Every finding on record at The Grand Rehabilitation and Nursing at Utica

Based on observations, interviews, and record review during the recertification survey conducted 5/27/2025 - 6/05/2025, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen. Specifically, following a wastewater back up from the grease trap and drains flooding the main kitchen on 5/27/2025, the facility failed to adequately address wastewater cleanup including monitoring, evaluating, and sanitizing as necessary, cooking equipment and appliances in the main kitchen. Additionally, there was no detectable level of sanitizer in the 3-bay sink and dishwasher to adequately sanitize dishware. This resulted in Immediate Jeopardy to resident health and safety for all 215 residents of the facility. Findings include: The facility policy Food Receiving and Storage, last reviewed 1/2025, documented the facility would maintain clean food storage areas at all times. The undated facility policy Sanitization, documented the food service area should be maintained in a clean and sanitary manner; all kitchens, kitchen areas, and dining areas should be kept clean, free from litter and rubbish; all equipment should be maintained in good repair; sanitizing of environmental surfaces must be performed with one of the following solutions: 50-100 parts per million chlorine solution, 150-200 parts per million quaternary ammonium compound, or 12.5 parts per million iodine solution; manual washing and sanitizing would employ a three step process for washing, rinsing, and sanitizing: sanitize with hot water or chemical sanitizing solution that consisted of chlorine 50 parts per million for 10 seconds, iodine 12.5 parts per million for 30 seconds, or quaternary ammonium compound 150-200 parts per million for time designated by the manufacturer. The policy's dishwasher specifications did not match those found on the facility dish machine. The undated facility policy Cleaning Dishes/Dish Machine, documented dishes and cookware were washed and sanitized after each meal and the dish machine gauges would be checked throughout the wash cycle to assure proper temperatures. Wastewater back up: During an observation and interview on 5/27/2025 at 10:43 AM, scattered areas of water were on the floor in the food preparation area of the main kitchen. The 3-bay sink area had a large amount of standing murky water. Staff were standing in the water while washing items in the sinks. The dish machine area had a large amount of water and food debris on the floor. Staff were trying to remove the standing wastewater into drains using a tool with a flat, smooth rubber blade (a squeegee). [NAME] #4 stated when the sinks drained, they would get backed up causing the water to come back out. They stated that did not happen often and there was a company out in the parking lot that was coming in to suck out the drain. Facility work orders documented the following: - On 3/21/2025 at 3:13 PM, the facility dish machine was clogged and not draining properly; this was closed out on 3/21/2025 at 5:53 PM - On 3/28/2025 at 10:49 AM, the 3-bay sink water not staying in when drains were closed; this was closed out on 5/28/2025 at 2:13 PM with the comment the vendor cleaned out the drains and grease trap. - On 4/25/2025 at 4:41 PM, sinks are backing up and flooding the floors; this was closed out on 5/28/2025 at 2:13 PM with the comment the vendor cleaned out the drains and grease trap. - On 5/20/2025 at 2:36 PM, the drain in the dish room was clogged. Additional notes included the drain was snaked and was only able to reduce the level of water in the 6-inch drain by almost a foot. The snake would have to be done again the next day and may need to be addressed by a professional plumber. This was closed out on 5/20/2025 at 6:40 PM. - On 5/26/2025 the grease trap and drain by the dish machine was backing up; this was closed out on 5/27/2025 at 11:42 AM with the comment the supervisor had been notified to contact an outside plumbing vendor. A 5/27/2025 septic and sewer vendor invoice documented the grease trap line was jetted and pumped; the tank was over full and had not been pumped in over a year. The vendor recommended pumping every two (2) months. The following observations were made in the main kitchen on 5/28/2025: - at 9:18 AM, a puddle of gray water was under the shelving of the middle walk-in cooler and floors were stained with dried food, debris and spills. - at 9:27 AM, puddles of wastewater were under the 3-bay sink with a floor fan blower unit left from drying the floors on 5/27/2025. - at 9:30AM, the cover to the grease trap located by the 3-bay sink was rusted and chipped. -at 11:58 AM, the fan by the side exit was blowing across the floor towards the cookline and walk-in coolers. Standing water in front of the 3-bay sink was visibly tracked into the walk-in coolers as staff wheeled carts in and out. The floor was wet from the 3-bay sink to the back exit, the walk-in coolers, the cookline, and through to the dish area. During an interview on 5/28/2025 at 11:45 AM, Dietary Aide #7 stated when they came in that morning at 7:00 AM, there was water backed up in the kitchen. The pipe was clogged under the 3-bay sink, which was on the same drain line as the dish machine. The water was backing up out of the drain under the dish machine and around the 3-bay sink from the black plate (rusty lid of the grease trap). They stated the water that had backed-up from the drains was not clean water, it contained all the liquids that drained from the dish machine and did not smell clean. There was a very strong odor when they opened the grease trap to clean it out. They stated to clean up the water, floors were mopped, squeegeed and a no rinse floor cleaner was applied. Everyone in the kitchen stepped in the water puddles and they assumed the water was tracked throughout the kitchen. During an interview and observation on 5/28/2025 at 12:01 PM, [NAME] #4 stated they worked on 5/27/2025 and the grease trap was clogged causing water to back up. The water was in the back corner of the kitchen, and they squeegeed it to the drain by the walk-in coolers and out the back door into the parking lot. The water came from the clogged grease trap. The water was not clean; it was gray in color and smelled when the grease trap cover was removed. The vendor came in and suctioned out the grease trap. Breakfast was prepared and served on 5/27/2025 during the wastewater back up and they continued to cook while the wastewater was being cleaned up. They tried to avoid the area to not track wastewater across the kitchen, but some did get tracked across the kitchen including the walk-in coolers, behind the cook line, under and around the prep tables and cooking equipment. They assumed there was some aerosolization (fine spray) of the wastewater as it was suctioned up and nothing was done to prevent it from spreading around the kitchen. After the drain was cleared, the lid was put back on and the floors were hosed down with the no rinse floor cleaner. They stated a good portion of the kitchen was washed and sanitized. A review of the no rinse floor cleaner product label did not document it sanitized or disinfected surfaces. The product's safety data sheet documented the product use was a floor cleaner and did not document it was a sanitizer or disinfectant. During an observation on 5/28/2025 at 12:01 PM, there was a dried pattern present on the parking lot where the liquid from the kitchen had previously flowed. The back exit passageway had dried debris and grease on the floor. During an interview on 5/28/2025 at 12:31 PM, the Director of Nutritional Services stated they worked 5/27/2025 and there was a backup in the grease trap in the kitchen. It started Sunday night, and because Monday was a holiday, the vendor was unable to come out until Tuesday. The trap backed up before and the company recommended the trap be cleaned every two (2) months, but Corporate only allowed it to be done every three (3) months. The backed-up water was not clean and smelled when the grease trap was opened. Staff continued to cook while the wastewater was cleaned up and stepped in the puddles and tracked the water where they walked including the food service and cook line areas, the coolers, and the storage rooms. After the drain was cleared, it was hosed down and squeegeed out the door. They washed and sanitized the floors in the walk-in coolers, under and around the food prep tables and cooking equipment. They stated to prevent the wastewater from being spread around the kitchen they tried to maintain the puddles and squeegee them out the door, but nothing was done to contain the spray. During an interview on 5/28/2025 at 2:41 PM, the Administrator stated they were made aware Monday night (5/26/2025) of the wastewater water backup in the kitchen by the Director of Nutritional Services but was unsure of the exact time. The vendor was called but was not immediately available to respond due to the holiday, and they would come the following morning. The vendor arrived Tuesday (5/27/2025) morning and fixed it. The kitchen was then cleaned per their policy. During an interview on 6/5/2025 at 10:07 AM, the Director of Nutritional Services stated the grease trap was supposed to be clean. The lid should not have been rusted. A vendor came in two (2) months ago and told them that chunks of rust were falling into the grease trap causing it to clog more often and recommended it be cleaned every two (2) months. They stated they overheard the vendor say the grease trap needed to be replaced. Dishwasher: The manufacturer's specifications listed on the facility's dish machine Model ADC-66 documented the following operational requirements: Hot water sanitizing: - final sanitizing rinse minimum temperature was 180 degrees Fahrenheit. - pumped rinse tank minimum temperature was 160 degrees Fahrenheit. - wash tank minimum temperature was 160 degrees Fahrenheit. Chemical Sanitizing: - final rinse minimum temperature was 120 degrees Fahrenheit. - pumped rinse tank minimum temperature was 120 degrees Fahrenheit. - wash tank minimum temperature was 140 degrees Fahrenheit. - sanitizer required: 50 parts per million available chlorine. - to convert from hot water sanitizing to chemical sanitizing, adjustments shall be conducted by the manufacturer or its authorized service agent. The March 2025 High Temperature Conveyor Style Dish Machine Temperature Log documented temperatures were to be taken 3 times a day with each meal served, breakfast, lunch, and dinner. The temperatures were not checked on 3/12/2025, 3/17/2025, and 3/31/2025. The April 2025 High Temperature Conveyor Style Dish Machine Temperature Log documented temperatures were not checked on 4/5/2025 at lunch and dinner, 4/6/2025, 4/20/2025, 4/24/2025, and 4/28/2025. The May 2025 High Temperature Conveyor Style Dish Machine Temperature Log documented the dish machine was broken from 5/16/2025 - 5/21/2025. There were no documented temperatures on 5/26/2025 and 5/28/2025 - 5/31/2025. During an interview on 5/28/2025 at 1:24 PM, Dietary Aide #9 stated the dish machine was supposed to be emptied between meals and the temperature was checked to make sure it was hot enough. They thought the temperature was supposed to be around 170-180 degrees Fahrenheit, and the rinse temperature was lower, but they were not sure and did not normally perform those checks. Temperatures should be documented but they were unsure if it was done today. During an observation on 5/28/2025 at 1:29 PM, the dish machine wash temperature was 142 degrees Fahrenheit, the final rinse gauge did not move and was stuck below 90 degrees Fahrenheit. During an interview on 5/28/2025 at 1:34 PM, the Director of Nutritional Services stated the dish machine was high temperature sanitization, but it was not heating up yesterday and they were told to use the chemical sanitizer. They did not have anything to check the level of sanitizer to know what the level was, and they were not aware of the required level of chemical sanitizer. The vendor who maintained the machine came in monthly, but they had not come in yet this month. During an observation on 5/28/2025 at 1:38 PM, the final rinse water was checked with a chlorine test strip, and it did not detect any chlorine. Confirmation was made the chemical in use was a chlorine-based sanitizer. During an observation on 5/30/2025 at 4:04 PM, the dish machine was not reaching required temperatures. The 5/28/2025 report from the commercial cleaning vendor documented a backup pump was installed for chemical sanitation to be used if the temperature of the dishwasher got below 180 degrees Fahrenheit. They recommended the use of chlorine sanitation if the temperature went below 180 degrees Fahrenheit. 3-Bay sink: The May 2025 3-compartment sink (3-bay sink) Log documented testing was performed on 5/29/2025-5/31/2025 and ranged from 200-400 parts per million with a standard of 200-400. No documented testing was performed prior to 5/29/2025. The June 2025 3-compartment sink parts per million log documented testing was performed on 6/1/2025 and 6/2/2025 and ranged from 200-400 parts per million with a standard of 200-400. During an interview on 5/28/2025 at 1:50 PM, Dietary Aide/Dishwasher #6 stated they did not do any sanitizer checks and thought it was regulated by the faucet for the right amounts. They did not know how to check the level of the sanitizer and had never seen it done. During an observation on 5/28/2025 at 1:51 PM, the sanitizer level in the sanitizing bay water of the 3-bay sink was measured with the surveyor's test strips. The strip was dipped for one second and after waiting 5-10 seconds, there was no change in color which indicated sanitizer was not detected. It was confirmed that the bottle attached to the pump was a quaternary sanitizer (type of disinfectant). The sanitizing equipment on the 3-bay sink was not working properly and dishes were not sanitized properly. During an interview on 5/28/2025 at 1:54 PM, the Director of Nutritional Services stated they did not do any sanitizer level checks on the 3-bay sink. During an observation on 5/28/2025 at 6:35 PM, sanitizer level was measured at the 3-bay sink and was over 500 parts per million; the required amount was between 200 and 400 parts per million. During an observation and an interview on 5/30/2025 at 11:32 AM, Dietary Aide #11 dipped a chemical test strip in the sanitizer water of the 3-bay sink. The strip turned a dark green which was darker than the darkest green on the chemical strip container's color chart. The darkest green on the color chart indicated the level detected was 400 parts per million. Dietary Aide #11 stated the results were normal. During an observation on 5/30/2025 at 5:22 PM, Dietary Aide/Dishwasher #6 was setting up the 3-bay sink. They drained the third sink, refilled it by adjusting both the black knob for the sanitizer pump and the faucet for the water. When tested, their test strip and the surveyor's test strip did not register any sanitizer. During an observation on 6/2/2025 at 4:36 PM, Dietary Aide #30 filled the 3-bay sink by turning on the cold water and the sanitizer pump. They stated, the test strip was yellow and not right. They checked the jug, which was visibly not pumping correctly with mostly air bubbling through, but they did not identify the jug was empty. The sanitizer level was tested with a result of 0-150 parts per million on the yellow end of the scale. During an interview on 5/28/2025 at 4:22 PM, the Administrator stated there was no way to know for sure if the dishes and equipment were properly sanitized if the dishwasher and 3-bay sink did not have sanitizer or a way to check the levels of chemical sanitizer. They had fixed the 3-bay sink and planned to wash dishes there until the dish machine was fixed. During an interview on 6/2/2025 at 12:15 PM, Dietary Supervisor #35 stated they used Knoxville (disinfectant) for sanitizer in the 3-bay sink and the levels on the test strips should have been between 200-400 parts per million. The Disinfectant+Sanitizer+Virucide product label documented the product was used as a sanitizer on dishes, glassware, utensils and on food processing equipment at 200-400 parts per million. Clean up: During an observation on 5/28/2025 at 2:40 PM, Dietary Aide #7 was preparing cut watermelon, and an unidentified staff member was preparing cold cuts. During an interview on 5/28/2025 at 6:07 PM, The Director of Nutritional Services stated the cold cuts served were sliced two days ago. When asked when the sanitizer stopped working in the 3-bay sink they stated yesterday there was pink stuff in there but did not know what the level was because they did not test it. They stated that they did not know what level was required to safely sanitize the dishes, nor did they have the means to test the level of sanitizer. They stated the slicer was cleaned and sanitized properly two days ago and was washed in the 3-bay sink. The wastewater began backing up on Sunday 5/25/2025 (three days prior). They stated it was barely backing up, was just bubbling a little and there were only small puddles. During an observation and interview on 5/28/2025 at 6:11 PM, the Administrator stated they were pulling the sandwiches from the food carts. Unidentified staff stated carts were sent to the 6th floor and were told by the Administrator to call the 6th floor, pull the carts back down, and not serve any of the sandwiches. During an observation on 5/28/2025 at 9:07 PM, the walk-in cooler had prepped watermelon, tuna fish, and large amounts of food prepped for service from earlier in the day. Lettuce and whole basil leaves were in the 2-bay sink opened and exposed. During an observation on 5/28/2025 at 9:17 PM, the Director of Nutritional Services voluntarily discarded the items from the walk-in coolers that were prepped in the kitchen over the past three days. At 9:26 PM, content of walk-in coolers was placed in garbage cans and discarded in the dumpsters. During an observation and interview on 5/29/2025 at 9:20 AM, the Director of Maintenance from a sister facility was hosing down racks outside in the back parking lot over a storm drain. They stated they were told to start hosing the racks down in the parking lot and they were unaware they could not be washed outside. They were unaware they were producing wastewater that had to be contained and disposed of properly. During an interview on 5/29/2025 at 9:33 AM, the Administrator and the Corporate Educator were unaware the wastewater could not go into the sanitary sewer in the parking lot. During a follow up interview on 6/5/2025 at 10:32 AM, the Director of Nutritional Services stated it was not okay to squeegee wastewater into the parking lot because it could contaminate the area, people walked through it, it was a high traffic area, and people were going in and out. They should not have dumped the wastewater into the public sewers because it could have polluted the sewers more than they already were. During an interview on 5/28/2025 at 2:41 PM, the Administrator stated the kitchen, silverware, dishes and utensil should have been cleaned with disinfectant daily and per their policy. If there was no sanitizer in the 3-bay sink and/or the dishwasher they were not sanitized properly which could cause bacteria to grow and the residents could get sick. If the food service area was contaminated by wastewater and it was not cleaned/sanitized properly bacteria could grow around the kitchen. If the 3-bay sink and dishwasher did not have sanitizer in them anything that went through them was not cleaned or sanitized properly. During an interview on 5/28/2025 at 2:45 PM, the Director of Nursing stated they were not aware of the wastewater back-up in the kitchen. If the food service production area was contaminated by wastewater the food could be contaminated and if served, the residents could get sick. The kitchen should be cleaned and sanitized with the proper sanitizer before food preparation. They should have been made aware of the issue so they could monitor for any resident illness. During a phone interview on 5/28/2025 at 2:45 PM, the Medical Director stated if residents received unclean plates or food, or there was improper sanitizing of the kitchen it could cause risk of gastroenteritis or infections. During an interview on 5/28/2025 at 2:59 PM, the Infection Control Nurse stated if the kitchen was not properly sanitized, pathogens could get to the residents and cause gastrointestinal issues. Everything should be sanitized, and they expected kitchen supervisors to know the proper means to do so and what the proper temperature and sanitizer ranges were. Food should not be prepared if the sanitization was not done, and they should have been notified so they could consult and educate if needed. NYCRR10 415.14(h) ___________________________________________________ An Immediate Jeopardy in F-812 was issued to the Administrator on 5/28/2025 at 6:22 PM. The Immediate Jeopardy was removed on 6/03/2025 at 5:39 PM prior to the completion of the survey. The facility performed the following steps to lift the Immediate Jeopardy: - As of 5/28/2025 at 10:22 PM, the facility's immediate plan was reviewed and accepted. - As of 5/30/25 at 10:46 AM the kitchen had been cleared and the facility was able to resume full use of the kitchen except for the dishwasher that had not been corrected. - As of 5/30/2025 at 4:00 PM, 85% of all food service and dietary staff had been educated on kitchen sanitation procedures. - As of 5/31/2025 at 3:45 PM, 100% of all food service and dietary staff had been educated on kitchen sanitation procedures. - Staff education was verified onsite during interviews on 6/2/2025. Multiple food service and dietary staff were interviewed to determine retention of education provided and were able to accurately report content of the education. - As of 6/03/2025 at 9:16 AM, staff was able to successfully demonstrate proper chemical sanitation level of 200-400 parts per million for the 3-bay sink for dishware sanitizing.

Based on observations, record review, and interviews during the recertification survey conducted 5/27/2025 -6/5/2025 the facility did not ensure a safe, clean, comfortable, and homelike environment for one (1) of one (1) main kitchen, and two (2) of seven (7) resident unit refrigerators (Units 3 and 6). Specifically, the main kitchen had multiple unclean surfaces, broken tiles and wall strips, food items were not labeled or dated, and the walk-in freezer had ice buildup; Units 3 and 6 refrigerators were outside acceptable temperatures for food safety; and the Unit 6 ice machine had white build up. Findings include: The undated facility policy Sanitization, documented the food service area would be maintained in a clean and sanitary manner. All kitchens, kitchen areas, and dining areas shall be kept clean and free from litter and rubbish. All utensils, counters, shelves, and equipment were to be kept clean, maintained in good repair, and were to be free from breaks, corrosions, open seams, cracks, and chipped areas that may affect their use or proper cleaning. Ice machines would be drained, cleaned, and sanitized per the manufacturer's instructions and facility policy. Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime. The facility policy Food Receiving and Storage, last reviewed 1/2025 documented food storage areas were to always be clean. When food was delivered it was inspected for safe transport and quality prior to being accepted. Non-refrigerated food, disposable dishware, and napkins were stored in dry storage which was temperature and humidity controlled, free of insects and rodents, and kept clean. All foods stored in the refrigerator or freezer would be covered, labeled, and dated. The facility policy Refrigerators and Freezers, last reviewed 1/2025, documented staff ensured safe refrigerator and freezer maintenance, temperatures, and sanitation. Acceptable temperature ranges were 35 degrees Fahrenheit to 40 degrees Fahrenheit for refrigerators and less than 0 degrees Fahrenheit for freezers. Monthly tracking sheets for the refrigerators included time, temperature, initials, and action taken. The action taken was only to be completed if the temperatures were not acceptable. Food service supervisors or designated employee checked and recorded refrigerator and freezer temperatures daily. The supervisor was to immediately act if the temperatures were out of range. Main Kitchen: The following observations were made in the main kitchen: - on 5/27/2025 at 10:27 AM, the refrigerator to the left of the entrance to the kitchen had 4 trays of clear liquid cups with lids and one tray of varying cups. The cups contained clear, yellow, and red liquids with no labels. The toaster had yellow dried splatter on the left side. The steam table had left over food debris in four out five of the pan holders and was cracked and peeling on the outer layer. The tray line had dried food splatters and the wall behind the tray line had orange dried splatter. The meat slicer had residual food on it, the stove had dried food, and the floor around the stove had dark residue. - on 5/27/25 10:43 AM the kitchen sink was dripping water while the taps were turned off. There was dried splatter on the underside and legs of the sink. The two-bay fryer had dark oil and old French fries on the right bay. There was a yellow-colored film on top of the oil. The left bay was empty and was covered with brown grease and grime. The front and underneath the fryer had dried platter. The big soup pot had dried splatter out the outside of the bowl and the unit itself. The floor grate in front of the soup pot had chunky white matter on it. The walk-freezer had ice buildup and food debris on the floor. The fridge to the left had a tray labeled Feeding prep 5/27 with 3 containers of cottage cheese that were not labeled or dated. The fridge to the right had 3 trays of meat on the bottom shelf in a clear bag that were not labeled, and a box of open bacon that was not labeled. - on 5/28/2025 at 9:18 AM, there was a stand mixer with food splatter, significant cooked on food debris in the deep fryer, and a puddle of gray water under the shelving in the middle of the walk-in cooler. The dry storage to the right of the cooler had stained floors with dried on food debris and spills. There were numerous broken floor tiles in the dish washing area and along the walls. One of the refrigerators had yogurt and whipped cream on the floor. The walk-in freezer had built up ice and debris on the floor. - on 6/3/2025 at 11:32 AM, the floor entering dry storage had a missing transition strip and the floor was cracked and peeling. There was a puddle of water under the wire rack in the dry storage and boxes of paper products on the floor. There were rust spots on the floor in the dry storage room next to the slicer. The corner wall strips on the wall between the dish machine and the tray line area were broken and peeling away from the wall. At 11:43 AM, the walk-in freezer floor had food debris and was sticky. The drain next to the 3 bay sinks was covered with duct tape and had chipped floor tiles around it. - on 6/3/2025 at 12:04 PM there were frozen oral nutritional supplements in a bin in double sink prep area with cold water running over them. [NAME] #4 stated they were trying to thaw them in time for lunch as they were delivered frozen. They were left unattended with water running over them. - on 6/3/2025 at 12:07 PM, Dietary Aide #9 checked the puddle of water under the wire rack in the dry storage. They stated they believed it was from the water gallons that were stacked nearby. The quality in which the gallons were shipped was not good. The third box from the bottom held the gallons of water and was saturated and falling apart. The two boxes below were also damp. The box second from the bottom had two of six gallons of water partially empty. - on 6/5/2025 at 10:09 AM the dry storage area next to the dietary services office had shelves with rust that housed paper products. During an interview on 6/5/2025 at 10:07 AM, the Director of Food Services stated they put in work orders for the chipped tiles, rusty surfaces, and corner protectors that were coming away from the wall. After the work order was placed, it was out of their hands. They stated they put the work order in around December 2024. They ensured those areas were clean by hosing them down and tried to squeegee them. They were looking to obtain a floor machine for a deeper clean. All surfaces should be cleanable. The fryers were cleaned at least once a week, twice if they were utilized a lot. It was important they were cleaned for safety, to prevent cross contamination and bacteria. There should not have been a buildup of grease on the fryer or old French fries. The floor drain was covered with duct tape as a wheel of a kitchen cart fell into it. Maintenance was informed and that was the fix they put in, but it should not be covered with duct tape. It was a safety issue. There should not be any rusty surfaces in the kitchen as it could fall into the food and cause harm. It was okay the oral nutritional had cold water running over the cartons, but they should not have been submerged in water as it could affect the product and make the cartons soggy. Some of the jugs in the dry storage were deflated and they should have been discarded. Wet boxes could mold and attract fruit flies. Units 3 and 6: The May 2025 temperature log for the Unit 3 resident refrigerator did have documented temperatures for 5/4/2025, 5/16/2025 to 5/18/2025, and 5/22/2025 to 5/23/2025. The temperatures of the refrigerator were above 41 degrees Fahrenheit for every day documented in May except 5/3/2025. During observations on 5/29/2025 at 9:30 AM, the refrigerator on Unit 3 behind the nurses' station thermometers read 52 and 46 degrees Fahrenheit. The upper back wall had ice buildup and the temperature setting in the refrigerator was set to 7, the warmest setting. The temperature log was filled out for every day except 5/16/2025-5/18/2025 and 5/22/2025-5/23/2025. All the temperatures documented ranged from 46-51 degrees Fahrenheit except for 5/3/2025 which was 40 degrees Fahrenheit. The refrigerator contained a bag of individual creamers, an undated bottle of creamer, 3 bottles of salad dressing, 5 juices, unopened bottles of oral nutritional supplement, 7 containers of snack pack puddings, and two packages of fish filets. The refrigerator had both staff and resident personal food items in it. During an interview and observation on 5/29/2025 at 9:30 AM Licensed Practical Nurse #5 stated the refrigerator behind the nurses' station was utilized for resident items. Refrigerator temperatures should be monitored daily and the one behind the nurses' station was monitored twice a day. The acceptable range for the refrigerator was on the temperature log. The temperature should not be above 41 degrees Fahrenheit. If the refrigerator was above 41 degrees, it would not be cold enough and the food could spoil. They expected if the refrigerator was out of the appropriate temperature range, it was reported to the supervisor. No one had reported any concerns with the refrigerator to them. The ice buildup should be taken care of by either maintenance or the kitchen staff. They checked the log to ensure the refrigerator temperatures were within range. They stated when they checked the log that morning, the temperature was a little over what it should be at 50 degrees Fahrenheit. The items in the refrigerator were probably not good but it was all staff items. They noted the setting of the temperature knob and turned it down. They stated the half and half creamers, juice, bottles of oral nutritional supplements, soda, and pudding were all resident items. The May 2025 refrigerator temperature log for the sixth floor documented the temperature range for the refrigerator was less than 41 degrees Fahrenheit; and notify the supervisor immediately if the temperatures were above standard. There were no documented temperatures recorded for 5/10/2025, 5/19/2025, and 5/21/2025. The temperatures were above 41 degrees Fahrenheit on 5/11/2025 at 50 degrees, 5/15/2025 at 51 degrees, 5/18/2025 at 58 degrees, and 5/23/2025 at 45 degrees. The May 2025 work orders for the sixth floor documented one work order related to the refrigerator prior to 5/29/2025 was on 5/22/2025 regarding the refrigerator needing a new lock. During observations on 5/27/2025 at 12:23 PM and 5/28/2025 at 9:21 AM, the Unit 6 ice machine had white buildup in the collection tray. There were no documented work orders for the Unit 6 ice machine. During an observation and interview on 5/29/2025 at 9:26 AM, the refrigerator on Unit 6 was 58 degrees Fahrenheit. The milk temperature was taken and verified with Registered Nurse Unit Manager #53 and was 55.8 degrees Fahrenheit. Registered Nurse Unit Manager #53 was unsure what the milk temperature was supposed to be. They stated the refrigerator should be under 40 degrees Fahrenheit. The thermometer in the read 57 degrees Fahrenheit and the housekeeper was there to clean the fridge shortly beforehand. Temperatures in the refrigerator were to be maintained so nothing spoiled, and staff should throw out anything that was not marked or dated. They were unaware of who checked the refrigerator temperature daily. During an interview on 5/29/2025 at 9:31 AM, Licensed Practical Nurse #52 stated dietary checked the refrigerator and the temperature of the refrigerator. At 10:08 AM, Licensed Practical Nurse #52 stated there was something wrong with the refrigerator as it had built up ice. During an observation on 5/29/2025 at 10:18 AM the thermometer in the Unit 6 refrigerator was moved to the top shelf and read 58 degrees Fahrenheit. During an interview and observation on 5/29/2025 at 10:41 AM, there were three temperature gauges in the Unit 6 refrigerator: one on the top shelf, one on the second shelf that read 52 degrees Fahrenheit, and one on the bottom shelf that read 54 degrees Fahrenheit. The butter in the sixth-floor refrigerator measured 66.6 degrees Fahrenheit in the presence of Certified Nurse Aide #60. Certified Nurse Aide #60 stated they were never educated on how to take a temperature and had never taken one before. If food was outside safe temperature ranges, residents could get sick. At 10:53 AM, the half and half dairy product measured 61.5 degrees Fahrenheit. During a follow up interview on 5/29/2025 at 10:55 AM Registered Nurse Unit Manager #53 stated the refrigerator temperatures were not appropriate as the refrigerator was supposed to be under 40 degrees Fahrenheit. They stated all food should be disposed of as residents could get sick if the food was not kept at the right temperature. During a telephone interview on 6/3/2025 at 2:14 PM, Dietary Aide #61 stated they delivered the nourishments in the morning. They were responsible for checking the temperature on the unit refrigerator. They were to look at the temperature gauge in the refrigerator and mark it on the log with their initials. The normal temperature for the unit refrigerators was between 30 to 40 degrees Fahrenheit. If the refrigerator was about 40 degrees Fahrenheit, the food would need to be disposed of, and they would have to inform their supervisor of the issue. The sixth-floor refrigerator was not functioning properly. They left some of the log days blank because the refrigerator was about 50 degrees Fahrenheit. They informed the Director of Food Service the refrigerator was not working. If the food was too warm, the residents could get sick. During an interview on 6/3/2025 at 2:32 PM, the Director of Food Service stated the refrigerators on the units were checked by dietary staff when they were stocked. The temperature of the refrigerator was documented on the log attached to the refrigerator. The temperature should be between 30 to 40 degrees Fahrenheit. If the refrigerator was out of range, they should throw out the items in the refrigerator and contact maintenance. They should be informed as well. Nothing was to go into the refrigerator until it was at the appropriate temperature. If the temperature was not recorded, it meant the temperature was not taken. It was important to check the temperature of the refrigerators to ensure the food did not spoil and people did not get sick. The third and sixth floor refrigerators were not working properly since the middle of May. They had been informed by a staff member the refrigerators were not working properly. The food items were disposed of, and maintenance was informed. They were unsure if a work order was placed but the nursing staff on the units were aware. They checked the temperature logs at the end of the month and then filed them. They had not reviewed the temperature logs for May yet. The temperatures taken on the third and sixth floor were out of range. The temperature should always be documented even if it was out of range and the items disposed of. 10NYCRR 415.14

Based on observations and interviews during the recertification survey conducted 5/27/2025-6/6/2025, the facility did not ensure residents were provided food and drink that was palatable, flavorful, and at an appetizing temperature for two (2) of (2) two meals reviewed (Lunch meals on 6/3/2025 and 6/4/2025). Specifically, food was not served at palatable and appetizing temperatures during the lunch meal on 6/3/2025 and 6/4/2025. Additionally, six residents (Resident #64, #103, #138, #152, #161, and #173) stated the food did not taste good and was cold. Findings include: Resident interviews included the following: - on 5/27/2025 at 10:59 AM Resident #103 stated the food was not good. - on 5/27/2025 at 11:44 AM, Resident #161 stated the food was not good and was warm. - on 5/27/2025 at 12:11 PM, Resident #173 stated the food was normally cold. - on 5/27/2025 at 12:17 PM, Resident #138 stated the food was not good and sometimes it was half cooked and sometimes it was raw. - on 5/27/2025 at 12:32 PM, Resident #152 stated they did not like the food except for the pudding. - on 5/28/2025 at 9:45 AM Resident #64 stated they did not receive the food they requested, and the food was never warm. They stated the dinner the prior evening was under cooked rice and hard shells. They stated their family member helped supply them with food for their room because they disliked the food. During an observation on 6/3/2025 at 1:45 PM, Resident #175's meal was tested in the presence of Licensed Practical Nurse #50. A replacement meal was ordered for the resident. Food temperatures and tastes were as follows: - Diced pears were 62 degrees Fahrenheit and tasted bland - Cranberry Juice was 55 degrees Fahrenheit - Apple Juice was 59 degrees Fahrenheit - Water was 63 degrees Fahrenheit - Cheeseburger was 120 degrees Fahrenheit, was lukewarm and tasted bland. - Mixed vegetables were 114 degrees Fahrenheit, were lukewarm and tasted bland. During an observation on 6/4/25 2:02 PM Certified Nurse Assistant #65 removed a tray from the meal cart stating a resident had refused their tray and it was available as a test tray. Food temperatures and tastes were as follows: - Zucchini and spaghetti/chicken cacciatore were bland tasting and warm - Fortified mashed potatoes were 125 degrees Fahrenheit - Zucchini was 130 degrees Fahrenheit - Spaghetti with chicken cacciatore in a red sauce was 132.9 degrees Fahrenheit. During an interview on 6/4/2025 at 2:09 PM Certified Nurse Assistant #65 stated when the meal cart arrived on the unit, they passed meal trays. When a resident complained of their food being cold, they heated it in the microwave for about one minute. They stated they were unsure what temperature hot foods and cold foods should be served. During an interview on 6/4/2025 at 2:12 PM Licensed Practical Nurse #49 stated the meal trays arrived on the enclosed carts and the food was transported on covered hot plates. Once they removed the food from the hotplate they served the resident. They stated if a resident complained about the food temperature, they reheated it in the microwave. During an interview on 6/5/2025 at 10:23 AM the Food Service Director stated test trays were completed by the dietary supervisors. During that process they removed a tray from the tray line to assure all item were present. They checked the temperature of the tray and made sure the food had the appropriate consistency, look appealing and tasted flavorful. They stated it was expected the food was appealing and enjoyable. They stated hot foods should be served between 176 and 180 degrees Fahrenheit and cold foods should be at 40 degrees Fahrenheit or lower. The Food Service Director stated the temperatures taken during the two test trays was unacceptable. They stated plate warmers were utilized under the plates during transit, and they checked the temperature of the food on the tray line to ensure it was hot enough to be served. Once the cart was full, they immediately delivered the cart to the unit. They had no control of the speed at which the staff served the food once it reached the unit. 10NYCRR 415.14(d)(2)

Based on observations, record review, and interviews during the recertification and extended surveys conducted 5/27/2025- 6/5/2025 the facility did not ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, administration failed to ensure that residents received appropriate quality of care by allowing the following deficient practices to exist, placing residents at risk for serious injury, serious harm, serious impairment, or death, F 812 Food and Nutrition Services. The facility failed to adequately address wastewater cleanup including monitoring, evaluating, and sanitizing cooking equipment and appliances in the main kitchen. Additionally, there was no detectable level of sanitizer in the 3-bay sink and dishwasher to adequately sanitize dishware. Findings include: The facility Quality Assessment and Performance Improvement Plan reviewed 1/2025, documented the program's purpose was to evaluate the residents experience of the services provided to them to determine how the experience could improve and for continuous improvement in the delivery of care. The quality appropriateness and effectiveness of resident care, including identification of trends in performance would be monitored, evaluated, and assessed for improvement in all areas including nursing services, food and nutrition services, infection control, social services, rehabilitation services, recreational services, maintenance, and housekeeping and laundry services. The program would identify system breakdowns and deficits in an effort to improve performance. The program would be led by the governing body and administration. The administrator would ensure a leadership role and encourage input from facility staff, residents, and their families. Food and Nutrition Services, Refer to the citation under F812 The facility's failure to properly clean and sanitize multiple kitchen services after contamination by wastewater placed all 215 residents who received meals at the facility at risk for illness related to potential contamination of food and food service products. During an interview on 5/28/2025 at 12:31 PM, the Director of Nutritional Services stated they worked 5/27/2025 and there was a backup in the grease trap in the kitchen. It started Sunday night (5/25/2025), and because Monday was a holiday, the vendor was unable to come until Tuesday 5/27/2025. The trap backed up before and the company had recommended the trap be cleaned every two months, but Corporate only allowed it to be done every three months. The backed up water was not clean and smelled when the grease trap was opened. Staff continued to cook while the sewage was cleaned up and stepped in the puddles and tracked the water where they walked including the food service and cook line areas, the coolers, and the storage rooms. After the drain was cleared, it was hosed it down and squeegeed out the door. They washed and sanitized the floors in the walk-in coolers, behind the cookline, the cooking and preparation equipment, under and around the food preparation tables and cooking equipment. They stated to prevent the wastewater from being spread around the kitchen they tried to maintain the puddles and squeegee them out the door, but nothing was done to contain the resulting spray. At 1:34 PM, the Director of Nutritional Services stated the dish machine did not heat up yesterday and they were told to use the chemical sanitizer. They did not have anything to check the level of sanitizer to know what the level was. They stated they did not conduct any sanitizer level checks on the 3-bay sink. During an interview on 5/28/2025 at 2:41 PM, the Administrator stated the kitchen, silverware, dishes and utensils should have been cleaned with disinfectant daily and per their policy. If there was no sanitizer in the 3- bay sink and/or the dishwasher the items were not sanitized properly which could cause bacteria to grow and the residents could get sick. If the food service area was contaminated by wastewater and it was not cleaned/sanitized properly bacteria could grow around the kitchen. If the 3-bay sink and dishwasher did not have sanitizer any item that went through them was not cleaned or sanitized properly. At 4:22 PM, the Administrator stated there was no way to know for sure if the dishes and equipment were properly sanitized if the dishwasher and 3-bay sink did not have appropriate sanitizer. During an interview on 5/28/2025 at 2:45 PM, the Director of Nursing stated they were not aware of the wastewater back up in the kitchen. If the food service production area was contaminated by sewage the food could be contaminated and if served, the residents could get sick. They expected the kitchen to be cleaned and sanitized with the proper sanitizer if there was seepage before food prep was done. They would want to be made aware so they could monitor for any resident illness. During an interview on 5/28/2025 at 2:59 PM, the Infection Control Nurse stated if the kitchen was not properly sanitized, pathogens could get to the residents and cause gastrointestinal issues. Everything should be sanitized, and they expected kitchen supervisors to know the proper means to do so and what the proper temperature and sanitizer ranges were. Food should not be prepared if the sanitization was not done, and they should be notified so they could consult and educate if needed. 10 NYCRR 483.70(i)

