Every finding on record at Teresian House Nursing Home Co Inc

Based on observation, record review, and interviews conducted during a recertification survey, the facility did not ensure that its medication error rate did not exceed 5% for 1 (Resident #77) of 4 residents observed during a medication pass for a total of 25 observations. This resulted in a medication error rate of 24%. This is evidenced by: The facility's Policy and Procedure titled Administering Medications, last reviewed 3/16/2023 and Last Revision: 11/5/2024, documented medications were administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation #2: medications may be administered within (1) hour before or after prescribed times. Scheduled medications designated as time-critical (medications that may cause harm or sub-therapeutic effect if administered before or after the scheduled time were administered at the scheduled time (for example, rapid-acting insulin) or within 30 minutes of the scheduled time. #8: The individual administering the medication checks the label THREE (3) times to verify: a. right resident, b. right medication, c. right dosage, d. right time and e. right method (route) of administration before giving the medication. Resident #77 was admitted to the facility with a diagnoses of primary generalized osteoarthritis (characterized by joint pain, stiffness, limited range of motion, and weakness); adjustment disorder with anxiety (a strong emotional or behavioral reaction to stress or trauma); and unspecified dementia (mild cognitive impairment). The Minimum Data Set (an assessment tool) dated 9/02/2024, documented resident had severe cognitive impairment, could be understood, and understand others. Resident #77's current physician orders on the Medication Administration Record dated 11/2024 revealed that the resident should receive Tylenol Extra Strength 500 milligram (Acetaminophen) give 2 tablets by mouth every 8 hours (8:00AM), and the following medications at 9:00 AM: Ferrous Sulfate 325 milligrams give 1 tablet by mouth. Finasteride 5 milligram give 1 tablet by mouth. Flomax 0.4 milligram (Tamsulosin Hydrochloride) give 1 capsule by mouth. Lidocaine External Patch, apply to right side of ribs topically in the morning and remove at bedtime. Losartan Potassium 25 milligram give 1 tablet by mouth. Senna Plus 8.6-50 milligrams give 1 tablet by mouth. During a medication observation conducted on 11/06/2024 at 10:42 AM on Mount Carmel 1st floor [NAME] Wing. Licensed Practical Nurse #3 administered the following medication at 10:50 AM: Tylenol Extra Strength 500 milligram (Acetaminophen) 2 tablets by mouth; Ferrous Sulfate 325 milligrams 1 tablet by mouth. Finasteride 5 milligram 1 tablet by mouth. Flomax 0.4 milligram (Tamsulosin Hydrochloride) 1 capsule by mouth. Lidocaine External Patch, applied to right side of ribs topically; Losartan Potassium 25 milligram 1 tablet by mouth. Senna Plus 8.6-50 milligrams 1 tablet by mouth. During an interview on 11/06/2024 at 1:30 PM, Licensed Practical Nurse #3 stated they were late with their morning medication pass because it was a heavy medication pass and they were always running late with medication. Licensed Practical Nurse #3 was asked what the policy or protocol was when they were late with medication pass. Licensed Practical Nurse #3 stated they usually ask for help but did not ask today 11/06/2024. During an interview on 11/08/2024 at 11:04 AM, Nurse Educator #1 stated upon hire each nurse completed three days of general orientation. The third day of orientation was dedicated to nurse competencies including medication administration. The Nurse then was assigned a preceptor, and the orientation checklist is completed. Each nurse must pass a medication competency test. The medication competency test included the 6 rights of medication administration: a. right resident, b. right medication, c. right dosage, d. right time and e. right method (route) of administration before giving the medication. Nurse Educator #1 stated if a medication was given late the medication nurse was responsible to notify either their charge nurse and or the physician, then document in progress notes of the late medication, notification, and next steps. During an interview on 11/08/2024 at 11:17 AM, Director of Nursing #1 stated all nurses completed a medication pass competency with nurse educator and with their preceptor. It was the expectation that if a medication was late the nurse passing medication would call the physician and document in progress notes. If the medication nurse notified their charge nurse/manager of a late medication, it was the responsibility of the charge nurse/manager to notify the physician and document. During an interview on 11/08/2024 at 11:44 AM, Assistant Director of Nursing #1 reviewed the medication administration record for Resident #77 for the morning of 11/06/2024, Assistant Director of Nursing #1 verified Tylenol Extra Strength 500 milligram (Acetaminophen) was signed as given 11:10AM; and the following medications: Ferrous Sulfate 325 milligrams; Finasteride 5 milligram; Flomax 0.4 milligram; Lidocaine External Patch, apply to right side of ribs; Losartan Potassium 25 milligram; and Senna Plus 8.6-50 milligrams were signed as given 10:50 AM. 10 New York Codes, Rules, and Regulations 415.12 (m)(1)]

Based on observation, record review, and interviews conducted during a recertification survey, the facility did not ensure that residents were free of any significant medication errors for 2 (Resident #s 88 and 144) of 2 resident reviewed. Specifically, (a.) on 6/27/2024 Resident #88 received medications that were prescribed for another resident; (b.) on 11/02/2024 and 11/03/2024 Resident #144 did not receive a medication as prescribed. Additionally, there was no documented evidence that physician was notified, and that Resident #144 was monitored for side effects. This is evidenced by: The facility's Policy and Procedure titled Administering Medications, last reviewed 3/16/2023 and last Revision: 11/05/2024, documented medications were administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation #15: If a drug was withheld or refused, the nurse administering the medication should initial and code the space provided for that drug and dose. If resident refused medication after 3 attempts document in Electronic Medication Administration Record and report to Registered Nurse. If this occurs for 3 consecutive days, notify Medical Doctor/Nurse Practitioner. If any medication was unavailable from pharmacy, it must be reported to the supervisor and Director of Nursing. State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities (Rev. 211, 02-03-23) documents, under A. PROVISION OF ROUTINE AND/OR EMERGENCY MEDICATIONS: The regulation at 42 CFR 483.45 requires that the facility provide or obtain routine and emergency medications and biologicals in order to meet the needs of each resident. Procedures should identify how staff, who were responsible for medication administration: o Ensure each resident had a sufficient supply of his or her prescribed medications (for example, a resident who was on pain management had an adequate supply of medication available to meet his or her needs). At a minimum, the system is expected to include a process for the timely ordering and reordering of medication. o Monitor the delivery and receipt of medications when they were ordered; and o Determine the appropriate action, example: contact the prescriber or pharmacist, when medication(s) is not available for administration. Resident #88: Resident #88 was admitted to the facility with diagnosis of Alzheimer's dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), Osteoarthritis (degenerative disease that worsens over time, often resulting in chronic pain. Joint pain and stiffness) and history of falls. The Minimum Data Set (an assessment tool) dated 10/3/2024, documented the resident could not complete the Brief Interview for Mental Status due to severely impaired cognition; it further documented that the resident could rarely/never be understood and could rarely/never understand others. The Medication Error or Discrepancy Report documented on 6/27/2024 at 9:50 AM, Licensed Practical Nurse #7, in error administered the following medications prescribed for another resident to Resident #88: Morphine Sulfate 5 milligrams sublingual, Lantus insulin injection 10 units, Keppra 5 milligrams orally, Lasix 40 milligrams orally, metoprolol 25 milligrams orally and MiraLAX 17 grams mixed with fluid orally. The Medication Administration Record dated for June 2024 documented Resident #88 should have received the following medications at 9:00 AM: Cholecalciferol 500 micrograms orally; Ferrous Sulfate 325 milligram orally; Lasix 20 milligrams orally; Loratadine 10 milligrams orally; Cardizem 60 milligram orally; Cyclosporin 0.05% eye drops, 1 drop to both eyes. The facility's Investigative Report documented on 6/27/2024 at 10:30 AM documented Medical Director #2 initiated orders to hold scheduled medications for Resident #88; start intravenous fluids of normal saline at 150 milliliters per hour for a total of 250 milliliters. A Physician's Progress Note dated 6/27/2024 at 2:16 PM, documented Resident #88 had a medication error and subsequent low systolic blood pressure (the amount of pressure experienced by the arteries while the heart is beating) 91 and Heart Rate 80 manually. They were seen and examined personally. Resident was alert, breathing comfortably, not acutely ill-appearing, no distress, no sweating, Lungs: clear with auscultation (listening). The resident had no complaints. Medical Director #2 documented would give 250 milliliters normal saline intravenously at 150 milliliters per hour for good measure. During an interview on 11/08/2024 at 2:26 PM, Director of Nursing #1 stated Resident #88 was given another resident's medication. Resident #88's scheduled medications were held, and Medical Doctor #2 ordered intravenous fluids. They stated Licensed Practical Nurse #7, who gave the wrong medication quit shortly after the incident. The staff were in-serviced to remember to verify the identity of the resident to whom they provide medication to ensure it was the correct resident. The current expectation was that staff checked the resident's bracelet before administering medication to a resident. Resident #144: Resident #144 was admitted to the facility with a diagnoses depression (a mood disorder that causes a persistent feeling of sadness and loss of interest); dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), and right middle cerebral artery (MCA) stroke (occurs following damage to the right distribution of the middle cerebral artery). The Minimum Data Set (an assessment tool) dated 8/02/2024, documented for the resident was cognitively intact, could be understood, and understand others. During an observation and interview on 11/04/2024 at 10:49 AM, Resident #144 stated they had not received prescribed Ingrezza for the third day. Resident #144 stated they had been up all night unable to sleep, grinding teeth with upset stomach. Resident #144 stated they were told it was to be re-ordered the previous Friday (11/01/2024) but was not ordered due to insurance pre-authorization. Review of Resident #144's Medication Administration Record dated 11/2024 documented: 11/02/2024 12:09 PM, Ingrezza Oral Capsule 40 milligrams Give 1 capsule by mouth one time a day for tardive dyskinesia - On order. 11/03/2024 11:13 AM, Ingrezza Oral Capsule 40 milligrams Give 1 capsule by mouth one time a day for tardive dyskinesia. Spoke with pharmacy who stated medication was on its way. 11/04/2024 10:17 AM, Ingrezza Oral Capsule 40 milligrams Give 1 capsule by mouth one time a day for tardive dyskinesia Unavailable. During an interview on 11/04/2024 at 11:03 AM, Registered Nurse #3 stated they were in process of calling the physician regarding medication that required pre-authorization by the insurance company. Registered Nurse #3 was unable to present documentation of physician notification. They stated Resident #144 had not received Ingrezza medication since Friday, 11/01/2024, and the physician was not made aware until now. During an interview on 11/04/2024 at 11:15 AM, Director of Nursing #1 sated when a medication was up for re-order, the medication nurse notifies pharmacy. If the medication was not available, the physician was notified for further direction. During an interview on 11/04/2024 at 11:45 AM, Medical Director #1 stated when a drug required prior authorization from the insurance carrier, it was difficult to obtain. It was a long process to get through to the insurance company and wait for the decision. Medical Director #1 stated if a medication was not available to be given, the physician should be notified. Medical Director #1 stated they were not made aware of the unavailable medication. If they had been notified, they would have authorized a 3-day supply to be paid by the facility, so that the patient would have medications as prescribed while awaiting insurance authorization. During an interview on 11/06/2024 at 8:40 AM, Licensed Practical Nurse #2 stated they attempted to re-order the medication on Thursday 10/31/2024 for Resident #144. However, the re-order would not go through as the medication required prior authorization. Licensed Practical Nurse #2 stated they notified Registered Nurse #3 on 10/31/2024 that drug required pre-authorization. They stated on Friday morning 11/01/2024 they administered the last pill in the packet to Resident #144 and left after their morning medication pass. 10 New York Codes, Rules, and Regulations 415.12(m)(2) 51742

Based on interviews and record review during the recertification survey and an abbreviated survey (Case #NY00346710), the facility did not ensure that (a.) all alleged violations of resident abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or resulted in serious bodily injury, to the administrator of the facility and to other official (including the State Survey Agency and adult protective services where state law provided for jurisdiction in long-term care facilities) in accordance with State law through established procedures; and (b.) reported the results of all investigations to the administrator or their designated representative, and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for 2 (Resident #s88 and 144) of 5 residents reviewed for reporting of allegations. Specifically, for (a.) Resident #88 received a wrong medication and the initial report was submitted more than 24 hours after the incident; (b.) Resident #141 sustained a fracture to the left hand on 8/18/2024, and then another fracture to the right wrist diagnosed on [DATE], neither severe injury was reported to the State Survey Agency. In addition, a 5-day investigation report was not submitted when . This is evidenced by: A facility policy, Abuse Prevention Program, last revised 10/20/2022 documented that the facility would ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property were reported immediately but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the administrator of the facility and to other officials (including the State Survey Agency and adult protective services where state law provided for jurisdiction in long-term care facilities) in accordance with State law through established procedures. It further documented to report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident and if the alleged violation is verified appropriate corrective action must be taken. Under the section titled What to Report, it documented both Federal and State regulations require the reporting of alleged violations of abuse, mistreatment, and neglect, including injuries of unknown origin. The administrator would provide the appropriate agencies or individuals listed above with a written report of the finding of the investigation within five working days of the occurrence of the incident. State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities (Rev. 225; Issued 08-08-2024) documents that injuries should be classified injuries of unknown source when all of the following criteria are met: the source of the injury was not observed by any person, and the source of the injury could not be explained by the resident, and the injury is suspicious because of a. the extent of the injury or b. the location of the injury or c. the number of injuries observed at one particular point in time or d. the incidence of injuries over time. It further documents that examples of injuries of unknown source that were required to report: unobserved/unexplained fractures, sprains or dislocations, unobserved/unexplained swelling that is not linked to a medical condition, and unobserved/unexplained injury requiring transfer to a hospital for examination and/or treatment. Resident #88 Resident #88 was admitted to the facility with diagnosis of Alzheimer's dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), osteoarthritis (degenerative disease that worsens over time, often resulting in chronic pain. Joint pain and stiffness) and history of falls. The Minimum Data Set (an assessment tool) dated 10/03/2024, documented the resident could not complete the Brief Interview for Mental Status due to severely impaired cognition; it further documented that the resident could rarely/never be understood and could rarely/never understand others. The Medication Error or Discrepancy Report dated on 6/27/2024 at 9:50 AM documented Licensed Practical Nurse #7, in error administered the following medications prescribed for another resident to resident #88: Morphine Sulfate 5 milligrams sublingual, Lantus insulin injection 10 units, Keppra 5 milligrams orally, Lasix 40 milligrams orally, metoprolol 25 milligrams orally and Miralax 17 grams mixed with fluid orally. The Incident Report submission form documented that the Director of Nursing reported the medication error on 6/28/2024 at 1:35 PM to the State Survey Agency. It further documented that the Administrator was first made aware of the incident on 6/27/2024 at 10:20 AM. There was no documented evidence of 5-day investigation report for this incident (NY00346710) was submitted to the Department of Health. During an interview on 11/08/2024 at 3:15 PM, Director of Nursing #1 stated that someone from the department of health called about the intake that was submitted and the Director of Nursing believed the department of health had all of the information and no 5-day report was needed. In addition, they said they did not get an email with a link to complete the 5-day report. During an interview on 11/08/2024 at 3:38 PM, Administrator #1 stated they were with Director of Nursing #1 when the department of health called, and the Administrator did not get an email with the link to submit a 5-day investigation report and that was the only way to submit a 5-day report to the Administrator's knowledge. Resident #141 Resident #141 was admitted to the facility with the diagnoses of adjustment disorder with mixed disturbance of emotions and conduct (difficulty adjusting to new situations causing changes in emotions and behaviors), dementia with psychotic disturbance (a degenerative neurological disease causing memory loss and significant behavior changes), and age-related osteoporosis (weakening of bone density related to aging). The Minimum Data Set, dated dated dated [DATE] documented the resident was able to be understood, understand others, and was significantly cognitively impaired. Facility's Incident Report #757 dated 8/18/2024 at 1:52 PM documented that Resident #141 was noted to have swelling and a darkened area between the left thumb and left index finger and the resident complained of pain when it was touched. The resident was not able to describe what happened, but they were observed using the inner part of the wheelchair to propel instead of the outer wheel. It documented that an x-ray of the left hand reflected a displaced fracture of the fifth metacarpal (bones that connect wrist to fingers). Facility's Incident Report #805 dated 9/04/2024 at 3:00 PM documented that Resident #141 was observed on the floor and was unable to state what happened due to dementia. The resident was assessed, and no injury was found, and range of motion was intact without pain. There were no documented evidence of reported incidents involving injury of unknown origin reported for Resident #141 to the Department of Health. A Progress Note dated 9/10/2024 at 4:56 PM documented that Resident #141 had 2 skin discolorations on the left facial area due to the fall on 9/04/2024. A Skin Evaluation note dated 9/16/2024 at 12:58 PM documented that skin color was within normal limits and no issues were documented. A Skin Evaluation note dated 9/23/2024 at 2:19 PM documented that skin color was within normal limits and no issues were documented. A Progress Note dated 9/26/2024 at 8:31 PM documented that Resident #141 had swelling to the right mid lateral forearm, right elbow and right index finger, no recent trauma, and pain when palpated. A Progress Note dated 9/27/2024 at 8:59 AM documented a new order for an x-ray to the right forearm, wrist, hand, and fingers. A Progress Note dated 9/27/2024 at 12:55 PM documented that because Resident #141 had no fall since 9/4/2024, the present fracture was determined to be a direct result from the fall on 9/4/2024. A Progress Note dated 9/27/2024 at 7:54 PM documented that Resident #141 was sent to the emergency room at 3:50 PM. A Progress Note dated 9/28/2024 at 5:13 AM documented that Resident #141 returned from the emergency room with a new diagnosis of a closed fracture of the distal end of the right ulna (wrist) and a cast. During an interview on 11/8/2024 at 2:26 PM, Director of Nursing #1 stated that when a fall or injury occurs the nursing staff would notify the Director of Nursing, and the Director of Nursing would determine if they looked suspicious and if so it would be reported within 2 hours. They stated just because Resident #141 could not describe what happened and it was not witnessed does not mean it was suspicious and required to be reported in their understanding. 10 New York Codes, Rules, and Regulations 415.4(b)(2)

Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure a Significant Change Minimum Data Set assessment was completed for a 1 (Resident #141) of 42 residents reviewed for significant changes in health status. Specifically, Resident #141 sustained a fractured wrist on 8/18/2024, and a fracture of the other wrist on 9/27/2024 after a fall on 9/04/2024. There was no documented evidence that a significant change assessment was done. This is evidenced by: The policy Change in a Resident's Condition or Status, revised 3/3/2023, documented that if a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current OBRA regulations governing resident assessments and as outlined in the Minimum Data Set Resident Assessment Instrument instruction manual. Resident #141 was admitted to the facility with the diagnoses of adjustment disorder with mixed disturbance of emotions and conduct (difficulty adjusting to new situations causing changes in emotions and behaviors), dementia with psychotic disturbance (a degenerative neurological disease causing memory loss and significant behavior changes), and age-related osteoporosis (weakening of bone density related to aging). The Minimum Data Set (an assessment tool) dated 10/18/2024 documented the resident was able to be understood, understand others, and was significantly cognitively impaired. It further documented that Resident #141 had no major injuries from a fall, and the definition of major injury included bone fracture. A nursing assessment note dated 8/18/2024 at 12:43 PM documented that the resident was observed to have left hand discoloration, swelling and complaints of pain. A nursing note dated 8/19/2024 at 11:12 AM documented that the resident had a left- hand fracture due to the incorrect use of their wheelchair. An x-ray dated 8/19/2024 showed a fracture of the 5th metacarpal (palm bone) on the left distal side that was slightly displaced. A follow up note dated 8/19/2024 at 3:48 PM documented that a brace was ordered by orthopedics and the resident was referred to physical therapy for treatment. A physical therapy note dated 8/21/2024 at 4:51 PM documented that the resident would receive skilled physical therapy services 5 times a week for 4 weeks to improve transfers and functional mobility. There was no documented evidence that a Minimum Data Set assessment was done to account for the change in condition of the resident's left wrist. A nursing note dated 9/26/2024 at 8:31 PM documented that the resident was assessed for swelling and pain to the right forearm. A nursing note dated 9/27/2024 at 12:55 PM documented that the resident had a right hand fracture which was attributed to a fall the resident had on 9/04/2024. There was no documented evidence that a Minimum Data Set assessment was done to account for the change in condition of the resident's bilateral broken hands. During an interview on 11/08/2024 at 1:48 PM, Minimum Data Set Coordinator #1 stated that a fracture would be a significant change of condition and 2 fractures would definitely be a significant change that would require an updated Minimum Data Set (resident assessment). They stated they missed the fractures for Resident #141. They stated they were s going to look into the situation and get back with the surveyor, but no further information was provided. During an interview on 11/08/2024 at 2:26 PM, Director of Nursing #1 stated they believed a fracture was a significant change and it was the responsibility of the Minimum Data Set Coordinator to update the Minimum Data Set after a significant change. The Director of Nursing stated sometimes things get missed. 10 New York Codes, Rules, and Regulations 415.12(a)(3)

