Every finding on record at The Phoenix Rehabilitation and Nursing Center

Based on observation, record review, and interview conducted during the Recertification Survey from 09/16/2024 to 09/23/2024, the facility did not ensure infection prevention and control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, 1.) Certified Nursing Assistant #5 did not perform hand hygiene in between residents while assisting residents with hand hygiene prior to lunch being served. 2.) The facility did not have acceptable pathogen levels identified in the Water Management Plan for Legionella. 1.) The undated facility policy titled Dining documented the facility adheres to strict hand hygiene protocols to prevent the transmission of infections among residents, staff, visitors and other stakeholders. Hand hygiene procedure that reduces the risk of transmission of infection in the nursing home facility ensuring the safety and health of all residents and staff members. Hand hygiene must be performed before and after touching a resident, and before handling food and feeding a resident. During dining observation on the 7th floor on 09/19/2024 from 12:55 PM to 1:08 PM, Certified Nursing Assistant #5 was observed assisting residents in the dining room with hand hygiene prior to meals. Certified Nursing Assistant #5 assisted Resident #223 with hand hygiene and then assisted Resident #244 without performing hand hygiene and changing gloves. During an interview on 09/18/2024 at 02:29 PM, Certified Nursing Assistant # 5 stated they realized they did not clean their hands and changed their gloves in between residents. They stated they were supposed to perform hand hygiene after each helping each resident in cleaning their hands. During an interview on 09/18/2024 at 02:38PM, Licensed Practical Nurse #3 stated there is no reason for the staff not to perform hand hygiene the right way since they had received in-service and hand sanitizers are available. During an interview on 09/23/2024 at 12:37PM, the Infection Preventionist stated Certified Nursing Assistants must assist residents in cleaning their hands before meals using hand wipes. They stated that staff must perform hand hygiene as a safety precaution, so they do not transfer anything from one resident to another. During an interview on 09/23/2024 at 12:49 PM, the Director of Nursing stated that for infection control purposes, the staff should not use the same gloves and must wash their hands before they proceed to helping the next resident with hand hygiene. 415.19 (b)(4) 45344 2.) A review of the facility's Legionella Water Management Plan with a revision date of 04/10/2024 documented that the facility would maintain and monitor the water system for Legionella. A review of the facility's Water Management Program revealed that it was missing the range specifying acceptable pathogen levels. During an interview on 09/23/2024 at 01:30 PM, the Assistant Administrator stated they would ensure that the Water Management Plan includes the range of acceptable pathogen levels. 415.19(a)(1-3)

Based on observations, record review, and interviews conducted during the Recertification Survey from [DATE] to [DATE], the facility did not ensure that food was stored in accordance with professional standards for food service safety. Specifically, there were multiple expired enteral feeding observed in the kitchen dry storage room. This was evident during the Kitchen Task. The findings are: The facility policy titled Food Storage with a revision date of [DATE] documented that all stock must be rotated with each new order received. Old stock is always used first, first in - first out method. Routine checks on the storeroom will be conducted by the Food Service Director or designee to ensure that stock is rotating properly. An initial tour of the kitchen and emergency food storage area was conducted on [DATE] from 09:48 AM to 10:42 AM with the Food Service Director and Dietary Aide. During the observation, 3 boxes of 1 liter bottle enteral feedings, a total of 24 bottles, were found with a past due use by date. Two boxes of enteral feeding had a use by date of [DATE] and 1 box had a use by date of [DATE]. During an interview on [DATE] at 10:43 AM, the Dietary Aide stated they rotate the food items and that they put old food items in the front and new items behind the old items. During an interview on [DATE] at 01:25 PM, the Food Service Director stated they look for expired food products during daily rounds. They stated they noticed the expired enteral feedings and instructed the dietary aide to remove them, but it slipped the dietary aide's mind. 10 NYCRR 415.14(h)

Based on observation, record review, and interviews conducted during the Recertification Survey from 09/16/2024 and 09/23/2024, the facility did not ensure that a resident who needs respiratory care including tracheostomy care, was provided such care consistent with professional standards of practice. This was evident in 1 resident (Resident #193) reviewed for tracheostomy care out of 38 total sampled residents. Specifically, Resident #193's family member was observed performing tracheostomy care to the resident without training and staff supervision. The findings are: The facility policy titled Tracheostomy with a revision date of 10/2023 documented that the purpose of the policy was to guide tracheostomy care and cleaning of reusable tracheostomy cannulas. The policy documented that aseptic technique must be used during tracheostomy dressing changes and enhanced barrier precautions must be followed. The procedure guidelines documented that resident's skin must be assessed and resident must be assessed for respiratory distress during tracheostomy dressing change. The policy documented that in cleaning the removable inner cannula, the supplies must be set-up in a sterile field. On 09/18/2024 at 09:49 AM, Resident #193's family member was observed performing tracheostomy care to the resident in the room without supervision or observation by any licensed staff. The family member used regular gloves to remove Resident #193's dirty tracheostomy collar, dirty dressing, tracheostomy mask, and inner cannula. The family member washed the dirty tracheostomy items in the sink inside Resident #193's room and placed them back on the resident's tracheostomy site without changing their gloves. Using the same gloves, the family member applied a new gauze on the tracheostomy site, replaced the inner cannula and the tracheostomy collar and mask. Resident #193 was admitted to the facility with diagnoses that included Coronary Artery Disease, Non-Alzheimer's Dementia, and Tracheostomy Status. The Quarterly Minimum Data Set, dated dated dated [DATE] documented the resident had severe impairment in cognition, is on suctioning, on oxygen therapy, on tracheostomy care, and was totally dependent on staff for all activities of daily living. A comprehensive care plan for tracheostomy related to impaired breathing mechanics was initiated on 02/01/2022. The facility interventions included tracheostomy / stoma care every shift and as needed and suction as necessary. A physician's order dated 06/07/2023 documented to apply gauze pads to neck topically every shift for tracheostomy care, to cleanse skin under trach collar with soap and water and apply gauze pads, and to change inner cannula every shift and as needed. A review of the Treatment Administration Record from 09/01/2024 - 