Based on interview and record review during the recertification and abbreviated surveys (NY00352395) conducted 5/27/2025-6/5/2025, the facility did not ensure that each resident and/or resident representative participated in the development of the comprehensive care plan for one (1) of one (1) resident (Resident #214) reviewed. Specifically, there was no documented evidence Resident #214 participated in the development of their Comprehensive Care Plan or was invited to attend their initial comprehensive care plan meeting. The facility policy Care Planning-Interdisciplinary Team, revised 1/2025, documented the resident care plan was developed by the Care Planning/Interdisciplinary Team based on the resident's comprehensive assessment and the resident was encouraged to participate in development and revisions. The facility policy Discharging of the Resident, revised 1/2025, documented discharge planning began at admission; was based on the resident's assessment; and goals for care would involve direct communication with the resident. The facility policy Care Plans, Comprehensive Person-Centered, reviewed 1/2025, documented the Interdisciplinary Team in conjunction with the resident would develop and implement a comprehensive, person-centered care plan for each resident and each resident's comprehensive person-centered care plan would be consistent with the resident's rights to participate in the development and implementation of their plan of care; including the right to participate in the planning process and to see the care plan. Resident #214 was admitted with a diagnosis of right femur (leg) fracture. The 5/13/2025 Minimum Data Set assessment documented the resident had moderately impaired cognition; required partial assistance with most activities of daily living; and an active discharge plan was occurring for the resident to return to the community. The Comprehensive Care Plan initiated 5/19/2025, and revised on 5/22/2025, documented the resident's placement was short term. Interventions included facilitate discharge planning with all disciplines via a comprehensive care plan meeting. The 5/12/2025 Occupational Therapist #57's Evaluation and Plan of Treatment documented the resident would like to return home to live with their sons. The 5/15/2025 at 11:14 AM Social Worker #55's progress note documented the resident was cognitively intact and planned to discharge back home where they lived with their two sons. There was no documented evidence of a Comprehensive Care Plan Interdisciplinary Team meeting attendance sheet, a care plan meeting invitation for Resident #214, a 48-hour signed baseline care plan, or any additional progress notes regarding conversations with the resident or their family regarding their plan of care including discharge goals. During an interview on 5/27/2025 at 11:46 AM Resident #214 stated they did not attend a care plan meeting and did not know when they were going home. No one told them anything and they asked staff every day about it. They went to therapy every day and were told they were doing well. They were worried about their two sons who were at home and was anxious to get home. During an interview on 6/2/2025 at 2:50 PM Licensed Practical Nurse Manager #5 stated the Admissions Nurse did the initial care plans and social work scheduled the care plan meetings. All residents, regardless of their cognition, should be invited to care plan meetings. Discharges were discussed on Tuesdays at the Utilization Review meetings. They were not aware of discharge planning meetings being held with residents but anything that was discussed at the Utilization Review meetings should be communicated to the resident and the family. During a follow up interview on 6/3/2025 at 1:09 PM, Licensed Practical Nurse Manager #5 stated they believed Resident #214 just had a care plan meeting last week but after they checked the schedule stated they had not. The resident was discussed during Utilization Review meetings. The social worker should talk to the resident whenever they spoke to their family and regarding anything discussed at the Utilization Review meetings. It was important for residents be involved in care plan meetings because they had the right to know what was going on with their care. During an interview on 6/4/2025 at 10:08 AM Social Worker #55 stated they scheduled the care plan meetings, hand delivered an invite letter to the residents and placed a phone call invite to the family. All residents were invited regardless of cognition and the care plan attendance sheet was signed at the meeting. The discharge planning process started at admission. They always asked the resident what their discharge plan was then discussed that at their care plan meeting. There were on going conversations with the residents regarding their discharge that would be documented in a note. If a resident voiced that they wanted to go home and was alert and oriented, they would bring it to the team so they could try to accommodate the resident and make it a safe discharge. Resident #214's discharge plan changed. Initially, the resident said they wanted to go home with their sons, but then the sister called and said the resident was going home with them. They checked with the resident who said they wanted to go with the sister, so they had help. They brought that change to the team and their supervisor. Those conversations were about a week ago but were not documented; they were unsure why they did not document it. They had not yet had a care plan or discharge meeting and did not see an upcoming meeting on the schedule. During an interview on 6/4/2025 at 10:52 AM the Director of Social Work stated their department scheduled the care plans based on the list the Minimum Data Set Coordinator put out. New admission care plan meetings were scheduled within a couple weeks of admission. They did not think Resident #214 had a meeting yet and did not see them on the schedule. They always told their social workers to document everything, including conversations with residents, because if they did not, it did not happen. During an interview on 6/4/2025 at 11:34 AM the Minimum Data Set Coordinator stated new admissions had to have a care plan meeting within 21 days or less from their admission date. When a new admission came in, they entered a care plan review date in the system for 21 days later. Social Work then sent out the schedule based on those dates. Resident #214 was admitted on [DATE]. Their care plan meeting should have been on or before 5/28/2025. They did not enter this date so unfortunately it did not get done. Care plan meetings should be timely so the Interdisciplinary Team could meet with the resident and the family so they knew what the plan was, could interact with their care, understand their care, and have some input regarding their discharge. 10 NYCRR 415.11(c)(2)(iii)

Based on observations, record review, and interviews during the recertification and abbreviated (NY00358322) surveys conducted 5/27/2025-6/5/2025, the facility did not allow one (1) of three (3) residents (Resident #185) to return to the facility to their previous room or immediately upon the first availability of a bed. Specifically, Resident #185 was not accepted back to the facility in a timely manner once cleared by the hospital for discharge Findings included: The facility policy Bed Reservation (Bed Hold), dated 5/29/2019, documented if a resident left the facility due to hospitalization, the facility was not obligated to hold the bed until the resident's return unless prior arrangements had been made for a bed hold. In the absence of a bed hold, the resident may be placed in any appropriate semi-private bed at the facility at the time of return from the hospital, provided a bed was available. The facility policy Discharging of the Resident, revised 1/2025, documented discharge planning involved the interdisciplinary team working with the resident. The facility must permit the resident to remain in the facility, and not discharge the resident unless, the health and safety of the resident was endangered. The medical record must support the basis for discharge such as indicating what needs could not be met. Residents who were sent to an emergent acute care setting, such as a hospital, must be permitted to return to the facility. Resident #185 had diagnoses including bipolar disorder, schizoaffective disorder, and intermittent explosive disorder (mental health disorders). The 10/6/2024 admission Minimum Data Set assessment documented the resident had modified independence with daily decision making; depressive symptoms; physical behaviors directed towards others; verbal behaviors directed towards others; other behavioral symptoms not directed towards others; wandered; was independent or required set-up assistance with all activities of daily living; received an antipsychotic and antianxiety medication; and wore a wander detection device. The 9/11/2024 Pre-admission Screening and Resident Review documented the resident had a serious mental illness and was recommended for a Level II evaluation. The 9/20/2024 Pre-admission Screening and Resident Review Level II recommendations/skilled services documented the resident had needs of daily nursing support, medication administration assistance, therapy for strengthening, and a nursing facility appeared to be the best choice of placement in the least restrictive setting. The 9/26/2024 pre-admission hospital psychiatry note documented the resident had a history of incarceration, polysubstance use disorder, schizoaffective disorder, homelessness, seizure disorder, and neurocognitive impairment. The resident was seen for psychotropic medication management and behavioral control. The resident had conflicting emotions about acceptance to a nursing home and anxiety about their unknown future. The resident demonstrated chronic impulsivity and poor frustration tolerance. The resident had been redirectable. There were no contraindications for discharge to the next accepting facility. There was no indication for psychiatric admission at that point. Progress notes documented the following: - on 10/7/2024 at 5:31 AM by Licensed Practical Nurse #36 the resident was placed on high risk for elopement. - on 10/8/2024 at 1:31 PM by Licensed Practical Nurse #37 the resident was yelling at staff they wanted to go outside and became verbally abusive. Staff attempted to and were unable to redirect. - on 10/9/2024 at 9:14 AM by Licensed Practical Nurse #37 the resident was yelling and became verbally abusive to staff. Staff were unable to redirect the resident. - on 10/10/2024 at 8:15 AM by Licensed Practical Nurse #36 the resident was at the nursing station, became upset as they wanted a cup of iced coffee, could not get one, and threw a cup of ice water at the nurse. - on 10/10/2024 at 2:36 PM by Licensed Practical Nurse #37 the resident was screaming and swearing at other residents. When attempting to redirect the resident, the resident pushed staff. The resident walked down the hall screaming they were going to hurt someone and hit them with a soda can. The social worker was made aware and went to speak with the resident. - on 10/10/2024 at 3:00 PM by Social Worker #38 the resident was expressing distress in the unit hallway and agreed to meet with the social worker in their office. The resident expressed frustrations and a desire to return home. The 10/10/2024 facility Transfer/Discharge Notice documented the resident was sent to the hospital for aggressive behavior and assaulting staff. The notice documented the facility was not able to meet the resident's needs. The 10/10/2024 hospital emergency room report documented the resident was admitted to the emergency room due to the resident being aggressive and throwing a cup of coffee at facility staff. The emergency room staff reported the resident did not want to go to the hospital, was frustrated, and stated the facility did not take care of their needs. Upon assessment, the resident was not in acute distress. The resident was alert and oriented to person, place, and time. The emergency room physician documented they spoke with facility staff (unidentified) and the facility told them the resident could not come back until they were evaluated by the hospital psychiatric team. The 10/14/2024 at 4:55 PM hospital Psychiatrist #39 progress note documented the resident was upset, frustrated, and anxious. The resident asked to be returned to the facility and had no unsafe behaviors. The resident did not appear manic or psychotic. There were no safety concerns. The resident was stable for discharge from the hospital. The hospital had tried to optimize medications. The 10/15/2024 at 3:45 PM Hospital Case Manager #40 progress note documented the facility's hospital liaison told them the Medical Director would not take the resident back unless a psychiatric admission was done. The 10/17/2024 at 11:55 AM Hospital Case Manager #40 progress note documented they spoke with the facility's hospital liaison who told them the facility Medical Director would not accept the resident back without a psychiatric admission. The psychiatric provider was to contact the Medical Director at the facility to discuss the situation. The 10/17/2024 at 11:55 AM Hospital Case Manager #40 progress note documented they were trying to get the resident discharged back to the facility and the resident wanted to return there. The resident was willing to be discharged to other facilities in the area if the facility did not want to take them back. The hospital liaison told the case worker that they were unaware of the provider calling the facility's Medical Director. The 10/17/2024 at 3:46 PM hospital psychiatrist #39 progress note documented the resident was anxious, was redirectable, and had no aggressive behaviors since 10/12/2024. The resident did not meet the criteria for psychiatric admission. The agitation appeared to be caused by medication induced delirium. The resident was cleared for discharge from a psychiatric standpoint and was appropriate for long term placement. The 10/18/2024 at 1:09 PM Hospital Caseworker #41 progress note documented multiple messages were left for the facility's Administrator to call the hospital back. The case manager spoke with the facility's Director of Admissions who told them the Administrator no longer needed to talk to the provider and the facility would accept the resident back if a private room was available which could be the following week. The case worker suggested another sister facility and the Director stated they would reach out and see if a private room was available in a sister facility. The 10/21/2024 at 4:26 PM Hospital Case Manager #40 progress note documented they spoke with the facility's Administrator who told them there were no private rooms available yet for the resident. The 10/23/2024 at 2:38 PM Hospital Case Manager #40 progress note documented they spoke with the facility's hospital liaison who told them there were no private rooms available yet for the resident. The 10/24/2024 at 1:28 PM Hospital Caseworker #41 progress note documented they called the New York State Department of Health hotline phone number and spoke with them regarding the facility unwilling to take the resident back. The 10/25/2024 at 4:01 PM Hospital Case Manager #40 progress note documented was discharged back to the facility. The 10/25/2024 hospital discharge summary documented the resident's discharge diagnoses were hypertensive urgency, acute kidney injury, hyperammonemia, acute psychosis, obesity and agitation. The resident was sent to the local hospital for aggressive behaviors and was seen by psychiatry. The resident was being discharged . The 10/25/2024 at 4:30 PM Registered Nurse #42 admission note documented the resident was sent to the hospital for behaviors and aggression. The resident was picked up from the hospital by the Administrator. The resident was currently aggressive/combative/resisting care/refusing care and had the potential for violence. The 10/29/2024 at 12:40 PM, Medical Director progress note documented the resident was seen per nursing request for behavioral issues. The resident was recently admitted and discharged from the hospital. The resident was consulted with the hospital inpatient psychiatric. A psychiatric consult was required for the resident's underlying aggressive behaviors. During an interview and observation on 5/27/2025 at 2:34 PM, Resident #185 stated they were upset. Unit staff attempted to calm the resident as the resident stated they did not want to be at the facility and began crying. Staff offered snacks as redirection and the resident accepted. On 5/29/2025 at 9:45 AM, Resident #185 was ambulating down the hallway of the main activities room on the second floor and headed towards elevator. The resident was pleasant with a stoic face while greeting all persons passing in the hallway. On 5/29/2025 at 12:37 PM, Resident #185 was sitting in the unit dining room with their head down on their hands on the table. There were other residents in the room watching TV. The resident did not exhibit any behaviors. During an interview on 5/27/2025 at 2:47 PM, Hospital Caseworker #41 stated the facility would not take the resident back when the hospital determined the resident was ready for discharge back to the facility. The resident would not be taken back due to behaviors and the facility filled the resident's bed when they were sent to the hospital. The caseworker stated no other facility would accept the resident due to behaviors, the hospital stabilized the resident, and the hospital physician gave the resident discharge clearance on 10/16/2024. During a telephone interview on 6/3/2025 at 10:25 AM, Registered Nurse #42 (no longer employed by facility) stated the admissions team made the decisions to accept residents back to the facility. Residents were allowed back if a bed was available. The resident had a history of throwing things at staff and being inappropriate with other residents. The nurse thought the resident was not a danger to self or others. The resident was sent to the hospital in 10/2024. The hospital told the facility the resident was only under observation. During an interview on 6/3/2025 at 2:55 PM, the Administrator stated once a resident was admitted to the hospital, the regular discharge process would be done. The resident was very behavioral during their initial stay, and those behaviors caused the facility to send them to the hospital. The behaviors were uncontrollable, and the facility felt they could not manage the behaviors. The facility did not want to take the resident back until the hospital admitted the resident for a psychiatric stay and stabilization. The hospital kept telling the facility they performed a psychiatric evaluation, and the resident did not meet the criteria for a psychiatric admission. The facility refused to accept the resident back to the facility without a psychiatric evaluation being done until they received a call from the New York State Department of Health telling them to take the resident back. The facility did not agree with the hospital determination. During an interview on 6/4/25 at 11:01 AM, the Director of Social Services stated they were unaware of any concerns regarding the resident's return from the hospital, the resident stated they would like to be transferred to an area they considered home, and referrals had been sent without any acceptance. The resident had psychiatric services while at the facility and continued to do so. During a telephone interview on 6/4/2025 at 11:39 AM, the Director of Admissions stated the facility was usually aware of a resident's history prior to admission. Resident #185 had a previous psychiatric history prior to the first admission. The director did not know the specifics about the 10/2024 hospital admission other than the facility wanted a psychiatric evaluation done and a private bed for the resident when they returned to the facility. The facility took the resident back the day the hospital called and said the resident was ready for discharge. There was no documentation about communication with the facility as the department did not write progress notes. They stated they were not aware of any facility staff saying the resident was not allowed to return from the hospital and should have been made aware by facility staff. During an interview on 6/4/2025 at 2:46 PM, the Director of Nursing stated they were not in communication with the hospital staff but did speak to the Department of Health staff the day the resident returned to the facility. The Department of Health staff told them to take the resident back immediately as the resident was being discharged from the hospital and that was the facility's obligation. Once a resident was admitted to the hospital, the facility did not communicate with them and the hospital liaison did all the hospital communicating. They stated the hospital liaison informed the facility the hospital was waiting for a psychiatric evaluation to be done prior to sending the resident back. They stated they never said the facility would not take the resident back. If a resident was gone from the facility past midnight, they were automatically discharged from the facility system. Staff should have written a progress note as to why the resident was sent to the hospital and about any hospital communication. The facility was obligated to admit a resident back once sent to the hospital unless the resident did not want to return. During an interview on 6/5/2025 at 2:04 PM, the Administrator stated the Admissions department, and the Hospital Liaison had no formal documents or progress notes regarding hospital communication. The Administrator made the decision the resident needed a private room upon readmission due to agitation and behaviors, and felt it was the most beneficial setting. There were no private rooms available at the time the hospital called and said the resident was ready for discharge. It took about a day to open a private room for the resident. They did not do so prior to the call from the Department of Health as it was taking time to match up resident that could move from a private to semiprivate room. 10 NYCRR 415.3(h)(4)(iii)

Based on observations, record review, and interviews during the recertification survey conducted 5/27/2025 - 6/5/2025, the facility did not ensure they established and maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three (3) of three (3) residents (Resident #33, #118, and #211) reviewed. Specifically, Resident #118's urinary drainage bag was observed uncovered and lying directly on the floor; and Residents #33 and #211 were administered eye drops by Licensed Practical Nurse #49 who did not perform hand hygiene or don gloves. Additionally, the facility did not conduct legionella (a bacteria that causes Legionnaire's disease, a type of pneumonia) testing as required. Findings include: The facility policy Administering Medications, last reviewed 1/2025, documented staff should follow established facility infection control procedures (handwashing, antiseptic technique, gloves, isolation precautions, etc.) for administration of medications, as applicable. The facility policy Legionella Water Management Program, revised 5/2023 documented the purpose of the water management program was to identify areas in the water system where legionella bacteria could grow and spread, and to reduce the risk of Legionnaire's disease. The facility policy Legionella Management Plan, last reviewed 3/3/2025, documented Legionella may develop and proliferate in potable water systems. To control the hazards, the facility was to inspect at 90 days intervals for the first 4 samplings then yearly. If the percentage of positive test sites was above 30%, the system should be re-sampled no sooner than 7 days and no later than 4 weeks after disinfection. If still above 30%, short term control measures were to be redone, and monitoring resumed as before. Long term control measures were based on facility determination and in accordance with direction of a qualified professional for persistent results. 1) Resident #118 had diagnoses including neurogenic bladder (impairment of nerves that control the bladder) and acute kidney failure. The 4/1/2025 Minimum Data Set assessment documented the resident had moderately impaired cognition, was dependent with activities of daily living, and had an indwelling urinary catheter. The Comprehensive Care Plan initiated 5/20/2024, and revised 11/4/2024, documented the resident had an indwelling urinary drainage device related to neurogenic bladder. Interventions included monitor for signs and symptoms of a urinary tract infection, monitor output, and to maintain the urinary drainage bag below the level of the bladder. The 7/1/2024 physician order documented indwelling catheter 16 French (size of tube) 10 milliliter balloon (used to anchor the device in the bladder), change monthly and as needed. Resident #118 was observed: - on 5/30/2025 at 11:36 AM, lying in bed with their uncovered urinary drainage bag resting directly on the bare floor on the window side of the bed. There was no barrier between the drainage bag and the floor. - on 6/3/2025 at 10:11 AM, 10:55 AM, and 2:35 PM, lying in bed with their uncovered urinary drainage bag resting directly on the bare floor on the window side of the bed. There was no barrier between the drainage bag and the floor. During an interview on 6/3/2025 at 2:44 PM, Licensed Practical Nurse Unit Manager #47 stated they thought the certified nurse aides received catheter training upon hire. The certified nurse aides were responsible for emptying the urinary drainage bag, keeping the tubing below the level of the bladder, and covering the urinary drainage bag with a blue privacy cover to maintain the resident's dignity. It was important to keep Resident #118's urinary drainage bag off the floor because it was an infection control issue. If the bag had a blue privacy cover it might helped prevent the germs from getting directly onto the urinary drainage bag. During an interview on 6/3/2025 at 2:52 PM, Certified Nurse Aide #51 stated they cared for Resident #118 during the day shift on 6/3/2025. They received catheter training during yearly in-services. They were responsible for completing catheter care during their shift which included ensuring the urinary drainage bag was covered to maintain the resident's dignity. They were not aware the urinary drainage bag was touching the floor and if they saw it on the floor, they should pick it up immediately and cover it with a blue dignity bag. It was important to keep the urinary drainage bag off the floor because the floor was dirty, and it could lead to an infection. During an interview on 6/4/2025 at 11:39 AM, Infection Control Nurse #32 stated the certified nurse aides were responsible for covering the urinary drainage bag with a blue privacy bag and ensuring the urinary drainage bag was kept off the floor. Resident #118 had a history of urinary tract infections so it was important to keep their urinary drainage bag off the floor because bacteria could travel up and into the bladder causing an infection. During an interview on 6/4/2025 at 2:43 PM, Assistant Director of Nursing #3 stated certified nurse aides were responsible for ensuring the urinary catheter drainage bag was covered with a privacy bag and ensuring the urinary drainage bag did not touch the floor at any time. It was important for the urinary drainage bag to be kept off the floor because of infection control issues which could lead to a urinary tract infection. 2) Resident #33 had diagnoses including glaucoma, left eye myopia (nearsightedness), and diabetes. The 3/1/2025 comprehensive Minimum Data Set assessment documented the resident was cognitively intact and had severely impaired vision. The 8/1/2024 revised Comprehensive Care Plan documented the resident was legally blind and refused medications or care at times. Interventions included administer medications as ordered, arrange referrals to eye physicians/vision consultants, and review medications for side effects affecting vision. Resident #33's 6/2025 Mediation Administration Record documented Licensed Practical Nurse #49 administered the following eye drops for the scheduled 8:00 AM time frame: - Ensure all eye drops were given 5 minutes apart to avoid drugs washing. - dorzolamide hydrochloride 2% solution instill 1 drop in both eyes three times a day for glaucoma. - polyvinyl alcohol-povidone 1.4-0.6% instill 1 drop in both eyes four times a day for dry eyes; and - timolol maleate 0.5% solution instill 1 drop in both eyes twice a day for glaucoma. Resident #211 had diagnoses including stroke. The 4/4/2025 Minimum Data Set assessment documented had moderately impaired cognition. Physician orders documented Resident #211's 6/2025 Medication Administration Record documented Licensed Practical Nurse #49 administered the following eye drops for the scheduled 8:00 AM time frame: - dorzolamide hydrochloride-timolol maleate 2-0.5% solution instill 1 drop in both eyes two times a day for glaucoma; and - latanoprost solution 0.005% instill 1 drop both eyes two times a day for glaucoma. During a medication administration observation on 6/3/2025 at 9:17 AM, Licensed Practical Nurse #49 entered Resident #33's room, applied gloves and administered timolol maleate eye drops and stated they would return to administer the second set of eye drops to Resident #33. Licensed Practical Nurse #49 left the room, removed their gloves and performed hand hygiene. Licensed Practical Nurse #49 then administered Resident #211's eye drops without donning gloves. Licensed Practical Nurse #49 entered Resident #33's room at 9:21 AM, did not perform hand hygiene or don gloves and administered polyvinyl alcohol-povidone eye drops to Resident #33. During an interview on 6/3/2025 at 9:22 AM Licensed Practical Nurse #49 stated they did not wear gloves nor perform hand hygiene between administering the eyedrops to Residents #33 and #211 and should have. They stated they should wear gloves when administering eye drops to prevent cross contamination between residents from hand to eyes and hand hygiene should be performed between residents for the same reason. During an interview on 6/3/2025 at 10:40 AM, Licensed Practical Nurse Manager #5 stated nurses should wash their hands between residents to prevent cross contamination that could lead to infection. The medication nurses should not go from one resident to another administering eye drops without wearing gloves or performing hand hygiene as it was an infection control concern. During an interview on 6/3/2025 at 11:42 AM, Infection Control Nurse #32 stated staff should wash their hands before and after providing eye drops and wear gloves while administering the drops to prevent possible cross contamination of germs between residents. During an interview on 6/5/2025 at 10:48 AM, the Director of Nursing stated gloves should be worn while administering eye drops and hands should be washed between residents so that possible infections would not be spread from one to the other. 3) Facility Legionella testing was done at random facility sites as follows: - on 2/23/2024 resulting in above acceptable limits in 6 of 18 sites tested (33.3%). - on 6/17/2024 not detected results for all previously sites tested. There were no test results for 115 days (almost 4 months). - on 1/28/2025 not detected results for all previously tested sites; and - on 3/27/2025 not detected results for all previously tested sites. During an interview on 6/5/2025 at 10:38 AM, the Director of Maintenance stated the Regional Director of Facilities was responsible for the facility's Legionella program. The director did not know who the test results went to, and the Regional Director covered Legionella testing for all the facilities in the region. The water should be tested from different areas within the facilities. During an interview on 6/5/2025 at 10:52 AM, the Regional Facilities Director stated they were responsible for the facility's Legionella program. Legionella testing was done quarterly and there was a failure in 2023. There was also 1 gap last year in 2024 as a bottle had leaked in shipping. The 2/23/2024 test was a bad test. Test results were usually obtained within 2-3 weeks posttest. The 1/25/2025 was late due to contaminated sample during shipping. Quarterly was to be done every 3 months. After the 2/23/2024 results, it should have been retested immediately after the facility received the results. The next results obtained were from the 6/17/2024 sample. The facility only used 1 vendor. The Corporate Administrative Assistant left employment in the fall of 2024 and all the vendor emails were going to them. There was a dispute with the vendor and the samples were not going to be sent until that dispute was settled. They stated they were not sure what the dispute was, as the administrative assistant oversaw that. They were now in contact with the vendor and dealt with them directly. Once tests resulted in an over 30% detectable amount, testing was to be done quarterly for a year. Once 4 negative results were obtained, then it went to annually testing. During an interview on 6/3/2025 at 11:42 AM, Infection Control Nurse #32 stated they were supposed to be involved in the Legionella testing process and were not aware of any issues. They stated testing was to be done annually. They stated they should be made aware of abnormal tests, but did not know at what percentage they were to be notified. Once Legionella was detected, the facility was to switch to residents only using bottled water for drinking and bathing. They stated the maintenance department was responsible for testing procedures for Legionella. During an interview on 6/5/2025 at 1:40 PM, the Administrator stated they were not employed at the facility in 2/2024 and was not aware of the reportable results. The Administrator stated they were not aware of any residents experiencing symptoms of Legionella. The Regional Facilities Director was responsible for the testing and reporting of abnormal results. 10 NYCRR 415.19

Based on observations, record review, and interviews during the recertification survey conducted 5/27/2025-6/5/2025, the facility did not ensure drugs and biologicals were stored in accordance with currently accepted professional standards for one (1) of five (5) medication carts (4th floor cart) and one (1) of four (4) medication storage rooms (4th floor medication room). Specifically, the 4th floor medication cart and medication room had expired stock medications and biologicals. Findings include: The facility policy Storage of Medications, last reviewed 1/2025, documented the facility would not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs would be returned to the pharmacy or destroyed. During a 4th floor medication room storage observation on 5/29/2025 at 1:43 PM with Licensed Practical Nurse #49, the following were observed: - 1 unopened 12-ounce bottle of antacid with a manufacturer's expiration date of 2/2025. - 1 unopened 12-ounce bottle of antacid with a manufacturer's expiration date of 3/2025. - the medication refrigerator had 1 opened multidose vial of tuberculin 5 tuberculin units/0.1 milliliters with a manufacturer's expiration date of May 2026. Neither the vial nor box contained an opened date. Licensed Practical Nurse #49 stated the bottles of antacid were expired. The vial of tuberculin should have an opened date written on it and was good for 30 days when opened. The vial was considered expired as they did not know when it was opened. They stated the Unit Manager did weekly audits on the medication carts and medication rooms which included checking for expired medications. They stated they did not know why the expired medications were not removed. During a 4th floor medication storage observation with Licensed Practical Nurse #49 on 5/29/2025 at 1:50 PM, the following were observed: - an opened bottle of Dairy Aid (a lactase enzyme supplement) with a manufacturer's expiration of 4/2025 and a handwritten opened date of 12/6. - an opened bottle of guaifenesin (expectorant) 400 milligrams with a manufacturer's expiration date of 4/2025 and a handwritten open date of 3/8/2025. Licensed Practical Nurse #49 stated that both medications were expired, they should have been discarded, and no residents had received those medications that day. During an interview on 6/2/2025 at 2:49 PM, Licensed Practical Nurse #49 stated she gave Resident #571 their tuberculin test from the undated vial. The resident had no adverse effects. They stated they should not have given the tuberculin test from the undated vial, they forgot to check to see when the open date was, and if the medication was expired, the test could be less effective. During an interview on 6/3/2025 at 12:49 PM, Licensed Practical Nurse Unit Manager #50 stated they brought the open tuberculin vial from another nursing unit and did not remember seeing an open date on it. The vial should have an opened date written on it and was only good for 30 days once opened. After 30 days, it lost its potency and was considered expired. They stated they expected unit staff to dispose of the vial if an open date could not be confirmed. Nurses should not use opened and undated vials. During an interview on 6/4/2025 at 2:37 PM, the Director of Nursing stated medication nurses should check for expired medications when administering medications. Unit Managers checked for expired medications weekly per the audit. The Purchasing department should check the central supply area monthly for expired stock medications. Vials should be dated when opened and were only good for 30 days. If the vials did not have an opened date written on them, they were considered expired and should be discarded. A tuberculin test could be inaccurate if done with an expired test. 10NYCRR 415.18(d)

Based on observations, record review, and interviews during the recertification and abbreviated (NY00372942) surveys conducted 5/27/2025-6/6/2025, the facility did not ensure residents received respiratory care consistent with professional standards of practice for one (1) of one (1) resident (Resident #57) reviewed. Specifically, Resident #57 did not receive bilevel positive airway pressure (BiPAP/a device to assist with breathing) as ordered. Findings include: The facility policy Continuous Positive Airway Pressure /Bilevel Positive Airway Pressure, last reviewed 1/2025, documented, Continuous Positive Airway Pressure /Bilevel Positive Airway Pressure, was provided for support of spontaneous breathing for residents with continuous positive airway pressure with or without supplemental oxygen. Resident #57 had diagnoses including chronic respiratory failure, obstructive sleep apnea (stops breathing while sleeping), obstructive pulmonary disease (restricted airway). The 4/16/2025 Minimum Data Set assessment documented the resident had intact cognition, was dependent for most activities of daily living, and received bilevel positive airway pressure and oxygen therapy. Physician orders documented: - on 11/18/2024 bilevel positive airway pressure device at bedtime for chronic obstructive pulmonary disease and sleep apnea. - on 2/25/2025 check functioning of bilevel positive airway pressure every evening and night shift. - on 2/26/2025 continuous 3 Liters of oxygen via nasal canula. The Comprehensive Care Plan revised 2/25/2025 documented the resident had an altered respiratory system related to chronic obstructive pulmonary disease and sleep apnea. Interventions included continuous bilevel positive airway pressure therapy at bedtime. The 2/2025 Treatment Administration Record documented from 2/15/2025 - 2/27/2025, the bilevel positive airway pressure with 3 Liters oxygen every evening was not administered and was documented as broken. The 2/19/2025 progress note by Nurse Practitioner #17 documented there had been a change in the resident's condition including lethargy(sleepiness), slowness to respond, dyspnea (shortness of breath), bradycardia (slow heart rate) and hypoxia (low oxygen saturation level). The Nurse Practitioner documented they were informed the resident had not used their bilevel positive airway pressure device in recent days as it was broken. They ordered a transfer to the hospital for evaluation of the resident's altered mental status and hypoxia. The resident's symptoms were consistent with hypercapnic respiratory failure (lung failure from unsafe levels of carbon dioxide). The 2/19/2025 hospital admission summary documented Resident #57 had a history of chronic obstructive pulmonary disease, chronic hypoxia, and hypercapnic respiratory failure, sleep apnea with nocturnal bilevel positive airway pressure device use. The resident presented to the emergency department for an evaluation of worsening shortness of breath, cough and had not used bilevel positive airway pressure device in three days as it was broken. The resident was found to have chronic obstructive pulmonary disease with acute exacerbation, sepsis due to a urinary tract infection and lower respiratory tract infection. During observation and interview on 5/29/2025 at 1:56 PM, Resident #57 was lying in their bed in the with oxygen in place. The bilevel positive airway pressure device was observed on the bedside table. The resident described how the machine had fallen off the table and cracked this past winter and stated they had been without it for over a week. Resident #57 explained they had been hospitalized due to too much carbon dioxide in their blood. During an interview on 6/02/2025 at 10:44 AM Respiratory Therapist #16 stated they recalled a time in February when Resident #57 bilevel positive airway pressure device was broken. The resident was hospitalized with chronic obstructive pulmonary disease. They stated the resident was retaining carbon dioxide which is why the bilevel positive airway pressure device was important as the carbon dioxide was reduced by using the bilevel positive airway pressure device. During an interview on 6/03/2025 at 12:42 PM Employee #12 from the purchasing department stated on 2/20/2025 the vender had delivered a replacement positive airway pressure device for Resident #57 however it was not the correct device, and it was returned. The correct bilevel positive airway pressure device was delivered on 2/27/2025. During an interview on 6/03/2025 at 2:00 PM the Director of Nursing stated nursing staff were expected to promptly report any broken breathing equipment to the purchasing department for replacement. They found out about the broken bilevel positive airway pressure device on 2/20/2025. The Director of Nursing stated there had not been a plan in place in the absence of the bilevel positive airway pressure device. The physician responsible for Resident #57 was not made aware of the broken bilevel positive airway pressure device until 2/19/2025 according to the chart, and the physician should have been notified when it broke. It was important to maintain breathing equipment for residents because not doing so could result in negative outcomes including respiratory failure. During a telephone interview on 6/04/25 at 11:33 AM Respiratory Therapy Director #14 stated respiratory equipment issues should be reported to them so they could assess the situation and make recommendations while the resident was without the device. They had not been made aware of any issues related to resident #57s bilevel positive airway pressure device not functioning on 2/15/2025. A resident with an order for bilevel positive airway pressure device should not go one day without it. During a telephone interview on 6/04/2025 at 11:40 AM Licensed Practical Nurse #15 stated they had received report from a nurse from the prior shift of whom they could not recall, that stated the residents bilevel positive airway pressure device was broken. Licensed Practical Nurse did not apply the bilevel positive airway pressure device and documented in the comment section of the Treatment Administration Record that it was broken. A provider had not been notified of the broken device and they should have been. During a telephone interview on 6/05/2025 at10:20 AM Physician #29 stated they had not been made aware that between the dates of 2/15/2025 and 2/27/2025 resident #57s bilevel positive airway pressure device was broken. Physician #29 stated they would have requested the help of respiratory therapy who would have been able to work on a solution if they had they been notified. They noted they would have increased the monitoring of the resident with knowledge of the situation. Interruptions in care should have been brought to the attention of the medical team and all other proper disciplines able to help resolve the situation and avoid interruption of care. A resident not having their bilevel positive airway pressure device could certainly result in hypoxia and carbon dioxide retention and most likely was a contribution factor in their decline. 10 NYCRR 415.12(k)(6)

Based on observations, record review, and interviews during the recertification survey conducted 5/27/2025 - 6/5/2025, the facility did not ensure residents were evaluated for hydration care consistent with the resident's comprehensive assessment for 1 (one) of 3 (three) residents (Resident #144) reviewed. Specifically, Resident #144's hydration needs were not reassessed or reviewed for adequacy by clinical nutrition staff after they were diagnosed with urinary tract infections. Findings include: The facility policy Resident Hydration and Prevention of Dehydration, last reviewed 1/2025, documented the dietitian would assess all residents for hydration adequacy at least quarterly, and more often as necessary per resident need; the dietitian, nursing staff, and the physician would assess factors that may contribute to inadequate fluid intake; nursing would monitor and document fluid intake and the dietitian would be kept informed of status; and the interdisciplinary team would update the care plan and document resident response to interventions until team agrees that fluid intake and relating factors are resolved. Resident #144 had a diagnosis of dysuria (difficulty urinating) and diabetes. The 4/4/2025 Minimum Data Set assessment documented the resident had intact cognition; required setup assistance with eating; and was frequently incontinent of bowel and bladder. The Comprehensive Care Plan initiated 6/19/2024, and revised 4/18/2025, documented the resident was at risk for malnutrition related to diabetes and morbid obesity with a goal to be adequately nourished and hydrated via intake from meals, fluids, and nourishments greater or equal to 75%. Interventions included monitor meal consumption records. The 6/18/2024 physician order documented record fluid intake three times a day, at the end of each shift. The 2/3/2025 Physician #76 progress note documented the resident had burning with urination. The plan was to obtain a urinalysis (a test for a urinary tract infection), Levaquin (antibiotic) 500 milligrams once a day for seven days for infection and encourage the resident to increase fluid intake. The 2/5/2025 urine culture result documented growth of greater than 100,000 colony forming units/milliliter Escherichia coli extended-spectrum beta-lactamase (an antibiotic-resistant bacteria) and was sensitive to Levaquin. There were no documented nursing progress notes referencing the resident's diagnosis of a urinary tract infection. There was no documented evidence Resident #144's care plan was updated, or fluid needs were reassessed by the registered dietitian when the resident was diagnosed with a urinary tract infection. The 2/18/2025 at 9:39 AM Registered Dietitian #62 progress note documented a significant weight loss; oral fluid intake was being monitored every shift; and estimated fluid needs were 1818-1944 milliliters (1 milliliter /kilocalorie). Medical progress notes documented the following: - on 2/20/2025 at 3:42 PM by Nurse Practitioner #77 the resident reported urinary frequency, urinary urgency and dysuria and the plan was to send a urine specimen for analysis and culture. - on 2/21/2025 at 2:45 PM by Physician #22 awaiting urine test results; ensure the resident drank enough water; and an order for 240 milliliters of additional water during each medication pass. - on 2/22/2025 at 2:33 PM by Physician #22 the resident was seen for increasing confusion for a possible urinary tract infection. Awaiting results of urinalysis. The plan was to ensure the resident drank enough water and an additional 240 cubic centimeters of water during medication pass was ordered. - on 2/25/2025 at 4:06 PM by Nurse Practitioner #77 the resident complained of urinary frequency, urinary urgency and dysuria for the past couple of days and would be started on Cipro (antibiotic) 500 milligrams twice daily for seven days. - on 2/26/2025 at 3:07 PM Nurse Practitioner #77 the antibiotic was switched from Cipro to Levaquin 500 milligrams once a day for six days for infection. There was no documented evidence Resident #144's care plan was updated, fluid intake was reviewed for adequacy, and fluid needs were reassessed by the registered dietitian when the resident was diagnosed with several urinary tract infections. The 4/4/2025 at 2:05PM Registered Dietitian #62 annual nutrition progress note documented a weight loss that may be related to edema; oral fluid intake was being monitored every shift; and estimated fluid needs were 2000-2400 milliliters (1milliliter/kcal). There was no documentation if the resident was meeting their estimated fluid requirements. The 4/21/2025 at 11:18 AM physician order documented an order for Bactrim DS (an antibiotic) 800-160 MG every 12 hours for 10 days for a urinary tract infection. There was no documented evidence Resident #144's care plan was updated, fluid intake was reviewed for adequacy, and fluid needs were reassessed by the registered dietitian when the resident was diagnosed with several urinary tract infections. The 5/16/2025 Registered Dietitian #62 progress note documented a significant weight loss through 180-day review; current body weight was 273.4 pounds; oral fluid intake was being monitored every shift; and estimated fluid needs were 1818-1944 milliliters (1milliliter/kcal). There was no documentation if the resident was meeting their estimated fluid requirements and had chronic urinary tract infections. The 5/21/2025 physician order documented the resident was to receive nitrofurantoin100mg (an antibiotic) two times a day for seven days for a urinary tract infection. The May 2025 Medication Administration Record documented daily fluid intake totals were at most 1320 milliliters a day. There was no documented evidence Resident #144's care plan was updated, fluid intake was reviewed for adequacy, and fluid needs were reassessed by the registered dietitian when the resident was diagnosed with several urinary tract infections. During an interview on 6/3/2025 at 2:25 PM, Certified Nurse Aide #54 stated Resident #144 had urinary tract infections and drank a little water but preferred soda and juices. They did not do intake and output monitoring for urinary tract infections, so they were unsure how much the resident drank. During an interview on 6/3/2025 at 2:35 PM, Licensed Practical Nurse Manager #5 stated new urinary tract infections were reported at morning meeting. The registered dietitian made sure the resident was meeting their fluid needs and was not dehydrated. Strict intake and output monitoring was not routinely done for urinary tract infections. The dietitian was responsible for following the intakes and if there was a problem the registered dietitian would communicate that to them. Resident #144 had a history of urinary tract infections. They had no interaction with the dietitian regarding the resident and there was not a urinary tract infection specific care plan other than providing good incontinence care. During an interview on 6/4/2025 at 1:25 PM, Registered Dietitian #62 stated the facility had a lot of urinary tract infections and new infections were reported during morning meeting. They liked to add more fluids to those residents and, additionally, the nurses tried to add 240 milliliters of fluid twice a day with medication pass. For residents on an antibiotic, fluid needs would be 30-35milliliters/kilogram higher in addition to what the nurses were doing on the unit, but they did not necessarily recalculate their fluid needs or write a note. They did not know if a resident was meeting their recommended fluid requirements because they could not see fluid intake data; they only knew what was being provided to drink. They based fluid intake on the percentage of food intake and if that percentage was good, they assumed the fluid intake was as well. Because formal intake and output monitoring were not part of the process at the facility, they did not think they needed to know if they were meeting specific recommendations. Resident #144 had frequent urinary tract infections and based on their meal intake, which was usually 75%, they assumed the resident drank well. If on an antibiotic a resident would need an additional 30-35 milliliters/kilogram of fluid. They did not write progress notes about the resident's urinary tract infections or recalculate their fluid needs when prescribed an antibiotic. If the resident's intake was poor, they would see the resident and write a note. During an interview on 6/4/2025 at 2:53 PM, Assistant Director of Nursing #3 stated new urinary tract infections were reported at morning meeting and should have dietitian involvement. They did not see much involvement from the dietitian but thought they looked at the chart and identified if a resident might need more fluids. The nurses documented those fluids on the medication administration record, but it did not always reflect the exact amount taken. If the dietitian recommended extra fluids, there should be a progress note. Fluid intakes should be reviewed to make sure the residents received what they needed. During an interview on 6/5/2025 at 10:48 AM, the Director of Nursing stated registered nurses generated and updated care plans. They expected active diagnoses, including infections/recurrent infections, to have a care plan. New urinary tract infections were reported at morning report. The aides were able to enter in the Kiosk the number of milliliters the residents took in. The dietitian did not usually document or have much involvement with urinary tract infections and did not monitor fluid intake; usually the nurses did that. If the provider added on extra fluids the dietitian might get involved especially if that resident was on a fluid restriction. They were not sure if the dietitian recalculated fluid needs for a resident being treated for a urinary tract infection and thought they should be looking at the fluid intakes to determine if they were meeting their fluid needs. 10NYCRR415.12(i)(1)