Based on observations, record review, and interviews conducted during a recertification survey, the facility did not ensure Comprehensive Care Plans were reviewed and revised based on changing goals, preferences, and needs for 2 (Residents #83 and #261) of 62 residents reviewed. Specifically, for Resident #s 83 and 261, the facility did not ensure an interdisciplinary care plan meeting reviewed the comprehensive care plan to include weight monitoring. This is evidenced by: The Policy and Procedure titled Change in a Resident's Condition or Status dated 04/22/2024, documented it was the facilities policy to promptly identify changes in condition, notify his or her attending physician, and the resident/representative of changes in the resident's medical/mental condition and/or status. The Interdisciplinary Team must review and update the care plan at least quarterly, in conjunction with the required quarterly Minimum Data Set assessment. The assessments of residents were ongoing and care plans were revised as information about the residents and the residents' conditions change. Resident #83 Resident #83 was admitted to the facility with the diagnoses of anxiety, Alzheimer's, and mood disorder. The Minimum Data Set (an assessment tool) dated 1/19/2024 documented the resident could rarely understand and rarely be understood by others; resident was cognitively impaired. The Comprehensive Care Plan dated 5/07/2024, documented the resident required assistance with Activities of Daily Living related to limited mobility, Alzheimer's, and inability to complete Activities of Daily Living tasks. Interventions included a shower every week. On 5/05/2022 Resident #83 was on comfort measures and per health care proxy request no weights to be obtained. The signed physician orders dated 01/22/2024 documented an order to discontinue weights and heights dated 1/08/2024. During an interview on 11/07/2024 at 11:30 AM, Resident #83's Family #1 stated they would assume the facility was weighing Resident #83 but was unsure. Family #1 stated they had been to all the care plan meetings but could not remember discussing the weight. During an interview on 11/07/2024 at 12:38 PM, Registered Nurse #5 stated they believed the weights should be gone over with residents/representatives at each family meeting. During an interview on 11/07/2024 at 12:53 PM, Social Worker #1 stated that Resident #83's family attended care planning meetings religiously. Social Worker #1 stated they were unsure why the order had been in effect for so long, they knew the providers would go over the orders and continue them or discontinue them when necessary. During an interview on 11/08/2024 at 01:01 PM, Director of Nursing stated they would expect the care plan to be updated as soon as possible. The weights should be discussed at the care conference, and they also discuss weights at their meeting titled Wounds and Weights. Resident #261 Resident #261 was admitted to the facility with the diagnoses of atrial fibrillation, coronary artery disease (damage or disease in the heart's major blood vessels), and hypertension,. The Minimum Data Set, dated dated dated [DATE] documented the resident could understand and be understood by others; resident was cognitively impaired. The Comprehensive Care Plan dated 11/01/2024, documented the resident required assistance with Activities of Daily Living related to dementia. On 08/23/2024 Resident #261, per health care proxy request, no weights to be obtained. Resident #261 had altered cardiovascular status and staff were to monitor/document/report any changes in weight. Review of the Medical Charting System listed no weight within the last 90 days. Medical Charting System listed a weight of 170.8 pounds on 8/21/2024. During an interview on 11/07/2024 at 11:45 AM, Resident #261's Family #2 stated they never told the facility not to weight Resident #261 and believed they should weight them. During an interview on 11/07/2024 at 9:06 AM, Certified Nurse Aide #4 stated they obtained weights from a list provided by the unit manager, enter them in the Medical Charting System, and return the list to the unit manager. During an interview on 11/07/2024 at 12:38 PM, Registered Nurse #5 stated they believed the weights should be gone over with residents/representatives at each family meeting. During an interview on 11/07/2024 at 12:53 PM, Social Worker #1 stated that health care proxies should be asked quarterly regarding weights. During an interview on 11/08/2024 at 1:01 PM, Director of Nursing stated they would expect the care plan to be updated as soon as possible. The weights should be discussed at the care conference, and they also discuss weights at their meeting titled Wounds and Weights. 10 New York Codes, Rules, and Regulations 415.11(c)(2)(i-iii) 51742

Based on observation and interviews during the recertification survey, the facility did not ensure that food was stored, prepared, distributed, or served in accordance with professional standards for food service safety in 2 of 14 resident unit kitchenettes. Specifically, refrigerators and freezers were not operating appropriately. This is evidenced by: A review of facility policy for the environment last revised 3/04/2024 documents that the facility was to maintain a clean and safe environment. The policy documents the facility would maintain the building and all department equipment to comply with all current Federal, State, and Local regulations and guidelines. The facility should maintain a regularly scheduled maintenance on all department equipment and repair as needed. During observations on the Carmel Garden [NAME] Unit on 11/06/2024 at 10:34 AM, the resident kitchenette refrigerator flashed an E-1 error code. During observations on the second-floor west unit on 11/06/2024 at 10:46 AM, the resident kitchenette freezer had a temperature reading of 33 degrees Fahrenheit. An observation of the food within the freezer was soft and not frozen. During an interview on 11/06/2024 at 11:30 AM, Director of Dining Services and Clinical Nutrition #1 stated that Catering Assistants should check the refrigerator and freezer temperatures during their morning routine and fill out logs for the daily temperatures. During an interview on 11/06/2024 at 11:35 AM, Director of Plant Operations #1 and Life Safety #1 stated that their maintenance supervisor performs morning rounds and takes temperature readings of all refrigerators and freezers in the facility. A review of temperature logs supplied by Director of Plant Operations #1 from 10/30/2024 through 11/06/2024 documented that the Unit 2B freezer temperature taken by Plant Operation supervisor ranged from 9 degrees at its lowest to 27 degrees at its highest. When asked if their supervisor mentioned that the freezer was not getting to the appropriate temperatures, Director of Plant Operations stated that they did not mention it. A review of temperature logs supplied by Director of Dining Services and Clinical Nutrition #1 from 10/01/2024 through 11/06/2024 documented that the Unit 2B freezer temperature taken by Catering Assistant ranged from 6 degrees at its lowest on 10/10/2024 to 30 degrees at its highest on 11/06/2024. When asked if the Catering Assistant assigned to the unit mentioned that the freezer was not getting to the appropriate temperatures, Director of Dining Services and Clinical Nutrition #1 stated that they did not mention it or reported it to anyone. During a follow-up interview on 11/06/2024 at 2:30 PM, Director of Dining Services and Clinical Nutrition #1 and Director of Plant Operations #1 stated that they had taken all the items out of the freezer on the unit and discarded them. They also stated they placed an out-of-order sign on the freezer door, so it was not used. They also stated that the code flashing on the Carmel Gardens unit was an error code for an evaporator probe for the unit and they would place a work order to get it repaired. 10 New York Codes, Rules, and Regulations 415.14(h)

Based on observation, record review, and interviews during a recertification survey, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain personal hygiene for 1 (Resident #83) of 9 residents reviewed for Activities of Daily Living. Specifically, Resident #83 was not provided assistance with personal hygiene during care leaving facial hair to grow on the upper lip. This is evidenced by: Resident #83 was admitted to the facility with the diagnoses of anxiety, Alzheimer's, and mood disorder. The Minimum Data Set (an assessment tool) dated 01/19/2024 documented the resident could rarely understand and rarely be understood by others; resident was cognitively impaired. The facility policy Activities of Daily Living Support effective 03/16/2023 documented residents who were unable to carry out activities of daily living independently would receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. The Comprehensive Care Plan dated 9/22/2023 documented the resident required assistance with Activities of Daily Living related to limited mobility, Alzheimer's, and inability to complete Activities of Daily Living tasks. Interventions included a shower every week. The following observations of Resident #83 were made: - On 11/04/2024 at 10:09 AM, resident was noted with facial hair on the upper lip. - On 11/06/2024 at 9:55 AM, resident was in the wheelchair in the room and noted to have facial hair on the upper lip. - On 11/07/2024 at 10:02 AM, resident noted with longer hair to upper lip. During an interview on 11/07/2024 at 11:30 AM, Resident #83's Family #1 stated their daughter used to provide the facial shaving for Resident #83 but cannot do it now, they would expect that staff provided the care for the facial hair. During an interview on 11/07/2024 at 10:02 AM, Certified Nurse Aide #1 stated they would shave the male residents on their shower day but did not think about shaving the female residents. They confirmed Resident #83 did have facial hair on their upper lip. During an interview on 11/07/2024 at 10:52 AM, Licensed Practical Nurse #1 confirmed Resident #83 had facial hair on their face. Licensed Practical Nurse #1 stated it was expected to be taken care of on bath days. During an interview on 11/08/2024 at 1:01 PM, Director of Nursing #1 stated they would expect all residents to receive shaving on bath days and as needed. 10 New York Codes, Rules, and Regulations 415.12(a)(3)

Based on observations, record review, and interviews during the recertification survey, the facility did not ensure a dependent resident was provided with appropriate treatment and services to maintain or improve their language and communication for 1 t (Resident #268) of 1 resident reviewed for Activities of Daily Living. Specifically, Resident #268 was not provided with an adequate, structured approach and tools to communicate effectively in accordance with professional standards of care. This is evidenced by: The facility's Policy on Communication with Residents with Speech Impairments reviewed on 1/24/2024, documented its purpose was to provide staff with a structured approach to communicate effectively and compassionately with residents affected by speech impediments due to stroke, ensuring clear, respectful, and supportive interactions. Procedures include use of communication aids; non-verbal cues; environment adjustments, documentation, and staff training. The New York State Department of Health Code, Rules and Regulation, Volume C (Title 10) Section 415.3 Effective 2/24/2022, documented each resident shall have the right to: (i) adequate and appropriate medical care, and to be fully informed by a physician in a language or in a form that the resident can understand, using an interpreter when necessary, of his or her total health status including but not limited to, his or her medical condition including diagnosis, prognosis, and treatment plan. Residents shall have the right to ask questions and have them answered. Resident #268 was admitted to the facility with a diagnoses of cerebral vascular accident (stroke), right side hemiplegia (paralysis of one side of the body), and aphasia (loss of ability to understand or express speech, caused by brain damage). The Minimum Data Set (an assessment tool) dated 9/01/2024, documented a Brief Interview for Mental Status score of 00 suggesting the assessment was incomplete. The documentation indicated resident could understand and be understood by others. Resident's Communication Comprehensive Care Plan dated 6/2024, documented Resident #268 was dependent on staff for meeting emotional, intellectual, physical, and social needs due to physical and verbal limitations status post cerebral vascular accident (stroke) resulting in aphasia. Resident is a very social and creative person and is interested in participating in activities during their short term stay for rehabilitation. Due to recent aphasia, Resident #268 preferred activities which did not involve the need for them to verbalize. Resident is presently limited to yes/no responses to simple questions. During an observation on 11/04/2024 at 11:53 AM, Resident #268 was observed sitting in their room in their wheelchair dozing off and on while watching television. Resident's speech was garbled and difficult to understand. Resident appeared to become frustrated when unable to express their thoughts and hold conversation. During an interview on 11/04/2024 at 11:57 AM, Certified Nurse Aide #2 and Certified Nurse Aide #3 stated some of them understand resident #268. They mostly speak in short phrases with closed ended yes/no answers. They stated resident was able to nod, shake head and point. Certified Nurse Aide #2 and Certified Nurse Aide #3 stated they did not receive training on stroke or resident with dysphagia (difficulty speaking) at this facility. During an interview on 11/06/2024 at 1:03 PM, Registered Nurse #1 stated Resident #268 was able to answer yes/no questions and points to objects. They had no other means of communication. Resident at times becomes frustrated with inability to express themselves. They stated Resident #268 was currently working with speech therapy and making gains. During an interview on 11/06/2024 at 1:20 PM, Speech Therapist #1 stated they were working with Resident #268 on dysphagia (difficulty speaking) and cognitive communication, targeting expressive and receptive skills including communication partner training picture based. Resident had no pictures in room; they point to objects. They had been using the therapy department's IPAD. Resident's family would bring in an IPAD, but first needed to delete some items prior to brining to facility. They stated Resident #268 was only communicating with closed end questions yes/no answers and pointing. During an interview on 11/08/2024 at 11:17 AM, Director of Nursing #1 stated when residents were admitted with language barriers, they were assessed by speech therapy. The resident was also discussed during interdisciplinary team meeting. Communication board and picture boards were used to assist with communication. 10 New York Codes, Rules, and Regulations 415.12(a)(2)

Based on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure that each resident received the necessary respiratory care and services that were in accordance with professional standards of practice for 1 (Resident #'s 148) of 4 residents reviewed for oxygen administration. Specifically, Resident #148's portable oxygen tank ran out of oxygen. This is evidenced by: A review of the facility's policy and procedure titled Oxygen Administration, last revised on 5/09/2024, documented that oxygen would be administered by licensed nurses with a physician's order. Oxygen could be delivered via an E size oxygen tank for short-term use and when the resident was not on their concentrator. Resident #148 was admitted to the facility with diagnoses including malignant neoplasm of the right upper bronchus or lung (a cancerous tumor located in the upper lobe of the right lung, specifically within the bronchus, the airway leading to the lung lobe), acute respiratory failure with hypoxia (breathing disorder when there is not enough oxygen in the body's tissue), and essential hypertension (high blood pressure). The Minimum Data Set (an assessment tool) dated 9/16/2024 documented that the resident could understand others and had intact cognition for daily living decisions. During an observation on 11/05/2024 at 11:34 AM, a portable oxygen tank on the back of Resident #148's wheelchair was set to deliver 2 liters per minute of oxygen via nasal cannula and the oxygen gauge showed the tank was in the red zone, indicating it was empty. During an observation on 11/06/2024 at 3:50 PM, a portable oxygen tank on the back of Resident #148's wheelchair was set to deliver 2 liters per minute of oxygen via nasal cannula and the oxygen gauge showed the tank was in the red zone, indicating it was empty. During the follow-up with Resident #148 and observation of their oxygen tank, Licensed Practical Nurse #8 came into the room and attempted to remove the oxygen tank from the surveyor's view. A record review for Resident #148 Medication Administration Record for November 2024 documented resident was to be on 2 liters per minute of oxygen via a nasal cannula for shortness of breath. The administration record also documented that the resident oxygen tank was to be monitored when the resident was on the portable oxygen and turned on. The oxygen tank needed to be changed when the gauge was in the red range or when necessary. During an interview on 11/06/2024 at 3:50 PM, Licensed Practical Nurse #8 stated that they were coming in to do their routine check and change the Resident #148 bottle. They stated that the oxygen tank usually lasts approximately 2-3 hours with the resident on their current oxygen flow of 2 liters per minute. During an interview on 11/08/2024 at 10:20 AM, Registered Nurse #6 stated that residents' oxygen should be checked every shift to ensure the portable oxygen tank had oxygen. They stated that the oxygen bottle should be checked whenever the resident was out of their room and not on their concentration. They stated that Certified Nurse Aides were allowed to check the level of oxygen in the tank but are not allowed to change the tank if nearing empty and would notify a nurse. Registered Nurse #6 was made aware of the observations made and the incident with the Licensed Practical Nurse. They stated that they would need to reeducate their staff regarding checking the tank for oxygen levels. 10 New York Code of Rules and Regulations 415.12(k)(6)

