beverage cup was empty and overturned at the table. At 11:57 PM, the resident was sitting with her fluids and her entree not eating, and staff were not present. On 9/22/2016 at 12:19 PM, the resident was seated at the dining table without staff present. The resident remained seated, not drinking, without staff present through 12:42 PM. The resident was served her dinner meal at 12:42 PM, and staff sat to assist the resident. The certified nurse aide (CNA) assisted the resident with her meal through 1:15 PM. The resident had consumed all of her chocolate shake. The resident's water was untouched, and the resident had not been served or offered a hot beverage. The CNA put a straw in the water at 1:20 PM. She offered the resident water, the resident accepted and drank several sips. The CNA removed the straw, allowed the resident to swallow, and set the water aside. The CNA asked, Are you done? The resident made no verbal or non-verbal response to the CNA. The CNA removed the resident's clothing protector, and removed the resident from the dining room. The CNA did not attempt to offer the water or additional beverages to the resident. During an interview with CNA #2 on 9/22/2016 at 4:16 PM, she stated the resident required total assistance with all ADLs including eating. She stated the resident's intake/consumption varied and the resident would sometimes hold a glass if it was handed to her. She stated the resident would consume her chocolate milkshake. She stated every now and then, the resident would consume a hot chocolate at her meal. She stated if the resident was provided a 4 ounce juice, she would drink half of it. She stated the resident would tighten her lips or turn her head if she did not want anything more. CNA #2 stated the resident did not have ordered nourishments outside of meal times. She stated she did not offer or provide the resident fluids at night. She stated the resident sometimes had fluids with her medication passes and she was not sure how much. CNA #2 stated if a resident required more fluids they would come up on a daily report, and she would not document fluids if a resident was not on a scheduled plan for fluids. She stated the resident was not on a scheduled plan. During an interview with licensed practical nurse (LPN) #3 on 9/22/2016 at 4:30 PM, she stated the resident required total assistance from staff at meals. She stated the resident would drink all of her milkshake and some of her juice. She stated the resident did not receive fluids at medication pass. During an interview with RD #6 on 9/23/2016 at 9:40 AM, she stated the resident had a decline in condition over time. She stated the resident had scheduled milkshakes and did well with them. She stated if a resident had a nourishment, it would be documented in the computer system and they would have an ordered fluid pass. She stated everyone should be offered an HS (bedtime) snack/drink. She stated there were no planned nourishments for the resident. She stated if a resident was not on a planned nourishment/supplements, staff did not have to document fluids offered to the residents throughout the day. She stated she would not know if a resident declined or was offered fluids by staff. During an interview with CNA #7 on 9/23/2016 at 10:30 AM, she stated the resident required total feeding by staff and the resident took a lot of encouragement to eat and drink. She stated the resident would shake her head no if she was done or did not want an item. She stated she did not document if fluids were offered to a resident unless they were on an intake/output documentation schedule. She stated this resident was not on a schedule. During an interview with registered nurse (RN) Manager #8 on 9/23/2016 at 10:40 AM, she stated the resident should have been offered more fluids at her meal. She stated staff should always offer fluids and wait for a response from the resident. She stated if a snack or fluid was offered that was not an ordered nourishment, this was not documented by staff. 10NYCRR415.12(j)

Based on record review, observation, and interview conducted during the recertification survey, it was determined for 3 of 21 residents (Residents #8, 10 and 21) reviewed for activities of daily living (ADLs), the facility did not provide the necessary services to maintain good nutrition and personal toileting needs. Specifically, Resident #10 was not assisted at meals as planned, and Residents #8 and 21 were not toileted as planned. Findings include: 1) Resident #10 was admitted on [DATE] and had [DIAGNOSES REDACTED]. An 8/29/2016 nursing progress note documented the resident would not initiate picking up her utensils at the dinner meal and was fed by staff. An 8/30/2016 registered dietitian (RD) progress note documented the resident required total assistance with meals by staff. The 9/5/2016 Minimum Data Set (MDS) assessment documented the resident was severely cognitively impaired, and required extensive assistance from staff with eating. The 9/13/2016 comprehensive care plan (CCP) documented the resident was at risk for weight loss related to suboptimal intake and decline in cognition. The CCP documented conflicting information on the resident's level of assistance at meals including, generally needs to be fed, set-up assist and encouragement as needed for meals, and required total assist with meals. The 9/20/2016 certified nurse aide (CNA) care instructions documented the resident needed to be fed/encouraged to eat. The diet detail history recorded the resident consumed 25% of her meals at breakfast, lunch, and dinner on 9/20/2016. The resident was observed on 9/20/2016 at 5:46 PM, 5:52 PM and 6:10 PM lying in bed with her meal tray