Based on observations, record review, and interviews during the recertification survey conducted 5/27/2025-6/5/2025, the facility did not ensure the resident environment remained free of accident hazards for one (1) of four (4) residents (Resident #91) reviewed. Specifically, Resident #91 who resided on the Dementia Care Unit had cough drops at their bedside not ordered by the medical provider. Findings include: The facility policy Medications Brought to the Facility by the Resident/Family, revised 1/2025, documented the facility would not permit residents and families to bring medications into the facility. Residents and families had to report to the nursing staff any medications they wanted to bring or have brought into the facility. If the medication was not otherwise available and was determined to be essential to the resident's life, health, safety, or well-being, the Director of Nursing, nursing staff, the attending physician, and the consultant pharmacist checked to ensure state law and regulations allow the use, the medications had been ordered by the resident's attending physician and documented on a physician's order sheet, and the contents of each container was labeled in accordance with established policies. The facility policy Administering Medications, revised 1/2025, documented medications were to be administered in a safe and timely manner, and as prescribed. Only staff licensed or permitted by the state to prepare, administer and document the administration of medications were able to do so. Residents may self-administer their own medications only if the Attending Physician with the Interdisciplinary Care Planning Team, determined they had the decision-making capacity to do so safely. The facility policy, Self-Administration of Medications, reviewed 1/2025, documented residents had the right to self-administer medications if the interdisciplinary team had determined that it was clinically appropriate and safe for the resident to do so. Staff were to identify and give to the Charge Nurse any medications found at the bedside that were not authorized for self-administration, for return to the family or responsible party. Resident #91 had diagnosis including dementia with severe agitation, paranoid schizophrenia, and delusional disorder. The 2/20/2025 Minimum Data Set documented the resident had impaired short-term and long-term memory, severely impaired daily decision making, rejected care 1 to 3 days, and required supervision or was independent for all activities of daily living. The Comprehensive Care Plan, initiated 5/29/2024, documented the resident had long term, non-correctable impaired cognitive function or thought processes related to dementia. Interventions included administer medications as ordered; provide a safe, clutter free environment, and modify as needed to meet the resident's needs; and provide simple directions to the resident in a non-rushed manner and allow resident time to process directions. On 6/24/2024 behavioral interventions included stop sign outside door to limit other residents from entering the room. During observations on 5/28/2025 at 9:19 AM Licensed Practical Nurse Unit Manager #10 removed a bag of cherry cough drops from Resident #91 in the dining room and brought them to the resident's room. The bag had the resident's full name across the front of the bag. At 9:35 AM, the resident's door was shut there was bag of cough drops on the resident's overbed table and the stop sign on the resident's door was not in place. At 10:15 AM, the resident's door was open, there was no stop sign across the doorway, and the bag of cough drops was on the overbed table. The resident was putting several cough drops in their pockets and stated they did not have a cough; they just liked the cough drops. There was no documented physician order for cough drops or self-medication of cough drops. During an observation on 5/29/2025 at 9:35 AM the resident was lying in bed with their head at the foot of the bed with blanket over them. The door to the resident's door was open with no stop sign across the doorway. There was a bag of cough drops on the overbed table. At 12:09 PM, the resident's door was open, the stop sign was not across the doorway, and a bag of cough drops was on the resident's overbed table. During an observation on 5/29/2025 at 2:10 PM, Certified Nurse Aide #27 retrieved the bag of cough drops from the resident's room and put them behind the nurses' station. During an interview on 5/29/2025 at 2:04 PM, Certified Nurse Aide #27 stated residents wandered in and out of each other's rooms on the unit. The residents grabbed things from other resident rooms and staff attempted to redirect residents away from taking items that did not belong to them. They were unaware why the resident had a bag of cough drops in their room and it was possible the resident's spouse brought them. The resident should not have a bag of cough drops in their room as they could choke if they were consuming them unsupervised. If the bag of cough drops was left unattended in their room, other residents could access the bag and could choke or take them when they were not supposed to. During an interview on 5/29/2025 at 2:10 PM, Licensed Practical Nurse #28 stated all medicated items needed orders and cough drops were considered medicated items. On the Dementia Unit, residents could not self-administer cough drops. They were aware Resident #91 had cough drops as they saw them in the dining room. Licensed Practical Nurse Unit Manager #10 had put the resident's name on the bag of cough drops and they thought the Unit Manager was building trust putting them in the resident's room and then they would be removed. They believed they came from the resident's spouse. If Resident #91 was self-administering cough drops the resident could choke. They were also a medicated item and not supposed to be eaten like candy. If the bag of cough drops was left unattended in the resident's room, other residents could access the bag and could choke. They did not make the provider aware the resident had cough drops. During an interview on 5/29/2025 at 2:18 PM, Licensed Practical Nurse Unit Manager #10 stated all medicated items needed physician orders and cough drops were considered medicated items. Resident #91 did not have an order to self-administer cough drops and did not have the cognitive ability to self-administer cough drops. If Resident #91 administered their own cough drops, they could choke or take too many. They did not inform the provider the resident had cough drops they were self-administering. Licensed Practical Nurse Unit Manager #10 stated they saw the bag of what they assumed was candy and removed it from the dining room so the resident did not give any to residents who could not have candy. They put the resident's name on the bag and put them in the resident's room without realizing they were cough drops. They realized they were cough drops when the certified nurse aide brought them behind the nurses' station today. Another resident could access the cough drops in Resident #91's room and could choke. During an interview on 6/4/2025 at 2:37 PM, the Director of Nursing stated a resident could have over the counter medication if they were evaluated to safely self-administer medications. The resident's unit was a memory care unit that had a lot of residents with a dementia diagnosis. There were no residents allowed to have their own medications in their room or self-administer medications. There were residents who wandered and took things from other resident rooms. Depending on the medication, it could harm a resident it was not prescribed for. The resident did not have an order for the cough drops. Another resident on the unit could choke on the cough drops. Staff should have noticed the cough drops and removed them. 10 NYCRR 415.12(h)(1)(2)

Based on record review, observations, and interviews during the recertification survey conducted 5/27/2025 - 6/5/2025, the facility did not ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection and prevent new ulcers from developing for 1 (one) of 3 (three) residents reviewed (Resident #96). Specifically, Resident #96 had pressure ulcers that were not monitored or have treatment/management interventions in place. The facility policy Repositioning, revised 1/2025, documented the purpose was to provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed- or chair-bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents; repositioning was critical for a resident who was immobile or dependent upon staff for repositioning; and repositioning was a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief. The facility policy Pressure Ulcer/Injury Risk Assessment, revised 1/2025, documented the purpose of a structured risk assessment was to identify all risk factors and then determine which could be modified and which could not, or which could be immediately addressed and which would take time to modify; risk factors that increased a resident's susceptibility to develop or to not heal pressure ulcers included decreased mobility, decreased functional ability and cognitive impairment; a resident-centered care plan and interventions based on the risk factors identified in the assessments would be developed; and the condition of the resident's skin (i.e., the size and location of any red or tender areas) and notification of the attending physician if a new skin alteration was noted should be recorded in the resident's medical record. Resident #96 had diagnoses including impulse disorder, left sided paralysis following a stroke, and aphasia (difficulty speaking). The 5/29/2025 Minimum Data Set assessment documented the resident had severely impaired decision making skills; was dependent for most activities of daily living; was at risk for developing pressure ulcers; did not have a pressure ulcer; and had pressure relieving devices for bed and chair. The 5/14/2025 Licensed Practical Nurse Unit Manager #5's Weekly Skin Monitoring note documented there was a new pressure ulcer on the resident's right knee (front). The 5/14/2025 Admissions Registered Nurse #20 Initial Wound Assessment documented: - a left 2nd toe Stage 2 (partial thickness skin loss) pressure ulcer measuring 0.5 x 0.6 x 0.1 centimeters; cause was unknown; plan was bacitracin (antibiotic ointment). - a right outer knee unstaged (full thickness skin loss when the base of the wound cannot be visualized) pressure ulcer measuring 10.5 x 7.0 x 0.1 centimeters; cause was resident flailed their legs and scraped their right leg along the wall; measurement was a cluster measurement of four separate areas; and plan was application of bacitracin to keep the wound moist while continuing to heal. The Comprehensive Care Plan initiated 12/7/2021 documented the resident was at risk for developing a pressure ulcer related to immobility and incontinence. Interventions included monitor/document/report to the physician as needed any changes in skin status. The comprehensive care plan did include current skin impairments or preventative measures including pressure reduction for the bed or chair. The 5/15/2025 at 9:48 PM Physician Assistant #63 progress note documented they were notified by the facility to review a clinical alert from 5/14/2025 for a new skin alteration noted. Per nursing note right knee (front) - pressure areas. Will continue to monitor. The 5/16/2025 physician order documented cleanse right knee with normal saline, apply antibiotic ointment, and keep open to air every shift. The 5/20/2025 at 12:38 PM Nurse Practitioner #21 progress noted documented the resident had no skin rashes, lesions, or ulcers. The 5/23/2025 the Assistant Director of Nursing #64 Narrative Assessment documented they assessed areas of skin concerns and did not see any areas of pressure. There were scabs from trauma obtained from the resident banging their leg against the wall. No treatment was needed at that time as areas were scabbed over. There was no documented evidence of an assessment of the left second toe. The following observations were made of Resident #96: - on 5/29/2025 at 2:39 PM in bed continually moving their legs and repeatedly hitting their right lower leg/lateral (outside) knee against the wall. The resident had a scabbed, nickel sized area to the lateral side of right knee and two red, nickel sized discolored areas adjacent to it. The areas were in alignment with where the resident was hitting their leg against the wall. - on 5/30/2025 at 10:12 AM in bed with a wedge like cushion placed just below the right upper siderail between the wall and the bed. The wedge did not reach the foot of the bed or provide any protection from the resident hitting their leg on the wall. - on 5/30/2025 at 11:24 AM lying on their back, the wedge cushion was sitting on the chair across the room. There was nothing to protect the resident from hitting their leg on the wall. - on 6/3/2025 at 9:28 AM in bed kicking their legs and hitting them against the wall. There was no cushion placed between the bed and the wall. The foot of the bed was pulled away from the wall about 6 inches creating a space between the mattress/bed frame and the wall. The resident, in between kicks, positioned their right lower leg in this space with direct contact with the corner of the wall. - on 6/3/2025 at 9:38 AM, Licensed Practical Nurse #49 was in the resident's room to reposition them. Licensed Practical Nurse #49 attempted to push the bed against the wall, but they could not get the head of the bed to move. They left the room leaving a space between the bed and the wall and without any protection from the resident hitting their leg on the wall. - on 6/3/2025 at 9:42 AM in bed moving their legs and hitting the lateral side of their right leg against the wall in the area where the dried scab was. During an interview on 5/27/2025 at 1:53PM, the resident's family member stated they put a wedge cushion between the bed and the wall so the resident would not kick the wall when they got restless. During an interview on 6/3/2025 at 10:10 AM, Certified Nurse Aide #66 stated beds were against the wall per resident preference. They did not put the bed fully against the wall because of the outlet and possibly popping the cord from it. They thought Resident #96's bed was against the wall as a precaution because the resident favored, and got closest to, the right side of the bed. The resident hit their leg against the wall and got red spots from that. They thought the wedge cushion was on the resident's care plan. During an interview and observation on 6/3/2025 at 10:20 AM, Licensed Practical Nurse Manager #5 stated if a bed was supposed to be against the wall it should be as close to the wall as possible. The position of the bed along with wedge cushions and positioning devices should be on the care plan. If a resident was prone to developing a skin issue, they should get an order for something like skin prep (skin protectant) and a positioning device. Resident #96 wiggled all the time. Their bed was against the wall for safety and to prevent a fall out of bed. They hit their right knee on the wall, so a wedge cushion was used to prevent them from hitting the wall. About two weeks ago they had a skin tear like area on their right leg caused from hitting the wall. The wedge cushion intervention had been in place before that skin tear was discovered. After referring to the medical record they stated the area was called a pressure change. They believed the wedge cushion was on the resident's care plan and if it was on their care plan it should be in place. The resident was observed with Licensed Practical Nurse Manager #5 who stated the bed was pulled away from the wall, there was nothing to protect the resident's leg from the wall and there should be a wedge cushion. The scaly, scabbed are on the resident's knee was what they observed two weeks ago. During a follow up interview and observation on 6/4/2025 at 9:11 AM Licensed Practical Nurse Manager #5 stated weekly skin checks were done on shower days. If there was an abnormality it would trigger on the dashboard for a registered nurse (any registered nurse) to do an assessment. Additionally, they talked about skin issues in morning report. They would have to notify the family and physician if a treatment was needed. Pressure wounds were then monitored weekly by the wound doctor/team on Wednesdays. Non pressure wounds were monitored weekly by the in house wound team that included a registered nurse. When there was a new skin area, an attempt to determine the cause would be done and interventions put in place. A root cause, treatments and preventative interventions were important to prevent wounds from getting worse and to prevent recurrence. They stated Resident #96, at one point, had an area on their toe. Upon observation of the resident with Licensed Practical Nurse Manager #5, the resident was in bed. The resident had a pea sized dark, scabbed- like area on top of the left second toe and dried, red, blood-like material between the 2nd and 3rd toe; the source of which could not be visualized due to the resident continually moving their legs. Licensed Practical Nurse Manager #5 stated Admissions Registered Nurse #20 did a follow up on 5/14/2025 to their 5/14/2025 note regarding the knee and added the toe pressure ulcer as part of their findings. They did not see anything had been done with that since then and did not recall Admissions Registered Nurse #20 talking to them about it. If they had, they would have put in an order and reported it to the Assistant Director of Nursing #64 who would then let the wound doctor know. There was no documentation the doctor knew about the skin impairments. They did not see anything in the resident's care plan to protect their leg or anything regarding their toe. Staff would not know about the use of the wedge or other interventions if they were not listed in the care plan. During an interview on 6/4/2025 at 11:01 AM, Admissions Registered Nurse #20 stated they did weekly skin rounds on Wednesdays with the doctor for anything pressure related. If a licensed practical nurse noted a pressure ulcer, they would let the Assistant Director of Nursing know and the wound would be assessed, and treatments put in place if needed. They noted a Stage 2 on Resident #96's toe on 5/14/2025. There was not any documentation regarding what was being done with the area or if it was followed by the wound team. They should have reported it to Assistant Director of Nursing #64 so it would be followed on wound rounds. During an interview on 6/4/2025 at 2:53 PM, Assistant Director of Nursing #3 stated Assistant Director of Nursing #64 monitored wounds. New pressure ulcers needed to be investigated, and interventions discussed. Pressure ulcers should be monitored weekly on Wednesdays. There should be a skin care plan problem with goals and interventions based on what the investigation uncovered. During an interview on 6/5/2025 at 10:48 AM the Director of Nurses stated if there was a new pressure ulcer it was reported at morning meeting or sent in an email if it was discovered after that day's morning meeting. Assistant Director of Nursing #64 would do the registered nurse assessment and determine whether it should be followed by the wound doctor or just the wound team. Any skin areas should have an investigation done to try and find out why it happened, and an intervention put in place to reduce the risk of getting more areas or existing areas getting worse. They received wound reports and were not aware of Resident #96's pressure ulcer until just recently. The Admissions Nurse did an assessment on 5/14/2025 documenting a Stage 2 on their left second toe. The plan was to apply bacitracin and keep moist until healed. There had been no assessment or treatment to the area since it was noted on 5/14/2025, no investigation into what caused it, and therefore no interventions. 10NYCRR 415.12(c)(1)

Based on observations, record review, and interviews during the recertification survey conducted 5/27/2025-6/5/2025, the facility did not ensure resident advance directives (instructions relating to the provision of health care when an individual is incapacitated) were accurately documented for 1 of 1 resident (Resident #55) reviewed. Specifically, Resident #55 did not have physician orders for advance directives and advance directives documented throughout the medical record did not reflect the resident's wishes to receive cardio-pulmonary resuscitation in the event of an emergency. Findings include: The facility policy Medical Orders for Life Sustaining Treatment, revised 1/2025, documented adequate information would be given to residents concerning resident rights, medical situations for decision making, and explanation of forms and procedures for making advance medical directives. Do not resuscitate (allow natural death) and do not intubate (placing a breathing tube) orders were reviewed every 30 days for the first 90 days following admission. Any changes in the residents wishes would be brought to the physician's attention by the social worker. Resident #55 had diagnoses including hypertension (high blood pressure), diabetes, and bipolar disorder (mental illness). The 3/17/2025 Minimum Data Set Assessment documented the resident was cognitively intact and had advance directives of do not resuscitate and do not intubate. The 3/13/2025 hospital discharge summary documented the resident's advance directives were do not resuscitate and do not intubate. The facility admission Record (face sheet) documented the resident was admitted on [DATE] with advance directives of full code (attempt cardio-pulmonary resuscitation). The 3/13/2025 at 5:12 PM admission evaluation by Registered Nurse #20 documented the resident was admitted from the hospital with advance directives of do not resuscitate and do not intubate. The resident's advance directives would be revised and reviewed as needed. A 3/14/2025 Statement of Capacity for Medical Decision Making signed by Nurse Practitioner #21 documented the resident had capacity to make their own decision regarding resuscitation and any supplemental advance directives. Physician orders dated 3/13/2025-5/31/2025 did include advance directives. The admission care plan initiated 3/13/2025 and revised on 3/21/2025 documented advance directives were do not resuscitate and do not intubate. A 3/14/2025 Social Worker #55 progress note documented they reviewed advance directives with the resident, and their code status remained do not intubate and do not use non-invasive ventilation or mechanical ventilation. A 3/14/2025 at 9:49 PM Social Worker #55 progress note documented advance directives were reviewed with the resident and were do not intubate and do not use non-invasive ventilation or mechanical ventilation. There was no documentation regarding the resident's wishes for cardio-pulmonary resuscitation. A 3/15/2025 Physician #22 progress note documented the resident was seen per nursing request for review of laboratory reports. The resident's code status was do not intubate and do not use non-invasive ventilation or mechanical ventilation. There was no documented evidence the medical provider reviewed advance directives with the resident to include their wishes for cardio-pulmonary resuscitation. The 3/28/2025 at 1:51 PM Social Worker #18 care plan meeting progress note documented the resident was requesting their Medical Orders for Life-Sustaining Treatment be changed. There was no documented evidence the resident had an active Medical Order for Life Sustaining Treatment or what the resident's wishes were for cardio-pulmonary resuscitation. There were no additional social work progress notes referencing the resident's advance directives from 3/28//2025-5/27/2025. During an interview on 5/27/2025 at 9:58 AM the resident stated no one talked to them about their wishes but they wanted to receive cardio-pulmonary resuscitation if anything ever happened. A 5/27/2025 at 7:30 PM Social Worker #19 progress note documented they attempted to review medical orders for life sustaining treatment with the resident. The resident was not interested in completing one at that time and understood they would remain a full code. There was no documented evidence the resident had an order for cardio-pulmonary resuscitation (full code). During an interview on 6/3/2025 at 9:16 AM Licensed Practical Nurse Unit Manager #23 stated Resident #55 was a do not resuscitate/do not intubate between 3/2025 and 5/2025. The discharge paperwork from the hospital documented the resident had advance directives of do not resuscitate/do not intubate. That information was copied into the electronic medical record upon admission. There was no advance directive order in the electronic medical record for the resident until 5/28/2025. They stated Resident #55 was opposed to completing a medical orders for life sustaining treatment document. The advance directive preference should have been communicated to the physician so they could place an admission order. They stated at some point, the do not resuscitate was removed and the electronic medical record only documented do not intubate. Licensed Practical Nurse Unit Manager #23 stated there was no documentation of discussion between any discipline and the resident to validate the change. During an interview on 6/3/2025 at 10:14 AM Social Worker #18 stated on admission the resident was approached regarding their code status preference however declined completing a medical order for life sustaining treatment. The code status was unclear on admission and was not clarified since their admission. They stated there were no corresponding orders or documented conversations with the resident regarding their code status preference. The social worker stated not having clear and concise advance directives could lead to a misinterpretation of a residents wishes. During an interview on 6/3/2025 at 2:23 PM the Director of Nursing stated the social worker assessed the resident's code status upon admission and would typically complete a medical order for life-sustaining treatment document. Resident # 55 had a do not resuscitate /do not intubate order per the hospital documentation. The Director of Nursing stated the information from the hospital discharge summary was copied into the facility's electronic medical record and the status was carried over regardless of a corresponding order. They did not know why the status was changed from do not resuscitate/do not intubate to do not intubate only. They stated advance directives should be correlated with a physician's order. The change on 5/28/2025 to full code status occurred after the facility became aware documentation of advance directives was incomplete. They stated a lack of clear, complete, and accurate documentation regarding code status could cause confusion during an emergency and potentially result in the wrong treatment being rendered. During an interview on 6/4/2025 at 1:27PM Registered Nurse #20 stated the resident was alert and oriented on admission. They entered the do not resuscitate/do not intubate code status into the batched orders on 3/13/2025 based on discharge documentation from the hospital. They stated they did not document their conversation with the resident regarding their desired code status and the resident's physician typically reviewed code status the following day. During a telephone interview on 6/5/2025 at 10:32 AM the Medical Director stated do not intubate meant not placing a breathing tube. A resident with a do not intubate status was typically considered full code unless otherwise specified. In the absence of medical orders for life sustaining treatment, the resident's wishes should be known and documented. They stated the social worker usually discussed code status with the resident, completed the medical orders for life sustaining treatment, and the physician would sign it. An order reflecting the resident's wishes should be entered into the electronic medical record. They stated the resident's status had changed from do not resuscitate/do not intubate, to do not intubate only, and then to full code without supporting documentation or orders. Conversations with the resident regarding advance directives should be supported with documentation and an order should be entered in the resident's record. They stated unclear code status could lead to inappropriate treatment. 10NYCRR 400.21(c)

Based on observations, record review, and interviews during the recertification survey conducted 5/28/2025-6/5/2025, the facility did not ensure a resident's ability to safely self-administer medications was clinically appropriate for 2 of 2 residents (Residents #20 and #144) reviewed. Specifically, Resident #20 had medications left in their room and Resident #144 had an inhaler (used for breathing difficulty) at their bedside, without physician orders to self-administer medications or documented evidence they were assessed to determine their ability to safely self-administer medications. Findings include: The facility policy Medications Brought to the Facility by the Resident/Family, revised 1/2025, documented the facility would not permit residents and families to bring medications into the facility. If the medication was not otherwise available and was determined to be essential, and brought in from the outside, the Director of Nursing with the support of the attending physician and consultant pharmacist shall check to ensure the medication was ordered by the attending physician, documented on the physician's order sheet, and labeled in accordance with established policies. The facility policy Self-Administration of Medications, last reviewed 1/2025, documented residents had the right to self-administer medications if the interdisciplinary team determined it was clinically appropriate and safe for the resident to do so. The staff and the nurse practitioner assessed each resident's physical and mental ability to administer medications to themselves. Staff were to identify and give to the Charge Nurse any medications found at the bedside that are not authorized for self-administration, for return to the family or responsible party. 1) Resident #20 had diagnoses including chronic obstructive pulmonary disease (lung disease), mild intellectual disabilities, and schizoaffective disorder. The 4/24/2025 Minimum Data Set documented the resident had intact cognition, required supervision or was independent for activities of daily living, and had a scheduled pain medication regiment. The Comprehensive Care Plan initiated 11/2/2021 documented the resident had an alteration in comfort related to the aging process. Interventions included to administer medications as ordered and to report to the nurse any complaints of pain or requests for pain treatment. The 11/11/2024 physician's order documented 325 milligram acetaminophen, two tablets by mouth every 6 hours as needed for pain or fever. There was no documented evidence the resident was assessed to safely self-administer medications. During an observation and interview on 6/2/2025 at 10:53 AM Resident #20 had two round, white pills in a clear medication cup sitting on their bedside table. Resident #20 stated the pills were acetaminophen the nurse had given them that morning. The medication administration record documented two tablets of acetaminophen were administered at 10:13 AM by Licensed Practical Nurse #48. During an interview on 6/2/2025 at 11:00 AM, Licensed Practical Nurse #48 stated the medications in the cup at the resident's bedside were acetaminophen. They signed for the resident's medication when they took the pills out. They stated the resident was eating so they left the medication for the resident to take when they were done with their meal. The resident always took their medication, and they usually went back and checked to make sure the resident took the medication. If the resident did not take their medication at the time, it was given it could affect the time the resident could have their next dose. It was also possible another resident could wander into Resident #20's room and take the medication. The medication administration record documented two tablets of acetaminophen were administered on 6/2/2025 with an updated time of 11:12 AM by Licensed Practical Nurse #48. 2) Resident #144 had diagnoses including chronic respiratory failure, anxiety disorder, and sleep apnea (pauses in breathing during sleep). The 4/4/2025 Minimum Data Set assessment documented the resident was cognitively intact, required maximum to set up assistance for the activities of daily living, and had shortness of breath while lying flat. The comprehensive care plan initiated 6/25/2024 documented the resident had an alteration in respiratory system related to chronic respiratory failure. Interventions included observe the resident's secretions color, consistency, and odor and report abnormalities to the medical provider and to observe the resident's vital signs as ordered and report vital signs not within normal limits. The 9/6/2024 physician order documented Breztri Aerosphere Inhalation Aerosol 160-9-4.8 micrograms per actuation, 2 puffs inhaled orally two times a day for anti-asthmatic. Resident may use medication from home as not on formulary, please rinse mouth after use. There was no documented physician order the resident could self-administer medications. During an observation and interview on 5/29/2025 at 1:39 PM, there was a battery box in Resident #144's room containing a Breztri 160 microgram/9 microgram/4.8 microgram inhaler with no pharmacy label. The resident stated the facility's prescription had run out at one point, so they filled the prescription they had at home and brought it in. They stated they took two puffs twice a day around breakfast and dinner time. The nurses did not bring the inhaler into them, and they kept it at their bedside, so it did not get lost. The nurses asked if they had administered their inhaler, but no one asked them to demonstrate how to use it. During an observation and interview on 6/02/2025 at 11:20 AM, the resident was up in their wheelchair and their inhaler was not in the box. They stated they did not know where it was and did not have it to use that morning. The 6/2025 medication administration record documented Breztri inhalation aerosol 2 puffs inhale two times a day for antiasthmatic, resident may use medication from home as not on formulary. The medication was signed as given on 6/2/2025 at 8:00 AM by Licensed Practical Nurse #48. During an interview on 6/03/2025 at 2:00 PM, Licensed Practical nurse #49 stated no residents on the third floor were able to have medications at their bedside. If a resident was allowed to have medications at their bedside or to self-administer, there would be a physician's order. They did not see any medications at Resident #144's bedside that morning and they did not have an order to keep their inhaler at their bedside. They looked for the resident's Breztri inhaler and was unable to locate it. Licensed Practical Nurse #49 stated it could not be reordered and the resident could use their own as it was not in their formulary, but they did not know if that meant the resident could keep it at their bedside. If the resident was able to keep it at their bedside, it was the nurse's responsibility to ensure the resident had it, there was enough medication, and it was being utilized properly. During an interview on 6/03/2025 at 2:25 PM, Certified Nurse Aide #54 stated they saw an inhaler in a tissue box on Resident #144's beside table but never saw the resident use it. During an interview on 6/3/2025 at 2:35 PM, Licensed Practical Nurse Unit Manager #5 stated when Resident #144 brought their inhaler in from home, the inhaler should be kept in the medication cart. Resident #144 was never approved to have medications at their bedside. During an interview on 6/5/2025 at 10:48 AM, the Director of Nursing stated if a resident's medication came in from home, the medication had to be kept in the medication cart with an order the resident's family supplied the medication. The order for family to provide the medication did not mean the resident could self-administer the medication or that it could be kept at the resident's bedside. The resident should be assessed to self-administer or keep a medication at bedside to ensure it was administered appropriately. Medications should never be left at a resident's bedside to take later as the resident may not take the medication or another person may walk in and take the medication. 10 NYCRR 415.3 (f)(1)(vi)

Based on observations, record review, and interviews during the recertification and abbreviated (NY00370441) surveys conducted 5/27/2025 -6/5/2025, the facility did not develop and implement a comprehensive person-centered care plan for each resident to include services provided to maintain the resident's highest practicable physical well-being for two (2) of five (5) residents (Residents #56 and #11) reviewed. Specifically, Resident #56 did not have a care plan for managing their peripherally inserted central catheter (intravenous line); and Resident #11's care plan did not reflect their current dialysis schedule or correct dialysis access site location. Findings include: The facility policy Comprehensive Person-Centered Care Plans, revised 1/2025, documented a comprehensive care plan was developed for each resident and included measurable objectives and timeframes to meet the resident's physical, mental, and psychosocial well-being. Assessments of the resident were ongoing, and care plans were revised when information about the resident and their condition changed. The comprehensive care plan was reviewed and updated by the interdisciplinary team when there was a significant change in the resident's condition, at least quarterly, and when the resident had been readmitted to the facility from a hospital stay. 1) Resident #56 had diagnoses including knee replacement, infection and inflammatory reaction due to internal joint prosthesis, and aftercare following joint replacement surgery. The 3/17/2025 Minimum Data Set assessment documented the resident had moderately impaired cognition and was independent with most activities of daily living. The 5/23/2025 hospital discharge summary documented Resident #56 underwent an incision and drainage (draining fluid from an infected joint) of the left knee. The resident was being discharged back to the facility with a peripherally inserted central catheter with a minimum of 6 weeks of intravenous (through a vein) antibiotic therapy. The 5/23/2025 physician order documented cefazolin (antibiotic) sodium solution reconstituted 1 gram. Use 2 gram intravenously three times a day for infection for 38 days until 7/1/2025; heparin lock flush solution 100 units/milliliter use 500 units intravenously every 12 hours as needed for peripherally inserted central catheter line. The orders did not include monitoring and maintenance of the peripherally inserted central catheter site The Comprehensive Care Plan initiated 5/15/2025 and revised on 5/27/2025 documented the resident was receiving antibacterial therapy for a wound infection. Interventions included monitoring for side effects of antibiotic use, the efficacy of the antibiotic, and any adverse reactions during or after its use. The Comprehensive Care Plan did not include interventions for management and monitoring of the peripherally inserted central catheter. During an observation on 5/27/2025 at 2:45 PM, Resident #56 had a peripherally inserted central catheter in their right upper arm with a dressing dated 5/23/2025. During an interview on 6/3/2025 at 10:49 AM, Certified Nurse Aide #46 stated Resident #56 had an intravenous line in their arm. They were unsure if it should have been in the resident's care plan, but it would be nice if it was included so the certified nurse aides would know it was there. During an interview on 6/3/2025 at 2:40 PM, Licensed Practical Nurse Manager #47 stated Resident #56 had a peripherally inserted central catheter in their right upper arm that was used for administering antibiotics and it was managed by the registered nurses. The licensed practical nurses were only able to monitor the central catheter, they could not administer the antibiotics or change the dressing. They were unaware it was not in the resident's care plan but thought it should be, so all staff knew it was there, how to monitor it, how often dressing changes were needed, and what complications to look for like bleeding or infection. Care plans were reviewed/updated during care plan meetings. They monitored care plans daily, but they had to notify a registered nurse to make any changes or initiate a care plan. During an interview on 6/4/2025 at 11:39 AM, Infection Control Nurse #32 stated they only initiated and monitored care plans that had to do with antibiotics because they tracked them, and they would discontinue the care plan when the antibiotic was completed. They thought Resident #56 should have a care plan for their peripherally inserted central catheter, so staff knew how to properly care for it. During an interview on 6/4/2025 at 2:47 PM, Assistant Director of Nursing #3 stated registered nurses were responsible for initiating and updating all care plans and licensed practical nurses could only review them. Resident #56 should have a care plan for their peripherally inserted central catheter with interventions, so staff knew to monitor for signs and symptoms of infection, dressing change schedule, what antibiotic they were on, and how to properly care for the line. 2) Resident #11 had diagnoses including end stage renal (kidney) disease and dependence on renal dialysis (procedure that removes waste products and excess fluid from the blood). The 4/27/2025 Minimum Data Set assessment documented the resident was cognitively intact and received renal dialysis. The 4/22/2025 physician order documented monitor [NAME] catheter (catheter placed into a large vein used for dialysis) to the left chest for signs and symptoms of infection. The 5/24/2025 physician order documented the resident attended dialysis three times a week on Tuesday, Thursday, and Saturday. Pick up time at 9:25 AM for a chair time of 10:25 AM. The Comprehensive Care Plan initiated on 6/30/2022 and revised on 8/11/2024 documented the resident went to dialysis related to chronic kidney disease. Interventions included encourage resident to go to scheduled dialysis appointments, dialysis on Monday, Wednesday, and Friday at 11:30 AM, and monitor hemodialysis catheter on the right chest for bleeding every Monday. The Comprehensive Care Plan was not revised to reflect the resident's updated dialysis schedule or the correct dialysis access site location to the left chest. During an interview on 5/27/2025 at 4:19 PM, Resident #11 stated they had been on dialysis for 2 years, they went to dialysis that morning at 9:15 AM and they usually returned between 2:30 PM and 3:00 PM. They stated their dialysis access site was on the left side of their chest. During an interview on 6/3/2025 at 9:21 AM, Certified Nurse Aide #51 stated they referenced resident's care plans daily, they included information on how to care for them, and care plans changed all the time. They did not think dialysis was on Resident #11's care plan and when they looked at the Kardex (resident care instructions) their dialysis days were not listed. During an interview on 6/3/2025 at 9:52 AM, Licensed Practical Nurse #52 stated care plans were important because they contained everything about the resident the staff needed to know to provide appropriate care. Dialysis days and the dialysis access site location should be listed correctly in Resident #11's care plan. During an interview on 6/3/2025 at 10:12 AM, Registered Nurse Unit Manager #53 stated they had care plan meetings every 3 months and they reviewed them any chance they had. It was important for care plans to be updated with accurate information for resident safety and so staff knew what instructions to follow so they could provide the best care to the residents. Resident #11's dialysis interventions were not accurate, they should have reviewed them when the resident transferred to their unit. If someone referenced the dialysis care plan, it was incorrect information. 10NYCRR 415.11(c)(1)

Based on observations, record review, and interviews during the recertification and abbreviated (NY00370441) surveys conducted 5/27/2025-6/5/2025, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for one (1) of six (6) residents (Resident #123) reviewed. Specifically, Resident #123 was not assisted with washing their hair or genital care as planned. Findings include: The facility policy Resident Care with Activities of Daily Living, last reviewed 1/2025, documented the facility was to accurately assist with residents' needs to support basic activities of daily living function. The supervisor was to be notified if the resident refused care and to report other information in accordance with facility policy and professional standards of practice. Resident #123 had diagnoses including urinary tract infection and neuromuscular dysfunction of the bladder (impairment of nerves and muscles that control the bladder). The 4/26/2025 Minimum Data Set assessment documented the resident was cognitively intact, had an indwelling catheter (a tube that removes urine from the bladder), required substantial/maximal assistance with showering/bathing, toileting hygiene and lower body dressing, and did not reject care. The Comprehensive Care Plan initiated 10/4/2023, and revised 4/23/2025, documented the resident required assistance with self-care and mobility related to a urinary tract infection. Interventions included substantial/maximal assistance for bathing/showering, partial/moderate assistance for personal hygiene, and morning and night care/bathing. The 12/26/2024 Urology consult progress note documented to cleanse the genital area twice a day with soap and water, pat the area dry, and return the foreskin (loose fold of skin on the penis) to the correct position. The 1/20/2025-4/22/2025 physician order documented to cleanse the foreskin twice a day with soap and water and pat dry. The 1/28/2025 Urology consult progress note documented to cleanse the genital area daily and return the foreskin to the correct position. The February 2025 Treatment Administration Record documented cleanse the foreskin twice a day with soap and water and pat dry. The treatment was documented as not completed: - on 2/3/2025 at 8:00 PM. - on 2/7/2025-2/9/2025 at 8:00 PM. The March 2025 Treatment Administration Record documented cleanse the foreskin twice a day with soap and water and pat dry. The treatment was documented as not completed: - on 3/5/2025 at 8:00 AM. The April 2025 Treatment Administration Record documented cleanse the foreskin twice a day with soap and water and pat dry, with a discontinue date of 4/22/2025. The treatment was documented as not completed: - on 4/13/2025-4/21/2025 at 8:00 AM. - on 4/6/2025 at 8:00 PM. - on 4/9/2025-4/10/2025 at 8:00 PM. - on 4/13/2025-4/21/2025 at 8:00 PM. The resident Kardex (care instructions) active as of 5/29/2025 documented AM/PM care/bathing; substantial/maximal assistance with shower/bathing; and shower/bath on Monday and Thursday. The following observations were made of Resident #123: - on 5/27/2025 at 12:29 PM, seated in their wheelchair wearing a hospital gown, their long hair was greasy and looked wet with comb lines through it. There were white flakes near the scalp. - on 5/27/2025 at 1:27 PM, lying in bed, their long hair was greasy and looked wet. They stated they had not been cleaned up for the day, they did not recall their last shower or their shower day, and they usually were cleaned up while they were in bed. - on 5/28/2025 at 9:22 AM, lying in bed, their long hair was greasy and looked wet with comb lines through it. - on 5/29/2025 at 9:44 AM, lying in bed wearing a hospital gown, their long hair was greasy and looked wet with comb lines through it. There were white flakes near the scalp. The resident stated they had not yet been cleaned up for the day. - on 5/30/2025 at 8:42 AM, lying in bed wearing a hospital gown, their long hair was greasy, looked wet, and had comb lines through it. The certified nurse aide flow sheet documented the resident received substantial/maximal assistance with shower/bathing: - on 5/27/2025 at 2:46 AM and 1:59 PM. - on 5/28/2025 at 2:42 AM, 1:59 PM, and 7:42 PM. - on 5/29/2025 at 5:15 AM. During an observation and interview on 5/30/2025 at 10:07 AM, Certified Nurse Aide #60 was completing morning care on Resident #123. The resident had white build up on their penis when the foreskin was pulled back. The suprapubic urinary catheter (inserted into the bladder to drain urine) had brown build up around the insertion site. The resident's hair was long and greasy and appeared wet. Certified Nurse Aide #60 stated Resident #123's hair looked like it had not been washed in 3-4 days and had an odor when they washed it. The certified nurse aide stated the resident's genital area looked like it had not been cleaned in days and had a lot of white buildup. Residents were supposed to be washed twice a day, so their skin was kept clean and to prevent skin breakdown. During an interview on 6/2/2025 at 11:33 AM, Licensed Practical Nurse #52 stated the certified nurse aides completed morning care which included getting the resident up, mouth care, and washing the resident. If Resident #123's genitals were not cleaned routinely it put them at risk for urinary tract infections and skin irritation. The resident's hair should be washed to prevent scalp irritation even if they did not receive a shower. If a resident refused care they should be notified. They stated Resident #123 never refused care. During an interview on 6/2/2025 at 11:46 AM, Registered Nurse Unit Manger #53 stated a bed bath consisted of washing the residents face, underarms, and their bottom part which included their penis. The certified nurse aides should document the care in the kiosk and if the resident refused care, they should document the refusal and notify the nurse. When completing care on Resident #123 it was important to wash all areas including their penis to prevent infection. 10NYCRR 415.12(a)(3)