Based on record review and interviews during an abbreviated survey (Case # NY00279837), the facility did not ensure residents were free from significant medication errors for 2 (Resident #s 1 and 2) of 3 residents reviewed. Specifically, the facility (1) did not ensure Residents #1 and #2 received their own medication as ordered when Resident #2 received Resident #1's antibiotic for 5 days from [DATE] through [DATE] for a total of 5 doses, and (2) did not ensure the electronic medical record was accurate for Resident #s 1 and 2 for those 5 days. This is evidenced by: The Policy and Procedure titled Physician's Order Entry last revised [DATE] documented physician orders would be entered by a licensed nurse in a timely manner. It documented all new orders entered in the electronic medical record order portal by a licensed nurse must be confirmed by a second nurse. It documented the nurse would document in the progress notes and on the 24-hour report that the new order was received and entered. If the order was found to be entered inaccurately, the second nurse must immediately re-enter the order seeking clarification from the ordering physician if needed. The third nurse checking the order would follow the same sequence of steps indicated above for the nurse completing the second check. If the 11 PM to 7 AM nurse was a Per Diem/Agency nurse, the Shift Supervisor would ensure the policy was followed. The Policy and Procedure titled Medication Errors, reviewed on [DATE] and last reviewed on [DATE], documented it was the facility's policy to have systems in place to monitor any medication errors. The purpose of the policy was to ensure that all medication concerns were reported in a timely manner and actions were taken to prevent further concerns. Resident #1: Resident #1 was admitted to the facility with diagnoses of dementia, fracture of lower end of right humerus (upper arm bone), and chronic kidney disease stage 1. The Minimum Data Set (an assessment tool) dated [DATE], documented the resident could be understood and could understand with moderate impaired cognition for decisions of daily living. Resident #1's Comprehensive Care Plan for Acute Kidney Failure related to kidney disease acute kidney failure and chronic kidney disease stage 1, initiated [DATE] and revised [DATE], documented a care plan goal that the resident would be free from infection. Care plan interventions documented to give medications as ordered by the physician. Resident #1's Comprehensive Care Plan for Infection of extended spectrum beta-lactamase (ESBL-an enzyme found in some bacteria that breaks down and destroys some commonly used antibiotics, making the drugs ineffective for treating infections) in the urine, initiated on [DATE], documented urinary tract infection and contact precautions were in place. Care plan goals documented the resident would be free from complications related to infection. Resident #2: Resident #2 was admitted to the facility with diagnoses of periprosthetic fracture around the internal prosthetic left hip joint (fracture of artificial hip joint), end stage renal disease with dependence on dialysis, and benign prostatic hyperplasia (enlarged prostate) without lower urinary tract symptoms. The Minimum Data Set, dated dated dated [DATE] documented the resident could be understood and could understand and cognitively intact. Resident #2's Comprehensive Care Plan for Fluid Overload or Potential Fluid Volume Overload related to end stage renal disease, benign prostatic hyperplasia, and primary malignant neoplasm of prostate (cancer of prostate), last revised [DATE], documented a care plan intervention to administer medications as ordered. The Laboratory/Prescription Note dated [DATE] at 11:39 AM for Resident #1 by Registered Nurse Manager #1 documented the physician/Medical Doctor #2 was notified about Resident #1's test result being positive for extended spectrum beta-lactamase in the urine. The Sub-Acute Medical Doctor/Nurse Practitioner Follow-up for Resident #1 dated [DATE] at 12:15 PM by the physician/Medical Doctor #2 documented the reason for the visit was urinary tract infection. The resident complained of mild dysuria (discomfort associated with urination). The Assessment/Plan documented urinary tract infection and the urine culture showed Proteus and E. Coli (bacteria) with multiple resistances (to antibiotics). The plan was to treat the infection with Bactrim DS for 5 days. Review of the Order Summary Report for date range [DATE] to [DATE] for Resident #1 did not document an order dated [DATE] for Bactrim DS for urinary tract infection. Review of the Order Summary Report for date range [DATE] to [DATE] for Resident #2 documented an order dated [DATE] for Bactrim DS ,d+[DATE] milligram to be given; 1 tablet every 12 hours for urinary tract infection for 5 days. Review of the Medication Administration Record for Resident #2 dated [DATE] documented the resident received Bactrim DS ,d+[DATE] milligram; 1 tablet every 12 hours for a urinary tract infection from [DATE] to [DATE], a total of 5 doses. The Medication Error Details Report - Occurrence #953387 written by the Registered Nurse Manager #2 who was then Assistant Director of Nursing documented an error was detected on [DATE] at 8:00 AM. It documented Registered Nurse Manager #1 was responsible for error type, wrong resident. The medication as ordered and as administered documented Bactrim DS ,d+[DATE] milligram: twice a day for 5 days. The error cause documented transcribed to wrong resident and documented 5 doses were administered. The residents were not named in the report. The Nurse's Note for Resident #2 dated [DATE] at 8:55 AM written by Registered Nurse Manager #1 documented the physician #1 was made aware that they made a mistake by putting the order for Bactrim DS to Resident #2 instead of Resident #1, and that it was discontinued the morning of [DATE]. It documented the physician #1 told Registered Manager #1 to let the resident know about this incident. The Nurse's Note for Resident #2 dated [DATE] at 9:46 AM written by Registered Nurse Manager #1 documented Resident #2 was made aware that they did not have a urinary tract infection and that they received antibiotics over the weekend by mistake. Resident #2 denied having adverse effects and no rash or swelling were noted. It documented the resident's vital signs were taken and were within normal limits. The Sub-Acute Medical Doctor/Nurse Practitioner Follow-up Note for Resident #2 dated [DATE] at 4:58 PM by the physician #1 documented they were asked to evaluate the resident. The resident was given antibiotics in error. The resident had no complaints and stated they were okay. Review of the Order Summary Report for Resident #1, date range [DATE] to [DATE], documented an order dated [DATE], for Bactrim DS ,d+[DATE] milligram to be given every 12 hours for 5 days for urinary tract infection. The Medication Administration Record dated [DATE] for Resident #1 documented the resident received the Bactrim DS ,d+[DATE] mg from [DATE] to [DATE] for urinary tract infection. Resident #1's Comprehensive Care Plan for Infection of extended spectrum beta-lactamase in the urine, documented a care plan intervention initiated on [DATE], to administer antibiotic as ordered by the physician; Bactrim DS 1 tablet twice daily for 5 days. The Follow up Report - Occ. #953387 dated [DATE] at 9:08 AM written by Registered Nurse Manager #2 who was then the Assistant Director of Nursing, documented the following conclusion: the interdisciplinary team met, and it was determined that the root cause was an order transcription error. Registered Nurse Manager #1 did not follow the facility's Physician's Order Entry policy that stated all new orders entered in the electronic medical record portal by a licensed nurse must be confirmed by a second nurse. A facility wide audit was performed on all medication orders initiated [DATE] to [DATE]. The Information Technology department was asked to investigate if users could confirm their own orders. It was discovered that confirm all pharmacy orders was set to on, meaning that prior to this date the Registered Nurse role users could confirm their own pharmacy orders. The option was immediately set to off and confirmed that all other confirm own order types was set to off as well. It documented this would ensure that a second nurse would confirm all orders prior to activation. Re-education on the Physician's Order Entry policy was provided to Registered Nurse Manager #1 and education to all facility nursing staff on this policy was initiated and was on-going. Administration, Quality Assurance, Nursing, and Medical Director met. The policy was reviewed and updated. The residents were not named in the report. The Medication Error Investigations [DATE] by Registered Nurse Manager #2 documented the following: -On [DATE], the physician/Medical Director #2 wrote an order for Resident #1 to receive named antibiotic twice daily for 5 days. The order was wrongfully transcribed into Resident #2's electronic medical record in error by Registered Nurse Manager #1 on the same date. The error was noted on [DATE] at 8:53 AM by the Registered Nurse Manager #1, who immediately reached out to the physician to discontinue the medication and re-prescribed for Resident #1. The medication error included: Resident #2 received 5 doses of Bactrim DS from Friday [DATE] through Sunday evening [DATE]. -Resident #1 was exhibiting symptoms of urinary symptoms on [DATE] and therefore urinalysis and culture (urine tests) were obtained for analysis at the laboratory. The culture report was finalized on [DATE] and reviewed by the physician/Medical Director (#2), who gave an order for Bactrim DS twice daily for 5 days. -Upon discovery of the medication error, the following actions were immediately activated: - Both residents were assessed, and no physical evidence of adverse reactions observed. - Physician #1 was notified and the medication for Resident #2 was discontinued and antibiotic therapy for Resident #1's urinary tract infection was initiated. - Representatives were notified. - Quality Assurance and Performance Improvement and the Interdisciplinary team met to discuss the incident and to determine the root cause and plan to prevent re-occurrence. It was determined that the Registered Nurse Manager #1 did not follow the facility's Physician Order Entry policy that stated, all new orders entered in the electronic medical record portal by a licensed nurse must be confirmed by a second nurse. - A facility-wide audit was performed on all new medication orders initiated [DATE] through [DATE]. - The Social Worker followed up with both residents and both were doing well at the time. - Staff were asked to closely monitor both residents. -The Physician Order Entry and Medication Error policy were reviewed and revised on [DATE]. -The Registered Nurse Manager #1 did not follow the facility policy for Physician Order Entry, as they were also the same person that confirmed the order in the [electronic ordering system]. Human Resources was directed to review their file and there were no negative findings in the manner of disciplinary actions or other adverse documentation. They were provided with one-on-one training and written up for the error. -On [DATE], the Information Technology Department was tasked with investigating why users could confirm their own orders. The findings into the role of Registered Nurse revealed that nurses could confirm their own orders as the setting was set to the ON position mistakenly. This was corrected and the option was set to OFF on [DATE] at 10:45 AM. With the OFF position now selected, nurses would no longer be able to confirm orders they put in the [electronic ordering system]. -The Registered Nurse Educator was directed and had initiated a facility wide Inservice on medication orders for all nurses (Licensed Practical Nurses and Registered Nurses), including evening and night supervisors on all shifts. -The facility's investigation was deemed complete; the necessary audits were complete; in-services were ongoing. Quality Assurance and Performance Improvement had put in place necessary safeguards to avoid recurrence of the medication error. There was no evidence of abuse, mistreatment, or neglect but would be reported to the Department of Health as it met the basic criteria for reportability. During an interview on [DATE] at 1:58 PM, the Director of Nursing #1 stated the Registered Nurse Manager #1 no longer worked at the facility. They stated they were not the Director of Nursing at the time of the incident. During an interview on [DATE] at 2:08 PM, the Administrator stated the facility acted immediately when the medication error was identified. They stated the interdisciplinary team, Quality Assurance Performance Improvement team, and Medical Director all worked together on the corrective actions and the nursing staff was educated immediately. During an interview on [DATE] at 2:10 PM, Registered Nurse Manager #2 stated they recalled the incident with the medication error. They stated the medication error was discovered by the Registered Nurse Manager #1 on [DATE]. They stated the Registered Nurse Manager #1 was very upset when they reported the error to them. They stated the error was remedied immediately and stated they had called interdisciplinary team on [DATE], to resolve the problem. They stated there was a setting in the [electronic ordering system] that allowed the nurse to confirm their own orders and stated the Information Technology staff changed the setting so that it could not be done. They stated both residents were immediately assessed and there were no negative findings. They stated Resident #1 had a urinary tract infection and there were no adverse effects from the delay in treatment. They stated nursing staff was monitored both residents closely following the incident. During an interview on [DATE] at 2:50 PM, Director of Nursing #1 stated antibiotic medication should have been entered into the [electronic ordering system] for Resident #1 but was entered for Resident #2 in error. They stated the Registered Nurse Manager #1 made the error and was the one who discovered the error on [DATE]. They stated the error was reported immediately. They stated corrective action began right away on [DATE], including education to the nurses on the facility's policies for ordering medication in the [electronic ordering system] and the need for a second nurse to review and verify the order. They stated on [DATE], the Information Technology staff identified and corrected the problem and Registered Nurse Manager #1 was provided with one-on-one training about the facility's policies for medication ordering. They stated the facility did their medication order audits and policy education on [DATE] and was in compliance with the regulation on [DATE]. During an interview on [DATE] at 9:34 AM, the Registered Nurse Manager #1 stated they were interrupted when they were entering the physician order for Resident #1. When they continued to enter the order, they did not realize they were in Resident #2's electronic medical record and the order was entered for Resident #2. They stated Resident #2 received 5 doses of the medication. They stated they realized the error on [DATE], and immediately called the physician. They stated they then told Resident #2 about the error and assessed the resident. They stated they also assessed Resident #1 and there were no negative findings. They stated they were still in orientation at the time and was not familiar with the facility's policy for medication ordering and the need to have another nurse review and confirm the order. They stated the facility found a problem in the [electronic ordering system] that was corrected right away. They stated the facility provided house-wide education to all nurses about the policy and the need to have another nurse confirm the order. They stated they were responsible and accountable for the error and reported it to the Registered Nurse Manager #2 who was the previous Assistant Director of Nursing. During an interview on [DATE] at 9:40 AM, Director of Nursing #1 stated the facility had no medication transcription errors since [DATE], and had no medication errors that were reportable to the New York State Department of Health. Past Non-compliance- F760 Based on the following corrective actions taken, there was sufficient evidence the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement at the time of this survey: -On [DATE], the facility identified a medication error, and the following corrective actions were taken immediately: -- The physician was notified and gave an order to discontinue the antibiotic medication for Resident #2 and initiate antibiotic medication for Resident #1. -- Resident #s 1 and 2 were immediately assessed by the Registered Nurse with no negative findings and were later evaluated by the physician with no acute concerns. -- The interdisciplinary team met to discuss the incident and directed all nurses to review new orders/charts of residents. No additional non-compliance was noted. -- Quality Assurance and Performance Improvement was summoned by the Administrator, including the Medical Director to review the incident and directed a facility-wide audit of transcribed medication orders/charts of all residents. No additional non-compliance was noted. -- The Staff Educator was directed and completed education for all nurses on all shifts on the proper policy and procedure for obtaining medication orders. - On [DATE], the following corrective actions were taken: -- Resident #s 1 and 2 were re-assessed with no physical evidence or adverse reactions observed and the physician/Nurse Practitioner continued to follow the residents. -- Facility-wide audit was completed on medication orders/charts for all residents in the facility. -- The Medication Error policy and Order Entry policy were both reviewed and needed a revision to include a nurse cannot confirm and verify their own orders in the [electronic ordering system]. -- Facility Information Technology staff fixed and corrected the self-confirm in the [electronic ordering system], to include the requirement noted above. This new requirement was consistent with the Quality Assurance Performance Improvement findings and interventions. -- The Social Worker followed up Resident #s 1 and 2 with no negative findings. Socioemotional care was provided to both residents. Social Worker to provide ongoing support when needed. -- Registered Nurse Manager (#1) received counseling for the medication error and was provided one-on-one training, including review of the facility's policies and procedures. - At the time of survey, there were no additional reportable significant medication errors identified. A randomly sampled in-house resident was reviewed during the survey; there were no findings identified with medication administration and/or significant medication errors. 10 NYCRR 415.12(m)(2)

Based on record review and interviews during an abbreviated survey (Case #s NY00312160 and NY00302754), the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. For 2 (Resident #1 and #2) of 2 residents reviewed for abuse reporting. Specifically, for Resident #1, the facility did not ensure that upon knowledge that the resident sustained an injury of unknown source on 3/6/2023 resulting in serious bodily injury (acute communicated left femoral fracture) was reported to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures immediately but not later than 2 hours after the allegation is made and for Resident #2, the facility did not ensure that upon knowledge on 9/21/2022 that the resident sustained an injury of unknown source resulting in serious bodily injury (acute right ulnar fracture), that the injury was reported to the other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures immediately but not later than 2 hours after the allegation is made. The facility reported the injury to the NYSDOH on 9/23/2022 at 9:04 PM. This is evidenced by: The policy titled Abuse Prevention Program last revised on 3/1/23, documented, in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility will ensure that all alleged violation involving abuse, neglect exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the administrator of the facility and to other officials(including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-terms care facilities) in accordance with State law through established procedure. Report the results of all investigations to the administrator or his/her designated representative and to other officials in accordance with the State law, including the State Survey agency within 5 working days of the incident and if the alleged violation is verified appropriate corrective action must be taken. The Policy and Procedure (P&P) titled Incident/Accident/Reporting/Investigation Injuries Quality Assurance last revised 10/22, documented the facility will report and investigate, accidents and incidents to support risk management actions and promote quality of life and a safe working environment. Incidents/accidents will be reported on the 24-hour Report. The Director of Nursing (DON) will review incidents reports to ensure timely completion of incidents investigations. If suspected crimes do not involve serious bodily injury, the report is to be made no less than 24 hours to the Department of Health and a local enforcement agency. Resident #1 Resident #1 was admitted to the facility on with diagnoses psychotic disorder with hallucinations, seizures, and unspecified dementia. The Minimum Data Set (MDS - an assessment tool) dated 3/8/23, documented resident had severe cognitive impairment, could not understand, or be understood by others. The comprehensive care plan (CCP) for Activities of Daily Living last revised on 3/14/23 documented resident was totally dependent on staff on and off the unit and bed mobility. The CCP for accidents and falls last revised on 3/14/23 documented, resident was at risk for falls, dependent on staff for proper positioning. Interventions included: use a dycem between residents and netted Hoyer sling (transfer assist device) when out of bed and in chair, totally dependent with two assists with transfers and toileting. Facility Incident Form dated 3/6/2023 for date and time of occurrence at 8:00AM by Registered Nurse (RN) #5, documented Resident #1 had a change in condition. On 3/6/23 at 10:37 AM, Resident #1's daughter who is the health care proxy/Power of attorney (POA) requested a physician to assess the resident. RN #5 stated they were made aware by the resident's daughter that the resident's left upper leg was swollen. No redness or bruising was noted. Nurse Practitioner (NP) #4 was notified and X-rays were ordered. The X-ray results showed acute communicated left femoral fracture. After examination by NP #4, it was determined that left femoral fracture was a result of significant degenerative joint disease, osteopenia, and poor born mineralization due to immobility and possible hip contractures due to poor mobility and possibility of being transferred with use of mechanical lift. A nursing progress note dated 3/6/23 at 08:10 AM, written by DON documented, resident's daughter at bedside requested to see a physician, POA removed the cover from the resident and pointed to the left upper leg which was noted to be swollen. NP #4 ordered an x-ray During an interview on 4/18/23 at 10:43 AM, RN #5 stated injuries of unknown source are reported immediately to the DON or the Assistant Director of Nursing (ADON) and an investigation is started right away. RN #5 stated they examined the resident when they became aware that the resident was experiencing pain, the resident's leg was rotated sideways. They reported the incident to the DON, and they expected the DON to notify the NYSDOH immediately. RN #5 stated they were under the impression that the incident was reported to NYSDOH. During an interview on 4/18/23 at 2: 23 PM, NP #4 stated on 3/6/23 at approximately 8:30 AM, it was reported that the resident was experiencing pain on their leg. The resident had slight discoloration and swelling, and they ordered an x-ray. The x-ray revealed a fracture of the left hip. NP #4 stated they were unable to determine the cause of the injury. NP #4 stated the DON, and the Administrator were responsible for reporting allegations to the NYSDOH. During an interview on 4/18/23 at 4:17 PM, the Administrator stated all abuse mistreatment and injuries of unknown source should be reported to NYSDOH within 2 hours and an investigation should completed and forwarded to NYSDOH within 5 days. The administrator stated they became aware of the incident on 3/6/2023 after the X-ray result showed left hip fracture. The DON started the investigation regarding the injury of unknown source on Resident #1. The Administrator stated the incident should have been reported to NYSDOH. During an interview on 4/27/23 at 10:40 AM, the DON stated on 3/6/23 the resident was assessed by the NP #4 and ordered an x-ray due to swelling on left hip. The x-ray revealed a fracture of the left hip. They started the investigation immediately. The DON stated the administrator was made aware of Resident #1's left hip fracture on the day of the X-ray. The DON stated there were some confusion regarding whether the incident was reportable, and they did not report to NYSDOH. The DON stated the incident should have been reported to NYSDOH. Resident #2 Resident #2 was admitted with diagnoses of peripheral vascular disease, hypertension, and renal insufficiency. The MDS dated [DATE], documented the resident's had severe cognitive impairment, could not understand, or be understood by others. The comprehensive care plan (CCP) for Accidents dated 7/22/19 and last revised on 2/19/23 documented the resident has a self-care performance deficit due to dementia and muscle weakness. Interventions included padding attached to the left side of the wall. The comprehensive care plan (CCP) for Activities of Daily Living (ADL) dated 10/09/19 and last revised on 9/23/22 documented the resident can be combative and resistive during care, moves arms freely. Interventions included staff to allow the resident to make decisions to provide sense of self control. The Facility Investigation Form dated 9/20/22 for date and time of occurrence 9/20/22 at 3:04 PM, the DON documented on 9/19/22, PH #8, was attempting to draw blood on the resident's right hand and the resident verbalized pain. PH #8 notified Licensed Practical Nurse (LPN) #5, who observed no abnormalities. On 9/20/22, at approximately 11:00 AM, CNA #11, was attempting to dress the resident, while fitting the resident's arm through their sleeve, the resident verbalized pain. CNA #11 notified clinical lead LPN #7 who observed the resident's hand to be swollen. LPN #7 notified NP #2 and they ordered a doppler, which came back with no abnormalities. On 9/21/22 NP #2 ordered an X-ray due to swelling; the results showed a right acute ulnar fracture. Facility documented, based on review of statements from staff and other residents on the unit, the incident appeared to be isolated and there was no abuse, neglect, or mistreatment to the resident. The NYSDOH Intake Information form for Case # NY00302754 dated 9/23/22 at 9:33 PM, documented receipt of a facility reported incident that occurred on 9/20/22 at 3:04 PM. During an interview on 4/18/23 at 4:30 PM, the Administrator stated all abuse mistreatment and injuries of unknown source should be reported to the NYSDOH within 2 hours and an investigation should completed and forwarded to NYSDOH within 5 days. The administrator stated they became aware of the incident on 9/21/22, the day of the X-ray results. The administrator stated all allegations need to be reported to NYSDOH in a timely manner. The administrator stated they were not aware of there was a delay in reporting the incident. During an interview on 4/27/23 at 10:40 AM, the DON stated on 9/20/22 they became aware Resident #2 had an injury of unknown source. On 9/21/22 X-ray results showed the resident had a right acute ulnar fracture and they notified the administrator. On 9/23/22 at 9:39 PM, the incident was reported to NYSDOH. They expected the administrator to report the incident in a timely manner. 10 NYCRR 415.4(b)(2)