on the bed side table in front of her, not eating or drinking. At 6:28 PM, a CNA offered the resident her sub and said she would move the tray closer to the resident. The CNA left the room. At 6:30 PM, the resident was in her room, holding her silverware, not eating or drinking. At 6:40 PM, the resident's tray was removed and the resident had not eaten her sandwich or consumed her fluids. The resident was observed on 9/21/2016 at 9:00 AM seated in the unit lounge dining area. The resident had her meal tray in front of her, was not eating, and staff were not present. At 9:10 AM, the staff left the lounge and the resident remained seated alone at the table, not eating or drinking. At 9:25 AM, a CNA removed the resident's tray and left the resident with 3 drinks she had not consumed. During an interview with CNA #11 on 9/21/2016 at 3:55 PM, she stated the resident was sometimes able to eat a sandwich by herself and staff always needed to be with her to assist at meals. She stated if the resident was not eating, then staff was to assist her. She stated she had delivered the resident's meal tray on the evening of 9/20/2016, and had set the resident up and left the area to assist in the dining room. She stated other staff were to check on the resident. During an interview with RD #6 on 9/23/2016 at 9:49 AM, she stated the resident was new to the facility and took several days to adjust to the new environment. She stated the resident required assistance and constant cueing at meals. She stated a staff person should have been seated by the resident to offer cueing and assistance throughout the entire meal. She stated the resident would not initiate eating without staff assistance. 2) Resident #8 had [DIAGNOSES REDACTED]. The 6/2016 bladder maintaining/retraining record did not consistently document the resident was toileted every 3 hours as planned on 6/4, 6/6, 6/11, 6/12, 6/14, 6/16, 6/17, 6/18, 6/26, 6/27, and 6/30/2016. The 6/22/2016 Minimum Data Set (MDS) assessment documented the resident was severely cognitively impaired. She required extensive assistance of two staff for toileting assistance, was frequently incontinent of bladder, and was on a current toileting program or trial. The 7/6/2016 comprehensive care plan (CCP) documented the resident had a [DIAGNOSES REDACTED]. The CCP documented the resident was frequently incontinent of bladder, required extensive assistance for all aspects of toileting, was on a diuretic, was on a restorative nursing program for toileting, and was scheduled to be toileted every 3 hours. The 7/2016 bladder maintaining/retraining record did not consistently document the resident was toileted every 3 hours as planned on 7/3, 7/8, 7/11, 7/12, 7/16, 7/27, and 7/31/2016. The 8/2016 bladder maintaining/retraining record did not consistently document the resident was toileted every 3 hours as planned on 8/2, 8/3, 8/4, 8/5, 8/7, 8/18, 8/23, 8/25, 8/27, and 8/31/2016. The 9/2016 bladder maintaining/retraining record did not consistently document the resident was toileted every 3 hours as planned on 9/4, 9/8, 9/9, 9/10, 9/11, 9/12, 9/17, and 9/20/2016. There was no documentation in the resident record the resident refused or declined toileting on the above dates. The 9/20/2016 certified nurse aide (CNA) care guide documented the resident was incontinent of bladder, and was on an every 3 hour toileting plan. The resident was observed seated at the dining table in her wheelchair on 9/20/2016 from 1:13 PM - 1:20 PM and from 5:35 PM - 6:23 PM; seated in her wheelchair near the nursing station on 9/21/2016 from 11:47 AM - 11:55 AM, from 1:12 PM - 1:25 PM, and at 2:45 PM laying in bed. During an interview with CNA #7 on 9/23/2016 at 10:30 AM, she stated the resident was dressed at the start of her shift. She stated the resident was able to assist with her upper body and required assistance of staff for all activities of daily living (ADLs) During an interview with registered nurse (RN) Manager #8 on 9/23/2016 at 10:40 AM, she stated the resident was on a restorative program that included toileting. She stated she was to be toileted by CNAs and by staff that worked through the early bird program (a program offered by the facility located in the activities department where the resident attended 7:30 AM - 11:30 AM daily). She stated regardless of where or when the resident was toileted, the bladder training sheet should be completed by any staff toileting the resident every 3 hours. 3) Resident #21 had [DIAGNOSES REDACTED]. The 5/25/2016 comprehensive care plan (CCP) documented the resident the resident was at risk for skin breakdown, was on a diuretic, and at times could tell staff if she needed to use the bathroom. The CCP documented the resident was on a restorative nursing program for activities of daily living (ADLs) including toileting. The resident required assistance for transfers with 2 staff with a mechanical lift; had frequent urinary incontinence; and required assistance with all aspects of toileting including transfers, hygiene, and clothing management. The CCP documented the resident was to be toileted every 3 hours. The 6/2016 bladder maintaining/retraining record did not consistently document the resident was toileted every 3 hours as planned on 6/2, 6/6, 6/10, 6/11, 6/14, 6/15, 6/17, 6/21, 6/23, 6/24, 6/25, 6/27, 6/28, 6/29, and 6/30/2016. The 7/2016 bladder maintaining/retraining record did not consistently document the resident was toileted every 3 hours as planned on 7/3, 7/5, 7/6, 7/9, 7/11, 7/12, 7/16, 7/17, 7/18, 7/23, 7/26, and 7/27/2016. The 8/10/2016 Minimum Data Set (MDS) assessment documented the resident was severely cognitively impaired. She was totally dependent