Based on record review and interview during the abbreviated survey (NY00343878), the facility failed to provide residents with treatment and care in accordance with professional standards of practice for 3 of 6 residents reviewed (Residents #1, #5, and #6). Specifically, - Resident #1 had an unwitnessed fall, the medical provider was not notified timely of the fall or outcome of the assessment, and there was no evidence neurological checks were implemented. Subsequently, the resident experienced a significant change in condition, the medical provider ordered the resident to be sent to the hospital, and Emergency Medical Services was not notified immediately for transportation. The resident was transferred to the hospital where they expired from asphyxiation (loss of oxygen) due to choking on their dentures. - Resident #5 had unwitnessed falls and neurological assessments were not initiated or completed. - Resident #6 sustained a fall with a head injury and neurological assessments were not continued after the initial assessment. The facility's failure to complete timely assessments, notify Emergency Medical Services timely, and respond timely to a change in condition for Resident #1 placed 204 residents in the facility at risk. This resulted in actual harm that was Immediate Jeopardy and Substantial Quality of Care to resident health and safety. Findings include: The facility policy, Neurological Evaluation, effective ,d+[DATE] and revised ,d+[DATE], documented a neurological evaluation was indicated upon physician order; following an unwitnessed fall; following a fall or other accident/injury involving head trauma, or when indicated by resident condition. The policy did not document the frequency or duration of the neurological checks. The Neurological Monitoring Sheet (data recording for neurological checks) dated ,d+[DATE] documented neurological checks were to be completed every 15 minutes x 4; every 30 minutes x 4; every hour x 4; every 4 hours x 8; and every 8 hours x 4. The monitoring sheet included pupil evaluation, hand grips, lower extremity evaluation, mental status, headache, and vital signs (blood pressure, heart rate, respiration rate). The facility policy, Change in a Resident's Condition or Status, reviewed ,d+[DATE], documented the nurse would notify the resident's attending physician or physician on call after an accident or incident involving the resident or a significant change in the resident's physical/emotional/mental condition (need to alter the resident's medical treatment significantly). A significant change of condition was noted as a major decline or improvement in the resident's status that would not normally resolve without intervention by staff or by implementing standard disease-related clinical interventions; impacted more than one area of the resident's health status; required interdisciplinary review and/or revision to the care plan, and ultimately was based on judgement of the clinical staff and the guidelines outlined in the Resident Assessment Instrument. 1) Resident #1 had diagnoses including Alzheimer's disease and a prior stroke. The [DATE] Minimum Data Set assessment documented the resident had severely impaired cognition; required supervision/touch assistance with oral hygiene; was independent with rolling left to right and chair/bed-to-chair transfers; held food in their mouth/cheeks or residual food in their mouth after meals; was on a therapeutic diet; did not have any falls since the last assessment; and did not have loosely fitting full or partial dentures. The [DATE] dental note documented the resident had a well-fitting upper complete denture. The [DATE] comprehensive care plan documented the resident had oral/dental health problems related to being edentulous (no teeth), utilized an upper denture, and they were at risk for falls. Interventions included the resident was independent with eating, needed supervision/touch assistance with transfers and with oral hygiene, they needed denture care, and staff were to anticipate needs. The [DATE] cardiology consult documented the resident was seen for follow-up for their implantable cardioverter defibrillator (device in the chest that monitors heart rate and delivers electrical shocks, when needed, to restore a regular heart rhythm). The [DATE] at 7:33 PM Accident/Incident Report completed by Registered Nurse Supervisor #4 documented the resident had an unobserved fall in their room. The resident was found on the floor on the side of the bed without injury. Nurse Practitioner #5 was notified at 8:12 PM and Emergency Medical Services transferred the resident to the hospital at 9:14 PM. The [DATE] at 8:21 PM Registered Nurse Supervisor #4 progress note documented the resident slipped and had an unwitnessed fall. They were able to wiggle their hands and legs. There was no external rotation of the resident's legs (when a joint is rotated outward from the body, indicating injury). The resident was pursed lip breathing (inhaling through the nose with mouth closed and exhaling through tightly pressed lips) when oxygen was placed . Blood pressure was ,d+[DATE] (resident's blood pressure ranged ,d+[DATE] to ,d+[DATE] from [DATE]-[DATE]), pulse 67 beats per minute (normal ,d+[DATE]), respirations 19 breaths per minute (normal ,d+[DATE]), oxygen saturation level 95% (resident's normal range was ,d+[DATE]% without oxygen administration). The resident was now not speaking and that is a change in the assessment. The resident had a pacemaker (an implanted device used to treat irregular heart rhythms) and per the nurse, while taking vitals, the resident's left arm lit up. Nurse Practitioner #5 ordered the resident was to be sent to the hospital. The [DATE] at 8:25 PM Nurse Practitioner #5's progress note documented they were called by Registered Nurse Supervisor #4 for an unwitnessed fall. The resident slipped on spilled water. The resident was initially responsive then suddenly became unresponsive. Staff reported the resident's arm lit up and Nurse Practitioner #5 noted they were not sure what that could have been. The resident was only responsive to painful stimuli, and there was no visible trauma to their head. The resident was positive for COVID-19, and they ordered the resident to be transferred to the hospital. There was no documented evidence the facility was aware of the resident's implantable cardioverter defibrillator. The [DATE] at 9:17 PM Registered Nurse Supervisor #4's progress note documented they were called to the unit for an unwitnessed fall. Upon entering the room, the resident was on the floor, had their head propped on a pillow against the end table, was wearing non-skid socks, but the floor was wet near the bed. The resident was short of breath and 4 liters of oxygen was placed via nasal cannula. Oxygen saturation level was 95% with the oxygen on. The resident was able to lift their arms and wiggle their fingers and follow commands. The resident then started acting odd, stiffening up, and not responding or following commands. The resident was placed in bed and an assessment was completed. Licensed Practical Nurse #2 reported when they checked the resident's pulse prior to their arrival, they noticed the resident's left arm lit up. The resident had a pacemaker. The resident reacted to sternal rub (rubbing the knuckles on the breastbone to cause painful stimuli to see if there is a reaction from an unconscious person) and was swinging their hands at them. Nurse Practitioner #5 was notified and ordered the resident to be transferred to the hospital. The resident left at 9:14 PM. The undated, unsigned Investigative Summary documented on [DATE] at 7:33 PM, the resident was found by Licensed Practical Nurse #2 on the floor near their bed next to a small puddle of water. Licensed Practical Nurse #2 paged Registered Nurse Supervisor #4 who found the resident alert and oriented with no visible signs of a head injury. The resident was transferred to the bed, could follow commands, and the source of water was unclear with no visible leaks to the toilet/sink . During the assessment, the resident appeared short of breath and oxygen was placed at 4 liters per minute bringing their oxygen saturation level up to 95%. The resident became hypotensive (low blood pressure) and only responded to a sternal rub. The on-call medical provider, Nurse Practitioner #5, was notified, and the resident was sent to the hospital at approximately 9:14 PM. The hospital called back and said the resident died from respiratory arrest at 9:59 PM. Based on information, it appeared the resident suffered a fall after experiencing cardiac/respiratory arrest related to pre-existing conditions and acute COVID-19 diagnosis . Abuse, neglect, mistreatment was ruled out. The Prehospital Care Report completed by Emergency Medical Services documented: - at 8:58 PM, they received a call from the facility and were enroute and arrived at the facility at 9:02 PM. - at 9:05 PM, the resident was clammy, cold, cyanotic (bluish color caused by low oxygen), capillary refill was above 4 seconds (the time it takes for blood to refill after applying pressure, normal ,d+[DATE] seconds), and the resident was unresponsive. - at 9:10 PM, 15 liters per minute of oxygen was applied via a non-rebreather (oxygen mask that delivers high concentrations of oxygen) with unchanged resident response. - at 9:20 PM, intravenous (administered through a vein) Versed (sedative) was administered and a foreign body was removed from the resident's airway. - at 9:22 PM, oxygen at 15 liters per minute via a non-rebreather with improved resident response. The narrative note attached to the report documented they were dispatched to the facility for a fall with possible pacemaker damage. Upon arrival, the resident was found lying in bed. The resident had dentures in their mouth, and they (unclear if referring to staff or Emergency Medical Services) could not get them out. The resident was not responsive and only responded when trying to remove the dentures manually. The dentures were in the back of the throat causing a partial airway obstruction. They attempted to open the resident's airway with modified jaw thrust and grabbing the dentures with forceps, though they were unable to open. The resident was then given Versed for sedation and the dentures were removed. The resident's pupils were now fixed and dilated (not moving and large, sign of serious life-threatening condition). Care was transferred from Emergency Medical Services to the hospital. The [DATE] hospital report documented the resident arrived at the hospital at 9:29 PM, was unresponsive and cyanotic with pupils fixed and dilated. The resident suffered cardiac arrest shortly after arrival and cardiopulmonary resuscitation was unsuccessful. The resident expired. The resident's [DATE] death certificate, signed by Medical Examiner #5 documented the resident's manner of death was an accident, the immediate cause of death was from asphyxiation due to choking on dentures. During a telephone interview on [DATE] at 10:35 AM, Certified Nurse Aide #1 stated the resident wore dentures and needed assistance of 1 with oral hygiene and putting in and removing dentures daily. The resident walked well with a walker. Dentures typically were removed at bedtime, around 7:30 PM. They never noticed any issues with the resident's dentures not fitting correctly. They were assigned to the resident's care on [DATE] and they showered the resident before dinner and brought their dinner tray around 6:00 PM to 6:30 PM. They and Licensed Practical Nurse #2 heard a thump (did not recall the time) and the resident's roommate yelled out for them. The resident was on found on the floor and they stayed with the resident while Licensed Practical Nurse #2 called the Supervisor. They did not see the resident the remainder of the night after the fall and left their shift at 8:00 PM. During a telephone interview on [DATE] at 8:56 AM, Licensed Practical Nurse #2 stated when a resident had an unwitnessed fall, the Supervisor was notified, and neurological checks were started immediately and done every 15 minutes for the first hour. There was a sheet they used to document neurological checks. If a resident had a change in condition, they notified the Registered Nurse or Supervisor, and the Registered Nurse/Supervisor assessed the resident and called the medical provider immediately. If orders were obtained to send the resident to the hospital, then Emergency Medical Services was notified immediately. Resident #1wore dentures, needed assistance to put them in and remove them and the aides assisted with that care. They were notified on [DATE] by the resident's roommate the resident fell , and they did not recall the time. They found the resident lying on their back and when they asked the resident if they were okay, the resident stated no and tried to get themself off the floor. They put a pillow under the resident's head and had the certified nurse aide stay with the resident while they got supplies to do vital signs and call the Supervisor. The resident's oxygen saturation level was close to 60% or below so they applied oxygen and the oxygen saturation improved to 95%. They were not sure if the resident hit their head. The resident did not want to talk and that was not their normal behavior. The resident did follow all Registered Nurse Supervisor #4's requests during the assessment. Licensed Practical Nurse #2 did the original set of neurological checks on the resident and reported them to Registered Nurse Supervisor #4, but they did not start the neurological check sheet. They thought the resident was sent to the hospital quickly and that was why neurological checks did not continue. They believed the medical provider was notified immediately as well as Emergency Medical Services. They stated at one point, they noticed the resident's top denture was sliding down in their mouth and when they attempted to remove them, the resident closed their mouth and would not allow removal. They did not recall what time that occurred and did not recall notifying anyone about the dentures. During a telephone interview on [DATE] at 9:57 AM and 5:51 PM, Registered Nurse Supervisor #4 stated after a resident had an unwitnessed fall, they were supposed to be monitored with vital signs and neurological checks and how often those were done was dependent on how the medical provider ordered them. When a resident had a change in condition, the Director of Nursing and the medical provider should be notified. If a medical provider ordered a resident to be sent to the hospital for a change in condition, it would take Registered Nurse Supervisor #3 quite a while to do the transfer paperwork. They did not specify what quite a while meant. On [DATE], the resident was found on the floor. They were not sure how the resident was acting when they assessed them because they did not know the resident's baseline. There were no injuries, and a quick neurological check was done and was normal. The nurse on the unit reported the resident was acting odd when they did vital signs before Registered Nurse Supervisor #4 got to the floor. Licensed Practical Nurse #2 reported when doing the resident's pulse, their whole arm lit up. Registered Nurse Supervisor #4 wondered if that had something to do with the resident's pacemaker. The pacemaker appeared to be in the correct position when they checked. The resident was found short of breath with pursed lip breathing during the assessment, but they knew the resident had chronic obstructive pulmonary disease (lung disease). Oxygen was applied and the resident's oxygen saturation improved to 95%. They did not notify the physician at that time because the resident was answering questions appropriately, had no injuries, and they were not planning to send them to the hospital. After getting the resident in bed, they left the unit. They did not recall if they left monitoring instructions with Licensed Practical Nurse #2 however it was standard procedure for nurses to do neurological checks and vital signs after an unwitnessed fall . They did not recall if they were notified to return to the unit or if they were checking on the resident however, about a half hour later, the resident would no longer respond verbally to questions, they had a blank stare and continued pursed lip breathing. They did a sternal rub and the resident only responded to pain. They told staff they were sending the resident to the hospital and that was when they notified Nurse Practitioner #6 of the fall and change in condition. Registered Nurse Supervisor #4 stated they did not notify Emergency Medical Services until they had all the transfer paperwork completed because it only took Emergency Medical Services 5 minutes to arrive once called. They stated they also needed to go to another unit to tend to one or two other residents peripherally inserted central catheters before they sent Resident #1 out. Nobody notified them the resident's dentures were loose in their mouth and they should have been notified. During an interview on [DATE] at 11:47 AM, the Director of Nursing stated they reviewed and completed the [DATE] investigation. Based on the documentation from the nursing progress notes, they understood the events occurred in succession. They were not aware of any significant gaps in time from when the resident's change of condition was noted, to the medical provider notification, to calling for emergency medical services. If Registered Nurse #4 was made aware of concerns related to the resident's condition immediately after the fall, the medical provider should have been notified at that time. When the resident had a change in condition and their arm was noted to have lit up, the medical provider should have been notified immediately. Once the provider directed staff to send the resident to the hospital, they should have called for an ambulance immediately. They were not made aware that Licensed Practical Nurse #2 observed the resident's dentures loose in their mouth, and stated they should have notified the supervisor immediately. During an interview on [DATE] at 1:49 PM, Nurse Practitioner #5 stated they expected to be notified of a fall immediately after the initial assessment. If a resident experienced a change from their baseline condition, such as low oxygen and pursed lip breathing after a fall, they expected to be notified immediately. Following their order to send the resident to the hospital, they expected nursing staff to notify Emergency Medical Services immediately for transport. The 39-minute time frame to notify the Nurse Practitioner after Resident #1's fall was not timely, it was an excessive amount of time that passed. Waiting 46 minutes to call Emergency Medical Services following the Nurse Practitioner's order to send to the hospital was also not timely. Staff should have called Emergency Medical Services immediately after receiving the order. During an interview on [DATE] at 1:05 PM, the Administrator stated they were involved in the review of Resident #1's fall and hospitalization on [DATE]. Based on the documentation from the nursing progress notes, they understood the events occurred in succession. They were not aware of any significant gaps in time from when the resident's change of condition was noted, to the medical provider notification, to calling for Emergency Medical Services. Forty-six minutes was not timely to notify Emergency Medical Services following an order to send the resident to the hospital. The Administrator was not aware the resident's vital signs and neurological status were not monitored pending hospital transfer and they expected monitoring to occur during that time. They thought events happened quickly and there were no time delays in provider notification or hospital transport. 2) Resident #5 had diagnoses including dementia. The [DATE] Admission Minimum Data Set assessment documented the resident's cognition was intact and they required partial to moderate assistance with rolling left to right and with chair to bed transfers. The resident had no falls prior to admission and had one fall since admission. The [DATE] comprehensive care plan documented the resident was at risk for falls. Interventions included staff were to anticipate needs. The [DATE] at 10:30 AM Assistant Director of Nursing #12's progress note documented they were called to the unit because the resident was found on the floor. The resident was attempting to get out of bed by themselves and slid to the floor. They were observed sitting on the floor with no apparent injuries. The resident was educated to ask for help. There was no documented evidence neurological checks were initiated or completed. The [DATE] Accident/Incident Review Checklist (checklist of items reviewed during the investigation) and Summary of the Investigation completed by Assistant Director of Nursing #15 documented the resident fell with no injuries and fall precautions were initiated. Multiple documents were noted as reviewed including staff statements, the care plan, and Fall Risk Evaluation. Neurological assessments were not documented as reviewed. The [DATE] at 12:22 PM Physician #13's progress note documented the resident was seen for a fall earlier in the day and the plan was to continue monitoring and neurological checks. The [DATE] comprehensive care plan documented the resident had an actual fall. Interventions included non-slip shoes, clutter free environment, and call bell in reach. The [DATE] at 3:07 PM Physician Assistant #14's progress note documented a fall follow-up and continued vital sign monitoring and neurological checks per facility policy. The [DATE] at 8:03 AM Assistant Director of Nursing #12's progress note documented the resident was found on the floor . The resident was trying to reach for a blanket, the mattress slid over the bed frame causing them to roll out of bed and they had a small abrasion to the knee. There was no documented evidence neurological checks were initiated or completed. The [DATE] Accident/Incident Review Checklist and Summary of the Investigation completed by Assistant Director of Nursing #15 documented the resident's mattress slid off the frame as they reached for an item and the plan was to have maintenance look at the bed frame. Multiple documents were documented as reviewed however neurological checks were not documented as reviewed. During a telephone interview on [DATE] at 12:23 PM, Assistant Director of Nursing #12 stated neurological checks were initiated after unwitnessed falls. The initial check was completed by the assessing nurse and the remaining checks were completed by floor nurses. On [DATE], the resident denied hitting their head and if a resident was alert and oriented, they took their word for it that they did not hit their head. The same was true for the [DATE] fall with the resident stating they did not hit their head. They were not aware the facility policy documented neurological checks for unwitnessed falls. During a telephone interview on [DATE] at 12:34 PM, Assistant Director of Nursing #15 stated the purpose of the Accident/Incident Review Checklist was to ensure all documents were readily accessible and to ensure the packet was completed. Neurological checks were instituted at the time of the fall and continued per policy. If a resident was alert and oriented and could tell you they did not hit their head, then neurological checks were not continued , and this was why the Accident/Incident Review Checklist did not contain neurological checks on [DATE] and [DATE]. They were not aware the facility policy documented that neurological checks were completed for all unwitnessed falls. 3) Resident #6 had diagnoses including dementia, diabetes, and urinary tract infection. The [DATE] Minimum Data Set assessment documented the resident had severe cognitive impairment and had behavioral symptoms including rejection of care. The resident required substantial assistance for bed mobility and was dependent for transfers. The resident had one fall with no injury since the last assessment. The [DATE] Accident and Incident Report completed by Registered Nurse Supervisor #16 documented at 10:15 PM, the resident had an unobserved fall in their room. The resident had a hematoma (pooling of blood from broken blood vessel) on their right forehead and complained of pain in the area. The resident's vital signs were documented and there was no documentation related to a neurological assessment. The [DATE] at 12:52 AM Registered Nurse Supervisor #16's progress note documented the resident was found on the floor and had a 2-centimeter hematoma on their right forehead with faint bruising noted and neurological checks were intact. The on-call medical provider was notified and ordered to send the resident to the hospital for evaluation due to the resident taking a blood thinner. Upon arrival of Emergency Medical Services, the resident refused to go to the hospital, and they were unable to transport the resident. The medical provider was notified and stated to continue neurological checks and notify them of any change in condition. There were no documented neurological checks following Registered Nurse Supervisor #16 initial assessment as noted in the [DATE] at 12:52 AM progress note. There was no documented evidence of attempts to obtain neurological checks or of refusal by the resident. The Accident/Incident Review Checklist, completed by Assistant Director of Nursing #15 documented the resident had a fall on [DATE] at 10:15 PM. The section to verify documentation included 7 items: fall risk evaluation, change in condition form, pain evaluation, registered nurse assessment, care plan updates, neurological assessment, and supervisor summary. All items were checked except for neurological assessment. The section to verify attachment of copies included the 7 items and neurological assessment not checked. There was no documentation related to the lack of neurological assessments in the checklist review. The [DATE] at 12:52 PM and [DATE] at 10:22 AM electronic Medication Administration notes entered by Licensed Practical Nurse #18 documented the resident refused to have their vital signs taken. There was no documented evidence of neurological assessments or attempts to complete neurological assessments from [DATE] to [DATE]. There was no documented evidence of neurological check monitoring sheets. During an interview on [DATE] at 1:18 PM, Licensed Practical Nurse #18 stated neurological checks were to be completed according to the time intervals on the neurological flow sheet. The Supervisor initiated the neurological checks, and the floor nurses continued them. When Resident #6 fell on [DATE], the Licensed Practical Nurse stated they were not working at the time. They worked the day shift on [DATE] and day and evening shifts on [DATE] and there was a neurological check sheet. The resident did not refuse when Licensed Practical Nurse #18 did the checks. Neurological check sheets were completed on paper and the nurse recalled there were some prior refusals noted on the sheet. When it was completed, the flow sheet went back to the Supervisor. During an interview on [DATE] at 1:29 PM, Registered Nurse Supervisor #16 stated on [DATE], they initiated a neurological check sheet for Resident #6. They then turned it over to Licensed Practical Nurse #17, who reported the resident refused to have the checks done. The Registered Nurse Supervisor stated the refusals were documented on the neurological flow sheet. When completed, the sheet was to be turned in with the fall packet. The Registered Nurse Supervisor stated they had since heard someone had trouble locating the neurological check sheet. During an interview on [DATE] at 1:50 PM, Assistant Director of Nursing #15 stated when they reviewed Resident #6's [DATE] fall, they noted the missing neurological check sheet. They asked Registered Nurse Supervisor #16 and the regular floor nurse (unidentified) who stated they could not recall initiating it or completing it and were unaware of where the sheet was. The Assistant Director of Nursing stated they were unable to locate a neurological sheet and did not believe one was done. The resident was initially going to be sent out to the hospital and it was likely a neurological check sheet was not initiated. 10 NYCRR 415.12 --------------------------------------------------------------------------------------------------------------------- Immediate Jeopardy was identified, and the Administrator was notified on [DATE] at 3:04 PM. Immediate Jeopardy was removed on [DATE] at 12:25 PM prior to survey exit based on the following corrective actions taken: - 93% of nursing staff (registered nurses, licensed practical nurses, certified nurse aides) were educated on calling the medical provider after a change in condition, completing neurological checks, immediacy of calling Emergency Medical Services after receiving an order to send to the hospital, and completing assessments including checking the airway. - The facility had a plan to educate the remaining staff prior to the start of their next shift. - Post-tests were issued and reviewed. - Staff education sign in sheets were reviewed and compared to the current nursing staff list and no discrepancies were identified. - 100% of nursing staff working [DATE] received education. - Staff education was verified during an onsite visit [DATE], multiple nursing staff on multiple units were interviewed. - Staff were able to report content of education and confirmed day received and the facility staff who presented the education (Assistant Directors of Nursing or Educator).

Based on observation, record review, and interview during the recertification and abbreviated survey (NY00332276) conducted [DATE]-[DATE], the facility failed to ensure resident preferences and physician orders related to cardiopulmonary resuscitation (perform chest compressions in the event of a cardiac arrest), and other advance directive issues were communicated throughout the facility so that staff knew immediately what action to take or not to take when an emergency arose. Specifically, staff were unable to consistently identify resident code status indicators in the event of cardiac arrest. On [DATE], Resident #400 was found without a pulse in a non-residential area of the facility. Staff did not know the resident's code status and initiated cardiopulmonary resuscitation (chest compressions). The resident had a physician order documenting do not attempt resuscitation (allow natural death). In addition, resident code status identification bracelets were documented as being in place and were observed not in place for Residents #2, #16, #64, #87, #126, and #185. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy but Substandard Quality of Care with the potential to affect all 202 residents in the facility during a cardiac emergency. Findings include: The facility policy titled Advance Directives, reviewed by the facility ,d+[DATE], documented advance directives would be respected in accordance with state law and facility policy. Upon admission, the resident would be provided information and formulate an advance directive. If unable to do so, the resident's legal representative would be given the information and formulate the advance directives. Information about the advance directives would be displayed prominently in the medical record. The plan of care would be consistent with those wishes. The resident would not be treated against their wishes. Do not resuscitate indicated that in the event of cardiac or respiratory failure, no cardiopulmonary resuscitation was to be used. The policy did not address code status identification bands. The facility policy titled Emergency Procedure-Cardiopulmonary Resuscitation reviewed by the facility ,d+[DATE] documented if an individual was found unresponsive and not breathing normally, a licensed staff member certified in cardiopulmonary resuscitation would initiate cardiopulmonary resuscitation unless it was known that the resident had a do not attempt resuscitation order. If a resident's do not attempt resuscitation status was unclear, cardiopulmonary resuscitation would be initiated until it was determined there was a do not attempt resuscitation order. The policy did not address code status identification bands. Resident #400 had diagnoses including atrial fibrillation (abnormal heartbeat), schizophrenia and high blood pressure. The [DATE] Minimum Data Set assessment documented the resident had intact cognition and required supervision with most activities of daily living. Resident #400's Medical Orders for Life Sustaining Treatment was verbally consented to by the resident's Health Care Proxy (a person designated to make health care decisions) on [DATE] at 12:47 PM and signed by the nurse practitioner on [DATE] and documented the resident's resuscitation instructions were do not resuscitate (allow natural death). The [DATE] at 6:35 PM registered nurse supervisor #15 progress note documented they responded to a code blue (medical emergency) at 6:35 PM that was at the first floor tower elevators. Upon their arrival, Resident #400 was found lying down face first on the floor. Resident #400 was found absent of a pulse and respirations. Resident #400 was pronounced deceased at 7:09 PM. During a telephone interview on [DATE] at 2:50 PM, registered nurse supervisor #15 stated Resident #400 was found on the floor by the back door elevator and had no pulse. They stated they started chest compressions as they did not know what the resident's code status was. There was no identification band on the resident, and they told staff to immediately get the resident's chart. Resident #400's [DATE] medication administration record documented check resident's identification band to be in place and intact, do not resuscitate/do not intubate. The last shift signed for was by licensed practical nurse #7 on the [DATE] day shift. During an observation on Unit 7 on [DATE] at 1:12 PM a poster at the nurse's station titled Wristband Dots documented: blue is diabetic. purple is do not resuscitate. yellow is fall. red is allergies. Resident #2's Medical Orders for Life Sustaining Treatment form documented a verbal consent was obtained from the resident's decision maker on [DATE] and was signed by the nurse practitioner on [DATE]. The form documented Do Not Attempt Resuscitation. On [DATE] at 11:53 AM and at 2:41 PM, Resident #2 was observed not wearing an identification band. Resident #2's ,d+[DATE] medication administration record documented check resident's identification band to be in place and intact every shift. The record documented the check was done and signed for by staff every shift on [DATE]. Resident #16's Medical Orders for Life Sustaining Treatment was signed by the resident and the nurse practitioner on [DATE] and documented Do Not Attempt Resuscitation. On [DATE] at 1:38 PM Resident #16 was observed not wearing an identification band. Resident #64's [DATE] physician order documented Full code. On [DATE] at 1:32 PM Resident #64 was observed not wearing an identification band. Resident #87's Medical Orders for Life Sustaining Treatment was verbally consented to by the resident on [DATE] and signed by the nurse practitioner on [DATE] and documented attempt cardiopulmonary resuscitation. On [DATE] at 11:53 AM Resident #87 was observed not wearing an identification band. Resident #126's Medical Orders for Life Sustaining Treatment was signed by the resident and the nurse practitioner on [DATE] and documented Do Not Attempt Resuscitation. On [DATE] at 3:26 PM, Resident #126 was observed not wearing an identification band. Resident #126's ,d+[DATE] medication administration record documented check resident's identification band to be in place and intact every shift for monitoring. Staff signed for the band every shift through the [DATE] day shift. Resident #185's Medical Orders for Life Sustaining Treatment was signed by the resident [DATE], was not signed by a medical provider, and documented attempt cardiopulmonary resuscitation. A physician order dated [DATE] documented the resident was a full code. On [DATE] at 1:32 PM Resident #185 was observed not wearing an identification band. During an interview on [DATE] at 1:12 PM licensed practical nurse #6 stated code status was documented on a wristband with colors. Blue meant do not resuscitate and they did not know what red meant. They stated they signed for identification bands during their shift. They could not always tell code status by the bracelet because the colors could fade in the shower. They stated even with a bracelet they would initiate cardiopulmonary resuscitation. During an interview on [DATE] at 2:40 PM licensed practical nurse Unit Manager #5 stated the Medical Orders for Life Sustaining Treatment would determine code status. The resident bracelets just told the resident's name on some floors but on the 5th floor it included code status. The bracelets had different color stickers for do not resuscitate and altered consistency, but the stickers fell off. If a nurse was documenting they signed for placement of a bracelet and they did not, they would not know the resident's code status. They stated they did not know what the colors meant but they could look at the poster at the nursing station. A certified nurse aide had told them there was a template on the back of their name badge. During an interview on [DATE] at 2:41 PM licensed practical nurse #12 stated to find a resident's code status they looked in the Medical Orders for Life Sustaining Treatment book or in the computer. They stated the residents used to have plastic bracelets that were labeled with the code status, but they were not sure if they were still using them. The identification bands checked in the treatment administration record were for resident identification and not code status. During an interview on [DATE] at 2:45 PM certified nurse aide #28 stated they would know a resident's code status by asking the nurse to check the chart, looking at the list at the nursing desk, or looking at the resident's bracelet. They stated the bracelets were color coded, but they did not know what the colors meant and had not been educated. During an interview on [DATE] at 2:49 PM, registered nurse #10 stated the residents were given an identification bracelet when they were admitted to the facility. The bracelet had the resident's name, code status, and other identification factors on different colored stickers. They stated most of the residents did not keep their bracelets in place so they would check the medical orders for life sustaining treatment and the order for code status. They stated the medication nurses should check the resident's bracelet every shift and document it in the record. They stated all units had a chart on the wall by the nurse's station that listed the meaning of the colored dots that were on the bracelets, and it was also on the back of their name badges. During an interview on [DATE] at 2:52 PM Education Coordinator #11 stated if a resident had a purple dot on their wrist bracelet it meant the resident was a do not resuscitate, and if there was no colored dot it meant the resident was a full code. Staff were also trained to check the resident's electronic medical record for code status. If a resident did not have a bracelet staff should notify the Unit Manager for a replacement. All staff name badges had an area on the back that explained the color codes on the bracelets, and this was all reviewed during staff orientation. During an interview on [DATE] at 2:55 PM licensed practical nurse Unit Manager #13 stated they determined code status by looking at the computer, the Medical Orders for Life Sustaining Treatment book, and there was also a bracelet the residents wore. They stated the bracelet was paper but the residents on their unit did not keep them on. If a resident was a do not resuscitate the bracelet would be purple. If a nurse documented in the medication administration record the bracelet was checked it meant the resident was wearing it. During an interview on [DATE] at 2:58 PM certified nurse aide #39 stated they would look at the resident's bracelet to determine code status. They stated there was blue and purple on the bracelets and they did not know what the colors meant. They stated they would also check the Medical Orders for Life Sustaining Treatment if needed. During an interview on [DATE] at 3:16 PM, licensed practical nurse #16 stated each resident should be wearing an identification band that identified their advance directive status. If a resident was found on the floor unresponsive, staff were to call a code blue and check the identification band for code status. They did not remember if Resident #400 had an identification band on [DATE]. They stated they did not always check for the bands when signing for them and usually checked only residents that had a habit of removing them. During an interview on [DATE] at 3:44 PM, the Director of Nursing stated staff should document in the medication administration record every shift for checking and placement of each resident's identification band. There should be a progress note made if a resident refused the band. Each Unit Manager was responsible for applying an identification band and ensuring the identification bands, physician's orders, and Medical Orders for Life Sustaining Treatment forms matched. The identification bands were an added step to quickly identify a resident's code status. During an interview on [DATE] at 4:30 PM licensed practical nurse #37 stated they would look at the Medical Orders for Life Sustaining Treatment or in the computer to determine code status. Every resident was supposed to have a bracelet that was checked every shift. During an interview on [DATE] at 11:13 AM, nurse practitioner #18 stated all residents in the facility should have an advance directive order so that staff knew whether the resident wished to be resuscitated in the event of cardiac arrest. Ramifications of initiating cardiopulmonary resuscitation included causing unnecessary bodily harm, broken ribs, and injuries to the person's internal organs if they were to be resuscitated. During a telephone interview on [DATE] at 3:04 PM, physician #40 stated cardiopulmonary resuscitation should not be initiated if a resident was a Do Not Attempt Resuscitation, as that was not their wish. All residents in the facility had Medical Orders for Life Sustaining Treatment. Staff should follow all advance directives orders. 10 NYCRR 415.3(e)(2)(iii) 37516 40803 48446 48632 48675 48895 49448

Based on observation, record review, and interview during the recertification and abbreviated (NY00328424) surveys conducted 1/24/2024-2/1/2024, the facility did not ensure drugs and biologicals were labeled and stored in accordance with currently accepted professional principles, and include the expiration date when applicable for 3 of 5 medication carts (4th floor, 6th floor and 7th floor) and 7 of 7 medication refrigerators (2 South, 2 West, 3rd floor, 4th floor, 5th floor, 6th floor and 7th floor) reviewed. Specifically, the 4th floor medication cart had eye drops for Resident #61 and Resident #136 without labeled open dates or discard dates; the 6th floor medication cart had eye drops for Resident #9 without labeled open or discard dates, and opened house stock cough syrup without labeled open date or discard date; and the 7th floor medication cart had eye drops for Resident #74 and Resident #94, and two insulin pens for Resident #105 that were not labeled with open or discard dates. Additionally, medication refrigerators on 2 South, 2 West, 3rd floor, 4th floor, 5th floor, 6th floor, and 7th floor did not have consistent documentation that temperatures were monitored or maintained. Findings include: The facility policy Storage of Medications revised 1/2024 documented nursing staff was responsible that medication storage was maintained in a safe and sanitary manner. The facility was not to use discontinued or outdated medications. Medications that required refrigeration were stored in the refrigerator in the drug room and all containers that had missing, incomplete, improper, or incorrect labels were returned to the pharmacy. The facility policy Medication Cart revised 1/2024 documented all medications were stored per the manufacturer's recommendations including temperature. All vials and bottles were dated when opened and expiration dates were visible on all medications and were discarded by the expiration date. The facility policy Medication Refrigerator revised 1/2024 documented a refrigerator temperature log was maintained daily. All vials and bottles were dated when opened and discarded per the recommended timeframe. The facility policy Stock/ House Medications revised 1/2024 documented medication containers were dated upon opening and discarded per manufacturer's recommendation after opening. Floor stock expiration dates were checked by nursing at the time of administration and periodically checked by a designee. The Pharmacy Medications with Shortened Discard Dates document revised 11/29/2023, documented Basaglar and Novolog insulin pens were to be discarded 28 days from the open date. Latanoprost eye drops were to be discarded 42 days from the open date. Artificial tears were to be discarded 4 days after foil pack was opened. Dorzolamide/ Timolol, Brimodine, Olopatadine and Systane eye drops as well as cough syrup were not included in the list. Directions at the top of the document provided a phone number to call the pharmacy for any medication not listed to determine the appropriate discard date. MEDICATION CARTS During an observation of the 4th floor medication cart on 11/26/2024 at 11:17 AM with licensed practical nurse #9, Resident #61 had opened artificial tear eye drops without an opened or expiration/ discard date on the label, and Resident #136 had three types of eye drops (latanoprost 0.005%, dorzolamide/timolol 2-0.5% and brimonidine 0.2%) that were opened and not labeled with opened or discard dates. Licensed practical nurse #9 stated all these medications should have an open date and pointed to the attached yellow sticker for the documented open/expiration dates that was blank. During an interview on 11/26/2024 at 11:27 AM 4th floor registered nurse Unit Manager #10, stated whoever opened the medication was responsible for documenting an opened date or a discard date. Without an opened date, the expiration date was unknown, and residents should not receive expired medications. Registered nurse Unit Manager #10 stated it was important opened and expired dates were documented for resident safety and appropriate medical treatment and expired medications may not work. During an observation of the 6th floor medication cart on 1/26/2024 at 11:47 AM with licensed practical nurse #67, Resident #9 had olopatadine 0.2% eye drops and Systane eye drops with no opened or expiration/ discard dates. House stock cough suppressant syrup was opened without an open or expired/ discard by date. Licensed practical nurse #67 stated all eye drops should be dated when opened or there was no way to know when they were expired. They stated house stock was supposed to be dated when opened as well. During an interview on 1/26/2024 at 11:55 AM 6th floor registered nurse Unit Manager #57, stated medications were labeled with an open date so staff would know the expiration date and when a medication should no longer be used. Residents should not have received expired medications as they could have an adverse reaction. During an observation of the 7th floor medication cart on 1/26/2024 at 12:03 PM with licensed practical nurse #6, Resident #74 had artificial tear eye drops that were not labeled with an opened or expiration/ discard date, Resident #94 had latanoprost 0.005% eye drops that were not labeled with an open or expiration/ discard date, and Resident #105 had an insulin Basaglar Kwik pen and insulin Novolog pen that did not have open or expiration/ discard dates. Licensed practical nurse #6 stated medications were dated when opened so an expiration date was known. If residents received expired medications, it could make them sick, they could have an adverse reaction and hospitalization may be required. During an interview on 1/26/2024 at 12:10 PM with registered nurse Supervisor #48 they stated staff was expected to date and time any medication when it was opened. The length of time a medication was good for varied by medication and without an open date, there would be no way of knowing if a medication was still good. Medications without an open date should not be administered because it would be unknown if they were good or expired. If a resident received a medication that was no longer good, it may no longer be effective, and the integrity of the medication could be compromised. During an interview on 1/26/2024 at 1:11 PM with Assistant Director of Nursing #65, all medications were labeled with an open date. This included over the counter house stock medications, eye drops, and insulins. Whoever opened the medication was responsible for labelling it with an open date. If a medication was opened but not labeled, it should be discarded. Medications without an open date were not to be administered. Open dates should be checked prior to medications being administered to verify that they were still good. Unit managers completed medication cart audits weekly and pharmacy completed medication cart audits at least annually. MEDICATION REFRIGERATOR TEMPERATURES Medication refrigerator temperature logs for December 2023-January 2024 did not document the medication refrigerator temperature was checked on the following units and dates: - 2 [NAME] on 12/10/2023, 12/11/2023, and 12/16/2023. There was no documented evidence of a temperature log for January 2024. - 2 South on 12/2/2023, 12/9/2023, 12/10/2023, 12/16/2023, 12/17/2023, 12/23/2023, 12/24/2023, 12/25/2023, 12/30/2023, 12/31/2023, 1/1/2024, 1/6/2024, 1/20/2024, and 1/21/2024. - 3rd floor on 1/1/2024 - 4th floor- there was no documented evidence of a temperature log for December 2023. - 5th floor on 12/1/2023, 12/4/2023, 12/6/2023, 12/7/2023, 12/8/2023, 12/9/2023, 12/11/2023, 12/12/2023, 12/13/2023, 12/14/2023, 12/16/2023, 12/17/2023, 12/192023, 12/20/2023, 12/21/2023, 12/22/2023, 12/23/1023, 12/24/2023, 12/26/2023, 12/27/2023, 12/28/2023, 12/29/2023, 12/30/2023, 12/31/2023, 1/1/2024, 1/3/2024, 1/4/2024, 1/5/2024, 1/6/2024, 1/7/2024, 1/8/2024, 1/9/2024, 1/11/2024, 1/15/2024, 1/16/2024, 1/17/2024, 1/22/2024, 1/23/2024, and 1/25/2024. - 6th floor on 1/26/2024 - 7th floor on 12/1/2023, 12/9/2023, 12/10/2023, 1/7/2024, 1/16/2024, 1/21/2024, 1/22/2024, 1/24/2024, 1/25/2024, and 1/26/2024. During an interview on 1/26/2024 at 11:36 AM licensed practical nurse #51 stated the medication refrigerator temperature was checked by the overnight shift and they did not check the refrigerator on the day shift. If appropriate medication temperatures were not maintained the medications could become spoiled and the residents should not receive them. During an interview on 11/26/2024 at 11:37 AM licensed practical nurse Unit Manager #5 stated they expected the nightshift staff to check and document the medication refrigerator temperatures but did not expect the day shift staff to check if it was not completed by the nightshift. It was important for the medication refrigerator temperature to be checked because medications had to be maintained at certain temperatures, so they did not spoil. No medications should be administered without verification that they were not spoiled by verifying appropriate refrigerator temperatures documented on the log. Without daily temperature documentation, there was no way of knowing if the medications were still good. During an interview on 11/26/2024 at 12:10 PM registered nurse Supervisor #48 stated the medication refrigerator temperatures were checked by the overnight shift licensed practical nurses and the Unit Manager was expected to verify the temperature was checked. If the refrigerator temperature was not accurate the medications such as insulins, eye drops, or vaccines may not be effective and could cause harm. Bacteria could grow in the medication. Without a completed temperature log staff would have no idea if the medications were still good and if temperatures were missing from the log, nothing should be administered from the refrigerator. During an interview on 1/26/2024 at 1:11 PM the Assistant Director of Nursing #65 stated daily medication refrigerator temperatures were checked weekly on the nightshift and the Unit Manager was responsible for checking that the log was completed. This was important because medications such as insulin needed to be kept at a certain temperature or they could spoil. If the temperatures were not being logged, there would be no way of verifying if a medication was safe to administer. Medications should not be administered to residents if the proper and safe temperatures could not be verified, and they should have been discarded. 10NYCRR 415.18(d)