09/17/2024 revealed that the physician's order on tracheostomy care was transcribed and were signed off by the licensed nurses. During an interview on 09/18/2024 at 09:50 AM, Resident #193's family member stated that they perform Resident #193's tracheostomy care every day because the staff were not doing it. The family member refused to answer when they were asked by the Surveyor if they had been trained by the licensed nurse in the facility on how to perform tracheostomy care. During an interview on 09/18/2024 at 02:24 PM, Certified Nursing Assistant #1 stated they had been assigned to Resident #193. They stated that Resident 193's family visits daily and that the family member performs the tracheostomy care for the Resident. During an interview on 09/18/2024 at 10:04 AM, Licensed Practical Nurse #1 stated that Resident #193's family member has been doing the Resident's tracheostomy care every day. They stated they do not know if the family member has been trained to perform tracheostomy care. During an interview on 09/18/2024 at 1:20 PM, Registered Nurse #1 stated that the unit nurse is responsible in performing tracheostomy care for Resident #193. They stated they had been seeing the family member visit daily but was not aware that they had been doing the tracheostomy care for the Resident. During an interview on 09/20/2024 at 09:26 AM, the Director of Nursing stated that the unit nurse is responsible in performing tracheostomy care. They stated they were not aware that Resident #193's family member had been doing the Resident's tracheostomy care. The Director of Nursing stated that if the family is interested in performing tracheostomy care, they need to be educated by the nurse on the proper way of doing it. 10 NYCRR 415.12(k)(5)(4)

Based on observations, record review, and interviews conducted during the Recertification and Complaint (NY00270919) survey from [DATE] to [DATE], the facility did not ensure safe food storage was practiced. This was evident during kitchen observation. Specifically, expired nutritional supplements and enteral feeds were observed in the kitchen's Dry Storage Room (DSR) and basement Overflow Storage Room (OSR). The findings are: The facility policy titled Food Storage last revised ,d+[DATE] documented all stock should be rotated with each new order received. Rotating stock is essential to assure the freshness and highest quality of all foods. Old stock should be used first (first in- first out method). Supervise the person designated to put stock away to make sure it is rotated properly. Food should be dated as it is placed on the shelves. As a final measure, to ensure that expired food, drinks, and nutritional supplies do not reach a resident area, the supply aide or designee will do a final check for the date before bringing the item to the units. On [DATE] at 08:31 AM, the DSR was observed, and 3 expired bottles of liquid nutritional supplements were observed on a shelf amidst boxes of the kitchen's active food supply: a 1.6-quart bottle of Glucerna with Carbsteady labeled with a use by date [DATE], a 1.58-quart bottle of Osmolite labeled with a use by date [DATE], and a 1.05 quart of Nepro-carb-steady labeled with a use by date [DATE]. On [DATE] at 08:42 AM, the basement OSR in the basement contained the following expired items: 24 cartons of Jevity 1.5 (8-ounce) supplements with use by date of [DATE], 6 bottles of Osmolite with expiration date on [DATE], 4 bottles (1.6 quart)of Glucerna with Carbsteady with expiration date [DATE], 6 bottles (1.6 quart) Glucerna Carbsteady 1.2 with expiration date of [DATE], 24 cartons of Two Cal HN with use by date of [DATE], and 6 bottles of 1-liter bottles of Nepro with Carbsteady 1.8 with expiration date of [DATE]. On [DATE] at 09:29 AM, an interview was conducted with Dietary Aide (DA) #2 who stated they are the backup storeroom person and when new items are delivered, the DA the new items in the back and pulls the older items forward. DA #2 checks the dates of food items every day, puts expired items in the trash, and informs the kitchen supervisor. DA #2 stated hey were receiving deliveries this morning and did not check the dates. On [DATE] at 10:05 AM, the Dietary Supervisor was interviewed and stated, most of the time, the storerooms are checked every morning and every other day for expired foods. The OSR was checked last Thursday, and the Dietary Supervisor did not get to complete checking the whole area for expired items. The Dietary Supervisor did not check the DSR for expired foods this morning. On [DATE] at 03:29 PM, the Food Service Director (FSD) was interviewed and stated they do rounds three times a week to check for spoiled and expired foods. On [DATE] at 10:55 AM, the Administrator was interviewed and stated that the food service clerk keeps a log and checks food items to ensure no expired food items are brought to the kitchen or resident floors. 415.14 (h)

Based on observation, record review, and interview conducted during the COVID-19 Focused Infection Control Survey completed on 11/23/2020, completed on 11/23/2020, the facility failed to establish and maintain an Infection Control Program to ensure the health and safety of residents to help prevent the transmission of COVID-19. Specifically, isolation gowns, eye protection, and gloves were not donned (put on) prior to entering the rooms of residents on quarantine related to COVID-19 exposure or new admission status. There were no signs posted to indicate the residents on quarantine were on contact and droplet precautions, and residents under quarantine were not directed to remain inside their rooms. This was evident for 3 out of 8 units observed for Infection Control (Units 2, 3 and 4). The findings are: The Centers for Disease Control and Prevention (CDC) guidance titled Preparing for COVID-19 in Nursing Homes, updated 6/25/2020, documents the facility should create a plan for managing new admissions and readmissions whose COVID-19 status is unknown. Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. HCP (Healthcare Personnel) should wear an N95 or higher-level respirator (or facemask if respirator not available), eye protection, gloves, and gowns when caring for the resident. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. Testing at the end of this period can be considered to increase certainty that the resident is not infected. Because of the higher risk of unrecognized infection among residents, universal use of all recommended (Personal Protective Equipment) PPE for the care of all residents on the affected unit (or facility-wide depending on the situation) is recommended when even a single case among residents or HCP is newly identified in the facility. The CDC guidance titled Responding to Coronavirus (COVID-19) in Nursing Homes, dated 4/30/20, documented that in the 48 hours prior to symptom onset of a newly identified [DIAGNOSES REDACTED]-CoV-2-infected Health Care Provider (HCP), the residents who were cared for by the HCP should be restricted to their room and be cared for using all recommended COVID-19 PPE (in accordance with CDC guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated November 4, 2020) until the HCP's COVID-19 test results are known. If the HCP is diagnosed with [REDACTED]. CDC guidance titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated November 4, 2020 provides: HCP who enter the room of a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator (or facemask if a respirator is not available), gown, gloves, and eye protection. The NYSDOH Health Advisory titled COVID-19 Cases in Nursing Homes (NH) and Adult Care Facilities dated 3/13/20 revised 7/10/20, documented that if there are confirmed cases of COVID-19 in a NH, all residents on affected units should be placed on droplet and contact precautions, regardless of the presence of symptoms and regardless of COVID-19 status. HCP and other direct care providers should wear gown, gloves, eye protection (goggles or a face shield), and N95 respirators (or equivalent) if the facility has a respiratory program with fit tested staff and N95s. Otherwise, HCP and other direct care providers should wear gown, gloves, eye protection, and facemasks. Facilities may implement extended use of eye protection and facemasks/N95s when moving from resident to resident (i.e. do not change between residents) unless other medical conditions which necessitate droplet precautions are present. However, gloves and gowns must be changed, and hand hygiene must be performed. The facility policy and procedure, titled, Coronavirus (COVID-19/Admission Guidelines), dated 08/19/20, documented the facility will dedicate specific units and staff to place residents who have an unknown or suspected COVID-19 status to ensure they are separate from residents who are COVID-19 negative. COVID-19 suspected residents will be isolated in a private room with the door closed. Staff caring for the resident will follow droplet and contact precaution protocols, and the resident will be monitored for 14 days for potential change or additional signs and symptoms. Residents will be placed on green, yellow and red zones depending on their COVID-19 status. The Yellow Zones are defined as follows: Yellow Zone A is used for new admissions who may have a negative COVID-19 test result on discharge from the hospital but may have potential exposure from the community. These residents are quarantined for 14 days. Staff may wear N95, preferred, or substitute a universal mask if unable to obtain an N95. Eye protection, gown, and gloves should be worn by direct care workers, as supply allows. Yellow Zone B is used for Symptomatic/Suspected cases. Residents are tested as soon as possible. While results are pending, the residents must be quarantined, placed in a room alone, and given a mask to wear. Staff may wear N95, preferred, or substitute a universal mask if unable to obtain an N95. Staff must use N95 for aerosol producing procedures. Eye protection, gown, and gloves should be worn by direct care workers. Staff should triage gowns for contact with bodily fluids. Yellow Zone C is used for residents placed on observation due to exposure to COVID-19 from a COVID-19 positive roommate. The resident will be placed by him/herself in a room for a 14-day quarantine and wear a mask during care. Staff should wear N95, preferred, or substitute a universal mask if unable to get N95, but staff must use N95 for aerosol producing procedures. Eye protection, gown, gloves should be worn by direct care workers as supply allows. 1) On 11/23/20, from 9:45 AM to 11:30 AM, the following was observed on Unit 2, a Yellow Zone A unit for new admissions. A Yellow Zone sign was posted by the nursing station directly opposite the elevator. The sign documented that a surgical mask should be worn at all times, and gloves and gowns should be worn as needed for care involving physical contact and exposure to bodily fluids. There were no contact/droplet precautions signs posted on unit. Staff (Registered Nurse (RN), Licensed Practical Nurse (LPN), Certified Nurse Aide (CNA), and Housekeeping staff) were entering the residents' rooms without wearing a gown, face shield, and gloves. They were wearing facemasks, and they donned (applied) gloves inside the room when performing contact care. On 11/23/20 at 1:51 PM, the [MEDICAL TREATMENT] technician (DT) was observed in room [ROOM NUMBER] sitting in a chair within 6 feet of a resident. The DT was wearing a surgical mask below her chin, exposing her nose and mouth. She was not wearing a gown, face shield, and gloves, and there was a gown draped over the chair. The DT was immediately interviewed and apologized for not wearing the mask appropriately and placed the mask above her nose. The DT further stated that she was aware that the facemask is required at all time, but gloves are only required when performing direct care and for contact with residents. On 11/23/20 at 10:30 AM, an interview was conducted with the Registered Nurse (RN #1) on Unit 2, who stated that the Yellow Zone indicates all residents are on a 14-day quarantine to be monitored for symptoms of COVID-19 because they are new admissions. She stated that the Yellow zone does not indicate isolation precautions. A surgical mask is always required. Gloves are required when providing direct patient care. Gowns are only required for contact precaution rooms, and no face shields are required because there are no symptomatic residents on the unit. When RN #1 was asked about the PPE recommendations in the Yellow Zone sign, she stated she has to clarify the gown usage requirements with the Infection Control Preventionist (ICP). On 11/23/2020 at 1:47 PM, an interview was conducted with the Licensed Practical Nurse (LPN # 1), who confirmed that Unit 2 is a Yellow Zone for new admissions on 14-day quarantine monitoring. Surgical masks are required in the hallway and when entering residents' rooms, and gloves are only required when providing direct patient care. Gowns and gloves are only required for residents on contact precautions. There are 2 rooms on contact isolation. LPN #1 stated all residents in the Yellow Zone are not on contact/droplet precautions. 2) A list of staff members out on quarantine documented the name of one CNA #3. The attached COVID-19 test results for the CNA, documented the CNA tested positive for COVID-19 on 11/16/20. The CNA worked on Unit 3. On 11/23/20, between 9:45 AM to 4:00 PM, Unit 3 was observed intermittently. There were no contact/droplet precautions signs posted on residents' doors, except for rooms with residents on contact precautions not related to COVID-19. Staff (RN, LPN, CNA) were observed entering the resident rooms wearing facemasks only. Gloves were donned prior to performing care. They were not wearing gowns and face shields. 