on staff for toilet use, was always incontinent of urine, and a trial toileting program had been attempted. The 8/2016 bladder maintaining/retraining record did not consistently document the resident was toileted every 3 hours as planned on 8/4, 8/5, 8/7, 8/10, 8/12, 8/13, 8/14, 8/18, 8/20, 8/25, 8/26, and 8/27/2016. The 9/2016 bladder maintaining/retraining record did not consistently document the resident was toileted every 3 hours as planned on 9/9, 9/10, 9/12, 9/13, and 9/17/2016. There was no documentation in the resident record the resident refused or declined toileting on the above dates. The 9/20/2016 certified nurse aide (CNA) care guide documented the resident had some incontinence of bladder, required extensive moderate assistance with rolling walker for toilet use, and was on an every 3 hour toileting plan. The resident was observed seated in her wheelchair in the dining room on 9/20/2016 at 12:40 PM and 6:00 PM; on 9/22/2016 at 11:16 AM in her room in her wheelchair sleeping with the television on, and at 12:19 PM and from 12:38 PM - 1:12 PM in the dining room. During interviews on 9/22/2016 with CNA #1 at 4:00 PM, and CNA #3 at 4:30 PM, the CNAs stated the resident required total assistance from staff with care. During an interview with CNA #7 on 9/23/2016 at 10:30 AM, she stated the resident required assistance of 2 staff with a mechanical lift for toileting. The resident was on a toileting schedule and was to be toileted every 2 hours, and they were to sign the toileting documentation located at the nursing station. 10NYCRR415.12(a)(3)

Based on record review, observation, and interview conducted during the recertification survey, it was determined the facility did not ensure residents maintained acceptable parameters of nutritional status for 1 of 4 residents reviewed for weight loss (Resident #10). Specifically, Resident #10 had a significant weight loss on admission; did not receive assistance at meals, snacks, or nutritious juice as planned; and was not referred to speech therapy as recommended. Findings include: Resident #10 was admitted on [DATE] and had [DIAGNOSES REDACTED]. Nursing progress notes documented on 8/29 and 8/30/2016 the resident's appetite was poor and staff fed the resident at meals. An 8/30/2016 registered dietitian (RD) progress note documented the resident required total assistance at meals. Per interview with family members, the resident had some swallowing and chewing concerns just prior to admission. The RD would have speech-language pathology review this. The resident's appetite had been very poor prior to admission. The family had notified the RD the resident enjoyed cookies and sweets. The resident was admitted with a weight of 145 pounds. The RD noted the resident had weighed 159 pounds at the facility she resided at prior to her admission. A nutritious apple-cranberry juice would be added to breakfast and supper. The RD recommended staff continue to offer and encourage liquids and solids frequently throughout the day in small amounts. There was no documentation in the resident's medical record a speech-language pathologist referral or assessment was completed for the resident. The diet detail summary (meal consumption report) dated between 8/30/2016 - 9/5/2016 documented the resident consumed between 0 - 50% at lunch and dinner. The resident consumed breakfast one time during those dates on 9/4/2016 and ate 25% of the meal. There was no documentation on the summary if the resident was offered, declined, or accepted snacks between meal times. The liquid detail report had no documentation the resident consumed her nutritious juice between 8/30/2016 - 9/5/2016. The 9/5/2016 Minimum Data Set (MDS) assessment documented the resident was severely cognitively impaired. She required extensive assistance from staff with eating, and had a unplanned significant weight loss. A 9/7/2016 RD progress note documented the resident continued with nutritious juices to add additional fluid and calories, and intake would be encouraged. The diet detail summary dated between 9/7/2016 - 9/13/2016 documented the resident consumed 0-50% of meals at breakfast, lunch, and dinner, and 75% at 2 meals. There was no documentation on the summary if the resident was offered, declined, or accepted snacks between meal times. The liquid detail report dated between 9/7/2016 - 9/13/2016 did not document the resident consumed her planned 6 ounce nutritious juice planned for the breakfast and supper meals. The 9/13/2016 comprehensive care plan (CCP) documented the resident had a significant weight loss on admission of 9% in 30 days, and was at risk for continued weight loss related to decline in cognition. The resident required total assistance with eating, was to be fed by staff at meals, and was on small portions at lunch and supper. The CCP documented the resident was to be provided with supplements at meals and snacks between meals. A 9/14/2016 RD progress note documented the resident's weight was 133 pounds, a 12 pound loss. Per policy a re-weight would be completed. The RD would add a cookie at supper as the resident enjoyed these. An addendum (not timed) to the note documented a re-weight documented 144 pounds and to continue with the meal plan. The diet detail summary dated between 9/14/2016 - 9/20/2016 documented the resident consumed 0-50% of meals at breakfast, lunch, and dinner, and 100% at 1 meal. There was no documentation on the summary if the resident was offered, declined, or accepted snacks between meal times. The liquid detail report dated between 9/14/2016 - 9/20/2016 did not document the resident consumed her planned 6 ounce nutritious juice planned for the breakfast and supper