Based on observation and interview during the recertification and abbreviated (NY00299391, NY00325885, and NY00331016) surveys conducted 1/24/2024 - 2/1/2024, the facility did not ensure residents had the right to a safe, clean, comfortable, and homelike environment for 18 isolated areas (resident rooms 263, 266, 270, and 273; second floor south hallway; second floor south dining room; second floor activities room kitchenette; second floor west shower room; second floor west lounge bathroom; second floor west soiled utility room; second floor south telephone room; second floor south closet near social workers office; resident rooms [ROOM NUMBERS]; third floor shower room; fifth floor hallway near resident room [ROOM NUMBER]; sixth floor hallways near elevator; and, resident room [ROOM NUMBER]). Specifically: - On multiple floors the halls, walls, and ceilings were in disrepair. - The hot water in second floor south dining room did not work. - The second floor activities room kitchenette had a broken paper towel holder and damaged packaged terminal air conditioner unit covers. - The second floor west lounge bathroom had a toilet wrapped with medical tape. - Resident room [ROOM NUMBER] had a broken electric bed plug. - Resident room [ROOM NUMBER] had a missing duplex outlet cover, a broken cabinet, and there was an unapproved electrical device in the room. - Resident room [ROOM NUMBER] was not maintained in a safe and homelike manner and fruit flies were observed. - The fifth floor hallway near resident room [ROOM NUMBER] had a broken duplex outlet cover. - Resident room [ROOM NUMBER] was not maintained in a safe and homelike manner. - The sixth floor hallway near the elevators had an unclean food cart. Findings include: The undated Resident Rights handbook documented the facility created an environment that promoted maintenance or enhancement of the residents' quality of life. The 10/26/2023 - 1/30/2024 Pest Control Logs did not document fruit flies in resident room [ROOM NUMBER]. The facility could not provide work orders for any of the findings found during tour of the facility. Observations were made on the following floors: Second floor: - On 1/24/2024 at 10:02 AM and during follow-up 2/1/2024 at 12:21 PM, resident room [ROOM NUMBER] had a gap between the packaged terminal air conditioner unit and the wall it was installed in and there was a missing 3-foot section of chair rail on one of the walls. - On 1/24/2024 at 10:29 AM and during follow-up on 1/26/2024 at 9:48 AM and 2/1/2024 at 12:35 PM, resident room [ROOM NUMBER] had missing cove base (trim between the wall and floor) molding under the heater unit and there were 1/8-inch gaps between some sections of the flooring material. Also, a door knob was damaged, and the wall behind the toilet in resident room [ROOM NUMBER] bathroom was damaged with a loose cove base. - On 1/24/2424 at 11:08 AM resident room [ROOM NUMBER] floor had 1/8-inch gaps between sections of the flooring material, and missing sections of flooring. Also, there was a missing quad outlet cover. - On 1/24/2024 at 12:31 PM and during follow-up on 1/26/2024 at 9:48 AM, the second floor south dining room hand washing sink hot water did not work and only cold water came out. - On 1/24/2024 at 12:43 PM the second floor south hallway had several stained ceiling tiles. - On 1/24/2024 at 12:53 PM the second floor south dining room had some curtains that were not properly attached and hanging loosely. During follow-up on 2/1/2024 at 12:13 PM, the ceiling paint near the window casing behind the curtains was peeling. - On 1/25/2024 at 3:10 PM the second floor activities room kitchenette paper towel holder cover was missing. Both packaged terminal air conditioner unit covers within this area were damaged. - On 1/25/2024 at 3:30 PM and during follow-up on 2/1/2024 at 12:02 PM, the second floor west shower room wall mixing valve cover plate was loose with an exposed hole in the wall. - On 1/25/2024 at 3:45 PM the second floor west lounge bathroom had a toilet with a closed lid and the lid was wrapped shut with medical tape. During follow-up on 2/1/2024 at 12:02 PM, the medical tape had been cut and partially removed with remnants left behind. - On 1/25/2024 at 4:00 PM and during follow-up on 2/1/2024 at 12:04 PM, the second floor west soiled utility room had a damaged 6-inch x 2-foot section of wall. - On 1/26/2024 at 9:39 AM the second floor south telephone room packaged terminal air conditioner unit cover was not attached to the packaged terminal air conditioner unit, and the gap between the packaged terminal air conditioner unit and the wall was not sealed. - On 1/26/2024 at 9:43 AM the second floor south closet near the social worker's office had broken ceiling tile pieces on the floor with unclean curtains on the floor around and on top of the ceiling pieces. - On 1/26/2024 at 9:45 AM the second floor south shower room floor had multiple missing floor tiles, and there was a damp, unclean folded towel under the toilet. - On 2/1/2024 at 12:18 PM resident room [ROOM NUMBER] had an electric bed and the ground for the electrical plug was broken. Third floor: On 1/24/2024 at 12:12 PM and during follow-up on 1/26/2024 at 12:56 PM and 2/1/2024 at 11:46 AM, resident room [ROOM NUMBER] had over fifty cups of juice, plastic containers of milk and salad on the window sill. Also, there were 15 coffee cups with lids on a bedside stand and the room was unclean. There were two fruit flies observed on 1/24/2024 at 12:12 PM and three fruit flies observed on 1/26/2024 at 12:56 PM. - On 1/25/2024 at 3:05 PM the third floor shower room walls around an old tub had multiple holes in them, and there was a bent, packaged terminal air conditioner heater filter being stored in the room. - On 1/26/2024 at 11:05 AM and during follow-up on 1/26/2024 at 12:40 PM, resident room [ROOM NUMBER] had a missing duplex outlet cover. The room had a cabinet with a missing access door, and the door was leaning against the wall. The room had an unapproved electrical heated blanket that was plugged in and on top of a resident. Fifth floor: - On 1/26/2024 at 12:24 PM the fifth floor hallway near resident room [ROOM NUMBER] had a duplex outlet that was broken. A computer laptop wire was plugged in to the top outlet plug which was loose, and the bottom outlet blocked the laptop wire from entering it. Sixth floor: - On 1/24/2024 at 9:43 AM and during follow-up on 02/1/2024 at 11:44 AM, the sixth floor hallway near the elevators had a food cart with wire shelving which was encrusted with dried debris. - On 1/24/2024 at 1:30 PM and during follow-up on 2/1/2024 at 11:50 AM, resident room [ROOM NUMBER] had multiple, stacked boxes and other items on the ground, and there was dust and debris throughout the room. During an interview on 2/1/2024 at 12:44 PM, the Housekeeping Director stated all housekeeping staff had been trained on how to use the work order system, and were not sure if the work order system was included during staff orientation. All housekeeping staff was trained every six months to a year but it was not documented. They were not aware of any work orders for the findings during survey and housekeeping staff would usually notify the Housekeeping Director directly or write it down on their task sheet. They did not have access to the work orders submitted, and would visually check each resident floor during daily rounding to see if any maintenance concerns had been fixed. It was important to ensure the facility was maintained in a clean and homelike manner for the residents, so that the facility was safe for residents and staff. During an interview on 2/1/2024 at 12:57 PM, the Corporate Director of Facilities stated they were not aware of any of the findings found during tour of the facility. All maintenance staff had been trained on how to use the work order system and they were not sure if the work order system was included during staff orientation. All staff on the resident floors should know how to submit a work order or at least communicate to someone who did know how to submit a work order, and they would have expected work orders to be made for all of the findings. They were aware that a resident room could fall into a state of disrepair over time. They were not aware of the hoarding conditions of resident rooms [ROOM NUMBERS]. It was important for the facility to be maintained in a clean and homelike manner so that the facility was safe for all residents and staff. 10NYCRR 415.29(j)(1)

Based on observation, interview, and record review during the abbreviated survey (NY 704) conducted on 2/1/22, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (Resident #2) reviewed. Specifically, Resident #2 had approximately 15 unwitnessed and observed falls from 6/17/21-9/24/21 and the resident was not provided with adequate supervision to prevent reoccurrence. The resident had 4 falls on 10/11/21 resulting in hospitalization with diagnoses including a thoracic (upper spine) compression fracture, multiple facial bone fractures, and kidney trauma. This resulted in actual harm to Resident #2 that was not immediate jeopardy. Findings include: The facility policy Falls Prevention Program revised 1/2021 documents residents must be assessed in a timely manner for potential causes of falls. The nursing staff in conjunction with the attending physician, pharmacist, therapy staff, and others will seek to identify and document resident risk factors for falls. After more than one fall, the physician/clinical team will review the resident's gait, balance, and current medications that may be associated with increased risk of falling. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. If an individual continues to fall, the staff and physician will re-evaluate and consider other possible reasons for the resident's falling besides those already identified and will re-evaluate the continued relevance of current interventions. The facility policy Managing Falls and Fall Risk revised 1/2021 documents staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. If falling recurs despite interventions, staff will implement additional or different interventions or indicate why the current approach remains relevant. If a resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to contribute or change interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. The facility policy Routine Resident Checks revised 2/2021 documents the facility will make every effort to physically observe all residents while in the facility. During the off-shifts or timeframe identified by the facility, the assigned staff will make physical rounds on residents at least routinely throughout the shift. Staff were to initial and sign that they saw the resident and ensured their safety; and it would be documented in the electronic medical record. Resident #2 was admitted to the facility with diagnoses including [CONDITION(S)] (paralysis on one side of the body) following cerebral infarction (stroke). The 8/7/21 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, required extensive assistance of 2 for transfers, did not walk, required supervision with assistance of one for locomotion on the unit. extensive assistance of 2 for locomotion off the unit, was not steady when moving from seated to standing position, had 2 or more falls with no injury since the prior assessment, 0 falls with injury, and did not use an electronic device that monitored movement or alerted staff when movement was detected. The comprehensive care plan, (CCP) initiated on 5/19/20, documented the resident was at risk of falls related to a history of falls, impulsive behaviors, and left-sided weakness from a cerebral vascular accident ([CONDITION(S)], stroke). The resident was to have the bed in the lowest position and staff were to anticipate and meet the resident's needs. Updates to the CCP included: - On 5/27/20, the resident was placed on a toileting schedule. - On 5/27/20 and revised on 6/4/20, a floor mat was placed to the right and left side of the bed, and the resident would place themselves on the fall mats and sleep there. - On 5/29/20, the resident exhibited poor safety awareness and interventions included distraction with activities including classic rock music, television, looking at picture boards, and talking with their family. - On 9/5/20, anticipate the resident's needs. The resident was noncompliant with transfers - On 9/15/20, the resident was to use non-skid socks, the bed was in the lowest and locked position, and they were to have the call bell within reach. The resident was to be referred to therapy services as needed. - The resident's medications were reviewed on 12/10/20 and 2/22/21. - On 5/21/21, the resident was to be in common areas when out of bed as the resident allowed. The resident had the following documented falls: - On 6/4/21 registered nurse Supervisor (RNS) #3 documented in an Accident and Incident Report (A&I) the resident was found on the floor in their bathroom. The resident had a scratch on their left nostril and a small cut on their upper gum. - On 6/13/21 at 6:02 PM Unit Manager #37's progress note documented the resident was transferred to the hospital at 6:00 PM after falling by the elevator at 4:40 PM. The resident had redness to their neck and head. At 10:45 PM, Unit Manager #37 documented the resident returned from the hospital with a facial laceration and six sutures. - On 6/17/21 licensed practical nurse (LPN) Unit Manager #13 documented in an A&I the resident was found lying on their right side in the dining room doorway and their knee was reddened. - On 6/18/21 at 8:27 AM, LPN #15's progress note documented the resident had swelling and bruising on their left hip. Per report, the resident had fallen twice the previous day and hit their left hip. - On 6/19/21, RNS #3 documented in an A&I the resident was found on the floor by the nurse's station, lying on their back with a rolling chair next to their head. Recommendations included a physical therapy (PT)evaluation and psychiatric nurse practitioner (NP) #28 was following the resident. - On 6/19/21 at 8:05 AM, RNS # 6 documented in a progress note the resident was sitting in a lounge chair and got up unassisted and tripped over a chair and landed on their back. The resident had a tennis ball size area with induration (hardening) and redness on the left side of the head. The resident was transferred to the hospital for evaluation. The resident returned to the facility at 11:56 AM with no issues noted. - On 6/22/21, LPN Unit Manager #13 documented in an A&I the resident was found on the floor in their room on their left side. Therapy staff found the resident on the floor and the resident's wheelchair was found pushed into the doorway. The resident reported pain in their left shoulder and X-rays were to be completed. The 6/22/21 Radiology report documented the resident had an age indeterminate fracture of the distal left clavicle (shoulder blade) and clinical correlation was needed. - On 6/24/21, LPN Unit Manager #13 documented in an A&I the resident was observed standing at the nursing station, went to sit in their wheelchair, fell on their side, and hit their head on the medication cart. The resident was sent to the ED (emergency department) for evaluation. - The 6/24/21 ED summary documented the resident presented following a fall. Their sutures were removed from their left eyebrow (from 6/13/21 ED visit) - On 6/29/21, LPN Unit Manager #13 documented in an A&I the resident was found in the hallway outside of a room, with one sock on and one sock off lying flat on their back. There was no apparent injury. - On 7/6/21 at 4:35 PM RNS #6 documented the resident was found by nursing staff on the third floor after their empty wheelchair was found at the fourth floor's locked stairway exit. The resident was assessed and found to have reddened area to the right forehead/temple area, right ear, back of left head at the base of the skull area, and a skin tear located to outer aspect of left forearm. Maintenance checked the functionality of the door, which was functioning properly, and unlocked the door after pressed for a certain period of time (delayed egress). The resident was to have safety rounding. - The 7/6/21 at 5:30 PM A&I completed by RNS #6 documented the resident was found on the third floor in the stairwell. Certified nurse aide (CNA) #9's statement, included with the report, documented CNA #9 was assisting another resident with dinner when the incident occurred. The resident had been agitated and restless all day, and they were last seen in their wheelchair going into other resident's rooms. - On 7/7/21, LPN #30's progress note documented the resident was seen out of their wheelchair standing and pushing against the emergency exit door. The resident was found banging on other resident's doors, trying to enter, and attempting to stand without assistance. PRN (as needed) [MEDICATION(S)] (antipsychotic) injection was administered There was no documented evidence the resident had a supervision plan in place, after multiple falls and falls with injury and after the resident was able to access a locked stairwell undetected, to ensure the resident was safe. The 7/12/21 at 7:30 AM A&I initiated by LPN #15 documented the resident was found on the floor next to the nurse's station on their back; the resident had a small bump on the back of their head. RN #7 added to the A&I under recommended steps to prevent recurrence, monitor the resident every hour and continue current plan of care. The Assistant Director of Nursing (ADON) documented in the summary of investigation the fall was unavoidable as the resident continuously stood up from their chair unassisted. The 7/12/21 at 12:00 PM a Change in Condition Evaluation and progress note completed by RN #43 documented the resident had a laceration above the left eyebrow. The resident had a fall earlier in the day and the laceration was not noticed at the time of the previous fall. The resident had a 1.4-centimeter laceration with slight swelling above their left eyebrow. The CCP, updated on 7/12/21, documented the resident had an actual fall with no new injuries; they were bleeding at their brow from a previous injury that day. The CCP also documented on 7/12/21, the resident was found on the floor next to their bed with a superficial injury. On 7/13/21, the updated CCP documented the resident was to be checked when passing their room and to continue safety rounds to ensure safety. The 7/14/21 A&I completed by LPN Manager #13 documented the resident fell outside of another room on the unit while attempting to walk into that room. The resident was bleeding from their left toe with a large amount of blood; they had a laceration under their second toe on their left foot. Recommended next steps were to provide shoes and socks, have their call bell within reach, and keep their bed in a low position. The conclusion documented the resident got out of their chair unassisted and fell . The resident had a large laceration, the bleeding could not be controlled, and the resident was sent to the hospital. There was no documented evidence how frequently the resident had been checked for safety rounds. The 7/14/21 ED note documented the resident had a laceration to a lesser toe on the left foot and had sutures. The 7/16/21 updated CCP documented to provide the resident with a wheelchair if noted to be self-ambulating. From 7/16/21 through 9/2/21, there were no updated interventions on the CCP for falls. The 9/2/21 at 5:40 PM, A&I documented the resident had an unwitnessed fall in the hallway with an abrasion to the inner left forearm. Recommended steps to prevent reoccurrence documented a medication review, refer to therapy for seating evaluation for their wheelchair, and monitor for latent signs of injury. The 9/2/21 updated CCP documented to initiate medication review to reduce fall risk and the resident was referred to therapy services. The 9/4/21 at 7:00 PM A&I completed by RN #38 documented the resident had a fall in another resident's room. The fall was unwitnessed and the resident that resided in the room was unable to state what occurred at the time of the fall. The resident had bleeding to the upper corner of their left lip and upper lip. Recommended steps to prevent reoccurrence documented the resident was to have a psychiatric evaluation for medication review. From 9/5/21 through 9/22/21, there were no documented updated interventions on the CCP for falls. The 9/7/21 unsigned Physical Therapy Screen documented the resident was being evaluated for a fall. The resident did not demonstrate a change in functional mobility and the resident's most recent fall was due to impaired safety awareness and behaviors. There were no additional recommendations. A&I reports documented the resident had the following falls: - On 9/12/21 at 8:46 AM, by LPN #39 the resident had an unwitnessed fall in their room. The bed was in the lowest position with fall mats on the floor; the resident had been sleeping in bed when last seen. The resident had swelling and redness to the left side of their face, redness on their left upper arm, and a cut/open area on their left lower arm. - On 9/22/21 at 6:40 PM, by the ADON the resident had an observed fall in the hallway; the resident was observed to hit their head and they had scabs on their left knee from a previous fall. The ADON documented medications were discussed with NP #19 and [MEDICATION(S)] (anti-psychotic) was decreased. - On 9/23/21 at 8:30 AM, by LPN Unit Manager #13 the resident had an unwitnessed fall in their room with no apparent injuries. The resident was encouraged to use their call bell for assistance. - On 9/24/21 at 4:00 PM, by RN #38 the resident had an unwitnessed fall in their room. - On 9/26/21 RNS #3 documented at 7:00 PM, the resident had a fall which occurred in the fourth-floor stairwell. The resident was found on the staircase facing up. The resident had no apparent injuries except a reddened left knee and left forearm. CNA #9's statement, included with the report, documented the resident was moving in their wheelchair and was eager to stand up. Steps to prevent reoccurrence documented physical and occupational therapy, anticipate the resident's needs, floor mats, provide appropriate footwear, toileting schedule, pain evaluation, medication review, and rounding on the resident. There was no documented evidence the resident had a supervision plan in place, after multiple falls and falls with injury and after the resident was found at the bottom of a stairwell, to ensure the resident was safe. On 10/11/21, nursing progress noted documented: - at 11:37 AM, LPN # 29 documented they were notified by a CNA the resident was lying on the floor of their room. Upon entering the room, the resident was observed lying on their left side on the floor next to the bed. The left forearm had purplish blue blotches. The resident denied pain. LPN Manager #13 was notified as well as the ADON for assessment (no RN assessment was documented). - At 11:44 AM, LPN Manager #13 documented the resident presented with a change in condition falls. All changes in their condition were documented and had been reviewed with NP #4 on 10/11/21 at 11:35 AM, they did not recommend any changes. The family was notified. - At 11:55 AM, LPN Manager #13 documented a pain evaluation for the resident. The resident had no complaints of pain, and no signs and symptoms of pain were noted. - At 12:21 PM, LPN Manager #13 documented the NP #4 was in to see the resident regarding the fall and blotchy areas noted on the arms and legs. NP #4 ordered laboratory work including complete blood count (CBC) and comprehensive metabolic panel (CMP). - The 10/11/21 untimed NP #19's progress note documented the resident had a fall and did not suffer any injuries. The resident had some discoloration noted to their extremities. The NP ordered a CBC and CMP for that day to see if there were any other processes going on. For the fall, the resident was to continue with the fall protocol, nursing was to continue neuro checks, and to notify the providers if there were any changes. The resident may need to be transferred to a higher level of care. - at 4:55 PM, LPN # 14 documented they heard a loud noise from the resident's room. The resident was observed lying on the floor in their room under the bedside table. The resident was not able to state what happened. The Supervisor was called to the unit. The resident was helped off the floor and cleaned up. The resident has a small laceration to the left eye and was bleeding from their nose. Neurological checks were in place from the previous fall that day. - at 6:30 PM, LPN #14 documented they were administering medications to another resident when they heard a loud noise from the resident's room. They ran to see what happened, and the resident was observed on the floor next to their bed. The resident was not able to answer question about what happened. The resident was assisted back to bed after approval from the Supervisor. There was no documentation by the Supervisor. - at 9:41 PM, LPN #14 documented they heard the resident fall in their room, and the resident was observed face down at the foot of their bed. The resident was bleeding, but they could not locate where the bleeding was coming from. A phone call was placed to the on-call physician/NP. The on-call NP instructed staff to send the resident to the hospital for an evaluation. When paramedics arrived, the blood was cleaned from the resident's face, and their left eye was swollen, black and blue, and there was a small laceration in the corner (of the eye) from the previous fall. The resident had a bloody nose and was sent to the emergency room . - There were no documented RN assessments or neuro checks on 10/11/21. The 10/11/21 Unit Staffing Sheet documented CNA #10, CNA #17, and LPN #14 were working on the resident's unit during the evening shift. The 10/11/21 CNA Documentation included the resident's every 3-hour toileting and turning and positioning was provided between 7:49 PM to 8:02 PM on the evening shift; there was no documentation the resident had more frequent checks on the evening shift. On 10/12/21 at 2:05 AM, LPN #66's progress note documented the hospital called the facility and stated the resident was being transferred to another hospital for left side facial fracture, orbital (bone around eye) fracture and maxillary sinus fracture. The resident was admitted to the hospital on 10/12/21 and was discharged and returned to the facility on [DATE]. The 11/19/21 hospital discharge summary documented the resident was admitted on [DATE] after an unwitnessed fall. The primary discharge diagnosis was thoracic (upper back) compression fracture, multiple facial bone fractures, acute blood loss [CONDITION(S)], and traumatic perinephric hematoma of the left kidney (blood outside the vessel near the kidney) secondary to the fall. The patient was transferred from another hospital after a fall at the long-term care facility. While hospitalized the patient was managed for behavioral issues which had been ongoing. The patient stay was prolonged due to their intermittent agitation, resident was seen by psychiatry and social work, behavior was stabilized. On 11/19/21 the patient was stable for discharge to the skilled nursing facility with condition upon discharge documented as non-verbal, alert, unable to assess denotation, need assistance while standing and walking, wheelchair bound, and risk for fall. On 1/4/22 at 9:50 AM, 10:53 AM, 1:25 PM, and 4:07 PM, the resident was observed lying in bed. The bed was in the lowest position with a fall mat on the floor; the other side of the bed was pushed up against the wall. The resident had a radio with music in their room. During an interview on 1/6/22 at 9:11 AM, LPN #1 stated they worked on the resident's floor before the last hospitalization when the resident was moved. LPN #1 stated in 7/21 when the resident fell down the stairs, the LPN was completing a medication pass and had seen the resident just before wander alert alarm sounded (a sensor that alarms when a resident wearing a wander alert device crosses the sensor) the LPN #1 stated they went to the door, found that it was ajar and saw a wheelchair at the landing between the floors. The RNS assessed the resident. The LPN stated following the 7/21 incident, the staff on the unit were checking on the resident more frequently for safety. The resident required a lot of redirection and more supervision and it was a team effort to provide the supervision the resident needed between the nurses, CNAs, and the unit helper. LPN #1 stated they were unsure if the resident's need for supervision was on the CCP. During an interview on 1/6/22 at 9:57 AM, physical therapist #8 stated the resident was very unsafe; they would transfer and walk when they wanted to. The resident was impulsive and had poor safety awareness. The physical therapist stated that supervision could be recommended but they were unsure if it would happen. If the resident was having falls and had fallen down the stairs, the resident should have been referred to therapy. During an interview on 1/6/22 at 11:28 AM, RN #7 stated if they were working as a supervisor, they updated CCPs when they responded to falls. RN #7 stated the resident had a lot of falls; was impulsive and would get up when they were not capable. RN #7 stated they were unsure what the facility staff put in place for the resident for fall prevention and thought they had 1:1 at times or was placed near the nurse's station. RN #7 stated when staff would walk away, the resident tried to stand. The resident needed supervision; they did not have 1:1 supervision every day and would likely be on hourly checks. Hourly checks were documented on paper by the CNAs. During an interview on 1/6/22 at 12:34 PM, RNS #3 stated the resident had quite a few falls; they were nonverbal and would not stay still. The resident would attempt to walk, and they were not safe to do so. The resident very much needed a 1:1 and increased supervision. The RNS stated in 9/2021, the resident had broken through the fire door and went down the stairs. When the resident went down the stairs, the wander alert alarmed which signaled staff to the stairwell. The resident had made it down of the stairs before falling. The RN stated the resident's fall interventions included mats on the floor, padding parts of their wheelchair, non-skid socks, and they would try to put a 1:1 on the resident whenever possible or try to keep the resident by the nurse's station. The RNS stated the resident needed supervision and it was difficult to provide at the facility. There was not enough staff to provide 1:1 supervision 24/7 for the resident. During an interview on 1/7/22 at 8:25 AM, CNA #16 stated the resident fell down a whole flight of stairs in 9/2021 when they were working. The resident moved around a lot and would attempt to stand on their own, which lead them to fall a lot. To keep the resident safe from falls, the resident had a low bed, fall mat, and had increased supervision. The resident did not have increased supervision documented on their care plan and the CNA had not been told to supervise them more; the CNA knew to supervise the resident from working with them During an interview on 1/7/22 at 8:33 AM, LPN #14 stated they were not regularly assigned to the resident's floor but worked with the resident a few times. The resident would wander the unit and into other resident's rooms. The LPN would help the CNAs keep an eye on the resident. The LPN worked on 10/11/21 and was told in report the resident had a fall in the morning. The resident had been sleeping in bed before the first fall of the shift. The LPN called for the Supervisor LPN #18 and reported the fall. The resident fell again, and the LPN paged the supervisor; LPN #18 came to the unit again. At the third fall, the LPN called the on-call medical provider that the resident continued to fall and asked for the resident to be sent out. The LPN stated each fall was about an hour apart. The resident had a low bed with fall mats in place at the time of the falls. If the facility had the staff, they would increase supervision and keep a close eye on the resident. There were 2 CNAs and the LPN on that day, and the LPN stated they did not think there was any more that they could have done. After the first fall, the resident had a slash above their eye which LPN #18 told the LPN to clean up. The resident fell again and had bleeding from the same area, then at the last fall, the resident had facial injuries. When the emergency medical technicians (EMTs) got the resident up and cleaned up their face, one of the resident's eyes was completely swollen shut. The LPN had spoken with the DON, who stated they were going to come to the floor, and they were sending LPN #18 in the meantime. No RN came to the unit. All three falls that evening the resident had fallen on their face; they had gotten up from their bed and walked across their room before falling. The resident needed more supervision and there was not enough staff to provide the level of supervision the resident needed. During an interview on 1/7/22 at 10:16 AM, CNA #17 stated the resident had a low bed to keep them from falling and they could not recall any other interventions. The staff on the unit kept an eye on the resident, but this was difficult to do if they were helping other residents. If they had extra staff, they would provide a 1:1 for the resident. During an interview on 1/7/22 at 10:37 AM, CNA #10 stated the resident had quite a few falls; they fell weekly, sometimes daily, or multiple times per day. The resident was impulsive and was hard to redirect. The CNA stated the resident needed to be a 1:1, especially when they started to exhibit behaviors and falls, but the staff could not take care of other residents when the resident acted like that. They did not do a 1:1 for the resident. During an interview on 1/7/22 at 12:06 PM, NP #19 stated they were notified when residents had falls; they would assess the resident at that time if they were in the building or the day after if the fall occurred on off hours. They evaluated their medications and medical condition to see if changes were needed; nursing took care of other interventions. The NP stated the nursing staff helped with supervision; they provided the resident with a little more attention to keep the resident safe. Nursing staff would attempt to put the resident at the nurse's station, but the resident could wheel away. It was hard to provide a 1:1; the NP thought the resident may still have fallen with a 1:1 given their stature and that a small CNA may only be able to assist the resident in falling. During an interview on 1/7/22 at 12:15 PM, LPN Supervisor #18 stated they assisted with supervising if there was no RN in the building and there would be a RN on call. Fall interventions were completed with the interdisciplinary team as part of the A&I process. The night the resident fell on [DATE], the LPN was working on a medication cart in addition to working as the supervisor. The LPN was not aware the resident had a fall earlier in the day. The nurse that was working on the unit had not had supervisory experience and was unsure what to do when the resident fell . The LPN went to the unit after the resident's first fall; they had a small cut on their eyebrow, they were very agitated, and the resident would not allow the staff to take vitals or complete neuro checks. The LPN Supervisor recommended giving the resident space since they were so agitated; they did not make any other recommendations. The DON was called When the LPN Supervisor spoke with LPN #18 a second time, the LPN Supervisor told LPN #18 they were passing medications and they would have to wait. LPN #18 reported the resident had another fall, was acting crazy, and the unit nurse was sending the resident out to the hospital. LPN #18 had paged for the supervisor on the overhead page. The LPN Supervisor stated when the resident exhibited behaviors, it did not matter how many staff were present since the resident was so agitated. During an interview on 1/19/22 at 10:49 AM, LPN Unit Manager #13 stated the resident was falling constantly, and it was hard to redirect them. They would place the resident near the nurse's station on the other side of the desk and the LPN would have to jump or reach through the window to keep the resident from falling since the resident was impulsive. The LPN stated the resident needed a 1:1 when they were exhibiting behaviors and was on the move; they needed someone with them constantly and there was not enough staff to do that. The LPN could not recall if they had discussed increased supervision as an intervention to reduce falls. The LPN stated a 1:1 or increased supervision was not on the resident's care plan; they had wanted a 1:1 for the resident but it was not feasible due to staffing. The LPN stated they would not put a 1:1 on the resident's care plan because they would not be able to do it. During an interview on 1/19/22 at 12:53 PM, the Director of Therapy stated they were familiar with the resident since they had several falls. The resident did not have safety awareness and had poor judgement control. If redirected or told to wait for assistance, the resident would not wait for help. The staff would keep the resident in common areas, but the resident would self-propel and was mobile so would not remain in common areas. The resident would have benefited from increased supervision. During an interview on 1/19/22 at 12:36 PM, the ADON stated they reviewed Accident and Incident Reports and ensured the care plans were updated. The resident had several falls, had an extensive TBI (traumatic brain injury) with poor safety awareness and it was difficult to redirect the resident. The resident's interventions included floor mats and frequent rounding. Frequent rounding was used for all residents and the resident was kept in the common areas. The ADON stated they tried to give as much supervision as they possibly could. If the resident got in a mood, then nothing would work to keep the resident safe. The facility did not usually use 1:1 supervision for the residents since they did not have the staff to provide it. The resident would have benefited from 1:1 supervision. The ADON stated they tried to find a facility which could provide additional supervision for the resident but were unsuccessful. During an interview on 1/19/22 at 1:04 PM, the DON stated common fall interventions included low beds, mats, closer supervision including putting in common areas, and different activities for the resident. Frequent rounding included putting the resident in common areas to visualize the residents. They did not typically do 15-minute and 1:1 supervision because it was difficult with the staffing in the facility, and they had to prioritize with the need they had. 10NYCRR 415.12(h)(2)