3) A list of current COVID-19 positive residents documented Resident #1 was one of the two COVID-19 positive residents on the 3rd floor. The test results for Resident #1 documented the resident tested positive for COVID-19 on 11/17/20. The face sheets for Resident #1 documented the resident's previous room was on Unit 4 in room [ROOM NUMBER]. Unit 4 was observed on 11/23/20 between the hours of 9:45 AM to 11:30 AM. There was a Yellow Zone sign posted by the nursing station. There no signs for contact and droplet precautions posted by the resident rooms. The Staff (RN, LPN, CNA, Housekeeping staff) entered the resident rooms with facemasks and donned gloves when performing care. They were not wearing gowns and face shields. There were no contact/droplet precaution signs posted by the door of room [ROOM NUMBER] where the former roommate (Resident #3) of Resident #1 still resided. Resident #3 was observed in the hallway multiple times wearing a surgical mask below the chin, exposing the mouth and nose. Staff were present, and no one redirected the resident to pull up the mask or instructed the resident to return to their room. On 11/23/20 at 11:00 AM, Recreation Staff #1 was observed in room [ROOM NUMBER], talking to Resident #3. She was wearing a face mask. She was not wearing a gown, gloves, or face shield. On 11/23/20 at 1:42 PM, CNA #2 was observed in the hallway sitting next to a resident while feeding them. The CNA was wearing a surgical facemask with no gloves or face shield. On 11/23/20 at 1:45 PM, Recreation Staff #2 was observed in room [ROOM NUMBER]. She was wearing an N95 mask with no gown, face shield, or gloves. On 11/23/20 at 11:00 AM, Recreation Staff #1 was interviewed and stated that she was not aware Resident #3 was on contact/droplet precautions or that the previous roommate tested positive for COVID-19. She stated that full PPE is only required if the resident is on isolation. Signs for droplet/contact precautions are posted by the room door if a resident is on isolation. On 11/23/20 at 11:30 AM, an interview conducted with the Registered Nurse (RN #2) on Unit 4, who stated that the 4th floor is a yellow zone, to make staff aware that there is a possible exposure of COVID-19 on the unit. She also stated that the whole unit is not on quarantine, except those rooms who have contact and droplet precautions signage posted. RN #2 further stated that the unit was made a Yellow Zone because a resident tested positive on 11/17/20 in room [ROOM NUMBER]. She stated that they removed the sign on 11/19/20 when Resident #3 tested negative. She then stated that the resident only requires monitoring for 14 days in the absence of COVID-19 testing. On 11/23/20 at 11:45 AM, an interview was conducted with RN #3, the medication nurse on Unit 4. RN #3 stated that the entire unit was made Yellow Zone because a resident tested positive for COVID-19 on 11/17/20. She stated that full PPE is only required when entering rooms of residents with contact precautions signs on the door. On 11/23/20 at 12:37, an interview conducted with CNA #1 who was assigned to Resident #3 in room [ROOM NUMBER]. CNA #1 stated that she never saw any contact and droplet precaution signs when she returned to work on Friday. She was told Resident #3's roommate tested positive for COVID-19. The CNA stated that they were told by the supervisor that no gown or face shield was required when working with the residents, except for those with contact and droplet preauction signs on their doors. On 11/23/20 at 1:45 PM, Recreation Staff #2 was interviewed and stated that she was performing a recreational session with the resident residing in room [ROOM NUMBER]. She further stated the resident was not on isolation, so full PPE was not required. On 11/23/20 at 2:45 PM, an interview was conducted with the ICP. He stated new admissions and residents who attend outside appointments, such as [MEDICAL TREATMENT], were placed in a Yellow Zone. He stated that Yellow Zone indicates that the resident may have had contact with someone who is COVID-19 positive. All residents in the Yellow Zones are being treated as possible cases. He stated that the staff should use full PPE, meaning that they should be wearing facemask, gown, face shield, and gloves when performing care in the Yellow Zone. The ICP also stated that the roommate of a COVID-19 positive resident should be on contact and droplet precautions for 14 days and have a weekly testing before they can remove the resident from isolation. On 11/23/20 at 3:21 PM, an interview was conducted with the Director of Nursing (DON). She stated that Yellow Zone means the resident is being observed due to possible exposure to COVID-19 or having an unknown COVID-19 status. She stated that the staff are always required to use a face mask, and full PPE is not required unless residents are on contact and droplet precautions. If we have a resident who is symptomatic, then we placed the resident on contact and droplet precautions. She stated that Resident #3 in room [ROOM NUMBER] was supposed to be on contact and droplet precautions, but that was not done because the resident tested negative for COVID-19 on 11/19/20. She stated if the exposed resident tests negative, they can be removed from isolation without waiting for 14 days. The DON stated there is no need to keep residents on isolation for 14 days when the facility does weekly testing. On 11/23/20 at 3:42 PM, an interview was conducted with the Administrator who stated that the new admits are kept in the Yellow Zone because they are at risk for developing COVID-19 because they came from the community. Even the residents who went to [MEDICAL TREATMENT] are kept in the Yellow Zone because the facility does not know what they are exposed to when they go out. The staff do not use full PPE; full PPE for newly admitted residents because it is not required. He stated that they follow the CDC guidelines and monitor the infection rates in the community and the hospital. He stated the residents are not at risk, so there is no need to use full PPE. 415.19(a)(1),(b)(1);400.2

Based on observation and staff interviews during the recertification survey, the facility did not ensure that internal temperatures of cold foods were maintained at professional standards of food safety practice. This was observed during the Kitchen Observation Task. The findings are: On 10/25/19 beginning at 11:41 AM, a tray line observation was conducted. The temperatures of the hot and cold foods held for service on the serving line were checked by the Food Service Director (FSD) and the following temperatures were taken: Tuna sandwich 49 degrees F (Fahrenheit) Ham sandwich 46 degrees F On 10/28/19 at 11:27 AM, a second tray line observation was conducted. The following temperatures were taken: Turkey and cheese 53 degrees F Chopped Ham and cheese sandwich 57 degrees F Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety Food (TCS) is food that requires time/temperature control for safety to limit the growth of pathogens (i.e. bacterial or [MEDICAL CONDITION] organisms capable of causing a disease or toxin formation). PHS/TCS foods must be maintained at or below 41 degrees F, unless otherwise specified by law. On 10/28/19 at 11:37 AM, an interview was conducted with the Dietary Aide (DA) responsible for preparing and labeling the sandwiches. The DA stated it takes 3 hours to make the sandwiches. The DA stated she does not take the temperatures while the sandwiches are being made. The whole pan of sandwiches are made then is placed back into the fridge. The DA stated the sandwiches were made today from 6:00 AM to 9:30AM. Afterwards, the sandwiches were placed in the refrigerator without ice because the refrigerator is cold. On 10/28/19 at 11:57 AM, the FSD was interviewed. The FSD stated sandwiches are made for lunch around 10:30am. The pan with product (turkey, ham, tuna) must be submerged in ice. The FSD stated staff were informed to prepare 10 sandwiches at a time and put them into the refrigerators. The FSD stated at around 8/8:30am, he observed how sandwiches were made, 10 at a time, labeled and dated and placed back in the refrigerator. The FSD stated the sandwiches were removed from the refrigerator to the freezer after 11:10am. The FSD stated the sandwiches are tested daily right before 11:30am service, but he does not document the temperatures. The FSD stated the sandwiches should be stored in the 2 inch pan shingles in the refrigerator. 415.14(h)