Based on observation, medical and facility record review, video footage, and staff interview during a recertification and abbreviated survey (Case # NY 505) the facility failed to provide adequate supervision for one (Resident #216) of 8 residents reviewed for accidents. Specifically, on 12/3/21 at 11:30 AM the facility failed to provide Resident #216, who was severely cognitively impaired, with supervision. Subsequently, Resident #216 was able to exit the building through a coded/locked door off the unit and 2 sets of alarmed doors exiting the facility for over two hours. Both alarmed doors were disabled by facility staff. Facility video footage revealed resident exited the facility at 11:30AM and facility staff did not discover the resident missing until lunch time at 12:15PM. In addition, facility staff did not follow their process for elopement when the facility staff member that exited through the coded/locked door did not observe and ensure the door closed and locked behind them; did not perform a headcount when the interior alarmed door sounded and the source of the alarm was not identified and the facility staff deactivated the alarmed door that exited to the outside and did not call a Code 1, when an alarmed perimeter door is breached, a Code 1 would be announced. This resulted in no actual harm with the likelihood for more than minimal harm that is Immediate Jeopardy and substandard quality of care/past noncompliance to resident health and safety. The Immediate Jeopardy was lifted on 12/15/2020. This was evidenced by: The facility's policy and procedure dated 6/2017 titled Resident (Missing) Code 1 Alarm, Doctor Yellow, Door Alarm (Interior) documented that when an interior door alarm sounds, staff would immediately respond to the alarm and if unable to determine the reason for the alarm, a head count would be performed on that unit and if a resident was missing, the staff would follow a Dr Yellow - potential missing resident alert. Additionally, it documented when an alarmed perimeter door was breached, a Code 1 would be announced, the staff in the immediate location must proceed to the door and determine the cause. If the cause is undetermined, search procedures will begin. A resident head count would be completed. Resident #216: Resident #216 was admitted to the facility with the diagnoses of dementia, adjustment disorder with anxiety, and hypertension. The Minimum Data Set (an assessment tool) dated 11/28/2021 documented Resident #216 was able to understand others, was able to make self-understood, and had severe cognitive impairment. Resident #216 was able to walk with supervision only. The Comprehensive Care Plan (CCP) dated as initiated on 1/18/2021 and revised on 8/24/2021, documented the resident was at risk for wandering related to disorientation to place, and impaired safety awareness. The CCP documented the resident was non exit seeking and the goal documented that the resident would not leave the facility unattended through 2/22/2022. Interventions included; provide structured activities, walking inside and outside, and re-orientation strategies. It documented to re-evaluate the resident's risk for wandering quarterly and as needed. The Behavior assessment dated [DATE] documented that Resident #216 had the behavior of unsafe wandering without regard to physical safety by ambulating or self-propelling their wheelchair, may attempt to open doors, enter unsafe areas, or follow others through exit doors but is not seeking to leave and does not verbalize the desire to leave. The assessment did not document that Resident #216 was a risk for elopement. Observation of video footage provided by the facility showed that the resident exited the facility on 12/3/2021 at 11:30 AM. Facility staff did not discover the resident missing until 12:15 PM. The Director of Information Technology verified the date and time of the video footage as above. The facility's Incident Report dated 12/3/2021 documented the resident was an elopement risk. The incident Report documented the date the resident was last seen before elopement was 12/3/2021, the time last seen before the elopement was 11:30 AM, and the time missing was 12:15 PM. The Incident Report documented the system to prevent elopement functioned properly. -The description section of the Incident Report documented; on 12/03/2021 at 12:40 pm, staff could not find Resident #216 in the dining room for lunch and proceeded to search the immediate areas with no results. A code Yellow (Missing resident) was called at 01:00 pm and a facility wide search began. -Resident #216 was seen and assessed by a Registered Nurse (RN), Physician and Nurse Practitioner (NP). Resident #216 had no evidence of distress, their skin was a bit warm and dry, no visible injuries were noted and appeared not to have had any psychological negative effect from the incident. -The investigation findings documented on 12/03/2021: 11:25 AM - Resident #216 left the unit through the west kitchen door after Certified Nurses Aide (CNA) #5 punched in the security code and left the unit for his lunch break. Resident #216 was following CNA #5 who was also Resident #216's caregiver for the day, by quickly grabbing the door and exiting taking a left turn, while CNA #5 proceeded straight ahead to the elevator: 11:30 am - Resident #216 proceeded to push and walk through a security door (Elevator E- Double-Door) while the alarm was sounding. The Director of Housekeeping (DOH) who had just come into the Carmel Garden core area from Carmel Gardens West heard the alarm, looked around in the core area, looked up the ambulance entrance hallway and did not see or hear anything unusual and reset the alarm. 11:35 am - Resident #216 was observed on video exiting the ambulance entrance (exterior door), walked to the left and got into an unlocked employee car (silver car) which was parked about 300 ft on a paved parking lot; 01:45 pm - Social Worker (SW) #1 found Resident #216 sitting alone in the back seat of the silver car after SW #1 approached the left back door and noticed the resident. SW #1 knocked on the window and Resident #216 responded by opening the door. SW #1 asked for the name and Resident #216 responded I'm cold. It's freezing out here. SW #1 gave Resident #216 their jacket and brought Resident #216 back into facility. 02:00 pm - Director of Nursing (DON) performed an RN assessment on Resident #216 after returning to the facility. Resident #216 showed signs of apprehension when approached, pulling away and folding arms. After about three minutes the resident was smiling and was offered something to eat and drink. Color was pale, skin warm and dry. No flush to face, arms warm. Resident #216 had socks and shoes on with a shirt and sweater. No bruises or redness observed to body. Resident #216 was able to ambulate without difficulty, was not able to relate how they got out of building, refused a BP and has a BIMS of 03. The Medical Director, Physician and NP were made aware. Resident #216's niece and responsible party were notified. The nursing progress note dated 12/3/2021 at 3:01 PM, documented at around 11:55 AM Resident #216 was seen on the cameras following staff. The staff member had entered the code to the exit door and Resident #216 was seen following right after the staff member out the locked unit. Code yellow initiated, Resident #216 found and redirected back to the unit without incident. Resident #216 was assessed by the Nurse Practitioner (NP) and MD #1 and no issues found. Medical Director notified. POA (power of attorney) notified. Roam alert (a system to provide protection to wandering-prone residents by controlling exit doors) placed on right wrists for Resident 216's safety. The nursing progress note dated 12/3/2021 at 4:31 PM documented Resident #216 was assessed by this writer after they were returned to facility, showed signs of apprehension when approached pulling away and folding arms. After about three minutes was smiling and was offered something to eat and drink. Color was pale, skin warm and dry. No flush to face, arms warm. Resident #216 had socks and shoes on with shirt and sweater. No bruises or redness observed to body. Resident #216 was able to ambulate without difficulty. Resident #216 was not able to relate how they got out of the building, had a BIMS of 3 and had diagnosis of Alzheimer/Dementia. Medical Director, MD #1, and NP was made aware. Family, niece made aware. Labs were ordered, Roam alert was applied to the resident's right wrist. Behavior assessment done. Care Plan and Care Card updated. During an interview on 12/21/2021 at 12:21 PM, the Director of Life Enrichment (DOLE) stated the west kitchen door was only used by staff. On the day of the elopement CNA #5 did not see Resident #216 come out of the door (west kitchen door) behind them. The second door (security door-Elevator E- Double-Door) was a push and go door, people did it all the time. It would alarm and could just be egressed (exited), staff would have to come to the door and reset the code, it was typical that someone would reset code after looking. During an interview on 12/21/2021 at 12:21 PM, the Registered Nurse Manager (RNM) of the secured memory unit stated, staff were expected to ensure all coded doors closed and locked prior to them leaving the area to ensure a resident did not exit the unit undetected. Resident #216 was not at risk for elopement and did not have exit seeking behavior. Before, the resident never demonstrated they wanted to leave the unit, they wandered throughout the unit and lacked safety awareness, liked to pick up residents' things and look into rooms and things would catch the resident's attention. All people are responsible for identifying compliance, if someone put in a code and came through the door it would stop the alarm for 20 seconds. The west kitchen door alarm did not go off that we know of. The second door (security door-Elevator E- Double-Door) alarm would go off a lot, the code had to be entered physically at the door. During an interview on 12/22/2021 at 9:20 AM the Director of Environmental Services (DES) stated they heard the alarm while on a resident unit. DES approached the alarming door (security door-Elevator E- Double-Door), was unable to identify the cause of the alarm and entered a code to silence the alarm. A resident head count was not completed. The alarm goes off a lot and staff became complacent about responding to the alarm. During an interview on 12/22/2021 at 09:44 AM the Assistant Director of Maintenance stated the double doors (security door-Elevator E- Double-Door) was, push and open doors that had a local alarm, that would sound only in the area of the door and on both units on that same floor. The alarm would go off when the doors were held open a little too long. That alarm was not considered a Code 1 alarm, when the alarm goes off staff needed to search the immediate area, a head count should have been initiated and was not done. The back door (ambulance entrance-exterior double door), the right-side door had no code but was alarmed and had a crash bar. The left side door had a Mag lock (automatic releasing mechanism) and delayed egress. Both doors would have alarmed at the front reception desk. During an interview on 12/22/2021 at 12:26 PM, the Director of Plant Management (DPM) stated staff became desensitized to the interior door (security door-Elevator E- Double-Door) alarm as the alarm sounded five to six times per day from staff members holding the door open too long. After the cause of the alarm going off was unable to be identified, staff did not implement a resident head count, and they should have. Then, when the resident exited the back door (ambulance entrance-exterior double door) the alarm was activated at the front reception desk and a Code 1 should have been called by the receptionist and was not called. It was more than an hour later that a staff member called the receptionist and had them announce a Code Yellow for a Missing Resident. After the incident a Mag Alarm was added for extra protection. The staff are educated frequently for responding to the alarms no matter how often they go off. The DPM stated there was no camera at the double doors in the vestibule, and cameras were placed after the incident. During an interview on 12/22/2021 at 12:45 PM the Director of IT and a member of their alarm company stated, they confirmed the alarm was activated when the resident exited the facility (as confirmed by video and an alarm log reviewed by the facility). A Code 1 was not called, a resident head count was not completed and a Dr Yellow - missing resident search was not initiated. During an interview on 12/22/2021 at 1:40 PM the Front Lobby Receptionist stated they took their lunch break every day at 12:00 PM until 12:30 PM. From the timeframe of 11:00 AM until 12:00 PM no alarms for the exit doors had gone off, the alarms are so loud that anyone in the surrounding area would have heard them. The Receptionist would have looked at the panel that would display which door was alarming, and the computer screen at the reception desk showed every exit door in real time, then the button to turn off the alarm would have to be pushed to disarm the alarm once it was determined there was no problem. During an interview on 12/22/2021 at 5:18 PM, the Administrator (ADM) stated the double doors in the vestibule (security door-Elevator E- Double-Door) needed to have a code put in and then you could go through, it had a 15 second delay, then the alarms would start sounding. The ADM was not aware that staff were not compliant with the door alarm. If there is an alarm going off staff must respond to it. If ADM had been aware that staff were desensitized to the alarm, the ADM would have rolled out an education right then and there. The alarm is part of an elopement protocol. There is always someone at the reception desk. After the incident when the alarm did not sound at the reception desk, we did a sweep of all the egress doors. The ADM stated they knew the receptionist denied an alarm had gone off, and that all receptionists have been re-inserviced on the alarms. On the Memory Care Unit, they have individualized dining, there was no set time for a resident to have lunch, Resident #216 was always on the go. Immediately following the event, a Mag Alarm was placed on the security door-Elevator E- Double-Door that eliminated the 15 second delay and cameras were also installed in that area. In the future Administrative staff will receive text messages when the exit doors are breached. The ADM assessed the search for Resident #216 in order to improve upon the protocol. Improved pictures of all residents have been placed at the front reception desk. 10NYCRR483.25(d)(1)(2) Based on the following corrective actions, the facility corrected the non- compliance as of 12/15/2021. The facility reached past noncompliance by taking sufficient corrective actions prior to the recertification and abbreviated survey to both remove the immediate jeopardy and fully correct the noncompliance before the start of the survey. The facility's corrective actions included the following effective 12/15/21: - 95% of staff have been reeducated on elopement. The education provided included: unsafe wandering/elopement in-service that includes if the reason for an alarmed door cannot be determined a headcount is performed, and elopement prevention policy and procedure with emphasis on making sure there are no residents behind staff when going through any door on the secured unit and ensure the door has closed and was locked before leaving the area. -A delayed egress with Westminster Chimes feature was added to the right interior door on 12/14/2021 (the left door opens from the other direction). When the crash bar is depressed, within 5 seconds, this door alarms locally and via the nurse call system; the Westminster chimes alarm throughout the unit. The door releases 30-seconds after the delayed egress feature is activated. The keypad bypasses the delayed egress feature and all alarms. -A delayed egress with a local alarm feature was added to the right leaf of the exterior doors on 12/13/2021. The left leaf had been delayed egress. When the crash bar is depressed, within 5 seconds, either door will alarm locally and at the Reception Desk. The keypad bypasses both local alarm and reception alarm. Surveillance staff from the Capital District Regional Office remained onsite to complete the recertification survey.

Based on observation, record review, and staff interview during the recertification survey, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The sanitizing chemical in the final rinse of low temperature automatic dishwashing machines are to be within a specific range, and food preparation and serving areas are to be kept clean. Specifically, the automatic dishwashing machine chemical sanitizing final rinse was too concentrated, and the unit kitchens required cleaning. This is evidenced as follows. When checked on 12/19/2021 at 9:14 AM, the concentration of sanitizing chemical in the final rinse of the automatic dishwashing machine final rinse was 200 parts per million of available chlorine (ppm). The directions on the bottle of sanitizing chemical concentrate state the concentration is to be between 50 and 100 ppm. The Director of Dining Services stated in an interview on 12/19/2021 at 11:16 AM that the vendor will be contacted to adjust the concentration of available chlorine to be compliant. In the interim, dishes will be manually sanitized. When checked on 12/19/2021 at 10:00 AM, cabinetry, floors, and windowsills on the unit kitchens were soiled with food particles or grime. The Director of Environmental Services stated in an interview on 12/19/2021 at 11:35 AM that the nursing units are on a cleaning schedule, and the findings today will be addressed. The Administrator stated in an interview on 12/19/2021 at 1:23 PM that the facility has identified and developed a schedule to address the cleaning issues on the unit kitchens and will make sure the kitchen dishwashing machine final rinse is as required. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.110, 14-1.112, 14-1.170, 14-1.171

Based on observation, record review and interviews during a recertification survey, the facility did not maintain the residents' right to personal privacy and confidentiality on 2 (1st floor and 6th Floor) of 6 units (the 4th floor was closed). Specifically, for the 1st Floor and 6th Floor, the facility did not ensure the residents' right to privacy and confidentiality were maintained when finger sticks (blood sugar monitoring for diabetes) and blood pressures were obtained, and the results were read out loud, with other residents were present in the dining rooms and common areas. This was evidenced by: The Policy and Procedure titled Resident Dignity dated 10/31/2019, documented the policy of the facility was to promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity and respect in a full recognition of their individuality, and this included maintaining resident privacy. A review of Resident Council Minutes dated 12/2/2021, documented the dining room was sometimes used as a laboratory. Vital signs were taken in there, as well as blood draws. During a Resident Council Meeting on 12/20/2021 at 10:00 AM, 5 of the 5 residents in attendance, representing 5 different units in the facility, stated staff were taking blood pressures, doing finger sticks, and taking resident temperatures in the dining room during meals. The Council stated these issues had been talked about over and over, but there had been no resolution to their expressed concerns because it was still happening. A Council Member stated they sit a table with 4 other residents in the dining room and everyone at the table knew what the resident's vital signs were. The other 4 residents in the Council Meeting stated this happened in the dining rooms on their units too, and they were not happy about it. The Council stated they did not like other residents knowing their blood pressures when the nurse would say it for everyone to hear. During an observation on 12/21/2021 at 8:15 AM, Licensed Practical Nurse (LPN) #4 on the 1st Floor/ Mount Caramel unit, checked the blood pressure of Resident #105 in the dining room with two other residents present and loudly stated 113 on 66, and informed the resident the blood pressure was very good and handed the resident a cup of medications. At 8:25 AM, LPN #4 checked the blood pressure of Resident #145 while sitting in a chair next to the dining area where three other residents were seated and loudly stated 130 over 60. LPN #4 handed Resident #145 with their medications and observed them being swallowed. During an observation on 12/21/2021 at 9:02 AM, LPN #1 on 6th Floor, was obtaining a finger stick on Resident #13 who was at the dining room table for breakfast. There were 4 residents at the dining room table with Resident #13. LPN #1 announced at the table that the resident's blood sugar was 186. During an interview on 12/21/21 at 8:40 AM, LPN #4 stated they were the only licensed nurse assigned to the 1st Floor (Mt. Carmel Unit) and were required to stay in the dining area during breakfast. LPN #1 breakfast lasted through 11:00 AM and therefore they needed to complete vital signs, glucose checks and pass medications to the residents in the common area and dining room. During an interview on 12/21/2021 at 11:12 AM, LPN #1 stated they did not normally take finger sticks in the dining room, but today they obtained the resident's finger stick in the dining room at the table. Finger sticks should be done in the resident's room and the LPN stated they normally brought the resident to their room but did not today. LPN #1 stated finger sticks and blood pressures were not supposed to be done in the dining room. LPN #1 stated it morning was busy and it was the last finger stick they had to do so they just did it at the dining room table. During an interview on 12/22/2021 at 9:57 AM, Registered Nurse (RN) #1 stated obtaining finger sticks at the dining room table was an infection control issue because blood was involved, and it was a privacy issue when the numbers were read out loud for others to hear. RN #1 stated they spoke with the nurses about this all the time, and no one should know that another resident had diabetes by seeing a finger stick be obtained and hearing the number read out loud. RN #1 stated blood pressures and finger sticks should not be done in the dining room and the resident should be taken to a private area. RN #1 stated if they saw anything like that in the dining room, they would address it immediately with that nurse. RN #1 stated they had seen blood pressures taken in the dining room but had not seen finger sticks being done in the dining room. RN #1 stated they addressed things they saw on the spot with the nurse, so it would not continue. During an interview on 12/22/2021 at 11:06 AM, the Director of Nursing (DON) stated they had not seen staff taking vital signs including blood pressures and temperatures, or finger sticks in the dining areas. The DON stated they should not be doing those things in the dining room. The DON stated they did not recall this issue being brought to their attention. The DON stated the resident should be brought to their room or to a private area and staff were in-serviced during orientation to not obtain vital signs and finger sticks at mealtimes. Staff were aware it should not be done in the dining room and if another staff saw it happening, it should be brought to that nurse's attention at the time. 10NYCRR415.3(d)(1)

Based on record review and interviews during a recertification, the facility did not ensure that all alleged violations of abuse, neglect, or mistreatment were immediately reported to the Administrator of the facility for 1 (Resident #167) of 4 residents reviewed for abuse. Specifically, the facility did not ensure an allegation of abuse involving Resident #167 was immediately reported to the Administrator. This is evidenced by: Resident #167: Resident #167 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - an assessment tool) dated 12/2/2021 documented the resident was cognitively intact, was understood and could understand others. The facility's policy and procedure (P&P) titled Abuse Prevention Protocol last revised on 5/26/2021, documented abuse allegations were reported per Federal and State Law. The facility would ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law. A progress note dated 10/22/2021, written by Licensed Practical Nurse (LPN), who is no longer employed by facility documented Resident #167 had made an allegation of abuse against a Certified Nursing Assistant (CNA) on 10/20/2021 at 6:05 PM and that the supervisor had been made aware. A document titled Re-education Verification documented the CNA had been re-educated on safe patient handling during care, reading care Kardex before providing care and asking for help if in situations of uncertainty on 10/22/2021. A document titled Facility (Named) Resident Grievance/Complaint Investigation Form provided by the administration documented an investigation regarding Resident #167's allegation dated 12/21/2021 documented an investigation was initiated on 12/20/2021. During an interview on 12/19/2021 at 11:56 AM, Resident #167 informed this surveyor that a Certified Nurse Assistant (CNA) pulled on their arm during care and stated that the CNA was quite rude. Resident #167 stated they had reported it to Licensed Practical Nurse (LPN) #3 on 10/21/2021. During a phone interview on 12/22/2021 at 12:03 PM, LPN #3 stated that Resident #167 had informed them that a CNA had been rough with them the night before. LPN #3 stated they spoke to the CNA and informed the Nurse Educator the CNA may need more education. LPN #3 stated they spoke to Resident #167 who requested that this CNA not take care of them. LPN #3 stated they made sure the CNA was not assigned to Resident #167 but the CNA did work after reported incident. During an interview on 12/20/2021 at 1:12 PM, the Assistant Director of Nursing (ADON) #3 stated they had not been aware of Resident #167's allegation of abuse on 10/20/2021. ADON #3 stated the steps taken if they had known of the allegation would include to investigate, talk to the resident and staff, and based on information received they would take it to the director of nursing. An investigation would be done in some fashion. During an interview on 12/20/2021 at 1:30 PM, LPN #2 stated they remember hearing about this incident but wasn't directly involved in it. LPN #2 stated if an allegation of abuse was reported to them, they would take the CNA out of the room and off the assignment, immediately contact their supervisor and make sure the resident is all right. During an interview on 12/22/2021 at 3:19 PM, the Director of Nursing (DON) stated that progress notes for the previous 24 hours from the electronic medical record (EMR) were discussed in the morning interdisciplinary team (IDT) meeting. The DON stated they should have been notified of the allegation of abuse before the meeting. This incident was not in the 24-Hour Report so it was not discussed. The progress note was entered as a late entry and sometimes late entries are not picked up in the 24-Hour Report. The Educator who is longer employed by the facility should have elevated the incident and started an investigation including gathering statements. The Educator would have received this training about abuse, reporting and investigation when they were hired. The staff have been educated on reporting abuse and mistreatment. This education is ongoing and will be reinforced. During an interview on 12/23/2021 at 2:18 PM, the Administrator stated they were not aware of the incident until day 2 of the recertification survey on 12/20/2021. The Administrator stated normally any alleged abuse or mistreatment has to be ruled out including gathering statements immediately from resident and staff on the unit. Other residents would be interviewed if they were taken care of by the employee involved. The employee should also be suspended during the investigation and a report made to the New York State Department of Health (NYSDOH). Each morning the expectation is to review the 24-Hour Report which would include incidents and accidents and they do not recall this being discussed at the time of the allegation. The Administrator stated they don't know why the Educator didn't elevate the allegation. 10 NYCRR 415.4 (c)(1)(2)