Based on observation, interview, and record review during the recertification survey conducted on [DATE]-[DATE], the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety affecting the entire facility. Specifically, the facility failed to maintain a walk-in cooler in operating condition and was found to have an ambient air temperature above 45 degrees Fahrenheit (F). Milk from that walk-in cooler was found to be at 59.5 degrees F and was to be served to residents (required temperature: 45 F or less per New York State, NYS, code and 41 F or less per Food and Drug Administration, FDA, food code). Additional food product in a stand-up cooler that came from the improperly functioning walk-in cooler contained cottage cheese which was measured at 52 degrees F. The milk from the line was pulled at 12:45 PM. Unit 3 was called at 12:52 PM and the dairy products were not removed from the resident trays. Fifty-seven residents (Residents #6, 22, 24, 34, 38, 41, 49, 50, 54, 69, 71, 75, 76, 79, 86, 89, 96, 98, 100, 101, 102, 103, 105, 122, 123, 125, 129, 131, 143, 145, 147, 151, 152, 156, 161, 166, 168, 172, 178, 180, 184, 188, 198, 200, 202, 206, 208, 215, 216, 218, 221, 222, 223, 424, 425, 426, and 427) received potentially hazardous foods. The thermometer in the walk-in cooler was reading 39 F and there was not a process in place to calibrate the thermometer in the walk-in cooler. In addition, the seal to the cooler was ripped and torn. Adulterated food was found in the functioning walk-in cooler which included bags of spoiled lettuce and moldy garnishes. Hot food was not held at proper temperatures. During lunch service, meatballs, mashed potatoes, and red sauce were held at ,d+[DATE] F. (Required temperature: 140 F or above per NYS code and 135 F or above per FDA food code). The facility was unaware and informed by the surveyor. A leaking pipe from the compressor in the freezer was causing ice to build up and contaminate food products. A pan of leftover corned beef (wrapped in foil) was adulterated when the ice came in contact with the food. The facility's failure to properly maintain the kitchen puts 212 of the 216 residents at immediate risk for serious illness caused by consumption of potentially contaminated food and drink. This resulted in Immediate Jeopardy to resident health and safety. Findings include: Review of the undated test tray audit tool noted acceptable delivery temperatures must be 40 degrees Fahrenheit (F) (cold) and 140 degrees F or above for (hot). Review of the undated Food Receiving and Storage Policy documented refrigerated foods must be stored below 41 degrees F unless otherwise specified by law. Review of the undated Food Preparation and Service policy documented foods should be held above and out of the danger zone between 41 degrees F and 135 degrees F to prohibit the rapid growth of pathogenic organisms that cause food born illness. Review of the undated sanitization policy noted under bullet 1 all kitchen, kitchen areas and dining areas shall be kept clean. Under bullet 2 all utensils, counters, shelves and equipment shall kept clean and good repair. Food temperature concerns: Kitchen: The daily refrigerator temperature logs for the facility's large walk-in coolers for the month of ,d+[DATE] documented temperatures should be maintained at or below 40 degrees F, temperatures should be checked and recorded once a day (at the opening of the operation or during other stable time) and should be checked using the accurate internal probe. All temperatures recorded were within acceptable range. When observed on [DATE] at 11:50 AM, walk-in cooler #2's ambient air temperature was measured to be 50 degrees F. Butter, that was in the cooler, measured 53 degrees F. When observed on [DATE] at 12:06 PM, the following food items were removed from walk-in cooler #2, had temperatures that were out of range (over 41 degrees F), and were voluntarily discarded by the Food Service Director: - Cold cut turkey and ham was 55 degrees F. - A tray of egg salad was 53 degrees F. - A 6 inch tray of ham salad was 53 degrees F. - A tray of ground sausage was 55 degrees F and was labeled and dated on [DATE]. - A container of tomato sauce was 52 F and was dated [DATE]. - A large tray of stewed tomatoes, labeled and dated [DATE], measured 47 degrees F. - A box of cubed cheese was 55 degrees F. - A 4 inch deep hotel pan of hard boiled eggs was 52 degrees F. - A 4 inch deep hotel pan of rigatoni was 51 degrees F. - A case of shell eggs was 47 degrees F. - 7 boxes of shredded cheddar and mozzarella cheese were 44 degrees F. When interviewed on [DATE] at 11:30 AM, the Food Service Director stated they thought they had 8 hours to fix the temperature issues with the foods in walk-in cooler #2. The State surveyor intervened and stated food may be out of temperature for up to 2 hours for preparation, or service. The Food Service Director then stated they would discard the foods that were out of temperature because they were not sure how long the cooler was out of temperature. When observed on [DATE] at 12:43 PM, whole milk was in a glass in a standup cooler at the end of the tray line in the kitchen. The doors to the stand up cooler were open and the milk was 59.5 degrees F. At 12:44 PM, the surveyor informed the Food Service Director of the milk temperature and the Food Service Director stated they were going to remove milk from the meal service. At 12:45 PM, the milk in the standup cooler was removed from the cooler and a nectar-thick milk was checked and was 50 degrees F. At that time, milk from the standup cooler had been delivered to the nursing units and the Food Service Director stated they would ask the registered dietitian (RD) to call the units to remove the milk from the resident meal trays that had been delivered. The Food Service Director stated it was the first time they were aware of issues with milk temperatures and when they did test trays, the milk was usually around 43 degrees F. At 12:50 PM, the Food Service Director was observed removing items from the standup cooler at the tray line. The stand up cooler also contained cottage cheese which was measured at that time to be 52 degrees F. At 12:55 PM, the Food Service Director stated in an interview, Units 2S, 2W, 4, 5, and 7 had been served lunch trays already and Units 3 and 6 had not been served yet. When interviewed on [DATE] at 12:58 PM, dietary aide #49 stated the milk in the standup cooler during the tray line had been poured before 11 AM or maybe 10 AM that day and was moved from walk-in cooler #2 to the standup cooler. They stated after the trayline was done, the milk went from the standup cooler back into walk-in cooler #2. Additionally, at the time of the interview, the Food Service Director(who was present) stated walk-in cooler #2's door did not seal, but it could be pushed closed. During interview on [DATE] at 1:01 PM, the Administrator and Assistant Administrator were notified by the surveyor of the issues with the dairy products' temperatures and they stated they would call the units to ensure the items were removed from service on Units 2S, 2W, 4, 5, and 7. At 1:29 PM, a ham sandwich in walk-in cooler #2 was measured at of temperature of 53 degrees F. A turkey sandwich from a pan at the top of walk-in cooler #2 was measured at 76 degrees F. These were placed in the cooler after lunch service by a staff member. Unit 4 Observations on Unit 4 on [DATE] included: - at 12:39 PM, a milk from Resident #71's tray was 64 degrees F. - At 12:41 PM, a milk from Resident #105's tray was 65 degrees F. Unit 3: When observed at 12:49 PM, the residents on Unit 3 had milk on their meal trays and staff were not observed to remove milk from the meal trays. - At 12:52 PM, Resident #178 was assisted by certified nurse aide (CNA) #32; the resident consumed two sips of milk. Licensed practical nurse (LPN) #14 answered a telephone call and hung up the phone. - No milk was observed to be removed from residents' trays. - At 1:01 PM, Resident #178's milk was taken for a temperature and was 64 degrees F. On [DATE] at 1:08 PM, the meal trays were removed from the resident rooms on Unit 3. The surveyor told the unit staff to ensure no milk products were left in the resident's rooms. When interviewed on [DATE] at 1:15 PM. LPN #14 stated the telephone call they received at 12:52 PM was to tell them to remove all milk from the residents' trays but at the end of the call, the person on the other end of the phone told LPN #14 to forget about it and not to remove the milk. LPN #14 stated Residents #75, 123, 22, 54, and 129 had consumed all the milk on their lunch trays. LPN #14 stated they did not know who the person was on the other end of the phone. Unit 2S: When observed on [DATE] at 12:56 PM, the lunch meal cart arrived to Unit 2S. At 1:01 PM, a carton of milk was removed from Resident #168's lunch meal tray by the surveyor. The temperature of the milk was 73.1 degrees F. At that time, the surveyor asked LPN Manager #2 to remove all milk products from the residents' meal trays. An additional 14 residents (Residents #98, 100, 122, 145, 151, 152, 166, 168, 184, 188, 202, 206, 216, 218) had milk and milk products on their meal trays, which were removed prior to being served to residents (at the surveyor's direction). LPN Manager #2 stated in an interview at that time, they were not aware there was an issue with the temperature of milk and milk products in the building until the surveyor informed them. Unit 6: When observed on [DATE] at 1:29 PM, lunch meal was delivered to Unit 6. Included with the lunch meal were 2 ham sandwiches for residents, the temperature between the ham slices was measured to be 78.8 F. Staff were notified, and both sandwiches were disposed of. On [DATE] at 1:43 PM, the Administrator and Food Service Director were notified by the surveyor of the ham and turkey sandwich temperatures. They stated the sandwiches would be removed from service. On [DATE] at 2:06 PM, the Director of Nursing (DON) provided a list of residents who consumed dairy products from lunch. The DON stated the residents would be assessed by the registered nurse (RN) and nurse practitioner (NP). When interviewed on [DATE] at 2:46 PM, dietetic technician (DT) #19, stated the Food Service Director asked them to call Unit 2S at 1 PM to determine if they had received their lunch meals yet. DT #19 stated they called Unit 2S, were unsure who they spoke to, and was told the unit had not received their lunch meal cart at that time. They let the Food Service Direct know Unit 2 South had not received their meal cart yet at the time that they called. DT #19 stated they were unsure why they were asked to call Unit 2S, but did overhear discussions regarding milk product temperatures. They stated after lunch, they attended a care plan meeting until 2 PM and after the meeting, they informed the registered dietitians (RD) about the Food Service Director asking them to call Unit 2 South and about the discussions they overheard regarding the milk product temperatures. When interviewed on [DATE] at 2:49 PM, RD #21 stated they were not asked to call any of the units at lunch today and was informed by DT #19 at 2 PM, about the discussion in the main kitchen regarding milk product temperatures. When interviewed on [DATE] at 2:50 PM, RD #22 stated they were not asked to call any units during lunch that day and were informed by DT #19 at 2 PM about the discussion in the main kitchen regarding milk product temperatures. RD #22 stated the RDs completed a basic monthly main kitchen sanitation audit which included observing if the cooler and freezer temperature logs were filled out. They did not check or take any temperatures of food items in the coolers or freezer. RD #22 stated the last monthly audit completed was in ,d+[DATE] and the ,d+[DATE] audit was due [DATE]. When interviewed on [DATE], the Food Service Director stated: - at 2:53 PM, walk-in cooler temperatures were recorded daily around 7 AM. Staff constantly open and close refrigerators, but occasionally will leave the cooler open for a short time when they are busy. Temperatures were read off a similar thermometer as is in the walk-in cooler, located in the back on the bottom. - At 2:55 PM, the Food Service Director stated they randomly checked the cold food including thickened drinks, salad, and cold sandwiches. They stated they did not record any of the random temperatures that were measured of cold food items. When interviewed on [DATE] at 4:26 PM, nurse practitioner (NP) #4 stated it was a concern if residents had consumed items that were served at a suboptimal level. The residents who had been identified as consuming the dairy products were assessed on that day. The milk could have bacteria depending on how warm it got. If a resident had an adverse reaction from the milk, they would likely exhibit gastrointestinal symptoms such as diarrhea. The symptoms were likely to occur within 24 hours and the facility would continue to monitor. When interviewed on [DATE] at 4:39 PM, the Medical Director stated the impacts of dairy products being out of temperature depended on how long they were out of temperature. Typical side effects would be gastrointestinal issues such as nausea and diarrhea. They stated NP #4 was onsite everyday and would follow up with the residents involved. The Medical Director was not made aware of the issues with the consumed dairy products on [DATE]. Thermometer concerns: When interviewed on [DATE] at 11:30 AM and 11:57 AM, the Food Service Director stated they usually record the walk-in coolers' internal temperatures each morning approximately at 7 AM. They go by the temperature reading on the hanging manual thermometer maintained in the walk ins. That morning, they stated they recorded a temperature of 38 degrees F. When observed on [DATE] at 12:45 PM, the internal ambient air temperature of walk-in cooler #2 was measured to be 55 degrees F. The prepared milks in cups stored within the tray line holding refrigerators were measured to be between ,d+[DATE] degrees. The hanging manual thermometer within walk-in cooler #2 indicated the temperature of the cooler was 39 degrees F. The internal temperature of ham cold cut was measured to be 51 degrees F, located in walk-in cooler #2. When interviewed on [DATE] at 2:55 PM, the Food Service Director stated they do not calibrate the hanging thermometers in the coolers, nor do they check the temperature of any products in the coolers. Adulterated Food: When observed on [DATE] at 11:40 AM, there was a case containing lettuce that appeared rotten and partially liquefied, located on top shelf of the rack on the left side in walk-in cooler #1. The bagged lettuce was stamped by the manufacturer with the date of [DATE]. When interviewed on [DATE] at 11:40 AM, the Food Service Director stated the bagged salad was dated [DATE] but may have been frozen in transport. They voluntarily discarded the entire box. This produce box also contained unwrapped herbs that were wilted and rotting and pre-bagged salad mixes. The Food Service Director stated in an interview at that time, the cooks and food preparation staff usually notified the Food Service Director when foods were spoiled or rotten, and then they throw the food away. When interviewed on [DATE] at 2:55 PM, the Food Service Director stated the food service supervisors were responsible for food inspections in the cooler to make sure nothing was rotten and/or expired. They stated supervisors go through to check and make sure things are dated, and the Food Service Director will go through and check to make sure all items were dated. The Food Service Director stated they also made sure everything was labeled and added that there were no calibration or accuracy checks being done prior to today. They stated they had never taken random food temperatures of items in the walk-in coolers. Hot holding violations: When observed on [DATE] at 11:30 AM, the following food temperatures were measured on the service line, and were out of acceptable range for hot holding: - Red sauce was 128 degrees F. - Meatballs were 123 degrees F. - Mashed potatoes were 129 degrees F. - The steam table units were on and water within the steam tables measured at 158 degrees F. At the time of the observation, the Food Service Director stated the facility recorded food temperatures when items were put into the steam tables. Review of the temperature recordings documented by the facility at the start of meal service revealed each item measured had a temperature recorded as greater than 160 degrees F. After these temperatures were brought to the attention of the Food Service Director, for correction, the items were removed from service and reheated to 165 degrees F. When interviewed on [DATE] at 11:30 AM, the Food Service Director stated that the initial cooking temperatures were logged by the cook who was also doing the reheating. They thought that maybe these items being uncovered could have affected their temperatures. They stated the probe thermometers used by the cook's were calibrated daily. When interviewed on [DATE] at 2:55 PM, the Food Service Director stated they did random hot food checks and hot food should be at least 140 degrees F for hot holding. The Food Service Director stated if the foods were not 140 degrees F but were close, they would reheat the food item. The Food Service Director stated today they did their random check on the tuna noodle casserole and the peas. They stated there was not a policy for taking food product temperatures. Staff monitored temperatures on tray line periodically, but the Food Service Director will usually check them as well. They stated they did not record any of the random temperatures they took. The Food Service Director stated they did not check food temperatures again during the tray line or when food left the kitchen. The steam tables were turned on in the morning at 5:30 AM and they stayed on all day. The steam tables were set to high which was 10. The staff did not check the temperature of the water in the wells, they looked for the presence of steam from the steam table. Physical Contamination and Cleanliness: Review of the monthly kitchen audits documented on [DATE], the ice machine was clean with no lime, rust or mildew, ice scoop was stored appropriately outside of the machine. The [DATE] audit was completed by Regional RD #43. The [DATE], [DATE] and [DATE] kitchen audits did not mention the ice machine or the ice scoop storage. The [DATE], [DATE], and [DATE] audits were completed by RD #22. The weekly cleaning audits documented there was a different area or item of the kitchen cleaned each day on weekly rotations. The ice machine was not included in this rotation. When observed on [DATE] at 10:28 AM, the ice machine adjacent to the kitchen showed signs of dark spotty mold like substance on the inside on both sides of upper section of the unit. The top and outside of ice machine was unclean with food spills and was sticky. The ice scoop was noted to be in a plastic holder attached to the wall adjacent to the ice machine. The wall and the scoop holder attached to the wall that the scoop was in contact with was unclean and soiled. At the time of the observation, the Food Service Director stated daily cleanings were done by food service workers and then monthly deep cleans were performed. The walk-in freezer was observed on [DATE] at 10:34 AM, and the following was present: - frost was puddling under the condenser fans unit. - A 3 foot x 3 foot sheet of ice was present on the floor below the storage racks and main aisle between the racks. - Four boxes of food product were wet from dripping condensate on the outside and there was ice buildup. - There were 2 large sheet trays under the fans collecting condensate water and the water was frozen solid and spilling over the trays. At the time of the observation of the walk-in freezer on [DATE] at 10:34 AM, the Food Service Director stated in an interview, the walk-in freezer had been in the condition it was in for about ,d+[DATE] weeks. The Food Service Director stated they replaced the sheet pans each day when they were full of ice build-up from the dripping condensate. An HVAC (heating ventilation and air conditioning) vendor came in initially and the Food Service Director stated they hoped they would be back today ([DATE]). The Food Service Director stated the vendor stated they needed to wrap the line with installation to stop the condensation from dripping from the condenser unit. Observations in the kitchen on [DATE] at 10:44 AM, included: - Floors and walls in the food preparation areas and underneath and in front of the stoves/ovens were unclean and soiled with food debris. - Black soiled flooring was present in several areas and all the grout between flooring tiles was blackened. - Improper air drying and storage was observed behind the 3 bay sink area. The Food Service Director stated in an interview at that time, that section was a clean drying area for dishware. Numerous sheet trays and deep trays were present in this section and were being improperly air dried with water droplets on the outside and inside surfaces. These items were stored tight together. - Floors in front of and underneath the dish machine were not smooth and easily cleanable. The floor was missing tiles and grout and a 10 foot x 10 foot section contained standing water with unclean food debris and spillage under and between tiles. - The juice machine was unclean with juice spills on the lines. Under the machine was sticky and juice was draining into a cut plastic bucket. - Walk-in cooler #2 had pieces of sliced cold cut turkey on the floor, racks, and shelves. The floor also contained other food debris and was unclean. At the time of the observation on [DATE] at 10:44 AM, the Food Service Director stated in an interview, all items on the racks should be clean and air dried before moving them to be stacked and stored in that area. He further stated the spray gun and juice machine were cleaned every night. The tiles in the dish machine area have been black in color for at least three months. The grout gets filled and it wears away and needed to be done again. The Food Service Director stated maintenance replaced the grout when needed. Observations on [DATE] at 11:37 AM, (one day after initial inspection) included: - the kitchen floors remained unclean and soiled with food debris and black grout, including under and behind major appliances on the cook lines. - The stored dishware, behind the 3 bay sink section, including the pans and trays were stored wet and stacked together without being fully air dried. All items were stacked with water collecting inside and in between one another. - The dish washing area contained broken, missing floor tiles, and grout had food debris and milk spillage in the grout spaces and under floor. - The walk-in freezer contained a large sheet of ice formation on the floor under the storage racks approximately 8 feet x 4 feet. The sheet pans were full of ice under condenser fans. There were two 10 pound (lb) boxes of sausage, a 10 lb box of strudel, and a 14 lb box of pizza crusts covered in dripping refrozen unclean condensate ice water. When observed on [DATE] at 12:11 PM, the hand washing sink did not have paper towels in the dispenser. In addition, the can opener was unclean and soiled with a black sticky substance. The can holder and the blade were also unclean and soiled with the black sticky substance. When interviewed on [DATE] at 12:50 PM, the Food Service Director stated they were planning to move the food products that were wet and encased in the ice dripping from the compressor lines. The Food Service Director stated they were planning get the food out of the walk-in freezer today and the food had been there for about a week. The Food Service Director stated the majority of the facility's food stock turned over within one week to 9 days. At the time of the interview, there was corned beef in a foil pan wrapped in aluminum foil and labeled with a date of [DATE] and 2 cases Italian sausage (ground) heavily encased in ice and affecting the packaging. Meatballs and similar product cases were also compromised and encased in ice. The foil pan of corned beef wrapped in foil was voluntarily discarded due to the ice encasing it, the aluminum foil covering was partially ripped open and the condensate ice/water was in contact with the food product. When interviewed on [DATE] at 2:53 PM, the Food Service Director stated a HVAC repair person should be coming tonight ([DATE]) to look at the walk-in cooler #2 and the walk-in freezer. The freezer issues have been going on for 3 months and started approximately [DATE]. On [DATE], the condensation lines were wrapped on the roof and more was needed. They were not aware of the walk-in cooler #2 having issues with holding temperature. Review of kitchen maintenance log confirmed the dates of [DATE] for reporting freezer leak and HVAC vendor coming out. It also identified the condensation lines were wrapped on the roof. -------------------------------------------------------------------------------------------------------------------------------------------- Immediate Jeopardy was identified, and the facility Administrator was notified on [DATE] at 5:43 PM. The Immediate Jeopardy was removed on [DATE] at 4:42 PM, based upon the following corrective actions taken: - The freezer was repaired on [DATE] at approximately 7:00 PM. - Walk-in cooler #2 was found by the vendor to be cooling properly. The door/seal was broken and repair was planned. Use of walk-in cooler #2 was stopped until the repair could be made. - The facility implemented a plan to check accuracy of the thermometers in the walk-in coolers. - Drinks were maintained cold on the trayline in a pan with ice and the facility was no longer using the stand-up coolers during service. - Sandwiches were transported to the units in an Igloo cooler to the units instead of on a tray in the Cambro/hot box. - Kitchen staff were educated on hot holding temperatures and temperatures in the cooler. 100% of currently working staff were educated. - Education signage was placed throughout the kitchen on hot holding temperatures, refrigeration, and proper storage of food. - The heat to the kitchen was turned off which improved the ambient temperature of the kitchen. - A detailed cleaning schedule was posted and to be followed. - Monitoring of residents who consumed dairy products: with shift-to-shift report for 5 days and on the 24 hours report. 10NYCRR 415.14(h)

Based on interview and record review during the abbreviated survey (NY 380), the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 of 3 residents reviewed (Resident #1). Specifically, Resident #1 sustained head and facial injuries after a fall. The resident was not assessed timely when their condition changed to rule out worsening head injury. When the resident was later sent to the hospital, they were diagnosed with [REDACTED]. The resident expired in the hospital from an acute right hemisphere infarct (stroke) associated with an acute clot. This resulted in actual harm to Resident #1. Findings include: The facility ,[DATE] Falls - Clinical Protocol policy revised ,[DATE], documented staff will follow-up on any fall with injury until the resident was stable and delayed complications such as subdural hematoma had been ruled out or resolved. The ,[DATE] revised/reviewed Change in Resident Condition policy documents the nurse will notify the resident's attending physician or physician on-call when there is a significant change in the resident's physical, emotional, or mental condition. A significant change in condition is a major decline or improvement in status that will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions (is not self-limiting). The Neurological Assessment policy revised ,[DATE], documented neurological assessments were to be completed in the event of a physician's orders [REDACTED]. Neurological assessments should include checks of vital signs and any changes neurological status or vital signs, in a previously stable resident, should be reported to the medical provider immediately. The policy did not document the frequency or interval for conducting neurological checks. Resident #1 had [DIAGNOSES REDACTED]. The [DATE] Minimum Data Set (MDS) assessment documented the resident's cognition was severely impaired and the resident required extensive assistance from 1 person with bed mobility and transfers. The resident's Medical Orders for Life-Sustaining Treatment signed by the Health Care Proxy on [DATE] documented the resident's wishes were for do not resuscitate (DNR, allow natural death in the event the heart stopped) and send to the hospital for treatment if needed. The [DATE] comprehensive care plan (CCP) documented the resident had impaired cognition and was at risk for falls. Interventions for fall prevention included call light within reach, appropriate footwear, notify the physician of any changes in awareness, and anticipate needs. The [DATE] Accident and Incident Report, completed by registered nurse (RN) Manager #1, documented at approximately 10:35 AM, the resident fell and sustained a 2 centimeter (cm) x 2.2 cm hematoma (collection of blood under the surface) on the left zygomatic (cheek) region and a 2.4 cm x 2.6 cm hematoma on the left temporal (temple) region. Nurse practitioner (NP) #2 was notified and assessed the resident. The plan was to complete neurological checks. The [DATE] NP #2's progress note, signed at 2:02 PM, documented the resident fell out of the wheelchair that day and injured their head, left eye, and elbow. A small lump was noted to the left side of head and an ecchymotic (bruised) area to left lower eye. The resident was able to move all extremities, had left-sided weakness, and contracture was mild. The resident was alert and not in acute distress. The resident's had visible pain in the elbow and an x-ray was ordered to rule out fracture. The resident was at baseline with left [MEDICAL CONDITION] and the plan was to continue fall protocol. The Neurological Monitoring sheet documented: - neurological checks were to be completed after the incident every 15 minutes, four times; every 30 minutes, four times; every hour four times, and every 4 hours, eight times. - On [DATE], neurological checks were started at 10:45 AM and completed every 15 minutes as planned. The resident complained of a headache at all 4 checks and no other abnormalities were documented. The Neurological Monitoring sheet documented on [DATE] starting at 12 PM, neurological checks were completed every 30 minutes as planned and no abnormalities were documented and starting at 2:30 PM, neurological checks were completed every hour as planned and no abnormalities were documented. No further checks were documented between 5:30 PM and 9.30 PM when the Resident was transported out to the hospital. On [DATE] at 11:04 AM, licensed practical nurse (LPN) #9 stated in a telephone interview, on [DATE], he worked the 6 AM to 2 PM shift and at around 11 AM, he saw RN Manager #1 and NP #2 evaluating the resident after the fall. Neurological checks were started and were normal. LPN #9 stated that during the shift, the certified nurse aide (CAN), he did not specify who, reported to him that the resident vomited once, he in turn reported the vomiting to RN Manager #1, and RN Manager #1 told him she reported it to NP #2. There was no documentation in the medical record that LPN #9 noted the resident vomited on the day shift on [DATE] or that RN Manager #1 or NP #2 were notified. The [DATE] at 4:28 PM, RN Manager #1's progress note documented the resident's left hand appeared weaker. NP #2 evaluated the resident after the fall and ordered an x-ray to the left elbow, which was done with no findings. Neurological checks for 48 hours were ordered, and no neurological changes were noted. There was no documentation in RN Manager #1's progress notes about the resident vomiting on the day shift. On [DATE] at 10:14 AM, CNA #8 stated in a telephone interview: - On [DATE], she worked from 6 AM to 8:30 PM and cared for Resident #1. - When CNA #8 returned from their lunch break, they were told the resident fell . The resident was in a recliner chair in the dining room and had a big bump on the hairline and cheek, a scratch between the eyebrows, and the left elbow was swollen and bruised. - The resident vomited twice between 11 AM and 11:30 AM, LPN #9 was aware, and the LPN reported the vomiting to RN Manager #1. - CNA #8 kept the resident in the recliner chair and tried to keep them comfortable during the day shift. The resident was not acting like themselves. The resident's eyes looked cloudy and they were not making eye contact when spoken to. - CNA #8 ordered the resident a clear liquid lunch tray because of the vomiting and LPN #9 was aware. The resident took a few sips at lunch. - At 2 PM, CNA #7 helped her bring the resident to their room. The resident usually transferred with 1 person and could stand and pivot. On this day, the resident was limp, not bearing weight, and needed 2 people to help with transferring. CNA #8 informed LPN #4 about the change in transfer ability. - The resident vomited again around 2:30 PM or 3 PM and shortly after, vomited again. CNA #8 informed LPN #4 about the vomiting. LPN #4 said to give the resident crackers and gingerale. She did not give the Resident crackers because she thought Resident might vomit more. She gave the Resident gingerale and the Resident kept it down. - Later on, she gave the resident more gingerale and the Resident vomited. - CNA #8 stated she left the facility at 8:30 PM. On [DATE] at 1:41 PM, LPN #4 stated in a telephone interview: - she came on duty at 2 PM on [DATE] and was told in report by LPN #9 that the resident fell and was vomiting. - The resident had a bump on the back of the head, bruising on the eye, and RN #1 Manager, who was on the unit until 6 PM or 7 PM, told her there was an order for [REDACTED].>- She completed neurological checks on the resident, the resident was somewhat alert, pupils were reactive, and vital signs were stable. - She stated at one point during the evening shift, the resident would not open their mouth for medications and the CNAs reported the resident vomited twice between 3 PM and 8 PM. - She reported the resident's vomiting to RN #1 Manager who told her she and the physician were aware of the vomiting and to monitor the resident. - LPN #4 stated when she left the facility at 8 PM she gave report to LPN #6. She told LPN #6 the resident fell and had vomiting. LPN #6 was supposed to the report to LPN #3 (who was on break when LPN #4 left). She stated LPN #3 was supposed to move to the resident's unit at 10 PM and then work the night shift on the unit. LPN #4 documented on the ,[DATE] Medication Administration Record [REDACTED]. On [DATE] at 2:30 PM, RN Manager #1 stated in an interview, the resident fell around noon on [DATE] sustaining injuries to the head and elbow. NP #2 evaluated the resident and ordered neurological checks and an x-ray. She stated the resident did not vomit during her shift and she assessed the resident before she left her shift at 5 PM. LPN #4 never reported to her the Resident vomited and if she had, she would have called the physician. On [DATE] at 3:22 PM, CNA #7 stated in a telephone interview: - she came on duty at 2 PM on [DATE] and was told the resident fell during the day. - At around 2:15 PM, she saw the resident in a recliner chair in the dining room and the resident's face was very bruised. The resident normally yelled out daily and was very quiet that day. - She and CNA #8 put the resident to bed around 2:30 PM and the resident was very weak and not able to assist with the transfer. This was a change for the resident. - About an hour later, the resident started vomiting and she reported it to RN Manager #1. - At around 3 PM or 4 PM, the resident vomited again, and she reported it to LPN #4 who told her to give the resident crackers and ginger ale. When she gave the resident the ginger ale, they vomited again. - When she returned from break after 5 PM, CNA #8 told her the resident vomited again. - LPN #4 left the facility at 8 PM and there was no nurse on the unit at that time. - Before 9 PM, the resident vomited again. - After 9 PM, CNA #7 called an LPN on another unit (LPN #3) and asked them to come and assess the resident. On [DATE] at 10:51 AM, CNA #5 stated in a telephone interview: - on [DATE], she came on duty at 2 PM and was told the resident fell during the day and was put to bed. - Around dinner time, CNAs #7 and 8 told her the resident was vomiting and LPN #4 said they should give the resident crackers and ginger ale. - After 8 PM, she tried to call the Supervisor because she was concerned about the resident and she could not get a hold of a Supervisor. LPN #4 left at 8 PM and there was no nurse on the unit. - She called LPNs #3 and 11, who were working on other units, and asked them to come and check on the resident. They came and sent the resident to the hospital. - During the evening shift, the resident vomited a total of 4 to 6 times. On [DATE] at 2:45 PM, LPN #6 stated in an interview, on [DATE], she was working on another unit on the 2 PM to 10 PM shift and LPN #4 gave her the keys to the resident's unit when LPN #4 left the facility. She did not recall getting any report from LPN #4. LPN #6 was not feeling well so she gave the keys to the resident's unit to LPN #3 and left the facility at 8:30 PM. After she got home, she received a telephone call from a CNA saying she needed to come to the unit and assess the resident because she was vomiting. She told the CNA she was home and they should call the Supervisor in the building. On [DATE] at 3:01 PM, LPN #3 stated in a telephone interview, on [DATE], she was working on another unit from 2 to 10 PM and was scheduled to work on the resident's unit starting at 10 PM She never received report about the resident's condition, was not aware LPN #4 went home early, and was not aware she was expected to cover the resident's floor from 8 PM to 10 PM. She heard from a CNA on her unit that the CNAs on the resident's unit were concerned about the resident so she and LPN #11 went to the resident's unit to see what was going on. When she got there, the resident projectile vomited several times, their pupils were fixed, and they were only responsive to a sternal rub. The CNAs told her the resident had vomited 5 or 6 times during the evening shift. There was no RN in the building. She stated if she had known that LPN #4 left early and there was no nurse on the floor, she would have gone to the unit and checked on the residents. The resident left for the hospital around 9:30 PM. On [DATE] at 9:24 AM, RN #12 Supervisor stated in a telephone interview: - on [DATE], she worked the evening shift as the Supervisor and was also passing medications on another unit (not the resident's unit). - The Supervisors had a clipboard that listed residents who needed to be checked on during their shift and on [DATE], the resident was not on the clipboard nor did the Nurse manager ask her to check on the resident that shift. - RN Manager #1 did not tell her the resident fell during the day on [DATE] or that they were on neurological checks. The resident's fall was not listed on the clipboard. - No one reported to her the resident vomited and that could indicate a worsening head injury. - She expected to be made aware of changes in resident condition so she could assess the residents and notify the physician. - She stated on [DATE] on the evening shift, she completed her medication pass and the facility was quiet, so she gave report to LPN #6 and left the building at 7 PM. - After she left, LPN #6 was responsible to assess resident issues and report to the on-call nurse. The [DATE] investigative summary documented at 9:30 PM the Assistant Director of Nursing (ADON) was called with the change in condition. The resident was non-responsive to verbal stimuli, blood pressure was ,[DATE], and the resident was sent to the hospital. On [DATE] at 1:10 PM, the ADON stated in a telephone interview: - she was in the building on day shift on [DATE] but was not aware the Resident had fallen. - At around 8 PM or 9 PM, LPN #11 called and reported Resident #1's change in condition as the resident was slow to respond and vomiting. LPN #11 told her she could not reach the on-call provider. - During the call, another nurse got ahold of the Medical Director and the resident was sent to the hospital. - A head injury with vomiting warranted close monitoring or immediate attention. When the resident started vomiting, she expected a RN assessment to be done and if no RN was available, the physician should have been called. She stated the Resident was not assessed or sent to the hospital timely. The [DATE] hospital report documented the resident was transferred from the facility for mental status change after a fall. The admission notes documented the resident fell at the nursing facility at 10 AM and sustained a left side hematoma to the head. The resident vomited throughout the day and presented with altered mental status. The resident was vomiting on admission to the hospital and was responsive to painful stimuli only. The resident was found to have an acute clot and stroke. The resident was made comfort care and expired in the hospital. On [DATE] at 1:50 PM, NP #2 stated in a telephone interview, she evaluated the resident in the morning on [DATE] after a fall. The resident had a bump to the head, bruising under the left eye and a contusion to the left elbow. The resident's neurological status was at their baseline when she saw the resident. She was at the facility the entire day and no one reported to her the resident was vomiting. At a minimum, a RN should have assessed the resident and reported their findings to medical. Had she known the resident was vomiting, she would have considered sending them to the hospital because that was a change in their condition, and they needed further evaluation. 10NYCRR 415.12

Based on observation, record review, and interview during the abbreviated (NY 326) and recertification surveys, the facility failed to have an effective system in place to monitor and supervise residents who smoke for 2 of 5 residents (Resident #158 and 88) reviewed for smoking. Specifically, Resident #158 was a known smoker in a non-smoking facility and deemed unsafe to smoke.The resident continued to verbalize a desire to smoke and was caught smoking and in possession of smoking materials on several occasions. Resident #88 was caught smoking on two occasions.The facility failed to thoroughly investigate the smoking incidents, re-evaluate interventions for effectiveness to prevent accidents and develop and implement a plan to safeguard the facility residents from accidents caused by smoking. This resulted in no actual harm with the potential for more than minimal harm that was Immediate Jeopardy/Substandard Quality of Care for Resident #158 and no actual harm with the potential for more than minimal harm that was not Immediate Jeopardy for Resident #88. Findings include: The Smoke Free Facility Policy revised 8/2019 documents: - Any resident identified as non-compliant with the policy will have immediate corrective action including: notification of the nurse manager, social worker, Director of Nursing (DON), and Administrator; initiation of an incident report for each episode of non-compliance; and documentation in the medical record; - Any smoking related privileges, restrictions, concerns shall be noted on the care plan and all personnel caring for the resident shall be alerted to these issues: - Any resident with safety restrictions due to non-compliance with the policy shall have the direct supervision of a staff member as determined by the DON/Interdisciplinary Team (IDT) to ensure the resident's compliance with the non-smoking policy; - Residents are not permitted to give smoking articles to other residents; and - In the event a resident is discovered by any staff attempting to smoke or in possession of incendiary materials on facility grounds, generate an incident report in conjunction with a supervisor and generate an occupational therapy referral for evaluation. 1) Resident #158 had [DIAGNOSES REDACTED]. The 10/14/19 Minimum Data Set (MDS) assessment documented the resident had intact cognition, exhibited no behavioral symptoms, required supervision and limited assistance of one person for locomotion off the unit, utilized a wheelchair, and had upper and lower body impairment on one side. Current tobacco use was not documented. The 3/6/19 comprehensive care plan (CCP) documented a new smoking assessment was completed and the resident was deemed unsafe to smoke. The Accident and Incident report dated 8/22/19 at 2:50 PM documented the resident was smoking in the courtyard. The resident was re-educated on the smoking policy. There were no staff or resident statements included with the report, no documented evidence the facility attempted to identify the source of the smoking materials, and no documented interventions to ensure the safety of the resident or other residents. The Accident and Incident report dated 9/4/19 at 9:45 AM documented the resident was with 2 other residents smoking in the courtyard. Smoking cessation was offered and refused. The resident was re-educated he was not allowed to smoke. The Accident and Incident report dated 10/29/19 at 9:09 AM documented the resident was caught smoking in the courtyard and was found to have 2 [MEDICAL CONDITION] the right index finger and one old burn. Steps taken to prevent recurrence included resident education on the smoking policy, a room search, and the cigarettes obtained were destroyed. - Licensed practical nurse (LPN) Unit Manager #12's statement noted she found the resident in the courtyard smoking, he had burn marks on his right hand, 2 cigarettes were confiscated, and no lighter was found; - RN Unit Manager #9's statement documented she witnessed the resident smoking, he had 3 blisters on his right index finger, and staff assisted to obtain remaining cigarettes from the resident's pockets; The 10/29/19 investigation did not include a statement from the other resident who was smoking, how the residents obtained the smoking materials, or interventions to prevent recurrence to ensure the safety of all residents in the building. The 10/29/19 smoking evaluation documented the resident was a smoker, had a dexterity problem, and could not light his own cigarettes. The resident could not dispose of ashes or other tobacco related residue properly and had past accidents/incidents with smoking materials. A 10/29/19 facility smoking contract for Resident #158 documented residents were not permitted to smoke anywhere in the facility or on the grounds of the facility. The agreement was signed by the social worker and another staff member. The contract documented it was read to the resident and he refused to sign. The physician progress notes [REDACTED]. The resident stated he understood he was not allowed to smoke, he was non-compliant with the smoking policy, had attempted to smoke recently and he obtained cigarettes from others. A nurse practitioner (NP) progress note dated 10/29/19 documented the resident had 2 small ruptured blisters on his right hand and 2 superficial scabbed areas next to the blisters. The CCP initiated 10/29/19 documented the resident was a problem smoker, was unsafe and was non-compliant with the smoking policy. Interventions included: re-educate the resident on the smoking policy, he was not allowed to smoke, was deemed an unsafe smoker, and refer to the physician for medical interventions to promote smoking cessation upon request of the resident. There was no documented evidence the resident was care planned for non-compliance with the smoking policy prior to 10/29/19. During an interview with RN Unit Manager #9 on 11/20/19 at 12:10 PM, she stated on 10/29/19, she and LPN Unit Manager #12 were in the hall on the first floor, smelled smoke and observed Resident #158 in the courtyard smoking. He was holding a cigarette in his right hand and she saw 2 blisters on his right index finger. He threw the cigarette butt into the grass when he saw the nurses arrive. A lighter was not found when he was searched. It was unknown how he obtained the cigarette or how it was lit. On 11/20/19 at 12:15 PM LPN Unit Manager #12 was interviewed and stated she observed the resident outside smoking with Resident #88 about 2-3 weeks ago. The Assistant Administrator and RN Unit Manager #19 were called, and the resident became combative. Resident #158 had a burn on his right upper hand near the knuckle and when she asked to look at it, the resident pressed it and popped the blister. Two or 3 cigarettes and a lighter were found in the front pocket of Resident #158's [NAME]et. Resident #88 stated Resident #158 gave her the cigarette. LPN Unit Manager #12 stated Resident #158 often asked visitors for cigarettes. When interviewed on 11/22/19 at 11:52 AM, NP #16 stated she was aware of the resident's non-compliance with smoking and was notified when he was caught smoking. When she would visit the resident after he was caught smoking, he would deny he had been smoking and would not say where he obtained his smoking materials. The resident had physical limitations which would make him an unsafe independent smoker. She always offered to come see the resident for counseling and to offer smoking cessation. The resident refused nicotine replacement. On 11/20/19 at 8:38 AM, the resident's right index finger was observed to have 2 healing blisters on the outside of the right finger, below the knuckle. A nursing progress note by licensed practical nurse (LPN) #4 dated 11/15/19 at 3:29 PM documented a strong odor of lit cigarette smoke came directly from the resident's room. He denied any use of tobacco. The Assistant Director of Maintenance went to the room with her and assisted in checking the resident's pockets and a lighter was removed. The Accident and Incident report signed by RN Unit Manager #3 on 11/18/19 documented LPN #4 smelled a strong odor from the resident's bedroom. There was no date or time of the incident documented. A lighter was removed, education was provided on safety and the smoking policy, and smoking cessation options were offered and refused. LPN #4's statement, signed on 11/15/19, documented maintenance staff #5 alerted her of a strong odor of cigarette smoke from the resident's room. The resident denied smoking, a lighter was removed from his pants pocket and he was spoken to about safety. There was no documented evidence the incident was reported to a supervisor on 11/15/19. The investigation did not include any other staff statements, the potential source of the resident's smoking materials, and there were no interventions to ensure the safety of all residents in the building. During an interview on 11/20/19 at 10:54 AM, maintenance staff #5 stated he was doing rounds in the rooms on Resident #158's floor on 11/15/19. When he entered the resident's room, he observed him with a lit cigarette in his hand and blowing smoke out of the open window. He stated he told the resident he was not allowed to do that, immediately left and called his supervisor over his radio, reported it to LPN #4, and returned to the doorway of the resident's room to wait. He stated he left the area when his supervisor arrived. He stated the windows only open a few inches and the screens could be opened by prying, but it was not easy. He did not inspect the room or the window screen and was unaware of how the resident disposed of the cigarette. The resident was known to ask various staff members and visitors for smoking materials. The maintenance worker stated he was not asked to write a statement about his observation of the smoking incident and the interview with the surveyor was the first time he had been asked about the incident since it happened. When interviewed on 11/20/19 at 11:18 AM, the Assistant Director of Maintenance stated maintenance staff #5 called him to the resident's room in the evening on 11/15/19 because he had seen the resident smoking out his window. When he arrived, he did not see the resident smoking but there was an odor of fresh cigarette smoke in the room. He notified LPN #4 he needed assistance and she arrived with a CN[NAME] The Assistant Director of Maintenance stated he remained in the room while the CNA checked the resident's pockets and found a lighter. No cigarettes, ashes, debris, or cigarette butt was found. He could not recall if the screen was open. He was not asked to provide a statement and the interview with the surveyor was the first time he had been asked about the incident since it occurred. During an interview on 11/20/19 at 4:43 PM, LPN #4 stated maintenance staff #5 came to her in the evening (after dinner) on 11/15/19 and told her Resident #158 was smoking in his room. When she arrived at the resident's room there was no cigarette found. The resident denied smoking, was found with a lighter in his pocket which she removed. She did not notify a supervisor and should have. The LPN stated the resident was known to ask multiple staff and visitors for cigarettes and she did not know who gave them to him. He often left the unit independently, spent time in the living room on the first floor, and was not supervised when he was off the unit. The smoking evaluation dated 11/18/19 documented the resident was a smoker, could not light his own cigarette, and was deemed unsafe to smoke. The Kardex Report (care instructions) dated 11/19/19 did not include interventions for supervision or safety regarding the potential to obtain smoking materials and non-compliance with the smoking policy. During an interview with Resident #158 on 11/20/19 at 12:49 PM he asked the surveyor for a cigarette and matches. The resident stated other people give him smoking materials and would not state who the other people were and declined to discuss smoking. When interviewed on 11/20/19 at 12:59 PM, RN Unit Manager #3 stated she did not know how the resident obtained smoking materials. She stated the care plan had not been updated to reflect the multiple past smoking incidents and should have been. The resident did not require or receive supervision to go off the unit or outside, and the intervention to ensure the safety of other residents was the removal of smoking materials when found. She stated the incident report for 11/15/19 should have been completed immediately. When she returned to work on 11/18/19, she completed the investigation, did not obtain any staff statements and did not think to do so. There were no further interventions and the care plan was not updated. She turned the incident report in to the Director of Nursing (DON) and was not asked for any follow-up on the incident. During an interview on 11/22/19 at 3:35 PM, the DON stated she tracked the incident reports, was responsible for signing off on them, and had not done a quality assurance (QA) review of the reports related to smoking. Resident #158 was discussed in morning meetings, he recently had burns, and his room had been searched. Some of the Unit Managers had asked the resident where he got the smoking materials and he would not tell them. There were no changes to his plan of care. The facility had no plan to monitor the courtyard as it was the residents' right to go out there. When interviewed on 11/19/19 at 5:32 PM, receptionist #14 stated Resident #158 often asked multiple individuals for smoking materials. On 11/20/19 from 10:14 AM to 10:32 AM, the courtyard grounds was observed with cigarette butts in multiple areas including flower beds, bushes, around the gazebo, near a bench and along the brick walkway near a door. 2) Resident #88 had [DIAGNOSES REDACTED]. The 9/12/19 Minimum Data Set (MDS) assessment documented the resident had intact cognition, required extensive assistance with most activities of daily living, used a wheelchair for mobility and did not currently use tobacco. The 9/5/19 nursing admission assessment documented the resident did not have a history of smoking and did not currently smoke. Physician orders [REDACTED].>-on 9/6/19 wander alert device to left ankle, check placement every shift due to wandering, if wander alert device is missing implement 1:1 supervision until replaced; -on 9/10/19 nicotine 21 milligrams (mg)/24 hours daily [MEDICATION NAME], apply 1 patch once daily for 14 days until 9/23/19 for nicotine dependence, nicotine 14 mg/24 hours once daily for 14 days until 10/7/19 and nicotine 7 mg/ 24 hours apply 1 patch once daily for smoking cessation. A physician history and physical progress note dated 9/11/19 documented the family had brought the resident to the emergency room due to worsening cognitive decline and behavioral problems including causing fires due to cigarettes being left out and stealing cigarettes. There were no medical progress notes addressing nicotine dependence or the use of nicotine replacement. A 10/22/19 at 9:18 PM progress note by licensed practical nurse (LPN) #18 documented a certified nursing assistant (CNA) found a lighter in the resident's drawer. A 10/28/19 at 12:15 PM nursing progress note by licensed practical nurse (LPN) Unit Manager #12 documented the resident was found smoking outside in the courtyard with another resident. She had a burn hole in her pants which the resident claimed was old. The resident stated she got the cigarette from the man she was out there with. The cigarette was taken away, her room was searched, and no accessories were found. A smoking evaluation would be completed, and the resident was made aware of the smoking policy. The Accident and Incident report dated 10/28/19 at 11:30 AM, documented the resident was observed outside smoking with another resident. Resident #88 had a burn hole in her pants and her skin was intact. The resident's room was checked, and no smoking materials were found. The resident would not disclose where she obtained the smoking materials. A smoking evaluation completed on 10/28/19 by LPN Unit Manager #12 documented the resident was a smoker and a referral to Occupational Therapy (OT) was completed. The resident could light her own cigarette and required a smoking apron and supervision. The resident could not dispose of ashes or other tobacco residue appropriately. There was no documented evidence the resident was evaluated by OT. A 10/29/19 at 9:44 AM nursing progress note by registered nurse (RN) Unit Manager #9 documented the resident was found in the morning smoking in the courtyard. The resident was informed again of smoking policy since she was just caught outside yesterday. The resident handed over her cigarette without difficulty. There were no apparent injuries. The Accident and Incident report dated 10/29/19 at 9:09 AM documented the resident was observed in the courtyard smoking with Resident #158. She was re-educated on the policy, her room was searched, and no smoking materials were found. The Medication Administration Record [REDACTED]. The undated comprehensive care plan (CCP) documented the resident was an actual problem smoker and a non-compliant smoker. Interventions included administer meds/gum/patch as per physician orders, assess physical and mental ability as needed for ability to understand and follow policy, instruct on admission regarding facility's smoking policy and consequences of failure to adhere, refer to physician for medical interventions available to promote smoking cessation upon request of resident and remove cigarettes/lighters/matches and keep in secure location, instruct resident/significant other. During a telephone interview with LPN #18 on 11/20/19 at 11:28 AM she stated a CNA (unable to recall who) found a lighter in Resident #88's drawer. She stated she took the lighter, wrapped it in a piece of paper with a note for LPN Unit Manager #12 and placed it in the Unit Manager's inbox at the nursing station. The CNA did not find any other smoking materials. She stated she did not speak to the resident about the lighter and had never had any issues with the resident smoking. During an interview with LPN Unit Manager #12 on 11/20/19 at 12:15 PM she stated she did not see a wrapped paper in her inbox containing a lighter and it was never brought to her attention. She stated about 2-3 weeks ago she and RN Unit Manager #9 were coming back from a meeting and saw Resident #158 and Resident #88 outside smoking. Resident #88 stated Resident #158 gave her the cigarettes. She stated she spoke with Resident #88's family member who stated she did not give the resident cigarettes, but the resident had frequent visitors who may have been giving her smoking materials. She stated staff did not keep personal belongings in resident accessible areas. She stated resident #88 had a burn hole in her pants and they could not determine how old the burn hole was. She looked at Resident #88's skin and there was no injury near the burn hole. Residents #88 signed a new smoking policy after the incidents. _______________________________________________________________________________________ Immediate Jeopardy was identified and the facility Administrator was notified on 11/20/19 at 6:12 PM. Immediate Jeopardy was removed on 11/22/19 at 6:45 PM prior to survey exit based on the following corrective actions taken. The facility: -For Resident #158: placed on continuous 1:1 supervision until safely discharged or no longer a risk for unsafe smoking; the smoke detector in the resident's room was inspected to ensure function; care plan was reviewed and updated; room was searched; referrals made to all local nursing homes. -Conducted room searches on all residents with a history of non-compliant smoking; -Offered smoking cessation to known smokers; -Educated staff on the facility's smoking policy and procedure and on the process when a resident is suspected of smoking or in possession of smoking materials. -Educated family members on the facility smoke-free policy; -Compiled a list of non-compliant smokers with pictures to be placed in a binder at the reception desk; -Performed audits on staff knowledge of facility systems for smoking. 10 NYCRR 415.12(h)(1-2)