Based on observations, record review and interview during the recertification survey, the facility did not ensure that the infection prevention and control program (IPCP) was maintained and reviewed annually. Specifically, staff members did not wear appropriate PPE supplies when entering the room of residents on contact precautions for [MEDICAL CONDITION] (MRSA) and [MEDICAL CONDITION], and the IPCP was not reviewed and/or revised since (YEAR). This was evident for 2 of 8 residents reviewed for Infection out of a total sample of 38 residents (Resident #167 and #424) and the Infection Control facility task review. The Findings are: 1) Resident #424 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/28/19 the following observations were seen during a medication pass and fingerstick observation: At 11:31 AM, the Licensed Practical Nurse (LPN #1) entered the resident's room and only donned a mask over her nose and mouth, with no usage of a gown. Two gloves were taken out of the glove box with her right hand and remained in her closed hand as she entered the resident's room to take the blood pressure (B/P). She checked the resident's identification band and applied the cuff to the residents left arm without the use of the gloves in her hand. After obtaining the B/P she proceeded to throw the glove in the trash bin and washed her hands. The nurse exited the room and prepared the medication (meds). She reentered the room wearing a mask and gloves carrying the meds in a cup and the resident's inhaler, which was placed on the table. The resident coughed and covered her mouth with her right hand. The resident then picked up the [MEDICATION NAME] inhaler using both hands, inhaled 1 puff, and placed the inhaler back on table. The resident was not encouraged or reminded to wash her hands after coughing into her hand. At 12:28 PM, LPN #1 donned a mask and gloves and proceeded to the resident's room to obtain fingerstick results. After much coaxing, the resident agreed to have the fingerstick done and proceeded to wipe her nose with a tissue that was placed on the table. The resident then extended her fingers to the nurse for testing. The nurse did not encourage the resident to wash her hands after wiping her nose and before doing the fingerstick test. The physician's (MD) order dated 10/23/19 documented orders for Infectious Disease (ID) consult, pt [MEDICAL CONDITION] in nares, contact/isolation. The comprehensive care plan dated 10/23/19 documented that the resident is alert and oriented with intact cognition. The CCP further documented the resident had a potential for complications related to the [DIAGNOSES REDACTED]. An ID consult dated 10/27/19 documented the resident was seen due to resident being on contact isolation [MEDICAL CONDITION] in nares. The resident had a positive nasal swab in the hospital and treated with Mupirocin ointment nasally for 7 days. The resident was placed on contact precautions at the hospital and in the facility after discharge. The resident was afebrile with no signs of active rhinitis/sinusitis. The ID impression [MEDICAL CONDITION] colonization of nose that was treated at the hospital. They recommended repeating the nasal swab from each nostril [MEDICAL CONDITION]. If the results are negative, the physician may discontinue contact precautions. A Mandatory form of the inservices LPN #1 attended upon hire dated 3/6/19 documented that she received inservice on infection control and blood bourne pathogens, [MEDICAL CONDITION], and use of PPE supplies. The Lesson plan for infection prevention & control/bloodborne pathogens, revised 10/23/17, documented: To prevent the spread of infection, proper handwashing is the most single most important means of preventing the spread of infection. Observing standard precautions of Personal Protective Equipment (gloves, mask, gowns) must be worn when providing care to all residents. Contact precautions is defined as meaning that direct and indirect contact with the resident is considered a potential source of infection; therefore, PPE must be worn for all interactions (gloves and gowns) On 10/28/19 at 02:30 PM, LPN #1 was interviewed. She stated she has been working at the facility for 7 months floating, on different units. LPN #1 stated RN #8, the educator, provides inservices on infection control. She stated she did not receive an infection inservice since working at the facility. She stated if the resident is on contact precaution in nares and she is just passing meds and not giving care, then she should wear gloves and mask. When she is done, she should remove the mask and wash hands. If the resident sneezed, she would change gloves and wash hands. She should wipe down equipment with the wipes with the blue tops. LPN #1 stated she should have worn gloves when she did the B/P. She was nervous. She stated she should have told the resident to wash her hands after wiping her nose. If a resident is on contact precautions [MEDICAL CONDITION] in nares, and she is responsible for wearing PPE and resident education. The resident is alert and oriented x 3 and looks like she is independent. The RN charge nurse on duty would inform her of any infections and precautions during morning report. LPN #1 stated she knew the resident had something in nares, but didn't know the specific organism which is why she looked it up. The unit charge nurse (RN #2) spoke to her regarding the precautions. If the resident has a urinary infection she should wear gowns because urine is liquid. She only administers meds when assigned to the unit, unless the Certified Nursing Assistant (CNA) is not on the unit and she has to assist a resident to the bathroom. LPN #1 stated she received universal precautions education from school. LPN #1 stated when the resident coughed, should have encouraged/instructed the resident to wash her hands and wiped the inhaler with bleach before leaving the room. After the resident wiped her nose with the tissue, she should have instructed her to wash her hands. She read the signs posted on door, but she was so nervous about not wearing the gown. On 10/29/19 at 10:19 AM, the charge nurse (RN#2) was interviewed. She is responsible for making sure nurses and CNAs provide appropriate care and notifying the physician of changes. Staff were given report in morning, and all staff are aware of what residents are on contact precaution for, what have to do, and what PPE they need to wear at all times when entering room. Contact precautions for nares means that staff must wear gloves, gown, and mask. The PPE supplies is on each side and signs are posted on residents' doors. RN #2 stated that she and the Supervisor do education and check when aides and nurses are doing care. She has not found any concerns. She stated she observed LPN #1 giving meds on a previous day. RN #2 stated she made sure everyone was educated on infection control. LPN #1 had an inservice on infection control and there are signed inservice papers for the training, which was done by herself and RN #8. For Resident #424, the nurse should wear a gown, gloves, and mask before going into the room. From the time the resident used the tissue, the nurse should have told the resident to wash her hands before proceeding. LPN #1 should not have left the room with the inhaler. She should have gotten a wipe and wiped the inhaler in the room before coming out of the room with it. The resident was