Based on observation, interview and record review during the recertification survey and an abbreviated survey (Case #NY 147), the facility did not ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 (Resident #130) of 4 residents reviewed for ADLs. Specifically, for Resident #130, who was dependent on staff for ADL care, the facility did not ensure incontinence care was provided in accordance with the resident's care plan. This is evidenced by: Resident #130: Resident #130 was admitted to the facility with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS - an assessment tool) dated 10/24/2021, documented the resident had severely impaired cognition, could understand others and could make self understood. The Policy and Procedure (P&P) titled Activities of Daily Living (ADLs), Supporting dated 10/18/2021, documented appropriate care and services would be provided for residents who were unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care) and elimination (toileting). The Comprehensive Care Plan (CCP) for ADLs, last revised 4/23/2021, documented the resident was dependent for toilet use and required a full mechanical lift for transfers. The CCP for Frequent Bladder Incontinence, last revised 12/16/2021, documented the resident was incontinent and was to be checked every 2-3 hours and as required for incontinence. The CCP documented to change the resident every 2-3 hours and as needed (PRN). During an observation on 12/20/2021 at 11:08 AM - 2:35 PM (3 hours, 27 minutes), Resident #130 was not provided incontinence care every 2-3 hours and PRN in accordance with the CCP. -11:08 AM, the observation began with Resident #130 was in the common area facing the TV. -11:51 AM, the resident remained in the common area facing the TV. -1:34 PM, the resident was at the lunch table in the dining room. -1:43 PM, the Registered Nurse (RN) brought the resident from the dining room to their room to change their O2 tank. The resident's bedroom door was open. The resident was not changed or toileted at this time. -1:46 PM, the RN brought the resident out to lunch table after changing O2 tank. -2:03 PM, the Licensed Practical Nurse (LPN) brought the resident from dining room to the common area in front of TV. -2:35 PM, Resident #130 was in common area in front of the TV and the observation ended. A review of Certified Nursing Assistant (CNA) documentation, CNA #1 documented on 12/20/2021: -9:26 AM and 11:36 AM, the resident was incontinent of bladder. -9:27 AM, the resident was transferred, used the toilet, and had personal hygiene performed. -9:27 AM and 11:36 AM, the resident was checked and changed every 2-3 hours. Based on observation, Resident #130 was in the common area at 11:36 AM and was not attended to by staff at that time. CNA #1 was not available for interview 12/20/2021 as they had left the facility mid-shift. During an interview on 12/20/2021 at 2:30 PM, CNA #2 stated they did not assist Resident #130 to get up this morning and had not assisted to change the resident today. During an interview on 12/20/2021 at 2:31 PM, CNA #3 stated they assisted CNA #1, who left the facility for the day, to get Resident #130 out of bed around 10:00 AM. CNA #3 stated they had only assisted CNA#1 to get the resident out of bed and did not provide the resident with any other care since approximately 10:00 AM. During an interview on 12/22/2021 at 9:12 AM, CNA #4 stated Resident #130 was constantly incontinent of urine. The resident was supposed to be changed every 2 hours, before and after meals, and as needed when the staff did their rounds. CNA #4 stated they had to check on Resident #130 frequently because they were always incontinent of urine. The CNA stated the resident was always wet and the staff changed the resident more frequently than every 2 hours because she needed it due to always being wet. During a subsequent interview on 12/22/2021 at 9:16 AM, CNA #3 stated Resident #130 was changed every 2-3 hours because the resident was a heavy wetter. CNA #3 stated the resident was always wet and needed to be changed every 2-3 hours. During an interview on 12/22/2021 at 9:52 AM, RN #1 stated the residents had a schedule for check and changes and were changed every 2-3 hours. RN #1 stated they tried to facilitate timely toileting by encouraging staff to read the care cards and by communicating with the staff when they noticed a resident had been sitting for an extended period of time or when a resident was still in bed. The RN stated they believed in timely toileting because they felt no one should sit in waste. RN #1 did not want the residents to develop rashes, moisture associated [CONDITION(S)] (MASD- inflammation or skin erosion caused by prolonged exposure to moisture) or wounds from not being checked and changed as frequently as they should be. RN #1 stated they addressed concerns with the staff as they noticed them regarding timely toileting. During an interview on 12/22/2021 11:03 AM, the Director of Nursing (DON) stated all residents should be checked and changed every 2 hours and as needed for incontinence care. The DON stated it had not been brought to their attention that residents were not being toileted or checked and changed every 2 hours. The DON stated the nurses oversaw the care the CNAs provided, but the nurse managers, clinical leads, and all the staff should be looking to ensure toileting and ADL care were getting done. 10NYCRR415.12(a)(3)

Based on record review and interview during a recertification survey, the facility did not ensure as needed (PRN) orders for [CONDITION(S)] drugs were limited to 14 days, unless the attending physician or prescribing practitioner believed it was appropriate for the PRN order to be extended beyond 14 days, they should document their rationale in the resident's medical record and indicate the duration for the PRN order for 1 (Resident #195) of 5 residents reviewed for unnecessary medications. Specifically, for Resident #195, the facility did not ensure a PRN [MEDICATION(S)] (antidepressant medication) was not ordered for more than 14 days without a documented rationale from the attending physician or prescribing practitioner. This is evidenced by: Resident #195: Resident #195 was admitted to the facility with the diagnoses of major depressive disorder, anxiety disorder, and dementia with behavioral disturbance. The Minimum Data Set (MDS - an assessment tool) dated 11/19/2021 documented the resident had moderately impaired cognition, could understand others and could make self understood. The Policy and Procedure titled Antipsychotic Medication Use dated 12/17/2021, documented residents would not receive PRN doses of [CONDITION(S)] medications unless that medication was necessary to treat a specific condition that was documented in the clinical record. The need to continue PRN orders for [CONDITION(S)] medications beyond 14 days required the practitioner to document the rationale for the extended order. The duration of the PRN order would be indicated in the order. The Comprehensive Care Plan did not include a care plan for antidepressant medication. A physician order dated 9/7/2021, documented [MEDICATION(S)] tablet; give 25 milligrams (mg) by mouth every 24 hours as needed for agitation. The medical record did not include a clinical justification documented by the attending physician or prescribing practitioner for continuing the PRN [MEDICATION(S)] order for more than 14 days. During an interview on 12/21/2021 at 11:13 AM, Licensed Practical Nurse (LPN) #1 was interrupted during the interview by the physician who told the LPN to discontinue the [MEDICATION(S)] order for Resident #195. The LPN stated the physician told them to discontinue the resident's [MEDICATION(S)] order, so they did. During an interview on 12/22/2021 at 9:45 AM, Registered Nurse (RN) #1 stated they were aware of the regulation regarding PRN [CONDITION(S)] medications and stated the order for PRN [CONDITION(S)] medications should be for 14 days. The RN stated they tried to put PRN [CONDITION(S)] orders in for 14 days and then had the physician re-assess. The RN stated the policy should be that the doctor reassesses the need for the PRN medication after 14 days, and then decided whether to continue or discontinue the PRN order. During an interview on 12/22/2021 at 10:58 AM, the Director of Nursing (DON) stated the process should be that PRN [CONDITION(S)] medications were ordered for 14 days, then re-assessed by the physician, and the physician determined whether to continue it. If the order was to be continued, it should be reordered to include a duration for the order or there a stop date should be added to the order. The physician would write a progress note to say why the PRN should or should not be continued. The DON stated a PRN [CONDITION(S)] medication that had been ordered for longer than 14 days should have been noticed during the monthly pharmacy reviews. The DON stated they thought they saw a note with a medication justification to extend the PRN [MEDICATION(S)] order for Resident #195 and would provide it to the survey team. During a subsequent interview on 12/22/2021 at 5:42 PM, the DON stated they spoke to the Medical Director and the Medical Director would speak with the team of providers about PRN [CONDITION(S)] medications. The DON also spoke with the pharmacy to make them aware, and all the staff were in-serviced regarding PRN [CONDITION(S)] medications. The DON did not provide documentation of a clinical justification for extending the use of the PRN [MEDICATION(S)] past 14 days for Resident #195. 10NYCRR 415.12(1)(2)(ii)

Based on record review and interviews during an abbreviated survey (Case #NY 058), the facility did not ensure prompt notification to the ordering nurse practitioner (NP) of laboratory (lab) results that fell outside of clinical reference ranges for 1 (Resident #1) of 3 residents reviewed for notification of laboratory results. Specifically, on 10/20/19, the NP ordered for Resident #1 to have a CBC (complete blood count) laboratory test, to be completed in the morning on 10/21/19. The results of the CBC were reported and sent to the facility electronically by the laboratory on 10/21/19 at 12:11 PM. The report included results that were outside of clinical reference ranges. The provider was not notified of the lab results until 10/22/19. This is evidenced by: Resident #1: The resident was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], documented the resident had severe cognitive impairment. The Policy and Procedure (P&P) titled Laboratory Work (schedule of) last revised on 6/30/19, documented the 7-3 unit nurse was to check the computer system for all lab results drawn that day. If it was identified that a scheduled lab result was not in the system portal, the nurse was to first check under unmatched laboratory. If found, the results were to be matched. If results were not present in either portal, the nurse was to call the lab to inquire about the results. The electronic Medication Administration Record [REDACTED]. The Communication with Physician note dated 10/20/19 at 2:19 PM, written by Licensed Practical Nurse (LPN) #1 documented the family was concerned that Resident #1 was in pain, had increased restlessness, and was given Tylenol. NP #1 gave orders for a complete blood count (CBC) to be done in the morning (10/21/19). The Order Summary Report documented an order for [REDACTED].>A Lab Results report documented the results of the CBC test was reported to the facility on [DATE] at 12:11 PM. A Nurse's Note dated 10/21/19 at 6:45 PM, written by Register Nurse Manager (RNM #1), documented that at 5:00 PM the facility was still waiting for the laboratory results. A Nurse's Note dated 10/21/19 at 6:39 PM written by Registered Nurse Supervisor (RNS #2), documented the health care proxy (HCP) requested the resident be sent to the emergency room (ER) for evaluation. The provider was notified and gave an order to send the resident to the hospital. A Communication with Resident/Family note dated 10/22/19 at 10:08 AM, written by NP #2, documented NP #2 spoke with the HCP about the resident's status prior to the ER visit. The resident had a history of [REDACTED]. The resident was on a blood thinner, and the CBC laboratory test was done to rule out an acute bleed, and the result was still pending. The HCP was upset that the bloodwork was not done on 10/21/19 as ordered. NP#2 apologized for the missed lab which was a crucial basis for the next decision to be made as to whether to send him/her to the ER for acute bleed. During an interview on 11/15/19 at 12:19 PM, LPN #1 stated the CBC was ordered on [DATE] and was to be done in the morning on 10/21/19, and that lab results were sent directly to the computer. She checked the computer system for the results on 10/21/19, through 3:00 PM and did not see the results. She was certain she checked for the results because the resident's HCP called several times to ask about the resident's condition and the laboratory results. She said NP #2 told her he would be checking the computer for the results. During an interview on 11/18/19 at 9:20 AM, NP #2 stated he saw the resident on 10/21/19 for a wound on the lower leg. As he was leaving the unit, the nurse mentioned the resident had bruising on his/her abdomen. He told the nurse to follow up on the CBC and to call him with the results. NP #1 stated that, even if he had seen the bruising, he would have wanted to know the results of the CBC prior to sending the resident to the hospital. He knew the resident was on a blood thinner and needed objective data before he made his decision. During an interview on 11/18/19 at 11:03 AM, RNM #1 stated LPN #1 made NP #2 aware of the bruising on the resident, but did not know he asked her to follow-up on the CBC results. During an interview on 11/15/19 at 11:50 PM, NP #2 stated he was not made aware of the CBC lab results until 10/22/19. The HCP had concerns that the lab test had not been completed on 10/21/19, and he told her the blood work had been completed, but no one had notified him of the results. During an interview on 11/15/19 at 1:15 PM, the Director of Nursing (DON) stated lab test results were sent directly to the computer system, and a nurse was supposed to check for the results, however, the NP should have been able to check the results as well. The CBC result did not appear under the result tab as it should have, but was in the unmatched tab file, but someone should have been checking the unmatched file daily, and the nurse manager was responsible for educating the nurses on the unit to look under the unmatched tab for the results. The DON also stated LPN #1 should have known the results were usually there by 1:00 PM and should have told the nurse manager that she could not find the results in the computer. 10 NYCRR 415.20

Based on observation and staff interview during the recertification survey, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Automatic dishwashing machines are to operate in accordance with manufacturer specifications, and food and non-food contact surfaces are to be kept clean. Specifically, automatic dish washing machines were not rinsing at the specified water pressure, and floors and equipment were not clean. Also, safe food handling was not practiced to prevent the outbreak of foodborne illnesses. This is evidenced as follows: Finding #1: The main kitchen and unit kitchenettes were inspected on 10/03/2019 at 9:00 AM. The slicer and the floor under cooking equipment and next to walls in the main kitchen were soiled with food particles. The cabinets and cabinet doors, window sills, and floor next to walls were soiled with food particles. Finding #2: The automatic dish washing machine (machine) on the 4-B unit was rinsing at 0 pounds per square inch (psi). The machine on the Mount Carmel East unit was rinsing at 0 psi. The machine on the Carmel Gardens East unit was rinsing at 35 psi. And the machine on the Carmel Gardens West unit was rinsing at 35 psi. The data plate instructions on each machine state that the final rinse water flow pressure is to be 15 to 25 psi. The General Manager stated in an interview on 10/03/2019 at 11:25 AM, that the low pressure will be reported to the maintenance department, and there is an area for improvement with cleaning the kitchenettes and main kitchen. Finding #3: During an observation on 10/03/19 at 12:08 PM on 5B Unit, wearing gloves, CNA #1 unwrapped luncheon meat and cheese, opened the refrigerator, made and cut the sandwich in half, opened the cabinet and took out a bag of chips, placed chips on plate, put chips away and closed the cabinet door. She served the resident the sandwich. CNA #1 then removed her gloves but did not wash her hands. She wore the same gloves and did not remove them after touching non-food items. During an observation on 10/03/19 at 12:16 PM on 5B Unit, CNA #1, wearing gloves, took knife out of drawer, touched outside of bread wrapper, cut the sandwich, closed the container of sandwich filling, put it back in refrigerator and removed gloves without washing her hands. She wore the same gloves and did not remove them after touching non food items. During an observation on 10/03/19 at 12:18 PM on 5B Unit, wearing gloves, CNA #1 took break out of wrapper, opened the refrigerator, took out container, opened the drawer, retrieved a knife, spread contents from container onto bread, touched the bread, cut the sandwich, put container back in refrigerator, removed gloves and did not wash her hands. She wore the same gloves and did not remove them after touching non food items. During an observation on 10/03/19 at 12:24 PM, wearing gloves, CNA #1 opened the cabinet, opened the bread wrapper, removed the bread, closed the wrapper and placed back in the cabinet, opened the refrigerator, removed and opened a container, picked up the sandwich and cut it in half. She wore the same gloves and did not remove them after touching non food items. During an interview on 10/03/19 at 12:53 PM, CNA #1 stated she had been inserviced on safe food handling practices but was nervous because she was being watched and she forgot to change her gloves. During an interview on 10/10/19 at 07:43 AM, Food Service Manager #6 stated on orientation the staff receive basic handwashing inservicing, proper use of gloves, and basic kitchen etiquette. Additional inservicing takes place on the units. Gloves should be changed if any non-food items are touched. She would prefer for the staff to set up everything prior to making the sandwich. Ideally, staff should wash hands after removing gloves. Everyone is inserviced not to touch food if they touched anything else without washing their hands and changing gloves. 10 NYCRR 415.14(h); Chapter 1 State Sanitary Code Subpart 14-1.40(a) 14-1.110, 14-1.113

Based on observation, record review, and interview conducted during the recertification survey, the facility did not ensure development of comprehensive person-centered care plans, that included measurable objectives and timeframe's to meet the resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment, for five (Residents #'s 24, 120, 134, 152, and #221) of thirty-two residents reviewed for comprehensive care plans (CCP). Specifically; for Resident #152, the facility did not ensure a CCP for the [DIAGNOSES REDACTED].#221, the facility did not ensure a CCP was developed for the resident's [DIAGNOSES REDACTED].#24, the facility did not ensure a CCP was developed for the use of [MEDICATION NAME] (a medication for dizziness), and for Resident #120, the facility did not ensure that directions for not wearing socks until the resident's foot healed was not followed; and for Resident #134, the facility did not ensure a CCP was developed for a [DIAGNOSES REDACTED]. This is evidenced by: Resident #134: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-an assessment tool) dated 8/15/19, documented the resident was cognitively intact, was able to understand others and was able to understand. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A Nurses Progress Note dated 8/2/19 at 9:51 AM, documented the resident complained of left knee pain and was asking about her pain medication. She was informed she needed to inform the nurse if she was having severe pain as she had an order for [REDACTED].>A Nurses Progress Note dated 9/9/19 at 11:05 AM, documented the resident complained of left side/back pain like my shingles felt like in October. The electronic Medication Administration Record [REDACTED]. The eMAR dated 10/2019, documented the resident received PRN [MEDICATION NAME] 50 mg on 10/6/19 at 03:07 AM and on 10/07/19 at 11:59 PM. Clinician's Note dated 9/10/19, documented a [DIAGNOSES REDACTED]. Seen for chronic pain and pain on resident's left rib area. Continue to monitor for any changes in her pain and consider other medications. Consider other medical issues for a cause of increased pain and treat as necessary. During an interview on 10/07/19 at 09:31 AM, Licensed Practical Nurse (LPN) #4 stated the resident tells the nurse if she has pain and will request either Tylenol or [MEDICATION NAME]. The resident states she needs it because her sciatica flares up. During an interview on 10/07/19 at 09:54 AM, Registered Nurse Manager (RNM) #2 reviewed the careplans and reported she cannot find a Pain Careplan. The resident should have a pain careplan but does not. Resident #152: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident was understood and able to understand. A Nursing Progress Note dated 7/25/19 at 2:34 PM, documented the resident complained of [MEDICAL CONDITION], bladder scan (test to determine how much urine is left in the bladder after voiding) done, straight cath (catheterization-insertion of catheter to empty bladder) for 560 milliliter (mls) of urine. A Physicians Order dated 7/25/19, documented monitor voiding every shift, if no void may straight cath every shift for [MEDICAL CONDITION]. A Nursing Progress Note dated 7/26/19, documented resident continues to have [MEDICAL CONDITION], Medical Doctor (MD) notified, positive relief with straight cath, continue to bladder scan every shift if residual greater than 250 than resident is to be catheterized. If concerns persist will follow up with Urology. A Physicians order dated 7/28/19, documented give [MEDICATION NAME] Capsule 0.4 milligrams (mg) by mouth 1 time a day for [MEDICAL CONDITION], monitor voiding every shift, if no void may straight cath every shift for [MEDICAL CONDITION], document and monitor urine output each shift and document every shift for [MEDICAL CONDITION]. Daily Nursing progress notes from 7/26/19 to 8/21/19, documented the continued need for bladder scanning and straight cath procedure for [MEDICAL CONDITION] three times a day. A Nursing Progress Note dated 8/21/19 at 5:19 PM, documented the resident was seen by Urology for [MEDICAL CONDITION], continue [MEDICATION NAME], scanning and intermittent straight catherization three times a day. Resident has follow up appointment scheduled. Daily nursing progress notes from 8/21/19 to 9/9/19, documented continued need for bladder scanning and straight cath procedure for [MEDICAL CONDITION] three times a day. A Nursing Progress note dated 9/9/19 at 6:02 PM, documented the resident was seen by Urology. Continue bladder scan and straight cath if needed. Supra pubic catheter being considered. Follow up in 3 weeks. A Physicians Order dated 9/13/19, documented straight cath three times a day for [MEDICAL CONDITION] if residual is greater than 300 mls. A Physician order [REDACTED].> 400 ml. A Physician order [REDACTED]. Follow up with urinalysis (test for infection in the urine) after antibiotic is completed. An electronic Treatment Administration Record (eTAR) dated (MONTH) 2019, documented, resident had bladder scan every day, every shift due to [MEDICAL CONDITION], straight cath if amount greater than 250 mls. It documented the resident was straight cathed 54 times from 9/1/19 to 9/31/19. Daily nursing progress notes from 9/9/19 to 10/9/19, documented continued need for bladder scanning and straight cath procedure for [MEDICAL CONDITION] three times a day. An eTAR for (MONTH) 2019, documented, bladder scan every day, every shift due to [MEDICAL CONDITION], straight cath if amount greater than 400 mls. It documented the resident was straight cathed 10 times from 10/1/19 to 10/9/19. An electronic Medication Administration Record [REDACTED]. It documented the resident received the antibiotic 19 times from 10/1/19 to 10/10/19. An eMAR dated (MONTH) 2019, documented [MEDICATION NAME] Capsule 0.4 mg by mouth 1 time a day for [MEDICAL CONDITION]. It documented the resident received the medication 10 times from 10/1/19 to 10/10/19. Review of the resident's record did not include a CCP that addressed the resident's needs associated with the [DIAGNOSES REDACTED]. During an interview on 10/8/19 at 11:08 AM, RNM #5 stated there were no care plans in place for the [DIAGNOSES REDACTED]. She stated there should have been one in place with goals and patient specific interventions after this was identified to be a diagnosis. Bladder scanning and straight catheterization of the resident began in (MONTH) 2019. Treatment had changed course several times, resident was seen by Urology, and the resident currently had a Urinary Tract Infection [MEDICAL CONDITION] being treated with an antibiotic. During an interview on 10/9/19 at 1:35 PM, the Director of Nursing (DON) stated she expects CCP's to be developed by the Registered Nurses at the time the [DIAGNOSES REDACTED]. Resident #221: The resident was readmitted to the facility on [DATE], following a post-acute hospital stay with admitting [DIAGNOSES REDACTED]. In most cases, [MEDICAL CONDITION] embolism is caused by blood clots that travel to the lungs from the legs), Systematic [MEDICAL CONDITION] Response Syndrome (SIRS) of Non-Infectious origin (SIRS is an [MEDICAL CONDITION] state affecting the whole body) and [MEDICAL CONDITION]. The MDS dated [DATE], documented the resident has severe impaired cognition, could sometimes understand others and sometimes made self-understood. A review of the resident's Comprehensive Care Plan (CCP) did not include the resident's [DIAGNOSES REDACTED]. A Nursing Note dated 8/18/19, documented the resident was transferred to the hospital for an acute change in condition. A Provider note dated 8/23/19, documented the resident was re admitted from the hospital with a [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. During an interview on 10/09/19 at 2:47 PM, Registered Nurse Manager #1 stated there should be a CCP for the resident's [DIAGNOSES REDACTED]. The whole point of the CCP is to paint a picture of the resident's care needs and to make sure they are being met. 10NYCRR415.11(c)(1)