Based on observation, record review, and interview conducted during the abbreviated surveys (NY 377 and NY 524), it was determined for 2 of 4 residents reviewed for quality of care (Residents #1 and 2), the facility did not ensure residents received the necessary care and services to maintain the highest practicable physical well-being. Specifically, - Resident #1 was not assessed by a qualified professional for physical injury after the facility suspected she was mistreated by a staff member. - Resident #2 was assisted to the bed pan in the morning of 9/11/2017; was not turned and positioned as planned on the day or evening shifts on 9/11/2017, and was found on the bed pan the following morning (9/12/2017). The resident sustained [REDACTED]. This resulted in actual harm that is not immediate jeopardy Findings include: 1) Resident #2 was re-admitted to the facility on [DATE] following a hospitalization for [MEDICAL CONDITION] of the left arm and trunk. The resident also had [DIAGNOSES REDACTED]. Per the 8/21/2017 Minimum Data Set (MDS) assessment, the resident's cognition was intact. The resident's Kardex (certified nurse aide, CNA, care instructions) was updated as follows: - On 8/20/2017, the resident needed extensive assistance from 2 persons with bed mobility. - On 8/23/2017, the resident was to be turned and positioned every 2-3 hours while in bed or sleeping in the chair. Turning and positioning times were scheduled to be every two hours starting at 1 AM and ending at 11 PM daily. The comprehensive care plan (CCP), updated 8/23/2017, documented the resident was at risk for skin breakdown related to medical diagnoses. Interventions to prevent skin breakdown included extensive assistance of 2 persons with bed mobility including scooting up in the bed; turning and positioning every 2-3 hours; assisting with frequent changes in position every 2-3 hours and as needed, and for the CNAs to evaluate the resident's skin twice a day during care and as needed. The 9/11/2017 CNA Documentation History Detail (documentation of care provided) documented the resident was on her back at 7 AM and 9 AM; turning and positioning was documented as not performed at 11 AM; the resident was on her back at 1 PM; the resident was in the wheelchair at 3 PM, and the resident was on her back at 5 PM, 7 PM, 9 PM, and 11 PM. The 9/12/2017 CNA Documentation History Detail documented the resident was on her back at 1 AM and on her left side at 3 AM. The 9/12/2017 licensed practical nurse (LPN) #19's progress note at 6:01 AM, documented that 2 CNAs found a newly reddened area on the resident's buttocks, the Supervisor was called, and barrier cream was applied. The 9/12/2017 at 11:51 AM, registered nurse (RN) Manager #14's progress note documented she was notified the resident was left on the bed pan for an extended period of time between the hours of 2:00 PM and 6:00 AM. The resident stated the CNA left her for a long time and the resident had a red area to her buttocks measuring 18 centimeters (cm) x 1 cm bilaterally. The resident said her bottom is still sore and medical was notified. The 9/13/2017 at 12:48 PM, RN Manager #14's progress note documented herself and nurse practitioner (NP) #13 assessed the resident and she had 2 open areas to the top of the buttocks and 1 intact blister on top of the sacrum. RN #14 documented the wound was unstageable and measured 13 cm x 4.2 cm, the area was red and inflamed, and thin edges were adhered to the wound. A second note by RN #14 at 4:04 PM, documented the resident's wound was treated with [MEDICATION NAME] and the wound was covered with a dry dressing. The resident was then sent to the hospital for an unrelated medical concern. The 9/13/2017 NP #13's progress note documented the resident had a large unstageable wound on her buttocks. The wound measured 13 cm x 4.2 cm with 2 ruptured blisters on her sacrum and a third intact blister on the sacrum. The wound extended from the buttocks to sacrum and was red and inflamed. The NP documented she ordered [MEDICATION NAME] to be applied at that time as she was sending the resident to the hospital for an unrelated issue. There was no documented evidence an order was written for the [MEDICATION NAME] treatment. The hospital's admission history and physical dated 9/13/2017 and transfer summary dated 9/15/2017 contained no documentation in regards to the unstageable wound on the resident's buttocks and sacrum. The 9/15/2017 at 12:21 PM, RN #14's re-admission progress note documented the resident was readmitted with an open area to the top of the sacrum that measured 13 cm x 4.2 cm and the area was red and inflamed. The 9/15/2017 re-admission physician's orders [REDACTED].#14 who documented she read back the orders to the authorized prescriber. There was no documentation a treatment was ordered to the unstageable wound on the resident's sacrum. There was no documented evidence a treatment was administered to the unstageable area from 9/15/2017 through 9/18/2017. The 9/19/2017 NP #13's progress note documented a CNA asked her to look at the resident because she did not have an treatment ordered for the wound. The NP documented she ordered the wound to be treated with [MEDICATION NAME]. The 9/2017 TAR documented on 9/19/2017, an order for [REDACTED]. On 9/20/2017 at 1:08 PM, CNA #3 stated in an interview, she was assigned to the resident on 9/11/2017 from 6 AM to 2 PM. She stated since the incident occurred, she heard that CNA #18 put the resident on the bed pan in the morning of 9/11/2017 when she was off the unit and did not tell her she put the resident on the bed pan. She stated she did not check the resident for a bed pan because the resident could ring her call bell when she needed help. She stated she saw the resident when she refused lunch on 9/11/2017 and she also checked on her before she left at 2 PM. She stated the resident was not on a turning and positioning program as she rang to be repositioned so that was why she documented the resident's positioning as on her back for the entire day shift on 9/11/2017 as the resident did not ask to be turned. On 9/22/2017 at 8:07 AM, CNA #18 stated in an interview, on 9/11/2017 at 10:40 AM, the resident rang her call bell and she assisted her to the bed pan because her assigned CNA (CNA #3) was off the unit. She stated when CNA #3 returned to the unit, she did not tell her the resident was on the bed pan because the resident could ring her call bell and ask to be taken off. She stated she never saw the resident again on 9/11/2017 and assumed she was taken off the bed pan timely. On 9/19/2017 at 10:25 AM, CNA #9 stated in an interview: - When her shift started at 2 PM on 9/11/2017, she received report from the day CNA and was not told the resident was on the bed pan. - She checked on the resident between 4:30 and 4:45 PM, between 7:30 PM and 7:45 PM, and at 9 PM, and on all 3 occasions, the resident was lying on her back in bed with a blanket covering her and said she did not need anything. - She checked on the resident again on 9/12/2017 at around 1:30 AM and the resident was lying in the same position on her back and said she did not need anything. - On 9/12/2017 at 2:30 AM, CNA #9 saw a brown spot on the resident's sheet and when she pulled the blanket back, she saw the resident was on the bed pan. CNA #20 helped her clean the resident up and they told LPN #19 as the resident had an indentation in her buttocks that looked like a bruise. - The resident did not like to be repositioned and since she was alert and oriented she did not turn and position her as it was the resident's choice. - On 9/11/2017 at 3 PM when she documented the resident was in the wheelchair, that was an error as she was on her back the entire evening shift on 9/11/2017 and also on the night shift until 2:30 AM on 9/12/2017 when she found her on the bed pan. On 10/18/2017 at 12:35 PM, CNA #20 stated in an interview, at around 3:30 AM on 9/12/2017, she walked by the resident's room and saw CNA #9 in the room changing the resident's sheets. She stated she went into the room to see what was going on and she saw a huge ring around the resident's bottom. She stated she helped CNA #9 clean the resident up and change her sheets and they reported it to LPN #19. On 10/18/2017 at 2:37 AM, LPN #19 stated in an interview, on 9/12/2017 between 3 AM and 4 AM, CNA #20 told her the resident was found with a ring on her bottom. She stated she looked at the resident, the resident had an area shaped like a bed pan on her buttocks, she applied barrier cream to the resident's buttock, and called RN Supervisor #10 to come and see her. She thought RN Supervisor #10 assessed the resident but she also left a note on the nurse's station so the day RNs would be aware. On 9/19/2017 at 11:55 AM, RN Supervisor #10 stated in an interview, she recalled being notified the resident was found on the bed pan on 9/12/2017 and thought she was told at around 6:30 AM. She stated she was told staff thought the resident had been on the bed pan for a period of time and she told the unit staff to leave a note to have a day RN assess the resident as her shift was ending at 7 AM. On 9/20/2017 at 10:58 AM, RN Manager #14 stated in an interview, on 9/12/2017 when she came into work at 8 AM, staff told her the resident was left on the bed pan and had a red area on her buttocks. She stated she thought the area was found at 5 or 6 AM so the staff waited to have nurse assess the resident instead of the night Supervisor. She stated she saw the resident and her bottom was red. She stated the next day, she saw the resident with NP #13, blisters had developed, and NP #13 ordered [MEDICATION NAME]. RN #14 applied the [MEDICATION NAME] prior to the resident going to the hospital for an unrelated issue. RN Manager #14 stated when the resident came back to the facility on [DATE], she assessed her, the wound measurements were the same, and she called NP #13 to obtain readmission orders [REDACTED]. On 9/20/2017 at 1:50 PM, NP #13 stated in an interview, on 9/12/2017, she received a call from RN Manager #14 who stated she had to notify her because there was an incident, the resident was found on the bed pan after some period of time and her skin was fine and she had no red marks. The next day, she looked at the resident's skin and saw a very large area and questioned RN #14 as to why she told her the resident was fine when she initially called her. She did not recall exact measurements but thought one measurement was 13 cm and stated there were 3 blisters present. She stated she ordered [MEDICATION NAME] to be applied and covered the wound with a dressing because she had to send the resident to the hospital for an unrelated issue. NP #13 stated RN #14 was present and took the verbal order for the [MEDICATION NAME] on 9/13/2017. NP #13 stated yesterday (9/19/2017), a CNA approached her and asked her why there were no orders for the resident's open area so she saw the wound and ordered [MEDICATION NAME]. She stated when the resident was readmitted on [DATE], she did not receive a call from RN #14 for readmission orders [REDACTED] On 9/20/2017 at 2:53 PM, MDS LPN #15 stated in an interview, she updated the resident's CCP and Kardex in 8/2017 because the resident had been declining and was no longer able to reposition herself on her own and needed a turning and positioning program. LPN #15 stated since the resident was on a turning and positioning program, staff should be changing her position every 2 hours and document that in the record. LPN #15 stated that repeatedly documenting that the resident was on her back was not acceptable. On 9/20/2017 at 3:36 PM, LPN #17 stated in an interview, she worked on 9/16/2017 and did not complete a treatment to the resident's unstageable area as one was not ordered and she did not know the resident had an open area. She stated on 9/18/2017, she learned of the open area, saw that there was not a treatment ordered, and when she left at 10 PM, she told the oncoming nurse to follow-up and ask the Supervisor for a treatment. On 9/20/2017 at 10:30 AM, LPN #12 stated in an interview, she completed the resident's treatment on 9/19/2017 because NP #13 came in and noticed there was not a treatment ordered. LPN #12 stated she was off from 9/12-9/18/2017 so did not know the resident had the open area and did not know the resident needed a treatment order until NP #13 told her. In an interview with the former Director of Nursing (DON at the time of the incident) on 10/18/2017 at 9:37 AM, he stated on the morning of 9/12/2017 he was told the resident was left on the bed pan for an extended period of time. He stated when he was notified, he had RN Manager #14 assess the resident and she also started the incident report. He stated he was not aware RN Supervisor #10 was called to assess the resident on the night shift and was not aware that she did not complete the assessment. He stated the assessment should have been done at the time of discovery. He stated he left the faciity on [DATE] so was not aware what occurred with the resident's care or treatments after that date. 2) Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Per the 6/21/2017 Minimum Data Set (MDS), the resident's cognition was intact. The certified nurse aide (CNA) care instructions documented on 6/14/2017, the resident needed extensive assistance from one person with personal hygiene. The 8/9/2017 Incident Report Form initiated by the former Director of Nursing (DON) documented on 8/8/2017 at 5:57 PM, a CNA left the resident in a soiled state with feces covered washcloths between her legs. He documented the CNA responsible was terminated and the resident had no injury. On 8/9/2017, there was no documentation in the resident's medical record in regard to the incident and no documentation of the RN assessment. On 9/11/2017 at 1 PM, the resident stated in an interview, she had no feeling from her waist down so she did not always know when she had a bowel movement and she did not know that the CNA left her in a soiled brief with wipes inside of her vagina until the night shift CNA came in and noticed it and told her. On 9/11/2017 at 2:36 PM, licensed practical nurse (LPN) #1 stated in an interview, she was the nurse on the unit when the incident was discovered. She stated she went to the room and saw the resident with tons of stool in her brief and balled up wipes in her peri area. She stated she called RN Supervisor #10 and sent an email to the DON and the RN that she thought was covering the unit (RN #11) as the Manager was on vacation. LPN #1 stated RN Supervisor #10 came to the unit that night but she did not know if she assessed the resident. On 9/12/2017 at 12:10 PM, RN Manager #5 stated in an interview, she was on vacation from 8/4/2017 through 8/14/2017 and did not assess the resident after the incident occurred. On 9/19/2017 at 11:55 AM, RN Supervisor #10 stated in an interview, when she arrived on the unit on the night of the resident's incident, there were two residents she needed to assess so she went and saw the other resident. She stated she thought the issue with the other resident was more pressing and she did not think the resident's incident was a serious issue at that time. She stated she told the LPN to report it to the DON so it could be investigated. On 9/19/2017 at 1:10 PM, RN Manager #11 stated in an interview, on the night of the incident she received an email from the LPN and thought she received it because she had previously taken care of the resident when the resident resided on her unit and she still kept in contact with the resident. She stated when she received the notification, she forwarded the email to the DON and had no further involvement in the resident's incident. On 10/18/2017 at 9:37 AM, the DON stated in an interview, when the staff found Resident #1 with soiled washcloths inside her vaginal area he was notified the next morning, not at the time of the incident. He stated he was notified on 8/9/2017 first thing in the morning as the resident sent an email and the Administrator's Assistant also notified him. He stated he started the investigation as one was not started when the incident was identified. He stated that the investigation should have been started immediately and he did not know why it was not. He stated on 8/9/2017, he saw the resident and spoke with her. He stated he checked if she was alright or in any emotional distress. He stated she was okay but frustrated. He stated he did not complete a physical examination on her and would have asked the Unit Manager to do it (RN #5). 10NYCRR 415.12

Based on observation, record review and interviews conducted during the post survey revisit, it was determined facility Administration did not ensure corrective actions were implemented to address previous deficiencies from the 5/9/2014 survey involving fire safety and sprinkler coverage. Specifically, fire prevention/protective measures were not implemented as specified in the facility's Plan of Correction. Facility administration: - permitted a minimum of 10 staff members to continue working, without first attending fire safety education; - did not develop a policy that clearly defined and provided guidance to staff regarding fire drills procedures; - did not ensure the previously identified inadequate or missing sprinkler coverage in the penthouse elevator mechanical room and in the basement main electrical room were installed as specified in the corrective action plans for the 5/9/2014 survey. This resulted in no actual harm with potential for more than minimal harm that is not Immediate Jeopardy. THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY OF 5/9/2014. Findings include: 1) As a result of the Immediate Jeopardy survey of 5/9/2014, the facility was to develop a directed plan of correction that specified mandatory staff training regarding accident hazard prevention and response, as related to fire safety and prevention measures. During an interview on 7/9/2014 at 2:00 PM during the post survey revisit, the Administrator stated when the Fire Safety training was conducted, there were staff members who did not attend the training. The Administrator stated that due to their union contract, she was unable to discipline the staff or keep them off the schedule, until they received the Fire Safety training. Review of inservice attendance records revealed a minimum of 10 staff members were permitted to continue work without being trained in fire safety and prevention procedures by the outside consultant. 2) Review of the Fire Drill Policy, dated 6/11/2014, revealed it did not specify/clarify that fire drills: - were to be conducted on each shift quarterly; - times the drills were to be conducted would vary; - would be evaluated for effectiveness and specify the process for this evaluation; - would be conducted by a specific responsible party. During an interview on 7/9/2014 at 2:20 PM the Administrator stated: - she did not realize the Fire Drill Policy was missing information including the varying times and conditions of the fire drills; - the first contract company had led her to believe all areas were corrected; - she understood the penthouse elevator room must have sprinkler coverage and this could be a repeat deficiency; - the second contract company was behind at another facility and thought the second contract company was coming in yesterday. 10NYCRR 415.26(a)

Based on observation, record review and interview conducted during the standard survey, it was determined the facility Administration failed to implement fire prevention measures and corrective action following an actual fire in resident room [ROOM NUMBER]. The facility's Administration failure placed the entire facility census of 186 residents at immediate risk of fire injury. Specifically, a fire occurred on 3/17/2014 in resident room [ROOM NUMBER] (where Resident #29 resided), the facility's investigation determined a spark ignited dust/lint build up in room [ROOM NUMBER]'s PTAC unit (packaged terminal air conditioner) caused the fire. The plan to provide preventative maintenance to correct the identified fire risk was not implemented by the facility's Administration. This resulted in no actual harm with potential for serious harm that is Immediate Jeopardy to the health and safety the facility's 186 residents, staff, and visitors. Findings include: A facility life safety report documented there was a fire in room [ROOM NUMBER] on 3/17/2014 at 9 AM. An incident report, dated 3/17/2014, documented a heating unit caught fire. The incident report documented when the PTAC (packaged terminal air conditioner) unit was turned on sparks and fire were visible. The report documented the cause of the fire was a spark in the PTAC motor, that ignited lint that had settled on the motor. The report documented lint on the motor caused fire; all units were to be cleaned of lint; and some older units had no filters to prevent lint from getting onto the motor; audit all PTAC units for the need of a filter. During an interview on 5/7/2014 between 3 PM and 3:10 PM, the Director of Maintenance stated the fire on 3/17/2014 was not lint related. He stated there had been no follow-up checks done on any PTAC unit in the facility following the incident. He stated the PTAC unit in resident room [ROOM NUMBER], had lint/dust buildup and needed to be vacuumed. He stated he did not believe the lint/dust buildup was a hazard. On 5/7/2014 between 3:50 PM and 4:20 PM, in an interview with the Administrator: - She stated the fire was caused by dust in the heater. - She stated following the 3/17/2014 fire incident, she believed the Director of Maintenance went through and checked every PTAC unit in the facility. - She stated she was unsure of the results of the PTAC checks, or if the results were included in the investigation report. - She stated she was not aware of any dust/lint buildup on any units at that time. - She stated the facility conducted audits on the PTAC units for function and including quarterly preventative maintenance rounds. During the interview with the Administrator, the Operator joined the interview. He stated that all the units were tested for function last week and may have had some preventative maintenance. This information from the Administrator and Operator was unable to be confirmed, as the Director of Maintenance's interview (on 5/7/2014 between 3 PM and 3:10 PM) specified no documentation of preventative maintenance was completed and no follow-up checks were performed on the facility's PTAC units after the fire in resident room [ROOM NUMBER]. 10NYCRR 415.26(a)

Based on observation, record review and interview conducted during the standard survey, it was determined the facility failed to implement fire prevention measures and corrective action following an actual fire in resident room 426. The facility's failure placed the entire facility census of 186 residents at immediate risk of fire injury. Specifically, a fire occurred on 3/17/2014 in resident room 426 (where Resident #29 resided), the facility's investigation determined a spark ignited dust/lint build up in room #426's PTAC unit (packaged terminal air conditioner) caused the fire. The plan to provide preventative maintenance to correct the identified fire risk was not implemented. This resulted in no actual harm with potential for serious harm that is Immediate Jeopardy to the health and safety the facility's 186 residents, staff, and visitors. Findings include: A facility life safety report documented there was a fire in resident room 426 on 3/17/2014 at 9 AM. An incident report, dated 3/17/2014, documented the heating unit in resident room 426 caught fire. The report documented when the certified nurse assistant (CNA) turned on the heat, sparks and fire were visible. The resident was evacuated from the room, the CNA yelled fire, the fire alarm was pulled, and a licensed practical nurse (LPN) extinguished the fire with a fire extinguisher. The report recorded shortly after the fire was extinguished, the fire department arrived and placed fans in the window to remove the smoke. The investigative form dated 3/17/2014 documented the cause of the fire, in resident room 426, was a spark in the PTAC unit motor which ignited lint that had settled on the motor. The investigation documented no corrective action was necessary as staff followed all fire procedures to the letter. The fire alarm pull station was activated and alarms did not sound because the fire system was on bypass due to the installation of an elevator motor. There were two Nurse Managers who did not respond to the fire, who stated they thought it was a drill. The investigation documented lint on PTAC motor caused the fire; all units were to be cleaned of any lint; some older PTAC units had no filters to prevent lint from getting onto motor; and all PTAC units were to be audited regarding the need for filters. Observations on 5/7/2014 between 3 PM and 3:10 PM, showed the PTAC unit in resident room 506 had no filter, and had significant visible dust/lint build up along the sides of the unit, on the motor, and inside the blower cage assembly attached to the motor. In an interview with the Director of Maintenance on 5/7/2014 between 3 PM and 3:10 PM, he stated the PTAC unit in room 506 needed to be vacuumed. The Director said the fire in resident room 426 was not lint related, and that 99 percent of any dust was trapped by the PTAC filter. He stated he did not believe dust/lint build up on the PTAC units was a hazard. The Director said there were no records documenting preventative maintenance of the PTAC units. The Director said there was no follow-up checks performed on the facility's PTAC units after the fire in resident room 426. On 5/7/2014 between 3:10 PM and 3:16 PM, the PTAC unit in room 519 was observed with dust buildup, and significant dust/lint buildup around the motor, the sides of the unit, and in the blower cage assembly attached to the motor. On 5/7/2014 between 3:16 PM and 3:42 PM, the surveyor and the Director of Maintenance observed the following: - The PTAC unit in resident room 432 had no inside cover or filter, and contained dust/lint buildup on the exterior unit cover, the motor, and in the blower cage assembly attached to the motor. - The PTAC unit in resident room 408 had no filter and contained dust/lint buildup on the interior unit sides, the motor, and the blower cage assembly attached to the motor. - The PTAC unit in resident room 718 had no filter and contained dust/lint build up inside the unit, on the motor, and in the blower cage assembly attached to the motor. - The PTAC unit in resident room 719 had no filter and contained dust/lint build up under the unit, inside the unit, on the motor, and in the blower cage assembly attached to the motor. - The PTAC unit in resident room 604 contained significant dust/lint buildup on the filter, inside the unit, on the motor, and in the blower cage assembly attached to the motor. - The PTAC unit in resident room 606 had no filter and contained significant dust/lint build up below the unit, inside the unit, on the motor, and in the blower cage assembly attached to the motor. - The PTAC unit in resident room 326 had no filter and contained significant dust/lint build up inside the unit, on the motor, and in the blower cage assembly attached to the motor. - The PTAC unit in resident room 301 contained dust/lint build up on the filter, inside the unit, on the motor, and in the blower cage assembly attached to the motor. On 5/7/2014 between 3:16 PM and 3:42 PM, the Director of Maintenance stated the PTAC units in resident rooms 301 and 604 unit definitely needed to be cleaned. In an interview on 5/7/2014 between 3:50 PM and 4:20 PM, the Administrator stated on 3/17/2014 an employee turned the PTAC unit on in resident room 426 and there was visible smoke and fire. She stated the fire was caused by dust in the heater, and she believed the Director of Maintenance checked every PTAC unit in the facility after the fire. She stated she did not know the results of the PTAC unit checks, and she was not aware of any dust/lint buildup on any PTAC unit at that time. The Administrator said the facility conducted audits on the PTAC units for function and quarterly preventative maintenance. The Operator joined the interview and stated all PTAC units were tested for function last week, and may have had some preventative maintenance. This information from the Administrator and Operator was unable to be confirmed, as the Director of Maintenance's interview (on 5/7/2014 between 3 PM and 3:10 PM) specified no documentation of preventative maintenance was completed and no follow-up checks were performed on the facility's PTAC units after the fire in resident room 426. Additionally, during the Administrator's interview, she stated she did not report the fire in resident room 426 to the New York State Department of Health because the resident did not sustain any injury. 10NYCRR 415.12 (h)(1)

Based on record review and staff interview conducted during the extended survey, it was determined the facility failed to ensure the Medical Director oversaw the implementation of policies, procedures and coordination of medical care for 5 of 9 residents (Residents #6, 8, 9, 20 and 27) reviewed for oxygen/respiratory care and for 55 residents (including Residents #7, 29, 30, 31, 32, and 33) who required routine blood sugar testing. Specifically, the Medical Director failed to ensure the facility followed standard precautions during the performance of routine testing of blood sugars and failed to ensure glucometers were cleaned before and after use according to manufacturer's specifications. In addition, the Medical Director failed to ensure staff were adequately trained on how to provide respiratory care and services to meet the residents needs. Refer to F328 and F441. This resulted in no actual harm that was Immediate Jeopardy to the health and safety of Residents #6, 8, 9, 20, 27, 31, 32, and 33. The Immediate Jeopardy situation was removed on August 6, 2012 prior to the survey exit. Findings include: During an interview on July 31, 2012 at 1:30 PM, the Medical Director stated the facility used glucometers to check residents' blood glucose levels and he knew there were appropriate protocols to use when cleansing glucometers. He stated he could not remember which cleansers or wipes were approved for cleaning glucometers and stated the surveyor could contact the pharmacy for that. During an interview on August 2, 2012 at 10:40 AM, the Medical Director stated he was not aware of any problems with [MEDICAL CONDITION] or respiratory care in the facility. He stated the facility had policies and procedures regarding [MEDICAL CONDITION] and respiratory care and was he not aware of any problems with them. He stated if there was a problem with respiratory care he would expect them to be addressed in the quality assurance process and if the physician's orders [REDACTED]. Refer to F328 for 5 of 9 residents (Residents #6, 8, 9, 20 and 27) reviewed for oxygen/respiratory care. Refer to F441 for details regarding 55 residents (including Residents #7, 29, 30, 31, 32, and 33) who required routine blood sugar testing. In summary, the facility failed to ensure the Medical Director oversaw the implementation of policies and procedures and the coordination of medical care in the facility in regards to infection control/glucometers and respiratory care. -------------------------------------------------------------------------------------------- The Immediate Jeopardy situation was removed on August 6, 2012 based on the following corrective actions taken by the facility: - For Glucose Monitoring: policies and procedures were revised for proper blood sugar testing with glucometers and the disinfectant solution to be used. - For Respiratory Care: policies and procedures were revised regarding proper oxygen management procedures; most facility staff were trained on new/revised policy and procedures for the use of various respiratory care devices, the proper administration of oxygen, [MEDICAL CONDITION] care, the protocol for physician orders [REDACTED]. - The majority of facility staff were trained on revised and policies and procedures for glucometer use and proper respiratory care; a training plan was in place to ensure education for the rest of the staff; quality assurance monitoring was initiated by administrative staff to ensure compliance with these new/revised policies and procedures. 10NYCRR415.15(a)

Based on observation, staff interview and record review conducted during the extended survey, it was determined for 55 residents (including sampled Residents #7, 29, 30, 31, 32, and 33), with diabetes, who required routine blood sugar testing and 2 of 7 residents reviewed for infections, (Residents #8 and 12), the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment, and to help prevent the development and transmission of disease and infection. Specifically, for Residents #7, 29, 30, 31, 32, and 33, who required routine blood sugar testing, the facility: - failed to ensure licensed staff were aware of the policy and procedure for disinfection of glucometers; - failed to consistently implement the policy and procedure ; - failed to clean and disinfect the glucometers (a device to measure sugar in the blood), in accordance with the manufacturer's specifications, before and after use; - failed to ensure the necessary disinfectant solution to cleanse glucometers was available; and - failed to reduce the risk for the transmission of blood borne pathogens when performing routine testing of blood sugars. For Residents #8 and 12 the facility did not ensure care items were stored appropriately. This resulted in no actual harm that is Immediate Jeopardy to resident health and safety for 55 residents with diabetes, who required routine testing of their blood sugars, including Residents #7, 29, 30, 31, 32, and 33 and no actual harm with potential for more than minimal harm that is not immediate jeopardy for Residents #8 and 12. The immediate jeopardy situation was removed on August 6, 2012 prior to the survey exit. Findings include: The facility's policy titled "Glucose (sugar) testing devices and lancets (used to obtain a drop of blood)" dated December 3, 2010, documented a multi-use type of glucometer was used in the facility under the manufacturer's operating standards. The facility's policy noted the glucose monitors would be wiped down, after each resident, with the facility approved broad spectrum antimicrobial (Dispatch, PDI, or other designated product) containing 10% bleach solution, to reduce the spread of potential pathogens (germs) . The undated manufacturer's recommendations for the type of glucometer used in the facility (provided to the surveyor, on August 1, 2012 at 12:02 PM) documented sanitizing the device, including the test strip port, with any "EPA" approved disinfectant product that met the 1:10 bleach solution ratio. 1) Resident #30 had [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. During an observation of the medication administration on July 29, 2012: - at 4:07 PM, licensed practical nurse (LPN) #5 donned 2 pairs of disposable gloves and said she did so because Resident #30 had a blood borne pathogen. LPN #5 took the glucometer from the top of the medication cart, entered the resident's room, placed the glucometer on top of the resident's overbed table and performed the fingerstick blood sugar test. When she completed the test LPN #5 took the glucometer from the resident's room without cleansing, or disinfecting it and placed it back on top of the medication cart. - at 4:12 PM, LPN #5 removed the unclean glucometer from the top of the medication cart, and carried it into Resident #32's room. She stated she was going test Resident #32's blood sugar. At that time the surveyor stopped the LPN #5 from testing Resident #32's blood sugar. LPN #5 stated she should have used bleach wipes to clean the glucometer and she did not, as she was nervous. She looked in the medication cart for the wipes and there were none. LPN #5 placed the glucometer on top of the medication cart without cleansing or disinfecting it. - at 4:30 PM, the registered nurse (RN) #2, unit manager showed the surveyor a container labeled "Super Sani-Cloth Germicidal Disposable Wipe." The label instructions documented blood borne pathogens would be killed in 2 minutes. - at 4:45 PM, LPN #5 was observed taking the glucometer from the top of the medication cart and cleaning it with a germicidal wipe. She did not clean the top of the medication cart where the glucometer had been resting. After cleaning the glucometer LPN #5 placed it back on the medication cart. After 1 minute the LPN took the glucometer from the top of the medication cart, stated she was going to perform a fingerstick blood sugar test on Resident #33. The LPN stated the germicide should remain on the glucometer 1 minute to kill bacteria. During an interview with the Supervisor (RN #3), on July 29, 2012 at 4:50 PM, she stated the glucometer should be cleansed each shift. She did not state any other time the glucometer was to be cleansed, or disinfected. During an interview with the Infection Control RN on July 29 at 5:10 PM, she stated the glucometer should be cleansed with bleach after each use. She did not identify the type of product the facility used. During an interview with the Infection Control RN on July 31, 2012 at 11:58 AM, she stated she did not know information regarding cleansing of glucometers that had been provided to employees, as she was new to her role, and the previous Infection Control Nurse was no longer employed by the facility. During an interview with the Administrator on July 31, 2012 at 12:10 PM, he said he was notified by the Director of Nursing (DON) on July 30, 2012 of the problems with the cleansing and disinfection of the glucometers. He stated he "probably" should have been aware of the problem. During an interview on July 31, 2012 at 1:30 PM, the Medical Director said there were appropriate protocols to use when cleaning glucometers. He could not remember which product was approved for use and stated the pharmacy could provide that information. In summary the facility failed to reduce the potential risk for the transmission of blood borne pathogens when performing routine testing of blood sugars as they: - failed to consistently implement a policy and procedure for disinfection of glucometers and ensure licensed staff were aware of the policy; - failed to clean and disinfect the glucometers before and after use and in accordance with the manufacturer's specifications; and - failed to ensure the necessary disinfectant solution to cleanse glucometers was available. 2) Resident #31 had [DIAGNOSES REDACTED]. The physician note dated July 30, 2012 documented the resident was on sliding scale insulin coverage. During an observation of medication administration on July 30, 2012 between 4:10 PM and 4:50 PM, licensed practical nurse (LPN) #6 performed fingerstick blood sugar tests on 3 residents: - at 4:10 PM, LPN #6 inserted a blood glucose test strip into the glucometer, donned gloves, and obtained a fingerstick blood sample from Resident #29 onto the test strip. After completion of the test, LPN #6 disposed of the glucose test strip, cleansed the glucometer with an alcohol pad and placed it on top of the medication cart; - at 4:15 PM, LPN #6 placed a blood glucose test strip in the glucometer and took it into Resident #7's room. LPN #6 obtained a blood sample from the resident onto the test strip. After obtaining the resident's blood glucose level LPN #6 disposed of the test strip, cleansed the glucometer with an alcohol pad and placed it on top of the medication cart; - at 4:20 PM, LPN #6 placed a blood glucose test strip in the glucometer and took in into Resident #31's room. LPN #6 obtained a blood sample from the resident onto the test strip. After obtaining the resident's blood glucose level LPN #6 disposed of the test strip, cleansed the glucometer with an alcohol pad and placed it on top of the medication cart. During an interview on July 30, 2012 at 4:45 PM, LPN #6 was asked about cleaning the glucometer after use. She said "I don't have bleach wipes to wipe it down so I have to clean it using what I have, that is why I am using alcohol pads." During an interview with the Infection Control registered nurse (RN) on July 29 at 5:10 PM, she stated the glucometer should be cleansed with bleach after each use. She could not identify the product used by the facility. During a second interview with the Infection Control RN on July 31, 2012 at 11:58 AM, she stated she did not know what staff had been taught regarding cleansing of glucometers. She said she was new to her role, and the previous Infection Control Nurse was no longer employed by the facility. During an interview with the Administrator on July 31, 2012 at 12:10 PM, he said he was notified by the Director of Nursing (DON) on July 30, 2012, of the problems with the cleansing and disinfection of the glucometers. He stated he "probably" should have been aware of the problem. He stated he trusted the DON, she was handling the situation, and he had no reason to believe she did not know what she was doing. During an interview on July 31, 2012 at 1:30 PM, the Medical Director said there were appropriate protocols to use when cleaning glucometers. He could not remember which product was approved for use and stated the pharmacy would have that information. In summary the facility failed to reduce the potential risk for the transmission of blood borne pathogens when performing routine testing of blood sugars as they: - failed to consistently implement a policy and procedure for disinfection of glucometers and ensure licensed staff were aware of the policy; - failed to clean and disinfect the glucometers before and after use and in accordance with the manufacturer's specifications; and - failed to ensure the necessary disinfectant solution to cleanse glucometers was available. ---------------------------------------------------------------------------------------------The Immediate Jeopardy situation was removed on August 6, 2012 based on the following corrective actions taken by the facility: - Policies and procedures were revised to specify the correct procedure to follow when performing blood sugar testing with glucometers and the disinfectant solution to be used. - Greater than 80% of the facility staff have been trained on the new policies and procedures, with a plan to be certain all staff were trained before returning to work. - audits have been conducted and facility administrative staff monitoring was initiated to ensure compliance with new policies and procedures. 3) Resident #8 had a tracheostomy tube, a Foley catheter (bladder drainage tube) and a feeding tube. The urinalysis and culture and sensitivities laboratory test results dated June 4, 2012, documented the resident's urine had more than 70,000 colonies per milliliter (col/ml) of [MEDICATION NAME] faecalis (intestinal bacteria). The physician's progress note dated June 15, 2012, documented the resident was started on 100 mg (milligrams) of [MEDICATION NAME] (an antibiotic) twice a day for 5 days, for a urinary tract infection. The urinalysis and culture and sensitivities laboratory test results dated June 21, 2012, documented the resident's urine was hazy, had a large amount of white blood cells, a small amount of blood, and more than 100,000 col/ml Proteus mirabilis (intestinal bacteria). The physician's progress note dated June 25, 2012, documented the resident had urinary studies done, they tested positive for Proteus mirabilis greater than 100,000 col/ml, and the plan was to start 500 [MEDICATION NAME](an antibiotic) twice a day for 10 days. During an interview with the registered nurse (RN) unit manager on July 30, 2012, she stated the resident had a Foley catheter for urinary retention. She stated the resident was on isolation precautions because he had an UTI, and an infection in his nose. August 1, 2012, at 9 AM and 2:15 PM, boxes were observed on the floor of the resident's bathroom, which contained tracheostomy inner cannulas, and indwelling Foley catheters. During an interview with the RN unit manager on August 1, 2012 at 3 PM, she stated she told staff on Monday (July 30, 2012), to pick up the supplies that were on the floor of the resident's bathroom, and she was not aware supplies were still on the floor of the resident's bathroom. During an observation with the Director of Nursing (DON) on August 1, 2012 at 3:25 PM, resident care supplies were on the floor of the resident's bathroom, and the DON stated during an interview at this time the supplies should not be stored on the floor. August 2, 2012, at 8:30 AM, resident care supplies were observed on the floor of the resident's bathroom, and the licensed practical nurse (LPN) provided the surveyor an inventory of the supplies, which were 2 cases of tracheostomy care kits, 2 individual tracheostomy care kits, 2 boxes of disposable inner cannulas, 2 boxes of tracheostomy ties, 4 urinary drainage bags, and 2 urinary catheter irrigation kits. During a second interview with the DON on August 2, 2012 at 9:30 AM, she stated she had asked staff to take the resident care supplies off the floor of the resident's bathroom, and she was not aware this was not done. In summary the facility did not store the residents' care items, (Foley catheter drainage bags, disposable inner cannulas for the trach tube, and Foley catheter irrigation kits), in a manner that helped prevent the development and transmission of disease. 10 NYCRR 415.19 (a)(1-3)