admitted with this infection. The resident and family were educated on the infection, how it is spread and what to do when they visit. They were educated about hand washing, wearing a gown, gloves, and mask prior to entering the room, and how to remove the PPE when leaving. They were told to take gloves off first, then gown, then mask and discard them in the special bin in the room. They should then wash hands before they leave the room. The resident was educated on hand washing and wearing a mask before coming out of the room. All staff on unit monitor to make sure the resident is wearing mask and compliant. On 10/29/19 at 11:21 AM, the Infection Control Preventionist (RN #8) was interviewed. RN # 8 stated that there is a chance of soiling, therefore gown, mask, and gloves should be worn. An inservice for infection control has been done for all staff and departments within the building. All mandatories, including infection control & contact precaution, are done when hired. The nurse should have worn the PPE supplies provided each time she entered the room. Hand washing is constant. When the resident wiped her nose with the tissue, the nurse should have encouraged her to wash her hands before proceeding. The inhaler should have been wiped clean with the bleach blue top wipes. RN #8 stated that he goes on the unit at times during care and checks to make sure the signs are posted and that staff are following appropriate infection control practices. When concerns are found, they are reported to the DNS. On 10/30/19 at 12:01 PM, the Registered Nurse Supervisor (RN #5) was interviewed. RN #5 stated there are orders in the system for contact precautions and signs posted on doors. Upon admission or positive lab result, unit coordinators are notified and told to give report to all staff on the unit of the infection control precautions. The staff should wear gloves, gown, and mask upon entering the room, and the PPE should be removed before coming out with proper hand washing before & after. She has observed staff for handwashing. She last met with the unit coordinators about a month ago because residents were being admitted on contact precautions. RN #5 said they do rounds to make sure signs are hanging on doors and that the PPE rack/box are stocked on side A/B on each floor on a daily basis. She last received an inservice on infection control from the educator about 1 month ago regarding C auris, and when the Department of Health came in to test revisions on infection control and contact precautions. For residents on contact precautions staff, should don mask, glove and gown depending on type of infection. RN #5 stated they would not wear a gown if a resident [MEDICAL CONDITION] in nares. The staff could wear a mask and gloves without having to wear gown. The nurse should have encouraged resident to wash her hands after coughing into her hand and wiping her nose with a tissue. On 10/30/19 at 12:43 PM, the Director of Nursing (DNS) was interviewed. The DNS stated that she last met with staff, RN coordinators, and supervisors during morning meeting in regards to the antibiotic stewardship policy, orders and completeness of orders, transmission based precautions and signage. Contact/droplet and signs for usage were redistributed. For a resident [MEDICAL CONDITION] in the nares and contact precautions that came from hospital, staff will continue with contact precautions. Whenever they have direct contact or are going into the room, staff must have gown and glove and remove PPE and wash hands before exiting room. If resident is incontinent of urine, the CNA must wear gown/glove to give care. Gown and gloves are worn while caring for residents with respiratory infections, unless deemed as droplet precaution. They look at care needs depending on acuity and would increase staff for the unit if needed. The resident's unit is already staffed higher and no increase done of staffing. They have residents with C. auris all over the facility, and there was no need for increase in staff. The DNS stated she ensures staff are compliant by doing rounds, and RN #8 is her eyes on the unit. 2) The facility's policy and procedure titled [MEDICAL CONDITION] documented HCP Should still perform hand use guns and gloves when performing tasks that put them at risk of contaminating hands or clothing. These include wound treatments, linen change etc . Resident #167 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had intact cognition. On 10/25/19 at 12:57 PM, the Surveyor observed the Certified Nursing Assistant (CNA #1) going back and forth into the resident's room delivering the lunch tray, a clothing protector, and a cup of coffee without Personal Protective Equipment (PPE) on. physician's orders [REDACTED]. A laboratory report dated 10/16/19 documented results for [MEDICAL CONDITION] Surveillance testing. The report documented [MEDICAL CONDITION] DNA was detected. The facility's document Mandatory In-service Topics for CNA #1 documented Infection Control and Blood Bourne Pathogens, [MEDICAL CONDITION], and use of PPE was signed by CNA #1 on 07/26/2019. On 10/25/19 at 12:57 CNA #1 was interviewed immediately after the observation. CNA #1 stated when a resident is on contact precautions you don't go inside the room without a gown or mask. CNA #1 stated she did not see the sign the on door. CNA #1 stated she was supposed to put on a gown, gloves and mask, but she did not put on anything. CNA #1 stated she is floater for the week, and she was informed about contact precautions for another room. CNA #1 stated she made a mistake. On 10/29/19 at 12:48 PM, an interview was conducted with a Registered Nurse (RN #3) who stated if a resident is on contact precautions, orders are placed, the resident is placed on the 24 hour report to inform the other shifts, the precaution signs are placed on the resident's door, and the resident and/or family is made aware. RN #3 stated whoever is entering the resident's room has to don the PPE. RN # 3 stated she informs staff through huddles where they discuss residents who tested positive for C Auris. She handed out information sheets about C Auris and placed the stop sign instructing visitors to refer to the nurse before entering room. She posted a sign regarding how to don and remove the PPE on Resident's 523 door. RN #3 stated staff who are floaters are informed during the morning huddles daily. RN #3 stated she stresses the importance of donning/removing PPE, hand washing and tells the LPNs to monitor the CNAs as well. RN # 3 stated PPE should be applied when giving care and when providing meal trays to the resident. 3) The facility policy entitled Standard Precautions dated created 1/2017 and dated last revised 1/2017. The facility policy entitled Transmission-Based Precautions dated created 1/2016 and dated last revised 3/2017. The facility policy entitled [MEDICAL CONDITION] dated created 5/1/2017 and have no revised or revision date listed on policy. The facility policy entitled [MEDICAL CONDITION] (C. diff) [MEDICAL CONDITION] (C. Auris) dated created 9/2015 and dated last revised 7/2017. The facility Policy entitled Antibiotic Stewardship Program dated created 3/2017 and have no revised or reviewed date listed on policy. The facility policy entitled Influenza Vaccine - New York State Employees and Affiliates dated created 5/2008 and dated last revised 12/2017. The facility policy entitled Influenza and Pneumococcal Vaccinations dated created 5/2008 and dated last revised 12/2017 The Infection Prevention and Control Program Policies (IPCP) were not updated and reviewed annually. On 10/29/19 at 09:13 AM, an interview was conducted with the Direction of Nursing (DON) and Infection Control Preventionist for the facility. The DON stated the date on the policies did not change because there was nothing to change, and she was not aware that the policies needed to be reviewed or revised annually and as needed. The DON stated all the information on the policies meet the current regulations, and nothing had changed. The DON went to state she reviewed all the policies recently, although the policy it is not dated as such. The DON added all departments are educated on infection control. 415.19(b)(l)