meals. The 9/21/2016 certified nurse aide (CNA) care instructions documented the resident was on a regular diet, and needed to be fed/encouraged to eat. There was no documentation regarding additional snacks/nourishments. The resident was observed on 9/20/2016 at 5:46 PM, 5:52 PM, and 6:10 PM lying in bed with her meal tray on the overbed table in front of her, not eating or drinking. The resident's tray contained an 8 ounce chocolate milk, 6 ounces of water, nutritious apple-cranberry juice, 6 ounces of coffee, and a bowl of soup. Only 1 of the 4 cold liquids contained a straw. At 6:28 PM, a CNA offered the resident her sub sandwich and said she would move the tray closer to the resident and left the room. At 6:30 PM, the resident was in her room, holding her silverware, not eating or drinking. At 6:40 PM, the resident's tray was removed and the resident had not eaten her sandwich or had any of her fluids. The resident was observed on 9/21/2016 at 9:00 AM, seated in the unit lounge dining area. The resident had her meal tray in front of her, was not eating, and staff were not present. The resident had 6 ounces of tomato juice, 8 ounces of milk, nutritious apple-cranberry juice, water, and coffee. At 9:10 AM, the staff left the lounge and the resident remained seated alone at the table, not eating or drinking. At 9:25 AM, a CNA removed the resident's tray and left the resident with tomato juice, water, and apple-cranberry juice. During an interview with CNA #11 on 9/21/2016 at 3:55 PM, she stated the resident was sometimes able to eat a sandwich by herself, and staff always needed to be with her to assist at meals. She stated if the resident was not eating, staff was to assist her. CNA #11 stated the resident liked her chocolate milk, and occasional drank her juice. She stated she had delivered the resident's meal tray on the evening of 9/20/2016, and had set the resident up. She stated it depended on the day if the resident would use a straw. She stated she left the area to assist in the dining room, and other staff were to check on the resident. CNA #11 stated the resident did not have planned evening drinks or snacks, and she would not provide the resident with an evening drink or snack unless it was scheduled. She stated if the resident wanted something/asked for something she would provide it to her. During an interview with RD #6 on 9/23/2016 at 9:49 AM, she stated the resident was new to the facility and took several days to adjust to the new environment. She stated the resident required assistance and constant cueing at meals. She stated a staff person should have been seated by the resident to offer cueing and assistance throughout the entire meal. She stated the resident would not initiate eating without staff assistance. RD #6 stated staff were to offer frequent snacks throughout the day and there were snacks available on the unit. She stated staff would not document a snack was provided unless it was a physician ordered nourishment. 10NYCRR 415.12(i)(1)

Based on record review, interview, and observation conducted during the standard survey, it was determined that the facility did not ensure the disaster plan included detailed written plans to meet one of 3 potential emergencies and disasters reviewed, loss of power. Specifically, the loss of power plan was incomplete and inaccurate. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: Telephone and Paging Systems 1) The facility power outage plant dated 11/12/2009 documented the systems provided with emergency power from the facility 2 emergency generators. There was no documentation the telephone and paging systems were provided with emergency power. During an interview with the Plant Operations Director on 6/25/2015 at 3 PM, he stated the telephone system was plugged into an emergency power outlet in the boiler room of the new building. Surveyors observed the emergency outlet in the new building boiler room on 6/25/2015 between 3 and 3:30 PM. During an interview with the Administrator on 6/25/2015 at 4:15 PM, he stated if the telephone system had emergency power, it should be documented in the disaster plan. State regulations require that the telephone and paging systems have emergency power. Kitchen Walk In Refrigerators and Freezers 2) The facility power outage plant dated 11/12/2009 documented the systems provided with emergency power from the facility 2 emergency generators. There was no documentation any kitchen refrigeration equipment was provided with emergency power. During an interview with the Plant Operations Director on 6/25/2015 at 3 PM, he stated he believed the walk in refrigerator and freezer had emergency power. 10NYCRR 415.26(f)(1)

Based on interview and record review conducted during the standard survey, it was determined for 3 of 24 sampled residents (Residents #2, 18, and 19), the facility did not ensure all alleged violations involving mistreatment, neglect, or abuse were reported to the New York State Department of Health (NYSDOH) when required. Specifically, Residents #2, 18 and 19 had resident to resident altercations and the incidents were not reported to the NYSDOH. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1) Resident #2 had [DIAGNOSES REDACTED]. The event report dated 3/29/2015 at 4 PM, documented Resident #2 was standing to the left side of Resident #25's chair with her right hand on the arm of the chair and Resident #25 yelled at and slapped Resident #2 three times and the resident was not injured. The event report documented abuse/neglect was not substantiated and the incident was not reported to the NYSDOH. The event report dated 3/29/2015 at 7:30 PM, documented Resident #2 was trying to fix Resident #25's blanket and Resident #25 grabbed and twisted her arm. Resident #2 sustained 2 skin tears that measured 1.0 centimeter (cm) x 1.0 cm and 1.0 cm x 0.5 cm. The residents were separated. The event report documented abuse/neglect was not substantiated and the incident was not reported to the NYSDOH. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident was sometimes understood and sometimes understood others, her cognitive skills for daily decision were severely impaired, she required supervision for ambulation and locomotion, and she wandered daily. During an interview with the Director of Nursing (DON) on 6/26/2015 at 12:47 PM, she stated she looked at each individual case to determine if reportable and had the current reporting guidelines. She stated she was not aware of the requirement to report resident to resident altercations and these incidents were not reported. 2) Resident #18 had [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) updated 6/3/2015, documented the resident had cognitive loss and was at risk for wandering. The Minimum Data Set (MDS) assessment dated [DATE], documented the resident was sometimes able to understand and was sometimes understood. The resident had severe cognitive impairment and required extensive assistance for activities of daily living (ADL). The event report dated 6/21/2015 at 7:30 PM, documented Resident #18 was seated in her wheelchair when Resident #26 wheeled herself up next to her and asked her to move. When Resident #18 did not move, Resident #26 struck her with an open fist on the top of her left hand causing no injury. The event report documented abuse/neglect was not substantiated and the incident was not reported to the NYSDOH. During an interview with the Director of Nursing (DON) on 6/26/2015 at 12:47 PM, she stated she looked at each individual case to determine if reportable and had the current reporting guidelines. She stated she was not aware of the requirement to report resident to resident altercations and these incidents were not reported. 3) Resident #19 had [DIAGNOSES REDACTED]. The 5/28/2015 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, rejected care, and wandered. The comprehensive care plan (CCP) documented on 6/10/2015, the resident could ambulate and wandered in other residents' rooms and near other residents. The 6/12/2015 registered nurse's (RN) progress note documented at 11:10 AM, the resident stood up in the unit lounge and kicked an unidentified resident in her right shin and it was unprovoked. The 6/12/2015 event report documented Resident #19 kicked an unidentified resident in the shin, the incident was unprovoked, and her behavior was unpredictable. The report documented the abuse/neglect was not substantiated. The root cause was documented as a highly demented resident who is mobile kicked another resident completely unprovoked for unknown reason. The report documented the incident was not reported to the NYSDOH. On 6/26/2015 at 12:55 PM, the Director of Nursing (DON) stated in an interview, that she and the Administrator determined what incidents were reported to the NYSDOH and they did not think the incident when the resident kicked the other resident was reportable. 10NYCRR 415.4(b)(1)(ii)

Based on observation, record review, and interview conducted during the standard survey, it was determined the facility did not ensure food was stored and prepared under sanitary conditions in the main kitchen and the activities room. Specifically dishwashing was not done by an approved method (carafes, pitchers, and a sippy cup), an inaccurate thermometer was in the activities room refrigerator, and there were soiled floor surfaces in the main kitchen. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: Dishwashing Not by Approved Method 1) Surveyors observed the coffee carafes in the Units 1 and 2 serving kitchen on 6/24/2015 at 10:30 AM; 2 of the coffee carafes were covered and soiled with coffee colored liquid. On 6/24/2015 at 10:35 AM, the Food Service Director stated the coffee carafes were rinsed daily, and once per week they were washed in the potwash (3 bay) sink in the kitchen. On 6/25/2015 between 9:30 and 10 AM, a surveyor observed 5 coffee carafes in the Units 1 & 2 serving kitchen. Two of the 5 carafes were covered, and contained at least a tablespoon of coffee colored liquid. During an interview with the Food Service Director on 6/25/2015 at 4:30 PM, she stated she was aware that an approved dishwashing process would involve washing dishes either in the dishwasher or handwashing in the 3 bay sink. She stated the coffee carafes in the Units 1 and 2 serving kitchen were washed once a week. Surveyors observed pitchers and a sippy cup on a cart in the corner of the main kitchen dishroom on 6/24/2015 between 10 and 10:30 AM. The Food Service Director, who was present during the observation, asked food service workers working in the dishroom, whether the pitchers and sippy cup were clean. One of the food service workers responded that the pitchers and sippy cup were clean. One of the 2 quart pitchers was half full of water, and the sippy cup was covered and half full of water. The Food Service Director directed staff to rewash the items on the cart. During an interview with the Food Service Director on 6/25/2014 at 4:30 PM, she stated the pitchers/sippy cup were stored in a area which would normally have clean items, and there was a new food service worker, which may have been related to the confusion with the status of the pitchers/sippy cup. The facility policy Manual Dishwashing dated 2000 documented manual dishwashing would be done by a 3 step process (wash, rinse, sanitize). Dishes needed to soak in