Based on medical record review and staff interviews during an abbreviated survey (Case #NY 790), the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically, on 1/7/16, Resident #3 spilled hot coffee on herself and sustained first degree burns, and on 2/22/16, Resident #1 spilled hot tea on hreself and sustained second degree burns. Facility Administration failed to recognize there was no Policy and Procedure, or staff education for preparing hot liquids to residents. This resulted in actual harm to Resident #1, with the potential to effect all residents in the facility who could take food and fluids by mouth, and resulted in Immediate Jeopardy to Resident Health and Safety and Substandard Quality of Care. This was evidenced by: Refer to F 323 - Quality of Care - Scope/Severity I Resident #3: This resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed that the resident was usually able to understand others, was able to be understood by others, and had moderately impaired cognition. The MDS also documented the resident required one person supervision for eating. A Resident Incident Report (RIR) dated 1/7/16 at 10:10 am, documented the resident was unable to hold a coffee cup and dropped it on her lap, while seated in the resident dining room. The resident sustained [REDACTED]. Immediate interventions taken documeted that the resident was to be re-evaluated by Occupational Therapy. Resident #1: This resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed that the resident was usually able to understand others, was usually able to be understood by others, and had moderately impaired cognition. The MDS also documented the resident required setup help for eating. A Resident Incident Report (RIR) dated 2/22/16 at 5:30 pm, documented the resident had yelled out, and on inspection, her pants were wet and warm, and her groin was red with thin skin peeling off. The resident's family and the physician were notified. The report also documented the resident had impaired cognition, and had sustained a superficial burn. The resident had told a Licensed Practical Nurse (LPN) that the cup of tea had fallen on her, while in the dining room. The 24 Hour Condition Sheet dated 2/22/16, documented the resident had yelled out, and on inspection, he pants were wet and warm, and her groin was red with thin skin peeling off. The resident's family and the physician were notified. A Physician order [REDACTED]. The 24 Hour Condition Sheet dated 2/23/16, documented the resident had a second degree burn to the left thigh (groin area). Blisters were present and the skin was peeling. A Nurse Practitioner's Note dated 2/24/16, documented the resident had a Stage 2 burn to the left groin. Interviews: During an interview on 2/26/16 at 2:20 pm, the Acting Director of Nursing (ADON) stated any staff were allowed to prepare hot drinks for the residents, and she was not aware of any training provided staff regarding hot drink safety. She also stated the facility did not have a Policy and Procedure regarding preparing hot drinks, or heating water on the unit-based stoves or in microwaves. During an interview on 2/26/16 at 5:00 pm, the Director of Risk Management (DRM) stated she was the coordinator for Quality Assurance (QA). She stated incidents on RIRs were documented on the nursing report and QA reviewed them. The DRM reviewed the RIR for Resident #3 dated 1/7/16, and stated she was not aware of the incident. The facility did not have a Policy and Procedure (P&P) for hot beverage temperatures, but after the incident with Resident #1 on 2/22/16, the facility was discussing creating a P&P. During an interview on 2/29/16 at 9:20 am, the Administrator reviewed the RIR for 1/7/16, and stated she recalled seeing the incident on report, but did not consider the potential risks to other residents. After Resident #1 was burned by a cup of hot tea, she was concerned that anyone on staff could prepare hot drinks on the unit-based stoves or in microwaves, and they were discussing developing a Policy and Procedure and educating staff. She also stated that no facility-wide changes to preparing hot drinks for residents had been implemented after the 1/7/16 or 2/22/16 incidents. 10 NYCRR 415.26

Based on observation, record review and interviews during an abbreviated survey (Case #NY 790), the facility failed to ensure that the resident environment remains as free of accident hazards as possible and that each resident receives adequate supervision to prevent accidents. Specifically, the facility failed to have an effective system in place to monitor the temperature of hot liquids being served to residents from unit kitchens for 7 (Units 1, 2, 3, 4, 5, 6 and 7) of 7 units with unit-based kitchens. Subsequently, on 1/7/16 Resident #3 spilled hot coffee on herself and sustained 1st degree burns. On 2/22/16, a resident received 2nd degree burns, when they spilled a cup of tea served to them from the unit kitchen. Additionally, the facility lacked policies/procedures and staff education on monitoring the temperature of liquids served from the unit kitchens. This resulted in actual harm to one resident (Resident #1) with the potential to effect all residents in the facility who could take food and fluids by mouth, and resulted in Immediate Jeopardy to Resident Health and Safety and Substandard Quality of Care. This was evidenced by: Resident #3: This resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed that the resident was usually able to understand others, was able to be understood by others, and had moderately impaired cognition. The MDS also documented the resident required one person supervision for eating. A Resident Incident Report (RIR) dated 1/7/16 at 10:10 am, documented the resident was unable to hold a coffee cup and dropped it on her lap while seated in the resident dining room. The resident sustained [REDACTED]. Immediate interventions taken documented that the resident was to be re-evaluated by Occupational Therapy. The 24 Hour Condition Sheet dated 1/7/16, documented the resident spilled hot coffee in her lap. Redness was noted on her stomach, abdomen and thigh. During an interview on 2/29/16 at 9:20 am, the Administrator stated that she had seen this resident's 1/7/16 burn incident on the morning report, but she saw this as an isolated incident and did not review the facility's system for serving hot beverages to residents. During an interview on 2/29/16 at 9:42 am, Registered Nurse Manager (RNM) #1 stated she was aware of the 1/7/16 incident, but at that time did not think to consider the facility's system for giving resident's hot beverages. On 1/7/16, the resident was drinking coffee provided her from the unit-based coffee machine when she dropped it in her lap. There was no sytem in place to check coffee temperatures, and staff were expected to use common sense in making sure the coffee was not too hot for any individual resident. This incident was documented on the 24 Hour Condition Sheet, and signed by each staff member on each shift to ensure they were aware this resident dropped her coffee. She stated she did not know if other staff (non-nursing staff) read 24 Hour Condition Reports. RNM#1 stated RIRs were discussed in morning report with either the Director of Nursing (DON) or the Assistant DON (who was the Acting DON at the time of the interview) but could not recall which, or that the 1/7/16 incident specifically had been discussed. Resident #1: This resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed that the resident was usually able to understand others, was usually able to be understood by others, and had moderately impaired cognition. The MDS also documented the resident required setup help for eating. The Comprehensive Care Plan (CCP) for Self Care Deficit, with a review date of 10/12/15, documented the resident required supervision for meals. A Nurses Note dated 2/22/16 at 6:53 pm, documented this resident dropped a cup of hot beverage on her lap. The resident had a 10 centimeter (cm) long, and 10cm wide red area on her left upper thigh, and a layer of skin had peeled off. The physician was notified and ordered Bacitracin and a dry dressing to the area. The 24 Hour Condition Sheet dated 2/22/16, documented the resident had yelled out, and on inspection, her pants were wet and warm, and her groin was red with thin skin peeling off. The resident's family and the physician were notified. A Resident Incident Report dated 2/22/16 at 5:30 pm, documented the resident had yelled out, and on inspection, her pants were wet and warm, and her groin was red with thin skin peeling off. The resident's family and the physician were notified. The report also documented the resident had impaired cognition, and had sustained a superficial burn. The resident had told a Licensed Practical Nurse (LPN) that the cup of tea had fallen on her, while in the dining room. A Nurse Practitioner's Note dated 2/23/16, documented the resident had a burn to her left groin area as a result of a hot beverage spill. The burn was to be treated with Silvadene and a dressing. A Physician order [REDACTED]. The 24 Hour Condition Sheet dated 2/23/16, documented the resident had a second degree burn to the left thigh (groin area). Blisters were present and the skin was peeling. A Nurse Practitioner's Note dated 2/24/16, documented the resident had a Stage 2 burn to the left groin. The facility's Investigative Report dated 2/26/16, documented that on 2/22/16 at 5:30 pm, this resident had dropped a cup of hot tea in her lap, resulting in a 10cm by 10cm red area to the left upper thigh. The investigation found that a Certified Nursing Assistant (CNA) had heated water in a pot on the stove and served the resident a half cup of hot tea. The CNA had stated the water was not boiling, then she gave the tea to the resident. The resident then dropped the tea in her lap and yelled out. The CNA had also stated that she always heats water for 2 or 3 residents at one time. After this incident the resident was issued a sippy cup. The form was signed by the Acting Director of Nursing (ADON) and the Administrator. During an interview on 2/26/16 at 10:37 am, the ADON stated hot water for tea was prepared on the unit-based stoves and in microwaves, and that hot water temperatures were not obtained before giving the tea to residents. She stated the plan to prevent recurrence for this resident was to supply her with a sippy cup. During a follow-up interview on 2/26/16 at 1:36 pm, the ADON stated the facility was at that time discussing a policy regarding hot beverages, and that staff were still allowed to prepare hot tea on the unit-based stoves and in microwaves for residents. During an interview on 2/26/16 at 2:20 pm, the ADON stated on 2/22/16 staff heated water on the unit-based stove to make tea for this resident. She stated the water was not boiling, but when the resident received the tea, she spilled it on herself and she sustained a second degree burn. The ADON stated the facility issued this resident a sippy cup to prevent recurrence, but had not yet implemented changes to prevent similar occurrences in the facility. She also stated that all staff were allowed to prepare hot drinks for the residents, and she was not aware of any training provided staff regarding hot drink safety. She also stated the facility did not have a Policy and Procedure regarding preparing hot drinks, or heating water on the unit-based stoves or in microwaves. During an interview on 2/26/16 at 3:40 pm, the Food Service Director (FSD) stated he thought hot beverages could be served to residents between 150 and 175 degrees. The FSD stated he had not provided training to the unit or nursing staff on the units, only to dietary staff. He also stated that he did not participate in morning meetings and was not aware of an incident involving a hot beverage until 2/26/16. During an observation on 2/26/16 at 4:02 pm, on Mt. Carmel Unit, the tea kettle on the stove began to whistle and the Resident Care Coordinator stated that she was going to prepare and serve tea to a resident. The Food Service Director (FSD) took the temperature of the hot water, and the FSD stated the temperature was 176 degrees. During an interview on 2/26/16 at 5:10 pm on Unit 5, CNA #11 stated she used a pot on the stove to heat water for this resident's tea, and prepared her tea in this manner everyday. After Resident #1's incident, she was told to serve the tea tepid. CNA #11 stated that she continued to use a pot to boil water and had not received any other direction on hot beverage serving. During an interview on 2/29/16 at 9:55 am, the resident's physician stated the resident had sustained second degree burns from spilling hot tea on herself. The wound was being treated with Silvadene, and the resident did not appear to be in pain any longer, although documentation had shown she was in pain at the time of the incident. Additional Interviews: In an interview on 2/26/16 at 2:35 pm, on Mt. Carmel Unit, Light Duty Technician (LDT) stated that she prepares hot beverages for residents. The LDT stated that if a resident requests hot tea, she places the tea kettle on the stove, waits for the kettle to whistle and then serves the tea. The LDT stated that she may have been trained on serving temperatures when she first started, however does not recall. The LDT stated she does not know the temperature of the hot beverages she serves to residents. In an interview on 2/26/16 at 2:45 pm, on Mt. Carmel, a Unit Assistant (UA) stated that she prepares hot tea for resident using a tea kettle. The UA stated that she waits for the tea kettle to whistle and then serves the residents. The UA stated that she has not been trained on hot beverage temperatures and does not take temperatures of the hot beverages before serving them. In an interview on 2/26/16 at 2:50 pm, on Mt. Carmel, Certified Nurses Assistant (CNA) #1 stated that she prepares hot water to be served to residents by waiting for the water to boil. CNA #1 stated that she delivers the hot beverage to the resident immediately and does not take a temperature. CNA #1 stated she is unaware of any complaints or issues with hot beverages. In an interview on 2/26/16 at 2:55 pm, on Carmel Gardens, CNA #2 stated that she prepares hot water in the microwave for one minute. CNA #2 stated she is unaware of the temperature of the water when she serves it. In an interview on 2/26/16 at 2:57 pm, on Carmel Gardens, the housekeeper stated that she prepares hot water for tea for the residents. The housekeeper stated that she sets the time on the microwave for no more than a minute, because the residents have dementia and they can't handle hot here. In an interview on 2/26/16 at 3:00 pm, on Carmel Gardens, CNA #3 stated that she prepares hot water for tea in the microwave, sets the microwave timer at one minute, but lets it stand for a bit, because it is too hot. In an interview on 2/26/16 at 3:05 pm, on Carmel Gardens, CNA #4 stated that she prepares hot water for tea in the microwave and sets the timer for 30 seconds because ours gets hot quick. CNA #4 stated that she does not take the temperature of the water before serving it, has not been trained recently on serving temperatures, but didn't think that she was serving the beverage super hot. In an interview on 2/26/16 at 4:02 pm, on Mt. Carmel, Resident Care Coordinator #1 stated that she prepares hot water in the kettle on the stove. RCC #1 stated that she waits for the kettle to whistle. RCC #1 stated after removing the kettle from the stove top, she would prepare and serve the resident. In an interview on 2/26/16 at 4:40 pm, on Unit 2, CNA #5 stated that she prepares hot water for residents on the stove and waits until the water makes noise before serving the residents the hot beverage. CNA #5 stated that she does not take temperatures of the hot beverage. In an interview on 2/26/16 at 4:45 pm, on Unit 2, CNA #6 stated that she heats water in a pot on the stove and waits for the water to steam/boil before taking the pot from the stove and serving the residents. CNA #6 stated she does not know the temperature of hot beverages before serving residents. In an interview on 2/26/16 at 4:50 pm, on Unit 3, CNA #7 stated she uses an automatic beverage dispenser to heat water for tea and does not know the temperature of the hot beverage before serving it to residents. In an interview on 2/26/16 at 4:55 pm, on Unit 3, CNA #8 stated she places water in the microwave and heats it for two minutes before serving the hot beverage to the residents. In an interview on 2/26/16 at 5:00 pm, on Unit 4, CNA #9 stated she heats water in the microwave for hot tea for residents. CNA #9 stated that she feels the cup to make sure it is not too hot. In an interview on 2/26/16 at 5:05 pm, on Unit 4, CNA #10 stated he heats water in the kettle on the stove and waits for it to boil to make tea for residents. CNA #10 stated he lets the water sit, but does not know the temperature of the water when he serves it to residents. In an interview on 2/26/16 at 5:20 pm, on Unit 5, RCC #2 stated that no changes had been made yet to serving residents hot beverages. In an interview on 2/26/16 at 5:25 pm on Unit 6, CNA #12 stated a kettle is used to prepare hot water, but she does not know the temperature of the water when she serves it to residents. In an interview on 2/26/16 at 5:30 pm, on Unit 6, CNA #13 stated she uses a kettle for hot water and she waits until it whistles. CNA#13 stated she does not know the temperature of the water when she serves it to residents. 10 NYCRR 415.12(h)(1)

Based on record review and staff interviews during an abbreviated survey (Case #NY 790), the facility failed to provide a Quality Assurance (QA) program that readily and effectively identified issues with the potential to cause serious harm to the health and safety of residents. Specifically, on 1/7/16, Resident #3 spilled hot coffee on herself and sustained first degree burns, and on 2/22/16, Resident #1 spilled hot tea on herself and sustained second degree burns. The facility QA program failed to identify that there was not an effective system in place to monitor the temperature of hot liquids served to residents from unit-based stoves and microwaves. This resulted in actual harm to one resident (Resident #1) with the potential to effect all residents in the facility who could take food and fluids by mouth, and resulted in Immediate Jeopardy to Resident Health and Safety and Substandard Quality of Care. This was evidenced by: Refer to F 323 - Quality of Care - Scope/Severity I Resident #3: This resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed that the resident was usually able to understand others, was able to be understood by others, and had moderately impaired cognition. The MDS also documented the resident required one person supervision for eating. A Resident Incident Report (RIR) dated 1/7/16 at 10:10 am, documented the resident was unable to hold a coffee cup and dropped it on her lap while seated in the resident dining room. The resident sustained [REDACTED]. Immediate interventions taken documented that the resident was to be re-evaluated by Occupational Therapy. The 24 Hour Condition Sheet dated 1/7/16, documented the resident spilled hot coffee in her lap. Redness was noted on her stomach, abdomen and thigh. During an interview on 2/29/16 at 9:42 am, Registered Nurse Manager (RNM) #1 stated she was aware of the 1/7/16 incident, but at that time did not think to consider the facility's system for giving resident's hot beverages. She stated RIRs were discussed in morning report with either the Director of Nursing (DON) or the Assistant DON (who was the Acting DON at the time of the interview) but could not recall which, or that the 1/7/16 incident specifically had been discussed. Resident #1: This resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE], assessed that the resident was usually able to understand others, was usually able to be understood by others, and had moderately impaired cognition. The MDS also documented the resident required setup help for eating. A Resident Incident Report (RIR) dated 2/22/16 at 5:30 pm, documented the resident had yelled out, and on inspection, her pants were wet and warm, and her groin was red with thin skin peeling off. The resident's family and the physician were notified. The report also documented the resident had impaired cognition, and had sustained a superficial burn. The resident had told a Licensed Practical Nurse (LPN) that the cup of tea had fallen on her, while in the dining room. The 24 Hour Condition Sheet dated 2/22/16, documented the resident had yelled out, and on inspection, her pants were wet and warm, and her groin was red with thin skin peeling off. The resident's family and the physician were notified. A Physician order [REDACTED]. The 24 Hour Condition Sheet dated 2/23/16, documented the resident had a second degree burn to the left thigh (groin area). Blisters were present and the skin was peeling. A Nurse Practitioner's Note dated 2/24/16, documented the resident had a Stage 2 burn to the left groin. Interviews: During an interview on 2/26/16 at 2:20 pm, the ADON stated any staff were allowed to prepare hot drinks for the residents, and she was not aware of any training provided staff regarding hot drink safety. She also stated the facility did not have a Policy and Procedure regarding preparing hot drinks, or heating water on the unit-based stoves or in microwaves. During an interview on 2/26/16 at 5:00 pm, the Director of Risk Management (DRM) stated she was the coordinator for Quality Assurance (QA). She stated incidents on RIRs were documented on the nursing report and QA reviewed them. The DRM reviewed the RIR for Resident #3 dated 1/7/16, and stated she was not aware of the incident. The facility did not have a Policy and Procedure (P&P) for hot beverage temperatures, but after the incident with Resident #1 on 2/22/16, the facility was discussing creating a P&P. During an interview on 2/29/16 at 9:20 am, the Administrator reviewed the RIR for 1/7/16, and stated she recalled seeing the incident on report, but did not consider the potential risks to other residents. After Resident #1 was burned by a cup of hot tea, she was concerned that anyone on staff could prepare hot drinks on the unit-based stoves or in microwaves, and they were discussing developing a Policy and Procedure and educating staff. She also stated that no facility-wide changes to preparing hot drinks for residents had been implemented after the 1/7/16 or 2/22/16 incidents. 10 NYCRR 415.27(a-c)