Based on observation, interviews and record review conducted during the recertification survey, the facility did not ensure that a comprehensive person-centered care plan that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs was developed. Specifically, comprehensive care plans were not developed for a resident on Contact Isolation for [MEDICAL CONDITION]-resistant staphylococcus aureus (MRSA) in the respiratory tract. This was evident for 1 of 38 sampled residents (Resident #213). The findings is: The facility's policy and procedure titled Comprehensive Care Plan Policy and Procedure, revised 04/2010, documented each resident will have a Comprehensive Care Plan developed that includes the resident's problems, strengths and needs identified through the MDS assessment process and other assessment processes. Each care plan will have a specific measurable and realistic goals based upon the problem identified, and will include interventions developed by the CCP team to assist resident entertaining those goals. Resident #213 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had intact cognition. The Physician order [REDACTED]. Review of medical records revealed that there was no comprehensive person-centered care plan that addressed care for Contact Isolation [MEDICAL CONDITION] in the respiratory tract. On 10/30/19 at 01:42 PM, an interview was conducted with Registered Nurse (RN #2). RN #2 stated a care plan is developed upon admission, believes within the first 24 hours. RN # 2 stated she did not have the chance to add [MEDICAL CONDITION] to the care plan of Resident #213. RN #2 stated every morning staff are informed that Resident #213 is on contact precaution and personal protective equipment needs to be used. RN #2 also stated there is a sign on the resident's door for the isolation. RN #2 apologized for the error. 415.11(c)(1)

Based on record reviews and interviews during the Recertification and abbreviated survey, the facility did not ensure that a resident's representative was immediately notified when the resident developed severe pain in the right hip and had difficulty walking. This was evident for 1 of 1 residents reviewed for Notification of Change (Resident # 258) (Complaint ID # NY 028). The findings are: The Admission agreement revised 08/09/17 documented that upon a significant change in the resident's condition, the resident's or legal representative will be notified and the physician will be consulted. The facility's policy titled Acute Change of condition, revised in (MONTH) (YEAR), documented the licensed nurse should inform the resident's representative upon the resident's transfer to acute care facilities. The facility's policy does not document that the resident's representative must be contacted immediately upon the resident's change in condition. Resident #258 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had severely impaired cognition. The resident required limited assistance for walking in the room, walking in the corridor, and locomotion on and off the unit. The resident required extensive assistance for Activities of Daily Living (ADLs). On 10/29/19 at 12:22 PM, the resident's daughter was interviewed. She stated that the she was not notified of the resident's change of condition promptly. In the evening, on 06/6/19, she visited her mother and discovered that her mother was experiencing severe pain in the right hip. The resident's daughter stated that no one informed her on 6/5/19 that the resident had difficulty walking and pain in the hip. The resident's daughter stated that the resident was able to walk with limited assistance prior to developing pain to the right hip. She stated someone from the facility should have contacted her as soon they realized the resident was experiencing pain and had difficulty walking. A Nursing note dated 6/5/19 at 08:37 AM documented the resident was complaining of pain of the right leg and was unable to walk to the commode. A Nurse Practitioner note dated 6/5/19 at 02:40 PM documented the resident was seen due to pain to the right hip and having difficulty with walking. An X-ray of the right hip was ordered by the Primary Care Physician (PCP). A CNA statement dated 6/5/19 documented that the resident was noted to have difficulty walking to the commode. The Nurse coordinator on duty was informed. A Nursing note dated 6/6/19 at 07:49 AM documented the pain to right leg persisted. Close monitoring was continued. A Nursing progress note dated 6/6/19 at 12:27 PM documented the PCP evaluated the resident and made an order to transfer the resident to the emergency room for X-ray of the right hip due to severe pain. The resident's daughter was informed. An MD note 6/6/19 documented the resident was seen due to pain in the right lower extremity. The resident was transferred to the ER for imaging studies immediately. On 10/30/19 at 10:58 AM, the Reregistered Nurse was interviewed (RN #1). RN #1 stated that in the morning, on (MONTH) 5, 2019, the resident complained of right leg pain and was noted with difficulty walking. The Primary care physician was notified over the telephone. The PCP ordered an X-ray and Tylenol right away. The PCP evaluated the resident on the following day and discovered that the resident needed to be transferred to the hospital for immediate X-ray. The resident's daughter was then notified that the resident will be transferred to the hospital. RN #1 further stated that the policy of the facility is to notify the PCP of changes first. Based on the PCP evaluations and results of diagnostic tests, the staff would contact the resident's representative. On 10/30/19 at 11:41 AM, the PCP was interviewed. The PCP stated that she was notified of the resident's leg pain on 6/5/19. Tylenol and an X-ray were ordered. On 6/6/19 the resident was examined. The examination revealed that the resident was in severe pain and a fracture was suspected. The resident's daughter was informed that the resident would be transferred to the emergency room due to severe pain and for an X-ray of the right hip to rule out fracture. The PCP stated that she did not contact the resident's daughter on 6/5/19. The Primary Physician also stated that nursing staff are responsible for contacting the resident's family member promptly to inform them of any changes. On 10/30/19 at 12:15 PM, the Director of Nursing (DON) was interviewed. The DON stated that the resident's family should have been notified right away of the change in condition. The nursing staff are required to notify the family of any changes in condition right away. The Director of nursing further stated that the Primary Physician notified the resident's daughter on the day of transfer which was 6/6/19. 415.3(e)(2)(ii)(b)