Based on record review and staff interview conducted during the extended survey, it was determined for 55 residents, (including Residents #7, 29, 30, 31, 32, and 33), with diabetes who required routine testing of their blood sugars, and 5 of 9 residents (Residents #6, 8, 9, 20 and 27), reviewed for oxygen/respiratory care, the facility failed to ensure Administrative staff administered the facility in a manner that enabled the facility to use its resources effectively and efficiently to attain or maintain the highest practicable physical well-being of each resident. Specifically, the Administrator failed to ensure the facility followed standard precautions during the performance of routine testing of blood sugars and failed to ensure glucometers were cleaned before and after use according to manufacturer's specifications. In addition, the Administrator failed to ensure staff were adequately trained on how to provide respiratory care and services to meet the residents needs. Refer to F328 and F441. This resulted in no actual harm that was Immediate Jeopardy to the health and safety of Residents #6, 8, 9, 20, 27, 31, 32, and 33. Findings include: The Administrator was interviewed at 1:30 PM on July 31, 2012 and stated he was not aware of any problem with the glucometers until the previous day when informed by the Director of Nursing (DON). He stated the DON was handling the problem and he was confident she would handle it appropriately. He stated he should have been made aware of the problem prior to yesterday. During a second interview with the Administrator on August 2, 2012 at 9:50 AM, he stated he was not aware of any problems with [MEDICAL CONDITION] or respiratory care. He attended morning management meetings every day and he would expect to be notified of issues at that meeting. In summary, the Administration failed to administer the facility in a manner that protected the health and safety of its residents as the facility failed to have a system in place to provide appropriate respiratory care to residents and to safely perform fingerstick blood glucose testing. --------------------------------------------------------------------------------------------- The Immediate Jeopardy situation was removed on August 6, 2012 based on the following corrective actions taken by the facility: - For Glucose Monitoring: policies and procedures were revised for proper blood sugar testing with glucometers and the disinfectant solution to be used. - For Respiratory Care: policies and procedures were revised regarding proper oxygen management procedures; most facility staff were trained on new/revised policy and procedures for the use of various respiratory care devices, the proper administration of oxygen, [MEDICAL CONDITION] care, the protocol for physician orders [REDACTED]. - The majority of facility staff were trained on revised and policies and procedures for glucometer use and proper respiratory care; a training plan was in place to ensure education for the rest of the staff; quality assurance monitoring was initiated by administrative staff to ensure compliance with these new/revised policies and procedures. 10NYCRR 415.26

Based on observation, record review, and staff interview conducted during the post-survey revisit, it was determined for 3 of 12 residents (Residents #5, 7, and 8) reviewed for infection control concerns and 1 resident outside of the sample (Resident #20), the facility did not establish and maintain and Infection Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. Specifically, for Residents #5, 7, 8, and 20, isolation precaution care needs were not documented by physicians as part of the residents' program of care; the comprehensive care plans did not document the type of isolation precautions needed; staff did not properly dispose of isolation gowns after use according to infection control standards of quality, and a licensed nurse was not designated to oversee the facility's infection control program. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. THIS WAS A REPEAT DEFICIENCY FROM THE EXTENDED SURVEY OF August 6, 2012 AND THE STANDARD SURVEY OF May 12, 2011. Findings include: 1) Resident #7, readmitted to the facility October 17, 2012, with [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS) assessment, dated September 23, 2012, documented the resident was cognitively intact. Review of the physician re-admission orders [REDACTED]. A physician Admission History and Physical note, dated October 18, 2012, documented the resident had a blood borne pathogen disease, and was on fingerstick blood sugar testing with a sliding scale for insulin coverage. The note did not document isolation precaution needs regarding the resident's blood borne pathogen, methicillin resistant staphylococcus aureus (MRSA). The resident's October 2012 medication administration record (MAR) documented the resident was was to have fingerstick blood sugar testing before meals and at bedtime with a sliding scale insulin coverage based on the results. The comprehensive care plan (CCP), dated October 23, 2012, documented the resident had a MRSA infection and and did not identify the site of the infection. The planned interventions included following precautions as ordered. The CCP had no documentation related to the resident's blood borne pathogen diagnosis. During an observation of the resident's fingerstick blood sugar testing on October 23, 2012 at 11:05 AM, there was an isolation precaution sign by the entrance to the resident's room. The licensed practical nurse (LPN) wore an isolation gown and gloves when she entered the resident's room. The LPN made 2 unsuccessful attempts to obtain a blood sample for testing, then exited the room to obtain more supplies, without removing the isolation gown. The LPN came back into the resident's room to try to obtain a blood sample. After 3 attempts she exited the room removed her isolation gown and gloves then disposed of them in the medication cart trash can. During an interview on October 23, 2012 at 11:05 AM, the LPN stated the resident was on contact precautions for MRSA, could not state the source of the infection and did not state the resident had a blood borne infection. 2) Resident #8 had [DIAGNOSES REDACTED]. Physician orders, dated October 3, 2012, documented the resident was to have fingerstick blood sugar testing before meals and at bedtime, with an insulin sliding scale based on the results. There were no documented orders for isolation precautions. The Admission History and Physical, dated October 3, 2012, documented the resident was treated for [REDACTED]. There was no documentation the resident was on isolation precautions. The comprehensive care plan (CCP), dated October 23, 2012, documented the resident had impaired cognition. The CCP documented the resident had a resolved[DIAGNOSES REDACTED] infection, a methicillin resistant staphylococcus aureus (MRSA) infection and precautions were to be maintained as ordered. During an observation of the resident's fingerstick blood sugar testing on October 23, 2012 at 11:15 AM there was an isolation precaution sign by the entrance to the resident's room. The licensed practical nurse (LPN) wore an isolation gown and gloves when she entered the resident's room. The LPN obtained a blood sample for testing, exited the room, cleaned the glucometer with the Clorox wipes, and then removed her isolation gown/gloves. She disposed of the gown and gloves in the medication cart trash can. When asked during the observation on October 23, 2012 at 11:15 AM, the LPN stated the resident was on contact precautions for MRSA, and could not state the source of the MRSA infection. 3) Resident #20 had [DIAGNOSES REDACTED]. The physician orders, dated October 15, 2012, documented the resident had fingerstick blood sugar testing ordered before meals and at bedtime, with an insulin sliding scale based on the results. There were no documented orders for isolation precautions. The physician progress notes [REDACTED]. There was no documentation related to a need for isolation precautions. The comprehensive care plan (CCP), dated October 23, 2012, documented the resident had impaired cognition and fingerstick blood sugar testing per physician orders. The CCP documented the resident had [MEDICATION NAME] resistant [MEDICATION NAME] (VRE) and methicillin resistant staphylococcus aureus (MRSA) infections, and precautions should be maintained as ordered. The CCP did not document the source of these infections. During an observation of the resident's fingerstick blood sugar testing on October 23, 2012 at 11:25 AM, there was an isolation precaution sign by the entrance to the resident's room. The licensed practical nurse (LPN) wore an isolation gown and gloves when she entered the resident's room. The LPN obtained a blood sample from the resident, exited the room, removed her isolation gown and gloves disposing of them in the medication cart trash can. In an interview on October 23, 2012 at 11:25 AM, the LPN stated the resident was on contact precautions for VRE, could not state the source of the VRE infection and did not state the resident had an MRSA infection. When the registered nurse (RN) Manager was interviewed on October 23, 2012 at 3:15 PM, she stated staff should dispose of isolation gowns in the isolation trash can in the resident's bathroom. On October 23, 2012 at 3:40 PM, the Assistant Director of Nursing (ADON) stated in an interview, each RN Manager was responsible for the infection control program on their units and they could call her if they had questions. She stated staff should remove gowns and gloves before leaving isolation rooms and staff should be able to state the source of the residents' infection. On October 23, 2012 at 4:25 PM, the Administrator stated in an interview the ADON and Director of Nursing (DON) were sharing the role of overseeing the facility's infection control program at that time. In summary, the facility did not ensure: - isolation care needs were documented by physicians as part of the residents' programs of care; - residents' CCPs documented the type of isolation precautions needed; - staff disposed of isolation gowns using infection control standards of quality; and - a licensed nurse was designated to oversee the facility's infection control program. 10 NYCRR 415.19 (a)(1-3)

Based on observation, staff interview and record review conducted during the extended survey, it was determined for 5 of 9 residents (Residents #6, 8, 9, 20 and 27), reviewed for oxygen/respiratory concerns the facility failed to provide adequate respiratory care and services. Specifically for residents who required oxygen the facility: - failed to deliver oxygen at the liter flow and percentage ordered by the physician, Resident #8; - failed to apply a Passy Muir Valve (PMV) as ordered and train staff in its use, Resident #8; - failed to have oxygen order's specific to their needs, Residents #9, 20 and 27; - failed to maintain and monitor the concentration of oxygen delivered via a concentrator, Resident #27; - failed to ensure oxygen tanks contained oxygen, Resident #6; - failed to ensure a nasal cannula was applied properly, Resident #6, and - did not have documented physician orders for the type and size of [MEDICAL CONDITION] (trach) tubes, Residents #8 and 20. This resulted in no actual harm that was Immediate Jeopardy to resident health and safety for Residents # 6, 8, 9, 20, and 27 and Substandard Quality of Care. The Immediate Jeopardy situation was removed on [DATE], prior to the survey exit. Findings include: 1) Resident #8 had [DIAGNOSES REDACTED]. The comprehensive care plan (CCP) dated [DATE] documented the resident had altered cognition or thought processes. The CCP documented the resident: was unable to follow direction; was non-compliant; was agitated or anxious; had short and long term memory loss; had comprehension problems; had impaired decision making; hadcomprehension problems and poor judgement; had confusion and disorientation; was withdrawn or depressed with a [DIAGNOSES REDACTED]. a) Oxygen concerns The "Admission Assessment", signed by the registered nurse (RN), dated [DATE], documented the resident received 28%oxygen at 8 liters per minute (lpm) via [MEDICAL CONDITION]. The CCP dated [DATE], documented the resident had cognitive loss and did not document the degree of loss. The planned interventions included for staff to identify themselves, explain the purpose of their visit and all procedures, re-orient the resident as needed, review the activity calendar and invite the resident to daily activities. The CCP did not document the resident received oxygen. The registered dietitian's (RD's) progress note dated [DATE], documented the resident had a history of [REDACTED]. The physician's admission note dated [DATE] documented the resident had [MEDICAL CONDITIONS] and did not document the resident received oxygen. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact and had a feeding tube. The MDS recorded the resident had a trach, received oxygen and required suctioning. The physician's orders dated [DATE] documented the resident was to receive 8 lpm of oxygen via [MEDICAL CONDITION] at 28%. The Nurse Practitioner's (NP) progress note dated [DATE] documented he was concerned about the resident's risk for [MEDICAL CONDITION]. The NP did not document the resident's use of oxygen. Nursing notes dated [DATE] - 28, 2012 documented the resident received oxygen at 6 lpm on 10 occasions with no percentage documented. The Treatment Administration Record (TAR) documented the resident received oxygen at 6 lpm via [MEDICAL CONDITION], 3 times a day, from [DATE] - 30, 2012. There was no documented evidence the physician ordered a change in the resident's oxygen liter flow from 8 lpm to 6 lpm. The resident was observed on [DATE] at 1:45 PM and 3 PM. The oxygen percentage was set between 35% - 40% and the flow meter was set at 6 lpm. The resident was observed with the oxygen percentage set between 35% - 40%: - on [DATE], at 1:45 PM and 3 PM, and the flow meter was 6 lpm; - on [DATE] at 9:30 AM and the flow meter was 8 lpm; and - on [DATE] at 4:40 PM and the flow meter was 10 lpm. The Assistant Director of Nursing/Educator stated on [DATE] at 11:51 AM, that she had been employed at the facility for a few weeks and did not know what the previous educator had taught regarding oxygen administration. The previous educator was no longer employed at the facility. During an observation of the resident on [DATE] at 2:15 PM, the resident was receiving 6 lpm of oxygen at 40%. In an interview with LPN #3, at that time, he stated the resident's oxygen liter flow and percentage should be recorded in the TAR. The [DATE] TAR documented the resident was to receive oxygen at 6 lpm via the [MEDICAL CONDITION]. The percentage of oxygen was not recorded on the TAR. The resident's, undated, current CCP, printed on [DATE], did not document the resident received oxygen, or the liter flow and percent to administer. The RN unit manager stated during an interview on [DATE] at 3 PM, the physician's order should document the percentage of oxygen the resident received. The RN stated 6 lpm of oxygen was documented on the resident's TAR and the percentage of oxygen was not. She looked at the physician's orders and stated the orders did not specify the percentage of oxygen to administer to the resident. During an observation on [DATE] at 3:25 PM, the resident's oxygen was set at 10 lpm and 40%. The DON stated in an interview at that time the physician's order was for 28%. She stated the charge nurse noted orders and the night nurse checked them for accuracy. The DON stated staff should have been educated on oxygen delivery during orientation. She stated there were no staff competencies related to oxygen administration. The RN unit manager stated during an interview on [DATE] at 4:10 PM, the resident's oxygen set up was not clearly marked in increments below 35%. The resident was observed on [DATE] at 8:35 AM with the oxygen percentage set at 35% and the flow meter at 10 lpm. The resident's attending physician was interviewed on [DATE] at 9:25 AM and stated oxygen was a drug. He said giving too high a concentration of oxygen could affect the resident's breathing. The Medical Director stated in an interview on [DATE] at 10:45 AM he was not aware of any problems with oxygen administration. He said if there were problems they would be brought to the attention of the quality assurance committee. The Medical Director stated he expected there were policies and procedures in place regarding oxygen administration. On [DATE] at 11:54 AM, the RN unit manager stated there was no physician order for [REDACTED]. b) Passy Muir Valve The speech language pathologist (SLP) progress note dated [DATE], documented the resident tolerated 3 ounces of pudding thick juice while wearing the PMV (a device applied to [MEDICAL CONDITION] improve voice and swallowing) without overt signs and symptoms of aspiration. The SLP note dated [DATE] documented the resident consistently tolerated the PMV for up to 15 minutes at a time without a "significant" change in his oxygen level. The resident applied and removed the PMV independently; "however" he may "need some assistance to ensure the outside" of [MEDICAL CONDITION] clear of secretions. The recommendations included: - the resident was to wear" the PMV with supervision "ONLY" with "nursing or family who is comfortable in assisting the resident in removing the valve"; and - if the resident showed and signs or symptoms of distress, or if his breathing became difficult the valve was to be removed; Nursing notes dated [DATE] - [DATE] contained no documentation regarding the use of the PMV. The SLP's note dated [DATE] documented the resident had consistently tolerated trials of pudding thick liquids without signs or symptoms of aspiration. The note recorded the resident was to wear the PMV when eating and to begin pleasure feedings with 1:1 assistance from staff. The SLP documented to discontinue oral intake if the resident refused or was not tolerating the valve. The SLP's note dated [DATE] documented the resident was to wear the PMV during all meals. Oral food intake was to be discontinued if the resident refused, or was not tolerating the valve. The physician order dated [DATE] documented the resident was to use the PMV for all eating, with 1:1 supervision or assistance by staff or family. The physician order dated [DATE] documented the resident was to use the PMV for all eating, with 1:1 supervision or assistance by staff or family. The Nurse Practitioner's (NP's) progress note dated [DATE] did not document the use of the PMV. The physician's orders dated [DATE] documented the resident could consume "pleasure feedings" as tolerated, wearing the PMV. The physician's progress note dated [DATE], did not document the resident's use. The resident's consumption records, completed by the CNAs, dated [DATE] - 30, 2012 documented the resident consumed food by mouth on 18 occasions. The TAR (Treatment Administration Record) dated [DATE] - 30, 2012 documented the resident could have pleasure foods by mouth with the PMV in place and 1:1 supervision/assistance by staff or family. There were no signatures to verify if the resident used the PMV. The word information was written across the signature spaces. Nursing notes dated [DATE] - 31, 2012 contained no documentation regarding the use of the PMV. The resident's consumption records documented, from [DATE] - 31, 2012, the resident consumed food orally on 30 occasions. The SLP's note dated [DATE], documented the resident had not been wearing the PMV when eating by mouth. The SLP noted the resident was educated in the importance of increasing the time he wore the PMV. The SLP recommended using the PMV for all oral intake. On [DATE] at 9:30 AM the resident was observed with his breakfast tray in front of him. He was not wearing the PMV and there was no staff member him. The Assistant Director of Nursing/Educator stated on [DATE] at 11:51 AM that she had been employed at the facility for a few weeks and did not know what the previous educator had taught. The previous educator was no longer employed at the facility. The physician's progress note dated [DATE] did not address the use of the PMV. The [DATE], TAR documented only the resident's family member was to apply the PMV. The resident's undated current CCP printed [DATE], did not document the use of the PMV. On [DATE] at 9 AM the resident was observed with his breakfast tray in front of him. He was not wearing the PMV and no staff member was with him. During an interview with the RN unit manager on [DATE] at 8:35 AM she stated the resident was to use the PMV under direct supervision of the licensed practical nurse (LPN), the RN, or the resident's family member. RN #2 was interviewed on [DATE] at 9 AM, and she stated she did not know what a PMV was. LPN #3 was interviewed on [DATE] at 8:50 AM, and stated he "never heard" of a PMV. During an interview with the RN unit manager on [DATE] at 8:55 AM, she said she did not know if the resident consistently wore the PMV while eating. She re-approached the surveyor and stated the resident did not wear the PMV, as he refused to. The Assistant Director of Nursing/Educator stated during an interview on [DATE] at 9:15 AM, staff should monitor and document the use and removal of the resident's PMV. During an interview with the physician on [DATE] at 9:25 AM, and he stated he expected use of the resident's PMV to be monitored by an RN or an LPN. The resident was interviewed on [DATE] at 11:45 AM, and he stated he used the PMV. He stated he was not trained but his family member was. During an interview with the SLP on [DATE] at 11:24 AM, she stated she had educated staff, the resident and his family member regarding the use of the PMV. The SLP said there was no documentation regarding the education. She stated she was not aware nursing staff did not know how to use the PMV. c)[MEDICAL CONDITION] size and type The hospital discharge summary dated [DATE], documented the resident had a #8 Shiley non-fenestrated (type and size)[MEDICAL CONDITION]. The discharge documented "trach 28%-humidity 96%." The resident's hospital admission history and physical dated [DATE] documented the resident had a history of [REDACTED]. The admission note did not document the size or type of the resident's trach. The hospital "Discharge Summary" dated [DATE], documented the resident had [MEDICAL CONDITION]. The discharge summary instructed to [MEDICAL CONDITION] respiratory care "as before." The discharge summary did not include the size and type of the resident's trach. The resident's "Admission Assessment" dated [DATE] documented the resident had [MEDICAL CONDITION]. The type and size of [MEDICAL CONDITION] was not recorded. The Comprehensive Care Plan (CCP) dated [DATE], documented the resident had cognitive loss and did not document the resident had [MEDICAL CONDITION]. The physician's admission note dated [DATE] documented the resident had [MEDICAL CONDITION]. The type and size of the resident'[MEDICAL CONDITION] was not documented. Nursing notes dated [DATE] - [DATE], did not document the type and size of the resident'[MEDICAL CONDITION]. The Nurse Practitioner's (NP's) progress note dated [DATE] documented the resident had [MEDICAL CONDITION] and he was concerned about the resident's risk for [MEDICAL CONDITION]. The NP did not document the type and size of the resident'[MEDICAL CONDITION]. The physician's orders and progress note, dated [DATE] did not document the type and size of the resident'[MEDICAL CONDITION]. The resident's [DATE], and [DATE], TAR [MEDICAL CONDITION] was done every shift, and as needed. The TAR did not document the type and size of the resident'[MEDICAL CONDITION]. The physician's progress note dated [DATE] documented the resident had [MEDICAL CONDITION] to facilitate breathing. The size and type [MEDICAL CONDITION] was not addressed. The resident's undated current CCP printed [DATE], did not document the type and size of the resident'[MEDICAL CONDITION]. The resident was observed in his room on [DATE] at 2:15 PM. There was no [MEDICAL CONDITION] visible in the room. LPN #3, at that time, showed the surveyor a disposable inner cannula and stated that was the back up [MEDICAL CONDITION] The RN unit manager stated during an interview on [DATE] at 3 PM, and stated if the resident's [MEDICAL CONDITION] fell out, they would call 911, a nasal cannula would be used, and the resident's respiratory status would be observed. She stated each resident should have a back [MEDICAL CONDITION] available. The RN stated a class was provided a couple of years ago regarding [MEDICAL CONDITION]. The physician was interviewed on [DATE] at 12:55 AM. He stated staff would determine the type and size of the resident'[MEDICAL CONDITION] by looking at the hospital discharge summary or notes from the pulmonologist. He stated he did not know the type and size of [MEDICAL CONDITION] needed to be ordered by the physician. During an interview with the Medical Director on [DATE] at 1:10 PM, he stated staff could determine the type and size of the resident'[MEDICAL CONDITION] by looking at the operative report or hospital discharge report. He said the staff could look at [MEDICAL CONDITION] the resident had in place. The Medical Director said it was good practice to have the type and [MEDICAL CONDITION] in the physician's orders. The Director of Nursing (DON) was interviewed on [DATE] at 1:15 PM, and stated there should be a physician's order for the type and size [MEDICAL CONDITION] and she was not aware the resident did not have these orders in place. During an interview with LPN #8 on [DATE], at 11:50 AM, she stated she was responsible for the resident's care that day. She stated if the resident's [MEDICAL CONDITION] came out she would call the supervisor then go to the resident's room to check the size of [MEDICAL CONDITION]. In summary the facility: - failed to provide the resident with oxygen, at the flow rate and percentage ordered by the physician, to meet the resident's needs; - failed to ensure staff were trained and competent in applying the resident's oxygen and PMV; - failed to ensure the resident wore the PMV during oral intake as ordered; - did not have a physician's order for the type and [MEDICAL CONDITION] the resident used: and - did not have a [MEDICAL CONDITION] available. 2) Resident #27 was admitted to the facility with [DIAGNOSES REDACTED]. The hospital discharge summary dated [DATE] documented the resident was treated for [REDACTED]. The discharge summary recorded the resident was oxygen dependant. The nursing admission assessment documented the resident was readmitted to the facility after a hospitalization for aspiration pneumonia. The comprehensive care plan (CCP) dated [DATE] documented the resident was to receive oxygen as per the physician order. The [DATE] Resident's Plan of Care (care instructions), used by the certified nurses aides (CNA), did not document the resident used oxygen. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident was cognitively intact, required extensive assistance for activities of daily living (ADL), did not exhibit behaviors, and was not resistive to care. The MDS recorded the resident received oxygen therapy. The physician's orders dated [DATE] was documented the resident was to have oxygen "prn" (as needed) at 2 lpm "continuous." The orders included an oxygen saturation level (test of the percentage of oxygen in the blood) every shift and checking the placement of the resident's nasal cannula and ear protectors. The orders documented the resident was to receive, via a nebulizer: [MEDICATION NAME], 1 vial twice a day; [MEDICATION NAME], 3 milliliters twice a day; and [MEDICATION NAME], 1 vial every 3 hours as needed for shortness of breath. There was no documented clarification of the resident's oxygen order or parameters for the resident's oxygen saturation level. The nursing progress note dated [DATE] at 2:24 PM, documented the resident was lying in bed and stated he did not feel well. The resident had a moist cough, his respirations were labored, and he was using accessory muscles to breath. The resident's lung sounds were diminished with inspiratory and expiratory wheezes. The resident's vitals sign,were: temperature 100.7 F (Farenheit), pulse was 90 beats per minute, respirations 24 per minute, and blood pressure was ,[DATE] millimeters of mercury (mm/hg). The resident's oxygen saturation level was 90% on 3.5 liters of oxygen. The note recorded the resident's oxygen was changed from a nasal cannula to a mask, and a nebulizer treatment was given with little relief. The physician was notified and ordered an antibiotic (Z pack), [MEDICATION NAME] (a steroid) and a chest x-ray in the morning. The plan was to monitor the resident for changes. The resident was observed at 6 PM on [DATE]. He was lying in bed receiving oxygen via an oxygen concentrator. The oxygen mask was around his neck/chin it was not over his mouth and nose. The resident was observed with his oxygen mask in the same position at 6:40 PM. The licensed practical nurse's (LPN) note dated [DATE] at 11:14 PM documented the resident was alert, his oxygen saturation level was 90% on 3 liters of oxygen, and he was started on an antibiotic. The resident had congestion and a routine nebulizer was given with some effect. The resident refused supper and was resting in bed. The LPN recorded the plan was to monitor the resident. On [DATE] at 1 AM, the LPN's progress note documented the resident had increased congestion. His vital signs were: temperature 98.8 F; pulse 94 beats per minute; respirations 20 per minute; and blood pressure ,[DATE] mm/hg. There was no documentation of the resident's oxygen saturation level. There was no documented evidence the physician was notified of the resident's increased congestion and elevated blood pressure. A nursing progress note dated [DATE] documented the RN was called to the unit at 5:40 AM and found the resident unresponsive, with no heartbeat, pulse, blood pressure, or respiration. LPN #1 and the Assistant Director of Nursing (ADON) were interviewed on [DATE] at 9:15 AM. LPN #1 stated the resident expired last night. The ADON stated they did not know the sequence of events that led to the resident's death. The nurse practitioner's (NP) discharge summary dated [DATE] at 2:17 PM, documented the resident's death was caused by cardiopulmonary arrest, due to an upper respiratory tract infection, [MEDICAL CONDITION] exacerbation, all superimposed onto end stage [MEDICAL CONDITION]. The NP wrote this was all communicated to the resident before starting the antibiotic therapy, that he was at very high risk for [MEDICAL CONDITION]. The NP noted the resident was very non-compliant. The summary recorded the resident stated he did not want to go to the hospital, he wanted to be treated in the facility. The NP documented the resident agreed to antibiotic therapy, nebulizer treatments were being given and oxygen was being administered. The NP recorded the resident was stable at the time the orders were given however did succumb to his underlying, end stage, [MEDICAL CONDITION]. During an interview on [DATE] at 11:45 AM with the Director of Maintenance, he stated he cleaned the oxygen concentrators, including the air filters. He said he did not check the oxygen concentrators to ensure they were working properly. He said he did not know the current system in place for monitoring the oxygen concentrators. On [DATE] at 12:35 PM, the Director of Nursing (DON) was interviewed and stated in the past the nursing Supervisor tested all oxygen concentrators to ensure they were working correctly. The DON said currently the oxygen concentrators were not being tested . She said staff would know a concentrator was not working if there was a warning light or an alarm sounding. During this interview, the Director of Maintenance, using a meter, checked the level of oxygen delivered from the resident's concentrator. He stated the resident's concentrator was not supplying the correct amount of oxygen. There was no light to indicate malfunction or alarm sounding when the concentrator was checked. On [DATE] at 1:20 PM, LPN #7 stated in an interview, she monitored residents' oxygen concentrators by ensuring there was a light on and no alarms sounding. On [DATE] at 1:25 PM, CNA #5 stated in an interview, if she noticed an oxygen concentrator had an alarm sounding she would notify a nurse. During an interview on [DATE] at 6:30 PM with LPN #2, who worked from 3 PM to 11 PM on [DATE], he said the resident's condition was not good, he was receiving oxygen by mask and his oxygen saturation was 90%. The LPN said he had checked the resident's vital signs and was very surprised to learn the resident had later expired. He stated he did not document the resident's oxygen saturation level on the TAR but remembered it was 90%. When asked about the oxygen concentrator, he said a green light comes on and if there is a bubble in the humidifier it means oxygen is going through the water and hopefully into the tubing. He said the resident's oxygen flow rate was set at 3 liters and he did not change it. He stated the resident did not like to wear the oxygen mask. On [DATE] at 2:50 PM, the DON stated she disposed of the concentrator the resident had used as it was cracked and not working properly. In summary, the facility failed to ensure the resident was consistently provided with oxygen as ordered when they: - failed to monitor the oxygen concentrator to ensure it provided adequate oxygen; - failed to perform preventative maintenance on the oxygen concentrator; - failed to clarify the physician order for [REDACTED]. - failed to provide oxygen at the liter flow as ordered. 3) Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The [DATE] physician's orders documented the resident was to receive oxygen at 2 lpm (liters per minute) via a nasal cannula. The orders instructed to measure the resident's oxygen saturation levels (teat of the percentage of oxygen in the blood) every shift and as needed. The [DATE] Treatment Administration Record (TAR) documented: - the resident was to receive of oxygen at 2 lpm continuously via a nasal cannula and an oxygen saturation level was to be checked every shift; - the resident's oxygen was not signed as administered on 5 of 42 shifts; and - the resident's oxygen saturation level was not recorded as checked on 8 of 42 shifts. The [DATE] TAR documented: - the resident was to receive oxygen at 2 lpm continuously via a nasal cannula and an oxygen saturation level was to be checked every shift; - the resident's oxygen was not signed as administered on 8 of 90 shifts; and - the resident's oxygen saturation level was not documented as monitored on 7 of 90 shifts. The [DATE] Resident's Plan of Care (care instructions) did not document the resident used oxygen. The [DATE] Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition, did not exhibit behaviors, did not resist care and did not have shortness of breath (dyspnea) during the assessment period. The [DATE] TAR documented from [DATE] - 28, 2012: - the resident was to receive oxygen at 2 lpm continuously via a nasal cannula and an oxygen saturation level was to be checked every shift. The word "information" was written next to the oxygen order and there were no signatures verifying the oxygen was administered; and - the resident's oxygen saturation level was not signed as checked on 7 of 84 shifts. The resident was observed on [DATE] at 5:50 PM in the unit dining room with his nasal cannula in place, the oxygen tank was turned on and was empty. At that time, licensed practical nurse #2 (LPN) changed the resident's oxygen tank and set it at 3 lpm. At 6:10 PM, the LPN stated in an interview, he changed the oxygen tank because it was empty. There was no documentation on the TAR the resident's oxygen saturation level was checked on [DATE]. On [DATE] between 4:05 PM and 4:20 PM, the resident was heard yelling out from his room very loudly to staff. At 4:20 PM, LPN #6 was observed changing the resident's oxygen tank and after she left the room stated "Maybe that's why he's acting up." On [DATE] at 10:20 AM, the resident was observed sitting in the lounge area on the unit. His nasal cannula was in his lap and he asked the surveyor for his glasses. The surveyor told him he had his glasses on and he stated "no there's nothing in my nose right now." The resident continually called out for help and staff told him he had his glasses on. At 10:40 AM, the Assistant Director of Nursing (ADON) was observed sitting with the resident and his nasal cannula was in his nose. The physician's progress note dated [DATE] at 11 AM documented the resident was seen for a change in mental status and increased shortness of breath. The resident complained of feeling "uncomfortable all over" and his oxygen saturation level was 59% on 2 lpm of oxygen. The plan was to transfer the resident to the hospital. On [DATE] at 11:20 AM, the ADON stated in an interview, the resident had increased confusion, was anxious, was not feeling well and had low oxygen saturation levels. He was sent to the hospital. The Resident Transfer Form dated [DATE] at 11:30 AM documented the resident was sent to the hospital with low oxygen saturations and his oxygen flow rate was increased to 5 lpm. The [DATE] hospital history and physical documented the resident had low blood pressure likely related [MEDICAL CONDITION] (blood infection), hypoxemia (low oxygen levels), and confusion. On [DATE] at 1:20 PM, CNA #5 stated in an interview that the CNAs were not involved with oxygen administration. She stated they were not allowed to set-up oxygen or adjust flow rates. She stated she did not know how she would know if a resident's oxygen was set at the correct flow rate. She stated if a resident had an oxygen concentrator, she would know it was working correctly if the power light was on and no alarms were sounding. On [DATE] at 1:40 PM, LPN #6 stated she changed the resident's oxygen on [DATE] because his tank was empty. She stated she noticed it when she went to his room as he was yelling out and had behaviors. She did not know how long the oxygen tank was empty. On [DATE] at 6:30 PM, LPN #2 stated in an interview, he changed the resident's oxygen tank on [DATE] when it was "pretty much empty." He did not know how long it had been empty and stated it was the responsibility of all staff to monitor and ensure residents' oxygen tanks were not empty. He stated to his knowledge the resident's order was for oxygen at 2 lpm and he followed the order. He stated he did not recall if he checked the resident's oxygen saturation levels on [DATE]. On [DATE] at 1:05 PM, the ADON stated in an interview, she was familiar with the resident. She stated she saw him in the lounge on [DATE] and she thought he was more confused than usual. She stated he was brought back to his room where she checked his oxygen saturation level and it was low. The ADON said she started increasing his oxygen flow rate by 1 lpm and his saturation level started to come up. She stated she did not know what level she ultimately increased him to as the ambulance crew arrived and took over. She stated she was not aware the resident was observed with empty oxygen tanks twice during survey and a third time without his nasal cannula in his nose. In summary the facility: - failed to have a system in place to ensure the resident's oxygen tank consistently contained oxygen; and - failed to ensure the resident's nasal cannula was properly placed. --------------------------------------------------------------------------------------------- The Immediate Jeopardy situation was removed on [DATE] based on the following corrective actions taken by the facility. For Respiratory Care: - policies and procedures were revised regarding proper oxygen management procedures; - most facility staff were trained on new/revised policy and procedures for the use of various respiratory care devices, the proper administration of oxygen, [MEDICAL CONDITION] care, the protocol for physician orders clarification, and the maintenance procedure for the oxygen concentrators; - a training plan was in place to ensure education of the rest of the staff; and - quality assurance monitoring was initiated by administrative staff to ensure compliance with these new/revised policies and procedures. 10NYCRR415.12(k)(5)(4)

Based on record review and staff interview conducted during the extended survey, it was determined the facility failed to provide a quality assessment and assurance program (QA) that readily and effectively identified issues with the potential to cause serious harm to the health and safety of residents for 55 residents (including Residents #7, 29, 30, 31, 32, and 33) requiring routine blood sugar testing and for 5 of 9 residents (Residents #6, 8, 9, 20 and 27) reviewed for oxygen/respiratory care. Specifically, the QA committee failed to identify concerns with glucometer use and cleansing, failed to identify concerns with respiratory care and oxygen delivery and failed to implement corrective measures. Refer to F328 and F441. This resulted in no actual harm that was Immediate Jeopardy to the health and safety of Residents #6, 8, 9, 20, 27, 31, 32, and 33. The Immediate Jeopardy situation was removed on August 6, 2012, prior to the survey exit. Findings include: The Director of Nursing (DON) who was the head of the QA committee was interviewed on August 6, 2012 at 3 PM and stated prior to the survey she was not aware the facility was not properly cleansing glucometers before and after resident use. The DON stated she was not aware of concerns with respiratory care or oxygen delivery. She stated those topics were not currently under review by the QA committee. Refer to F328 for 5 of 9 residents (Residents #6, 8, 9, 20 and 27) reviewed for oxygen/respiratory care. Refer to F441 for details regarding 55 residents (including Residents #7, 29, 30, 31, 32, and 33) who required routine blood sugar testing. In summary, the facility failed to ensure the QA committee identified concerns and implemented corrective measures for glucometer use and proper infection control procedures and for respiratory care. This resulted in no actual harm. --------------------------------------------------------------------------------------------- The Immediate Jeopardy situation was removed on August 6, 2012 based on the following corrective actions taken by the facility: - For Glucose Monitoring: policies and procedures were revised for proper blood sugar testing with glucometers and the disinfectant solution to be used. - For Respiratory Care: policies and procedures were revised regarding proper oxygen management procedures; most facility staff were trained on new/revised policy and procedures for the use of various respiratory care devices, the proper administration of oxygen, [MEDICAL CONDITION] care, the protocol for physician orders [REDACTED]. - The majority of facility staff were trained on revised and policies and procedures for glucometer use and proper respiratory care; a training plan was in place to ensure education for the rest of the staff; quality assurance monitoring was initiated by administrative staff to ensure compliance with these new/revised policies and procedures. 10NYCRR 415.27(a-c)