the sanitizer solution for 30 seconds for non-chlorine sanitizer solutions then air dry. State regulations require the sanitizer step of the manual dishwashing process to include a one minute soak in the sanitizer solution for a sanitizer other than chlorine or iodine. The facility was using a quaternary ammonium compound sanitizer solution. Inaccurate Thermometer 2) Surveyors observed the thermometer in the activities room refrigerator was a liquid filled thermometer with the red liquid separated by air bubbles on 6/24/105 at 3:55 PM and 6/25/2015 at 3 PM and 4 PM. The refrigerator contained 3 or 4 half pint containers of milk and yogurt during each observation. During an interview with the Activities Director on 6/25/2015 at 4:05 PM, she stated activities staff did not check the refrigerator temperature, she believed housekeeping staff checked the refrigerator temperature, and she was not aware the thermometer was in poor condition. Soiled Floor Areas 3) Surveyors observed the floor in the main kitchen on 6/24/2015 between 10 and 10:30 AM. The floor was soiled with dirt and debris (cups and a plastic bin) under the ice machine, and was soiled with debris under the shelves in the dry storage room. 10NYCRR 415.14(h), 14-1.85, 14-1.110

Based on record review, observation, and interviews conducted during the standard survey, it was determined for 3 of 24 sampled residents (Residents #10, 22 and 23), and 4 additional residents (Residents #25, 26, 27, and 28) the facility did not promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity and respect as an individual. Specifically, Resident #22 was not spoken to in a respectful manner in an area where others could easily overhear a private conversation. Residents #10, 22, 23, 25, 26, 27 and 28 were not provided a dignified dining experience during two evening meal observations. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: 1) Resident #22 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was mildly cognitively impaired; felt down/depressed; required extensive assistance with activities of daily living; and limited assistance for eating. A diet technician's progress note dated 5/27/2014 at 9:01 AM, documented the resident had two hot beverage spills "yesterday", one was the resident's soup and the other was coffee. These beverages were not hot at the time, but she was sleepy at meals and did not manage her drinks well. The diet technician documented the resulting plan was to provide the resident with a protective apron for safety. The comprehensive care plan (CCP) dated 5/27/2014 documented the resident requested soup at lunch and supper. There were beverage spills on 5/27/2014, a protective apron was provided, and soup was to be served in a mug. On 7/10/2014 at 1:05 PM, the resident was observed in the unit dining area seated at the table with 6 other residents. The resident was heard asking the two certified nurses aides (CNA) assisting the residents, if they would warm up her soup. They told her they could not heat it up after it came from the kitchen. The resident continued to ask to have the soup warmed up, and CNA #1 continued to repeat to the resident, they could not because she may fall asleep. The resident said she could not eat it cold and would really like it warmed up. CNA #1 stated she would get into trouble if she reheated it. The resident said she was the problem because she can not help falling asleep so she "knows it's my fault." The resident said she just wanted to eat warm soup. On 7/11/2014 at 5:55 PM, the CNA #2 was observed warming up an item for a resident. When interviewed by the surveyor, she stated she was warming up Resident #22's soup per her request. During an interview on 7/14/2014 at 10:50 AM, with CNA #1 she said she remained on the unit during the resident's lunch to assist residents who did not eat in the main dining room. She said Resident #22 was not one of her regular assignments. CNA #1 said the resident told her she often fell asleep while eating. CNA #1 said she never asked why the resident ate on the unit. The CNA said she was told they could not reheat her food/soup as she had trouble spilling the soup, and now she had a blue (protective) apron. She did not think it was written on the CNA care instructions or anywhere in writing. CNA #3 joined the interview and said because the resident was wearing a blue apron they could not reheat food. She stated it was not written anywhere but it was what they were told. CNA #1 said she tried in the past to pull the resident aside to inform her privately, but Resident #22 did not want to leave the table. During an interview with the registered dietitian (RD) on 7/14/2014 at 11:30 AM, she stated if the resident asked the staff to reheat the soup, she thought the CNAs could reheat it and she was not aware of a plan that prevented them from doing so. 2) During observations of the evening meal in the Unit 2 dining room/lounge, on 7/10/2014 between 5:50 PM and 6:05 PM, 6 residents including Residents #10, 22, 23, 25 and 26 were seated at the long rectangular table. A licensed practical nurse (LPN) and a certified nurse aide (CNA) were at the table assisting the residents: - Resident #23 had no meal in front of her while the other residents were eating. The LPN stated the resident did not usually eat on the unit and they were waiting for her tray to come from the kitchen. - At 5:55 PM, Resident #25 and Resident #26 were seated at opposite ends of the table. The LPN stood between the residents and walked back and forth assisting one and then the other. - The CNA was assisting Resident #10 and left to answer a callbell. At that time, the LPN left Resident #26 and walked around