Based on record review and interview during the standard recertification survey, the facility did not provide the necessary care, and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, for one (#317) of three residents reviewed for death. Specifically; there was a lack of timely Medical Doctor (MD) notification of the resident's persistent, frequent, and loose bowel movements. Additionally, there was a lack of monitoring of the resident's stools by facility nursing staff who continued to administer bowel medications (a laxative and stool softener), despite the resident's persistent, frequent, and loose bowel movements, and did not notify the MD timely, of the recurring diarrhea. The resident was subsequently admitted to the hospital with [REDACTED]. This is evidenced by: The facility policy titled Change in Resident Health Status Notification (Change in Condition), last updated on 8/8/14, documented under the heading Guidelines for Notification of Physician: #6. nausea, vomiting or diarrhea that is recurring, abdominal distention with complaint of pain. Resident #317: The resident was admitted on [DATE], with the [DIAGNOSES REDACTED]. diff) (a bacteria which releases toxins that may cause diarrhea),[MEDICAL CONDITION] (a whole body [MEDICAL CONDITION] response to an infection), and oral thrush (a fungal/yeast infection that occurs in the mouth). The Minimum Data Set ((MDS) dated [DATE], assessed the resident as able to understand and to be understood, with a Brief Interview of Mental Status (BIMS) score of 6 out of 15, severe cognitive impairment. On 3/13/15, Physician orders [REDACTED]. [MEDICATION NAME] (a [MEDICATION NAME] supplement with beneficial bacteria that helps the digestive system work better) and [MEDICATION NAME] (a laxative solution used to stimulate bowel movements) 17 grams (gm) mixed in 8 ounces (oz) of fluid daily for constipation: [MEDICATION NAME] (a medication used to treat constipation and help soften stools) 100 milligram (mg) capsule orally, two times a day for constipation; and [MEDICATION NAME] (an antibiotic used to treat infections of the intestines that cause diarrhea) 5 milliliters (mls) orally every 6 hours until 3/24/15. On 3/30/15 at 9 am, MD orders documented: Discontinue the [MEDICATION NAME] capsules and start [MEDICATION NAME] liquid 5 mls twice daily. On 4/9/15 at 12:45 pm, an MD order documented to send the resident to the hospital for evaluation due to elevated blood pressure and respiratory distress. A review of Laboratory tests done on 3/19/15 documented: BUN (blood urea nitrogen, a measure of kidney function) = 29 elevated (10-25 is normal); Creatinine level (measure of kidney function) = 1.28 elevated (0.5-1.2 normal); Sodium level (electrolyte) = 144 (135-145 normal); Potassium level (electrolyte) = 4.3 (3.5-5.0 normal); Chloride level (electrolyte) = 110 (98-110 is normal). The resident's Bowel Records dated 3/31/15 through 4/9/15, documented: 3/31/15 - 1 loose bowel movement. 4/1/15 - 3 large, loose bowel movements. 4/2/15 - 3 large, loose bowel movements, 1 medium loose bowel movement, and 1 small loose bowel movement. 4/3/15 - 2 large, loose bowel movements and 1 medium bowel movement. 4/4/15 - 4 large, loose bowel movements, and 1 large bowel movement. 4/5/15 - 5 large, loose bowel movements, 1 large bowel movement, and 1 medium loose bowel movement. 4/6/15 - 3 large, loose bowel movements. 4/7/15 - 3 large, loose bowel movements, 1 large bowel movement, and 1 medium loose bowel movement. 4/8/15 - 4 large, loose bowel movements, 1 medium loose bowel movement, and 1 small bowel movement. 4/9/15 - 3 large, loose bowel movements. The Nursing progress notes dated 3/18 through 4/9/15 documented: 3/18/15- received an antibiotic (C. diff), had no loose stools, fair appetite and fluid intake. 3/23/15 - completed a course of antibiotic and temperature 98.1 degrees. 4/2/15 at 10:44 pm - caregiver stated resident is having large loose stools in the evenings and perianal area (the strip of skin between the anus and genitals) getting red. PeriGuard (a skin protectant ointment) applied. The resident was given [MEDICATION NAME] every morning. On 4/4/15 at 10:44 pm, the Certified Nurse Aide (CNA) reported foul smelling stools, mucous form and yellowish color. The Registered Nurse Supervisor (RNS) was made aware. On 4/5/15 at 6:58 am, the resident had a temperature of 98.2 degrees, and loose stools on one occasion. On 4/5/15 at 12:49 pm, appetite and fluid intake very poor for the shift. Very loose, watery stools two times. Refused Immodium (a medication used to treat and control diarrhea), and spit it out. On 4/5/15 at 11:53 pm, temperature 98.1 degrees. Nausea, refused supper and medications, poor fluid intake, and loose stools one time, foul smelling and yellowish in color. On 4/7/15 at 3:24 pm, made aware by the night shift nurse and CNA about this resident with loose stool. According to POC (the facility's computer system), the resident had been with loose stool daily, and multiple times in a 24 hour period. The resident was admitted to the facility with resolved [DIAGNOSES REDACTED] and had completed [MEDICATION NAME] (antibiotic) treatment through 3/24/15. MD was notified, message left and awaiting a call back with recommendations. Resident placed on precautions until determined. On 4/8/15 at 5:17 am, resident in bed the entire shift, no complaint offered. On 4/8/15 at 3:10 pm, stool sample collected and sent to lab, rule out [DIAGNOSES REDACTED]. The resident was incontinent of a very large loose bowel movement. The Speech Therapist was with resident for a long time trying to feed her without any result. It was noted that the resident was not swallowing and was refusing to eat or drink. On 4/8/15 at 10:36 pm, awaiting lab results for repeat [DIAGNOSES REDACTED]., on precautions, refused medications, would not open mouth, and had difficulties at meal with no swallowing, and pocketing of both food and drink. Temperature 98.6 degrees (normal) . On 4/9/15 at 6:46 am, a late nursing progress note dated of 4/8/15, documented a new MD order to collect a stool specimen to rule out [DIAGNOSES REDACTED], due to loose stools and history of resolved [DIAGNOSES REDACTED]. On 4/9/15 at 1:49 pm, the resident had signs and symptoms of respiratory distress. Oxygen (O2) saturation was at 45% (normal range 95%-100%). Resident was pale, with labored mouth breathing, and not responding to verbal, and tactile stimulation. Alert x 2 (to person and place). Resident put to bed with foot of bed elevated. O2 was applied via nasal cannula (a device used to deliver supplemental oxygen or airflow to a person) at 2 liters with readings ranging from 98-100% with noted desaturations. The resident's blood pressure was difficult to obtain and recorded at 261 over 170. Pulse was 78, and irregular, ranging from 58 to 86 beats per minute. Respirations at 40 (normal range 14 to 18 respirations a minute)and labored. Temperature of 96.8 Fahrenheit. MD was made aware. New order to send to the hospital for evaluation, dependant on the family's decision. The resident's daughter was notified and agreed to send resident to hospital for evaluation. Resident left the facility via ambulance at approximately 1:15 pm. On 4/9/15 at 10:36 pm, resident was admitted to the Intensive Care Unit (ICU) in the hospital with shock. The facility's 24 Hour Condition Sheets for the date range of 4/2 through 4/9/15, documented the following information: 4/2/15, evening shift, loose stools every evening, on [MEDICATION NAME], and perianal area was red/sore. 4/4/15, evening shift, temperature 98.9 degrees, foul smelling stool with mucous that was yellow in color. 4/4/15, night shift, temperature 98.2 degrees and loose stool one time. 4/5/15, day shift, spit out most medications, had loose stools two times. On evening shift, temperature was 98.1 degrees, nausea along with poor appetite and fluid intake, and loose stools one time. On the night shift, temperature 98.0 degrees and no complaints. 4/8/15, day shift, stool sample obtained for the lab (to rule out [DIAGNOSES REDACTED]). Resident not eating, drinking, or swallowing. On the evening shift, temperature was 98.6 degrees, refused medications, refused dinner, was pocketing and wouldn't open mouth, and would not swallow. On the night shift, no loose stool. 4/9/15, day shift, resident in respiratory distress, with cyanosis (bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood) at lunch. O2 saturation was 45%. Pale, respirations 40, and a blood pressure 261 over 170. Resident was responsive to name and touch. O2 was applied at 2 liters per minute via nasal cannula. Pulse range between 58 to 86. Resident sent to the hospital. The Medication Administration Record [REDACTED] [MEDICATION NAME] 17 gm mix with 8 oz fluid daily starting on 3/14/15 daily at breakfast. [MEDICATION NAME] 100 mg cap every day with supper starting on 3/14/15 and then changed on 3/30/15 to liquid. [MEDICATION NAME] and [MEDICATION NAME] were given to the resident daily as ordered. The MAR for April 2015 documented that [MEDICATION NAME] and [MEDICATION NAME] were given as ordered except on 4/5/15, 4/8/15 and 4/9/15, when the resident spit out or refused the medications. The Hospital ER report form dated 4/9/15, documented shortness of breath and lethargy as the present illness and [DIAGNOSES REDACTED]. diff. The Diagnostic Laboratory test results documented: White Blood Cell (measure of infection) count = 33.2 (elevated) (4.0-10.6 normal); Sodium =149 (elevated) (135-145 normal); Potassium = 2.9 (very low) (3.5-5.0 normal); Chloride = 113 (elevated) (98-110 normal); BUN = 79 (elevated) (10-25 normal); Creatinine = 4.56 (elevated) ( 0.5-1.2 normal). During an interview on 08/12/2015 at 1:28 pm, CNA #1 stated she vaguely remembered the resident, thought the resident had [DIAGNOSES REDACTED] smelling stools at times, but not always. She stated she did let nurses know the resident was having loose stools, but could not remember when. During an interview on 8/12/2015 at 1:32 pm, CNA #2 stated she remembered vaguely a lady who had[DIAGNOSES REDACTED], and foul smelling, loose stool. She stated that when you changed this resident, she was soiled with loose stools and she let the nurse know of the loose stools. She also stated that at the end of the resident's stay, her stools were getting worse. During an interview on 8/12/2015 at 1:37 pm, the resident's day Licensed Practical Nurse (LPN), stated she thought the resident was on precautions when she first came in. She stated that when the resident got here, she was not eating as well, then started eating more, and having more bowel movements, and that we had to keep changing her. She stated that over time, the resident was having more of the loose stools. She reported to the Registered Nurse (RN) about the loose stools. She stated that the resident had loose stools almost daily. She also stated that sometimes loose stools were put in the nursing notes if there was a complaint of nausea. She additionally stated that if the resident was off the [MEDICATION NAME], and continued to have loose stools, it should be in the nurse's notes. She stated she would not notify the doctor (about the loose stools), but the RN would do that. She stated we could do it, but usually the RN does it. She also stated she did not remember ever calling the doctor about the resident's loose stools. The resident did not take in a lot of food or fluid. She also stated that she did not look at food/fluid intake records daily. She stated the resident was not a good drinker, and that most of her drinks on record were Mighty Shakes (frozen supplements designed to provide extra nutrition, protein and calories). During an interview on 8/12/2015 at 2:33 pm, the Registered Nurse Manager (RNM) stated the resident had some loose stools when she came to the nursing home, but that these did not have odor or mucous. She stated when the stools got more extensive, the staff did a stool test. She also stated that she did not remember if they ever got stool results. She was asked when she was first was made aware of the loose stools, to which she looked at the nurse's notes and said she was made aware on the 7th of April by the 11:00 pm to 7:00 am nurse. She stated she called the doctor, and was awaiting a call back. She stated the order came in on 4/8/15 for a stool specimen for [DIAGNOSES REDACTED]. The RNM was shown the facility 24 Hour Report sheets. She stated on 4/2/15, when the 24 Hour Report noted the loose stools, they should have called the Doctor then. She stated she was on vacation from 3/31/15 to 4/6/15. She also stated the LPNs on 4/4/15 and 4/5/15, could have called the doctor about the loose stools or could have called an RN. She stated she should have picked up on the loose stools on the 6th, when she got back. She stated nurses should have contacted the MD sooner than when she got back from vacation. On 8/13/15, at approximately 8:40 am, the RNM stated that nurses could use nursing judgement to hold [MEDICATION NAME], when a resident was having loose stools. During an interview on 8/13/2015 at 8:31 am, the MD stated he did not write a note every time nurses notify him of anything. He did not recall being notified when the loose stools became more than one time a day for this resident. The MD was shown the bowel record that documents loose stools increasing on 4/1 and 4/2/15. He stated when the loose stools became more frequent he should have been notified, so he could decide what to do. He stated that if something was clinically changing, he should have been notified. He also stated that because of the resident's [DIAGNOSES REDACTED] history, the resident should have been monitored more closely for her bowels. The MD said the nurses should have held the [MEDICATION NAME] when the resident's loose stools became more frequent, and then should have let him know so he could make a decision on the [MEDICATION NAME]. He stated that loose stools will play havoc with electrolyte balance. He also stated that when someone becomes septic, they compensate with breathing. He stated he could not say that the loose stools [MEDICAL CONDITION], it takes less than 6 hours to go [MEDICAL CONDITION]. During a telephone interview on 8/13/2015 at 9:42 am, the evening shift RN Supervisor, who worked on 4/4/15, stated she could not remember this resident. When the 4/4/15 nursing progress note was read to her, she stated she would normally call the doctor for that many loose stools. She stated if she knew (of the loose stools) she could not imagine not calling the doctor, and that at 10:44 pm, change of shift time she might not have been the person notified. 10NYCRR415.3(e)(2)(ii)(b)

Based on medical record review and staff interviews (Case #NY 714) it was determined for one (Resident #1) of two residents reviewed for skin integrity, that the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, the resident was found by the Licensed Practical Nurse (LPN) to have an open area between two toes and another area with an ecchymosis (bruising) that streaked from the toe up the foot. This information was forwarded to the registered nurse supervisor(RNS), who did not assess the resident, did not initiate a skin tracker sheet or notify the physician. A treatment, previously ordered, to be done every shift, was completed without removing the resident's sock. The resident's weekly skin check was not documented as being completed. The resident was found, twelve days later, with a dressing on the resident's foot, with foul odor and severe discoloration of the left foot. The resident was transferred to the hospital and admitted with gangrene to the left foot. In addition, the hospital diagnosed the resident with [MEDICAL CONDITION]. This resulted in actual harm to Resident #1. This is evidenced by the following: Facility policy titled "Pressure Ulcer - Prevention & Care Planning" dated 2/2/02 and revised 8/23/09 documented under the section titled "Discovery & Documentation" that the caregiver who first notices an open area reports the area to a licensed nurse on duty; the licensed nurse observes the area and notifies the RNS and places the information on the 24 hour condition report. The RNS assesses the area and determines the course of treatment; initiates the Pressure Ulcer Tracker Sheet; documents in the nurses notes; documents on the 24 condition sheet; instructs the LPN to transcribe treatment orders, outlining specific steps to follow and ensures treatment is as ordered and prescribed tasks are followed; ensures appropriate measures have been initiated and documented. The primary registered nurse assesses the resident in relation to the presence of pressure ulcers, reviews initial documentation for accuracy and completeness, enters the open area as a separate problem on the care plan, creates a special care plan with measurable objectives and time tables, revises the aide assignment card to reflect the presence of pressure ulcers and new interventions if necessary, completes a pressure ulcer check list, re-assesses the resident's response to treatment weekly and documents the findings on the tracker sheet, evaluates the outcome of the treatment plan and revises the care plan as needed, completes weekly quality assurance tracker and send to the nursing office. Resident #1: The resident was admitted to the facility with [DIAGNOSES REDACTED]. The resident's comprehensive care plan titled "Potential for skin breakdown" initiated on 12/2/04 and last revised 9/13/13, documented the following interventions: the resident's skin would be assessed every shift, keep skin clean and dry, treat any open area according to house protocol or physician order, heels up in bed, dietary consult as needed, promote adequate food/fluid intake, do not elevate head of bed more than thirty degrees, give medications as ordered, give supplements as ordered, turn and position every two hours and as needed, keep bed linens free of wrinkles, monitor available labs, toileting program specific to resident routine, provide incontinence care, apply briefs and perineal care. Nurse's notes dated 10/6/13 at 8:30 am documented that the "care giver notified LPN#1 that the left foot had a bloody area between the third and fourth toes with a small slit/open area noted. Area was cleansed, gauze place for comfort." Additionally noted, was a linear ecchymosis on the second toe. Nurse's notes dated 10/7/13 at 7:00 am documented that the left foot dressing was intact, slit like open area between third and fourth toe, linear ecchymotic second toe unchanged during the night, resident has not exhibited any sign of discomfort. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"Skin prep to heels every shift". This was signed for everyday by the nursing staff. An additional entry titled "Nurse do skin check with weekly shower" was not signed as completed on 9/17/13. There was no treatment documented for the area found on 10/6/13 on the residents left foot. The physician orders [REDACTED]. Podiatry progress notes dated 9/30/13 (untimed) revealed no documentation of any open areas on the resident's foot. physician progress notes [REDACTED]. A facility form titled "Resident Incident Report" dated 10/6/13 at 8:30 am documented that the care giver noted blood on the sheet and the left foot area bleeding. Between the third and fourth toes a small open area was noted, a four by four was placed between the toes. The second toe was observed with a linear ecchymotic area. It was documented that the area was cleansed with gauze placed between the toes. The form was signed by an RN, as the person who completed the assessment. There was no documentation of an assessment in the resident's medical record by the RN. Nurse's notes dated 10/19/13 at 12:17 am documented that the resident was noted with left foot redness, necrotic area to third and fourth toes,and red streak from the foot up to the knees. Temperature 100.9 degrees (98.6 normal). Nursing supervisor and physician aware. The resident was sent to the emergency room . An additional note by the RN supervisor on 10/19/13 at 1:21 am documented the left foot with a large necrotic area along the third and fourth toes. Foot with [MEDICAL CONDITION] and redness throughout the ankle and a streak running from the foot up the leg. Warm to touch. Sent to hospital for treatment. The hospital form titled "History & Physical" dated 10/19/13 at 2:53 am documented that the facility sent the resident to the hospital because of a gangrenous left foot and the resident was febrile (fever). The facility noticed the foot condition and thought it was getting worse. There is no recent injury. The facility was unable to provide documentation that the resident's left foot was being monitored, assessed, or treated; or that the physician had been notified of the left foot open area and ecchymotic streak findings on 10/6/13, until the foot was noted to have necrotic areas on 10/18/13 at 8:45 pm. The statement documented by LPN # 2 dated 10/18/13 at 7:00pm included " At 7:00pm the aide reported that there was a dressing that needed to be changed on the resident's toe. It appeared old and there was reddened areas to the left lower extremity and swelling. I looked in the treatment book and there was no dressing documented. I took the old dressing off after irrigating the gauze because it was stuck to the residents skin. When I took the dressing off there was brownish black drainage on the gauze and the wound. During an interview on 10/28/13 at 12:15 pm LPN#1, who discovered the wound on 10/6/13, stated she noticed the area on the second toe, it had an ecchymotic streak and between the third and fourth toes there was an open area. She stated she put a dressing on the area. When asked about the skin checks being done, she stated it was missed. When asked about the skin prep being applied every shift, she stated the staff don't take the resident's sock s off. The LPN stated she was responsible to put the treatment in the MAR During an interview on 10/28/13 at 1:00 pm the RCC (Resident Care Coordinator) stated that on 10/6/13 the area was identified and that LPN#1 reported it to the RN Supervisor who did an incident report. A skin tracker form should have been started. She stated that staff said they removed the resident's socks everyday. When doing the heel treatments, they only lifted the heel of the sock off. She also stated that on the shower day, the aide forgot to get the nurse, and later asked the nurse if there were any changes, and the aide said no. An investigation was started when the area was noted on 10/19/13. 10 NYCRR 415.12