the table to assist Resident #10. - As of 6:05 PM, Resident #23 remained at the table with no food in front of her. During an interview with the LPN assisting in the unit dining room, on 7/10/2014 between 5:50 PM - 6:05 PM, she stated the normal staffing to assist in the unit dining room was 1 LPN and 1 CNA. She said how many residents ate on the unit varied depending on the residents' needs or wishes at the time. She stated usually there were 4 to 5 residents eating on the unit. Observations of the evening meal on 7/11/2014 showed the food cart arrived on the unit at 5:20 PM, for the residents who ate on the unit. Between 5:35 PM and 6:00 PM, 7 residents were in the Unit 2 dining room/lounge being assisted by 1 LPN and 1 CNA: - at 5:37 PM, the CNA started setting up the first tray at the table; - the LPN provided Resident #25 with her medications before her tray was placed in front of her; - Resident #10 had her tray placed in front of her and the cover removed at 5:40 PM; - the LPN repositioned Resident #23's chair; - the LPN left Resident #23, walked to the other side of the table and gave a spoonful of soup to Resident #10 as she stood next to her: - the LPN returned to Resident #23 provided her with a straw and stood next to her as she gave her a sip of water, and a forkful of food; - the LPN left Resident #23 and gave a spoonful of food to Resident #25; - the LPN left Resident #25 and gave a forkful of food to Resident #10 and returned to the other side of the table as Resident #25 started to feed herself; - at 5:53 PM, the CNA sat down next to Resident #10 and assisted the her with her meal; - the LPN the assisted Resident #25; - the CNA left the table to use the microwave (warmed up Resident #22's soup) and returned to assist Resident #10; - the LPN left the table to turn up the volume on the television located at the other end of the lounge; - the LPN returned to the table to assist Resident #28; - the CNA left Resident #10 to assist Resident #27 with his cookies and returned to Resident #10; - the CNA left Resident #10 to make a peanut butter and jelly sandwich for Resident #22; and - at 5:59 PM (40 minutes after the tray arrived on the unit), the CNA returned to Resident #10, looked at her and said "sorry" and began assisting her again with her meal. 10NYCRR 415.5(a)

Based on observation, record review, and interview conducted during the standard survey, it was determined for 2 of 24 residents (Residents #15 and 16), the facility did not ensure services provided met professional standards of quality. Specifically for Resident #16, the physician was not notified in a timely manner of laboratory results that were positive for infectious organisms, and these results were not communicated between shifts to the nursing or administrative staff. For Resident #15, there was not a consistent or defined way to check the placement of the percutaneous endoscopic gastrostomy (PEG) tube (a feeding tube). This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY OF 7/29/2013. Findings include: 1) Resident #16 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated 6/26/14, documented the resident had moderately impaired cognition, required extensive assistance with all activities of daily living (ADL), with the exception of eating, and had an indwelling catheter (urinary drainage tube). The urology consult, dated 6/30/14, documented the resident had a [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The urology consult note, dated 7/3/14, documented the urine culture from 6/30/14 was positive for [MEDICATION NAME] resistant [MEDICATION NAME] (VRE, an infectious organism) and [MEDICAL CONDITION] (MRSA, an infectious organism). the consult documented the infectious organisms were sensitive to [MEDICATION NAME] (an antibiotic), and recommended the resident be treated with [MEDICATION NAME] 100 milligrams (mg) twice a day for 7 days. The nursing progress note, dated 7/3/14 at 11:11 PM, documented the resident returned from the urology appointment and the nursing supervisor and physician were aware. The note did not document the information given to the nursing supervisor or the physician, and no new orders were documented. The nursing progress note, dated 7/4/14 at 10:03 PM, documented the resident was found urinating in the sink in his shared room earlier in the shift. The nursing progress note, dated 7/7/14 at 12:20 PM, documented a urine specimen was obtained, from the resident, and sent to the lab for urine analysis, and culture/sensitivity due to blood/leukocytes (white blood cells) in the urine. The social work progress note, dated 7/7/14 at 2:43 PM, documented a room change was planned for the resident on the next day for infection control purposes. The current comprehensive care plan (CCP), dated 7/9/14, documented the resident had a history of [REDACTED]. Interventions included assessing for signs and symptoms of UTI, a toileting schedule, and a urology follow up as scheduled. The CCP did not document the resident was on contact precautions and his urine tested positive [MEDICAL CONDITION]. The nursing progress note, dated 7/9/14 at 12:35 PM, documented the resident's urine tested positive [MEDICAL CONDITION]. The nursing progress note, dated 7/9/14 at 2:43 PM, documented a new physician order [REDACTED]. The nursing progress note, dated 7/9/14 at 10:30 PM, documented the resident was on contact precautions [MEDICAL CONDITION] and VRE in the urine. During an interview, on 7/10/14 at 10 AM, the registered nurse (RN) Unit Manager stated the resident was taking [MEDICATION NAME] for a UTI, [MEDICAL CONDITION] in his urine and a history of VRE in the urine, he was on contact precautions [MEDICAL