Based on medical record review and staff interviews during a complaint investigation (Case #NY 914), the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of two residents reviewed. Specifically, the facility did not ensure that Resident #1 was transferred in accordance with the manufacturers instruction for a Sabina Lift which allowed the resident to slide out of the lift during a transfer causing fractures to both legs. Additionally, the facility did not ensure that the Sabina Lift was in proper working order. This resulted in actual harm that is not immediate jeopardy. This is evidenced by the following: Resident #1 was admitted to the facility 2/8/07 diagnosed with [REDACTED]. The Minimum (MDS) data set [DATE] assessed the resident with severe cognitive impairment. Sabina II Manufacturer's Instructions documented the resident's feet should be placed in the middle of the foot rest with the shins parallel to the lower leg support, adjustments to the height and depth of the lower leg support should be made as needed for comfortable support below the knee cap and that the calf strap should be tightened. The facility policy titled Lift: Mechanical Sit to Stand last revised 5/21/07 documented that mechanical lifts will be used to prevent injuries of residents and staff during transfers from a sitting to standing position, stand pivot transfer and then back to a sitting position. The policy documented the step by step procedure to use the equipment and included "secure the leg strap of the Sabina". Resident #1s Care Card (undated) documented the resident required the Sabina lift and one care giver to assist in all transfers. Nurse's note dated 12/11/11 at 10:15 pm signed by Registered Nurse (RN) #1 documented that she was called to assess Resident #1 and observed the resident sitting on the floor and according to staff the resident slid out of the Sabina lift and was assisted to the floor. RN #1 documented that Resident #1 was complaining of right lower extremity pain with movement. RN #1 documented that pain in the right leg upon movement was usual per staff. The Nurse's note dated 12/12/11 at 7:00 am signed by Licensed Practical Nurse (LPN) #2 documented Resident #1 was lowered to the floor, continued to complain of right knee pain, 650 (mg) of Tylenol was administered with some effect. The note further documented that at 6:30 am, right knee was swollen and painful to touch. A Registered Nurse assessed the resident. A Transfer Form dated 12/12/11 (untimed) documented that the chief complaint/medical history documented that the resident was lowered to the floor on 12/11/11 at 10:15 pm during a transfer and the left knee is now very swollen, deformed and very painful with limited range of motion. An Incident Report signed by the Resident Care Coordinator (RCC) dated 12/12/11 documented on 12/11/11 at 10:20 pm Resident #1 was lowered to the floor during a sabina lift transfer, complained of right leg pain, was transferred to the emergency room and diagnosed with [REDACTED].#1)was aware of the missing clip. The Physician order [REDACTED]. Right knee deformed, swollen and painful. Roxanol 10 milligrams (mg) injection now for severe pain. In a statement prepared for the facility investigation, CNA #1 documented that she was assigned to Resident #1 on 12/11/11 and had transferred the resident with the same lift two other times during the shift prior to this incident. CNA #1 documented that she prepared the resident to be lifted the same way she always does and documented that she did not use the leg straps because it was broken, that it was broken all shift and that she could not recall when the leg straps were last working properly. CNA #1 documented that she noticed during the transfer that Resident #1's foot was not really on the foot rest but that she could not assist the resident because the resident would fall and just then, the Resident lost her grip of the lift. CNA #1 documented that she called for the Licensed Practical Nurse (LPN) who immediately responded and they decided to lower Resident #1 to the floor. CNA #1 documented that Resident #1's right leg was behind her left leg and when she and LPN #1 attempted to move her leg, Resident #1 screamed so they continued to lower the resident to the floor and Resident #1 sat on her right leg and her left leg was out straight after they moved the lift. In a statement prepared for the facility investigation, LPN #1 documented that she was called by CNA #1 to Resident #1's room on 12/11/11 and observed the resident up in the Sabina lift with her legs slightly turned in. LPN #1 documented that she directed CNA #1 to lower the resident to the floor, noted that the resident's feet were not properly straped and was not aware that the Sabina lift was broken. In a statement prepared for the facility investigation, CNA #2 documented that she stood the resident up at 2:00 am on 12/12/11, the resident complained of mild pain, no more than usual. CNA #2 documented that she stood the resident up again for care at 6:00 am at which time the resident complained of more pain and after calling the nurse, CNA #2 and the nurse noticed swelling to the right knee. CNA #2 documented that she lifted the resident both times the way she normally does, documenting that she does not use the bottom leg strap and therefore was unaware of the missing clip. The X-ray report for Resident #1 dated 12/12/11 documented fractures involving the distal femur of both the right and left leg which extend down to and involve the total knee replacements. During an interview on 12/29/11 at 1:15 pm, the RCC stated that she was informed about the incident on 12/12/11 and began the Incident and Accident Report and the investigation into the circumstances of the incident. The RCC stated that she began to interview staff and discovered that the lift had been serviced by maintenance one week prior as the up and down controls were malfunctioning. The RCC stated of the eight CNAs that she interviewed, 7 staff were not using the legs straps duing transfers with the Sabina lift and therefore reported to her that they did not know that the straps were broken. The RCC stated that two CNAs informed her that they routinely used the leg straps during transfers, however, about a week prior to the incident, they observed that the straps were broken, did not report the broken straps to anyone and continued to transfer residents using the lift. The RCC stated that she was not aware that the leg straps were broken and determined through her investigation that acutally, the straps were missing a clip to secure the straps during transfer. During an interview on 12/29/11 at 2:45 pm, the ADON stated that the lift should have been used in accordance with the manufacturer's instructions and the facility policy and realized through the investigaiton, that in most cases, CNAs were not using the lift properly. The ADON stated that she was not aware that the lift was broken and that upon observation of a malfunction, the lift should have been taken out of service and sent to maintenance for repair. 10NYCRR415.12(h)(1)

Based on medical record review and staff interviews during a complaint investigation (Case #NY 315), the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of two residents reviewed. Specifically, the facility did not ensure that Resident #1 was ambulated with the assistance of one person and a gait belt affixed to the resident as directed by the resident's plan of care. The resident was allowed to walk without hands on assistance and fell , sustaining multiple facial fractures. Although the care plan instructed the resident was a one assist for ambulation, there was confusion among staff members regarding the use of a gait belts and hands on contact while ambulating the resident. This resulted in actual harm that is not immediate jeopardy. This is evidenced by the following: Resident # 1 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE], assessed the resident as having severely impaired cognitive ability. The MDS further assessed the resident to require extensive assist of one for transfers and limited assist of one for ambulation on the unit. In a document titled, "Investigation of (Resident # 1) observed on the floor" the author documented that on 9/13/11 at approximately 1:40 pm Resident # 1 was observed on the floor, in the hallway adjacent to the dining room. First aide was administered and the resident was transported to the local hospital and diagnosed with [REDACTED].#1) did not use a gait belt on the resident while ambulating her and the care plan was not followed, which potentially may have contributed to the resident being observed on the floor. In a hospital discharge summary dated 9/26/11 the hospitalist dictated that Resident #1 had been sent to the hospital on [DATE] for evaluation after she was found on the floor at the nursing home. The resident's emergency room evalaution revealed facial and orbit fractures and the resident was admitted for appropriate care and treatment. Under the ambulation section of Resident # 1's CNA (certified nursing assistant ) assignment card (the card that instructs staff on the care required for each individual resident) dated 8/1/11, staff are instructed that the resident required the assistance of one person for ambulation with a wheeled walker and needs constant cueing (verbal direction)to use the walker properly and reach destinations. A facility policy titled "Transferring Residents," dated 12/18/95 and revised on 3/30/09 documented in the "notes" section of the policy, "All residents requiring hands-on assist will be transferred using a gait belt. In the "Sit to Stand: Assist of 1" section: the policy documents, "1) staff will be in front of resident facing the resident. 2) staff will move the resident forward to the edge of the w/c or bed. 3) staff will instruct resident to place hands on the bed/armrest to push up. Staff will grasp the gait belt already in place around the resident. The facility "Ambulation Procedure "policy, dated 1/2/01 and revised on 3/05/08, documented that each resident will be ambulated by staff according to the specific instructions indicated on the GT ( geratric technician)(CNA) assignment card. The procedure section of the policy instructed staff to review the GT assignment or nursing care plan before attempting to ambulate the resident; to place a gait belt around the resident and assist to stand.; once standing instruct the resident to grasp the assistive device; staff should guard the resident and will keep hold of the gait belt; staff should give verbal cues to the resident; staff will not rush the resident and when ambulation is completed staff may remove the gait belt. On an "Employee Warning Notice" dated 9/19/11, the author wrote, "On 9/13/11 a certified nursing assistant (CNA#1) was ambulating a resident who required one-assist with ambulation. According to policy, one-assist required the use of a gait belt which was not being used at the time. Moments after CNA #1 turned away from the resident to push a chair in, the resident was observed on the floor. In the "corrective action" section of this warning notice the author wrote that the CNA was suspended for three days without pay and was re-inserviced about the policy of using a gait belt with residents who require a "one-assist ambulation." During an interview on 9/22/11 at approximately 10:00 am the facility Director of Nursing stated that a facility policy instructed that all residents who require any assistance for ambulation, more than supervision, are to have a gait belt on during ambulation. Staff receive instruction on this policy during orientation and then are inserviced again periodically during their employment at the facility. During an interview on 9/22/11 at approximately 9:15 am, a Resident Care Coordinator (RCC # 1) stated that based on statements from staff members that were present on 9/13/11 when the resident fell , she had learned that CNA # 1 had assisted Resident # 1 out of a chair in the dining room and the resident was ambulating in the corridor but CNA # 1 had not placed a gait belt on the resident. Resident # 1 fell in the corridor and was transferred to the local hospital. The RCC stated that CNA # 1 would be suspended for not following the resident's care plan and would receive a written warning. During an interview on 10/13/11 at approximately 12:30pm, a registered nurse charge nurse (RCN) stated that Resident #1's care card (GT assignment card) instructed staff the resident was a one assist for ambulation. RCN stated all staff know that if a resident is a one assist (for ambulation) then staff should be walking the resident using a gait belt and staff should be holding on to the gait belt. The RCN stated that was the facility policy, that all "one-assists" residents have gait belts on while walking and added that she assumed that's how staff were walking with Resident # 1. During an interview on 10/13/11 at approximately 1:30pm, a certified nursing assistant (CNA #1) stated that on 9/13/11 at approximately 1:30pm she entered the resident dining area and saw Resident # 1 (who had been sitting at her table) attempt to stand unassisted. CNA # 1 approached the resident, moved the resident's walker in front of her and placed the resident's hands on the walker. She then asked the resident to take a few steps forward. CNA # 1 recalled that there was a chair in their way and as she turned away from the resident to move the chair, she heard a "thump" and turned back to see that the resident had fallen face-down on the floor. CNA # 1 stated she had not placed a gait belt on the resident to assist her as she walked and she was not holding onto the resident when she fell . CNA#1 admitted that she knew Resident #1 was a one assist for ambulation. When asked why she would not have used a gait belt to hold onto the resident as she walked with her she responded, "No one (meaning other staff) uses a gait belt when they walked (Resident #1)." During an interview on 10/04/11 at approximately 4:45 pm, a CNA (CNA # 2) stated that she always used a gait belt when she walked with Resident # 1. During an interview on 10/04/11 at approximately 5:00pm a CNA (CNA # 3) stated that she always used a gait belt on Resident # 1 when she walked with her. During an interview on 10/04/11 at approximately 5:15pm, a licensed practical nurse (LPN#1) stated, "We don't use a gait belt when we walk Resident # 1." During an interview on 10/13/11 at 12:15 pm LPN # 2 stated that if any resident's care card says "one assist" we always use a gait belt to walk the resident because that's the policy. When asked about ambulating Resident # 1, LPN # 2 stated, that the resident did not need a gait belt and that staff did not hold on to (Resident # 1) when they walked with her. LPN#2 added that Resident # 1 only needs cueing when she walks. When LPN # 2 was asked why it was documented on the resident's care card "one assist" for ambulation LPN #2 stated, "I can't explain why the care card says one assist, because we don't use a gait belt to walk (Resident # 1). 10NYCRR 5.12(h)(1)

Based on observation, record review and staff interview, during the partial extended abbreviated survey (Case #NY 799), it was determined that for 8 (#s 6, 7, 8, 9, 10, 11, 12 and 14) of 16 residents reviewed, the facility did not ensure that the resident environment remained as free of accident hazards as possible. Specifically, the facility did not ensure that residents were assessed/reassessed for the safe use of wheelchair Velcro safety belts and protected from accidents, including entrapment, related to the use of safety belts and did not evaluate the risks and/or benefits for use of the devices. Resident #6 was found entrapped in the wheelchair by the safety belt and sustained rib fractures. The facility did not ensure that Resident #9 who had a swallowing impairment was supervised during meals. This resulted in actual harm for Resident #6, with the potential for more than minimal harm that was not immediate jeopardy. This was evidenced by: 1. Resident #6 A Velcro seat belt was in use with this resident when she was in a wheelchair and there was no evidence of assessment/reassessment for the appropriateness of safety belt use. There was also no documentation of resident/resident representative education of the risks and benefits of safety belt use. Subsequently, a resident was found entrapped in the wheelchair by the safety belt and sustained rib fractures. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident to have had short term memory impairment, intact long term memory and as moderately impaired in cognitive decision making skills. The resident was assessed as requiring the extensive assistance of one staff member for transfers. The use of trunk restraints or a chair to prevent rising were not documented on this MDS. The Comprehensive Care Plan (CCP) for Falls, dated 12/13/09 documented that the resident had a history of [REDACTED]. The Fall Risk assessment dated [DATE] documented that the resident had more than one fall in the previous 30 days and more than one fall in the previous 31 to 60 days. The resident was assessed to have cardiovascular, sensory and cognitive risk factors that could contribute to fall risk. The resident was assessed to be at moderate risk for falls. The undated Resident Care Card, used by certified nurse aides (CNAs) to provide resident care, documented that the resident was at risk for falls and was to have an alarmed safety belt when in the wheelchair. The Policy and Procedure (P&P) titled, Restraint/Device Screen with a review date of 8/10/09, documented that there was to be a record system in place for residents who were to receive a restraint and/or device. Staff were to document the basis for the determination to use the device, the nature of the device and the resident's functional status in relation to the device. The resident's functional status in relation to the device was to be documented in order to establish whether the device constituted being a restraint or a therapeutic intervention. A registered nurse (RN) was to screen a resident to determine their functional status and/or need for the device. The medical record revealed that there was no assessment of the resident's functional status (ability to safely use the safety belt) or need for the device. There was also no documentation that the resident or the resident's representative was notified of the risks and benefits of safety belt use. A Resident Incident Report (I&A) dated 7/3/10 at 8:30 pm, documented that this resident was found on the floor in her room. The resident was on the floor next to her wheelchair and the alarmed safety belt was sounding. The resident was not independent in ambulation or transfers and was unable to give a report of this incident due to cognitive impairment. A nurse's note dated 9/2/10 at 3:30 pm, documented that this resident was found sliding out of her wheelchair. The safety belt was in place and was preventing the resident from falling to the ground. The resident was lowered to the floor and complained of rib pain. The physician was notified and an order was obtained to have the resident's ribs x-rayed. A nurse's note dated 9/2/10 at 9:00 pm, documented that the chest x-ray revealed fractures of the fifth and sixth ribs on the resident's left side. An I&A dated 9/3/10 documented that on 9/2/10 at 2:20 pm, the resident was sliding from her wheelchair, the safety belt was in place holding the resident. Injuries were documented as lower left fifth and sixth rib fractures. The Contributing Factors section of the I&A documented that the resident was mentally impaired due to a [DIAGNOSES REDACTED]. The x-ray Final Report dated 9/2/10 and electronically signed by a physician, documented that the resident was found to have fractures of the lower left fifth and sixth ribs. During an interview with the Primary RN on 11/10/10 at 3:11 pm, she stated that this resident had a history of [REDACTED]. The resident was provided with a Velcro safety belt when in her wheelchair as a reminder not to stand up by herself. On 9/2/10 the resident slid from her wheelchair, the seat belt did not open and it held the resident in place, preventing her from falling to the floor. The Primary RN stated that the resident often leaned to one side or the other while in the wheelchair and often leaned over to pick things up from the floor. She stated that she was responsible for completing a Restraint/Device Screen on resident's prior to applying a Velcro safety belt, but did not perform the assessment on this resident. She also stated that she could not recall ever having a discussion with the resident or the resident's representative about the risks and benefits of safety belt use. The Primary RN reviewed the medical record and could not provide documentation that the resident was assessed for the use of a safety belt or that the resident's representative had been notified of the risks and benefits of safety belt use. During an interview with the Resident Centered Care Coordinator (RCCC) on 11/10/10 at 3:38 pm, she stated that this resident was small and had recently weakened and often slid down in her wheelchair. She stated that on 9/2/10, she was walking by this resident's room and saw that the resident had slid down in her wheelchair, the safety belt was in place and was around her rib cage. She called for help and a CNA and a Licensed Practical Nurse (LPN) arrived, released the safety belt and lowered the resident to the floor. When the safety belt was released, the resident began to slide more toward the floor and was held in place by the CNA. The RCCC stated that the safety belt had kept the resident from falling to the floor. A physician was notified and a chest x-ray was completed which showed that the resident had rib fractures. The RCCC stated that the Primary RN should have completed a Restraint/Device assessment on this resident, prior to the safety belt being applied and that the use of a seat belt with this resident was not discussed in the Interdisciplinary Team meeting. During an interview with the Assistant Director of Nursing (ADON) on 11/12/10 at 2:32 pm, she stated that assessments for the need for and the resident's ability to safely use a safety belt were to be completed prior to seat belts being placed on a resident. The resident and/or the resident's representative should have been notified of the risks and benefits of safety belt use and this should have been documented in the medical record. During an interview with the Physical Therapist (PT) on 11/15/10 at 1:18 pm, she stated that PT did not perform assessments on residents for the use of safety belts. She stated that PT occasionally made recommendations to nursing about the use of safety belts on various residents for positioning assistance. The PT stated that no recommendations had been made regarding safety belts and this resident. During an interview with the Occupational Therapist (OT) on 11/15/10 at 1:21 pm, she stated that OT did not perform assessments on residents for the use of safety belts, that this was the responsibility of the Nursing Department. During an interview with the physician on 12/9/10 at 12:40 pm, he stated that this resident was occasionally capable of removing her safety belt. He stated that he assumed nursing had performed an assessment of the resident for the appropriateness of the safety belt prior to applying it. 2. Resident #12 A Velcro seat belt was in use with this resident when she was in a wheelchair and there was no evidence of assessment/reassessment for the appropriateness of safety belt use. There was also no documentation of resident/resident representative education of the risks and benefits of safety belt use. The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] assessed the resident to have had short and long term memory impairment and as severely impaired in cognitive decision making skills. The resident was assessed as requiring the extensive assistance of one staff member for transfers and the use of trunk restraints or a chair to prevent rising were not documented on this MDS. The Fall Risk assessment dated [DATE] documented that the resident had orthopedic, sensory, behavioral, mood and cognitive risk factors that could contribute to fall risk. The resident was assessed to be at low risk for falls. The CCP for Falls, dated 2/5/09 documented that the resident was unsteady when walking related to impaired cognition. It was also documented that on 3/27/09, an alarmed safety belt was to be applied when the resident was in a wheelchair. The undated Resident Care Card, documented that the resident was at risk for falls and was to have an alarmed safety belt when in the wheelchair. The Policy and Procedure (P&P) titled, Restraint/Device Screen with a review date of 8/10/09, documented that there was to be a record system in place for residents who were to receive a restraint and/or device. Staff were to document the basis for the determination to use the device, the nature of the device and the resident's functional status in relation to the device. The resident's functional status in relation to the device was to be documented in order to establish whether the device constituted being a restraint or a therapeutic intervention. A RN was to screen a resident to determine their functional status and/or need for the device. Review of the medical record revealed that there was no assessment of the resident's functional status (ability to safely use the safety belt) or need for the device. There was also no documentation that the resident or the resident's representative was notified of the risks and benefits of safety belt use. During an observation on 11/12/10 at 8:42 am, the resident was sitting in her wheelchair in the dining area on her unit. The Velcro safety belt was secured around her waist. An LPN asked the resident four times to remove the safety belt, the resident did not appear to understand what she was being asked to do and did not remove the safety belt. During an interview with the LPN on 11/12/10 at 8:42 am, she stated that this resident did occasionally remove the safety belt but that she was not capable of following commands due to her dementia. During an interview with the ADON on 11/12/10 at 2:32 pm, she stated that assessments for the need for and the resident's ability to safely use a safety belt were to be completed prior to safety belts being placed on a resident. The resident and/or the resident's representative should have been notified of the risks and benefits of safety belt use and this should have been documented in the medical record. During an interview with the Physical Therapist (PT) on 11/15/10 at 1:18 pm, she stated that PT did not perform assessments on residents for the use of safety belts. She stated that PT occasionally made recommendations to nursing about the use of safety belts on various residents for positioning assistance. During an interview with the Occupational Therapist (OT) on 11/15/10 at 1:21 pm, she stated that OT did not perform assessments on residents for the use of safety belts, that this was the responsibility of the Nursing Department. 3. Resident #9 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] assessed the resident to have had short and long term memory impairment, and as severely impaired in cognitive decision making skills. The resident was assessed as requiring the one person physical assistance with eating. The CCP titled, Potential for Aspiration dated 9/14/09 and reviewed 8/25/10, documented that the resident had a history of [REDACTED]. The resident had a "questionable history of choking," osteoporosis and long term use of antipsychotic medications. One of the interventions listed on the CCP was that the resident was to be monitored during meal and drink times. The undated Resident Care Card, documented that the resident was to be assisted with and supervised during meals. The physician's orders [REDACTED]. The Policy and Procedure (P&P) titled, Meal Monitoring with a revision date of 1/6/10, documented that a LPN was to oversee the dining room during all meals. On 11/12/10 from 8:52 am until 8:59 am, this resident was observed sitting at a table in the dining room eating a meal. The surveyor monitored the dining room and the unit for the entire period and there were no staff members in the dining room or within sight of the dining room. At 9:00 am a social worker entered the dining room. During an interview with the Social Worker on 11/12/10 at 9:00 am, she stated that there was normally staff present when residents were eating in the dining room. The Social Worker stated that none of the three residents eating in the dining room at that time required supervision while eating. During an interview with a CNA on 11/12/10 at 9:18 am, she stated that staff did not normally remain in the dining room when residents were eating because there was always other work to be done. She stated that there was always staff walking by the dining room, so if there was ever a problem someone would likely have seen it and been able to react. During an interview with the ADON on 11/12/10 at 9:52 am, she stated that it was required that a staff member be in the dining room when residents were eating and a staff member should have been present while the residents were eating. 10NYCRR 415.12(h)(1)