CONDITION] and wore a brief. During an interview, on 7/14/14 at 9:50 AM, the RN Unit Manager stated - she did not know the resident [MEDICAL CONDITION] until 7/9/14 and the resident was placed on contact precautions and started on [MEDICATION NAME]. - she was aware the urologist recommended [MEDICATION NAME] on 7/3/14 - the 3 -11 PM shift RN Supervisor called the physician with the urology consult report. - the on call physician did not want to start the resident on [MEDICATION NAME]. - she stated she had not seen the urology consult notes until 7/8/14 when the attending physician came in and signed the consult and told her to wait for the urine culture results for the urine sent on 7/7/14. - She stated she did not think precautions were needed prior to 7/9/14. - she stated they did not have a 24 hour report sheet, the supervisors gave a verbal shift to shift report. During an telephone interview, on 7/14/14 at 10:20 AM, the licensed practical nurse (LPN), who worked the 3-11 shift on 7/3/14, stated when the resident returned from the urology appointment she looked over the report and gave it to the RN Supervisor. She stated the RN Supervisor called the on call physician and he did not want the resident started on [MEDICATION NAME]. She stated she did not know why [MEDICATION NAME] was recommended or why the physician did not order it. During a phone interview, on 7/14/14 at 12:10 PM, with the on call physician for 7/3/14, he stated he was notified on 7/3/14 that the resident saw a urologist. The resident's indwelling catheter was discontinued, there was some blood in the resident's urine, and the urologist recommended [MEDICATION NAME]. He stated he knew the resident had a history of [REDACTED]. The On call physician stated he did not know urine culture was done on 6/30/14, and was not told the urine tested positive [MEDICAL CONDITION], and was sensitive to [MEDICATION NAME]. He stated he may have done something different if he had had all of the information. The 3 - 11 PM shift RN Supervisor, on duty on 7/3/14, was not available for interview. Phone messages were left at 10:30 AM and 3:30 PM on 7/14/14, and were not returned. The facility's policy for transmission-based precautions, dated 1/5/2010, documented contact precautions are implemented for urinary tract infections positive [MEDICAL CONDITION] ([MEDICAL CONDITION] resistant staphylococcus aureas) and VRE ([MEDICATION NAME] resistant [MEDICATION NAME]). 2) Resident #15 had [DIAGNOSES REDACTED]. The Minimum Data Set assessment (MDS), dated [DATE], documented the resident was severely cognitively impaired; required extensive assistance to total assistance for all activities of daily living (ADL); and had a feeding tube. The comprehensive care plan (CCP), dated 7/9/2014, documented the resident had a feeding tube. The physician's orders [REDACTED]. flush every 6 hours. The Medication Administration Record [REDACTED]. During a medication observation, on 7/11/14 at 9:10 AM, licensed practical nurse (LPN) #1 disconnected the resident's tube feeding, she filled the irrigation syringe with 10 cc of air, pushed the air through the PE[DEVICE], pulled back the irrigation plunger and did not see any residual. She then filled the syringe with 40 cc of air, pushed the air through the PE[DEVICE] and pulled the plunger back, no residual was observed. She filled the syringe with more air, and pushed the air through the PE[DEVICE] and pulled the plunger back, no residual was noted. The LPN did not listen with a stethoscope while pushing the air into the resident's stomach via the PE[DEVICE]. She then capped the feeding tube, mixed water with the medication she had earlier crushed, put the syringe (without the plunger) into the tip of the PE[DEVICE] and poured 50 cc of water, the medication, and 50 cc of water flush into the syringe. After the syringe contents flowed into the PE[DEVICE] LPN #1 reconnected the resident's feeding. During an interview, on 7/11/14 at 3 PM, LPN #1 stated checking for PE[DEVICE] placement was done by pushing approximately 40 cc of air through the syringe, then pulling back on the syringe to check for residual stomach content. During an observation, on 7/11/14 at 4:20 PM, LPN #2 was observed administering the resident's routine PE[DEVICE] flush, and was accompanied by LPN #3. LPN #2 disconnected the tube feeding, put the syringe in the PE[DEVICE] and pulled back, he then filled the syringe with 10 cc of air, place the stethoscope on the left upper quadrant of the resident's abdomen, and pushed the air in. LPN #2 removed the syringe, took the plunger out and flushed the PE[DEVICE] with 100 cc of water via gravity, and reconnected the tube feeding after the flush. LPN #2 was interviewed following the observation and stated he checked for residual by pulling back on the syringe, then he checked for placement by filling the syringe with 10 cc of air and listening, with a stethoscope, to hear a "gurgling" sound as he did so. LPN #3 stated she checked placement the same way as LPN #2, and both stated a stethoscope was necessary to check for placement. The registered nurse (RN) Manager was interviewed on 7/14/14 at 11:20 AM and stated placement of the PE[DEVICE] was checked by pulling the plunger of the syringe back and checking for gastric juices and residual tube feeding. She stated they did not do the air bolus method, it was an antiquated way to check placement and pushing air into the stomach could have caused bloating. The nurse practitioner (NP) was interviewed on 7/14/14 at 2:20 PM, and stated to check PE[DEVICE] placement, air was pushed into the stomach, and and a stethoscope was used to hear a "gurgling" sound. 10NYCRR 415.11(c)(3)(i)