Based on interviews and observations, during the Recertification survey, the facility did not ensure that residents received services that accommodated the resident's needs and preferences. Specifically, the call light was not kept within reach of the resident. This was evident for 1 of 4 residents reviewed for the Environment (Resident #523) out of 38 sampled residents. The finding is: The facility's policy and procedure titled Call Lights revised 04/2010 documented each resident has a functional call bell at the bedside within their reach to communicate need for assistance with the nursing staff. Position the call light on the resident's strong side. Resident #523 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/25/19 at 11:05 AM and 10/25/19 at 12:40 PM, the resident's call bell was observed tied to the bedrail and hanging down out of the resident's reach. On both occasions, Resident #523 asked the surveyor for a nurse. On 10/28/19 at 12:32 PM, 10/28/19 at 03:59 PM, and 10/29/19 at 12:04 PM, the call bell was observed tied to bedrail and hanging off bedrail not within reach of resident. On all three occasions Resident #523 asked the surveyor for a nurse. On 10/28/19 at 12:32 PM, Resident #523 was interviewed. The resident stated she has been paralyzed for [AGE] years. She cannot reach the call bell and cannot reposition/move herself. Resident #523 stated that staff infrequently comes to check in on her. On 10/29/19 at 12:10 PM, the Certified Nursing Assistant (CNA #2) was interviewed. She worked with Resident #523 the week of 10/15/19 and today 10/29/19. CNA #2 stated Resident #523 alerts staff when she needs assistance at times by the call bell, and most of the time, Resident #523 has used the call bell. CNA #2 stated the call bell is always within reach and was placed within reach of Resident #523 today. CNA #2 stated Resident #523 has a bad right hand, but the left hand is good. CNA #2 stated the tv remote, bed remote, and the call bell were placed on Resident #523's chest. CNA #2 stated the resident used the call bell twice today. CNA #2 and the surveyor walked to Resident #523 room and observed the call bell wrapped around the bedrail. CNA #2 stated she had just returned from her break and she did not know how the call bell got wrapped and was not in reach of Resident #523. CNA #2 stated Resident #523 cannot reposition herself without assistance. On 10/29/19 at 12:23 PM, Resident # 523 stated the call bell was not placed on her stomach, and she did not use the call bell today. On 10/29/19 at 12:31 PM, an interview was conducted with the Registered Nurse (RN #3). RN #3 supervises the 2 LPNS and 5 CNAS. RN # 3 stated she conducted rounds in the morning by going into each room to check on the status of the residents. During the rounds, she checks for call bells and remotes being within reach of the residents. RN # 3 stated when Resident #523 needs something she will use the call bell, and she may ring the call bell 3 to 4 times during the shift. RN # 3 stated the call bell was within reach for Resident # 523. RN # 3 stated she was not sure if it was used today. RN # 3 stated the call bell was clipped on the left side of the pillow and that Resident #523 is able to move her arm. When the surveyor showed RN #3 the resident's call bell, RN #3 stated the call bell should not be wrapped around the bedrail and unwrapped the call bell. On 10/29/19 at 02:20 PM, CNA #2 was re-interviewed. She stated Resident #523 cannot lift her left arm. She did not clip the call bell to the resident's pillow, and that was the reason why she placed the call bell on the resident's chest. CNA #2 stated the resident's call bell does not have a clip. She did not wrap the call bell around the bedrail this morning, but sometimes, if there is no clip attached to the call bell, the CNAs wrap the call bell chord around the bedrail, so it is not on the floor. 415.5 (e)(1)

Based on staff interviews and record review conducted during an abbreviated survey (NY 130), the facility did not ensure that the Office of the State Ombudsman was notified of the transfer/discharge of a resident. This was evident in 1 out of 4 residents sampled (Resident #1). Specifically, the facility initiated discharge for Resident #1 but did not notify the Office of the State Long Term Care(LTC) Ombudsman before or after Resident #1 was discharged from the facility. The Facility's Policy and Procedure titled, Discharge Planning-Notice of Transfer/Discharge, dated 7/25/2017, states that for all hospital and facility initiated discharges, a copy of the notice must be sent to the Ombudsman. Resident #1 was admitted to the facility on [DATE] from the hospital with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated 2/2/2018 documented that a Brief Interview for Mental Status (BIMS - used to determine attention, orientation and ability to recall information) score 15/15, associated with intact cognition, (00-07 severe impairment, 08-12 moderate impairment & 13-15 cognitively intact). A Notice of discharge date d 2/18/2018, signed by Resident #1 on 2/21/2018, documented that the facility initiated discharge proceeding to discharge Resident #1 to a shelter on 2/21/2018. In addition, the document states that Resident #1's needs could not be met in the facility due to loss of insurance coverage on 2/20/2018 and the denial of appeal by the insurance company. A Social Worker's (SW) Discharge Summary Note dated 2/21/2018 at 4:22pm documented that Resident #1 was discharged to a shelter and left the facility via ambulette service with his belongings. In addition, the SW documented that she explained to Resident #1 on multiple occasions that the shelter will assess him to find an appropriate shelter that can accommodate his medical needs. Resident #1's assigned SW was interviewed on 5/11/2018 at 11:55am. The SW responded to a question regarding discharge notification of Resident #1 to the Office of the State Long Term Care Ombudsman. She replied, what is that? She further stated that she did not notify or send a copy of the discharge notice to the Ombudsman and that she was not aware of the procedure to notify the Ombudsman. The Director of Social Service was interviewed on 5/11/2018 at 1:20pm and stated that the Ombudsman was not notified of Resident #1's discharge and that he was not aware he had to notify the Ombudsman. 415.3(e)(2)(ii)(d)?

Based on staff interviews and record review conducted during an abbreviated survey (NY 130), the facility did not ensure that appropriate information was communicated to the receiving institution. In addition, the facility did not ensure that the receiving institution was able to meet the resident's medical needs. This was evident in 1 out of 4 residents sampled (Resident #1). Specifically, Resident #1 was discharged from the facility to a shelter on 2/21/2018. Upon Resident #1's arrival to the shelter, he was deemed medically inappropriate for the shelter and was transferred to the hospital via Emergency Medical Services (EMS) on 2/21/2018. Resident #1 was admitted to the facility on [DATE] from hospital with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated 2/2/2018, documented a Brief Interview for Mental Status (BIMS - used to determine attention, orientation and ability to recall information) score 15/15, associated with intact cognition, (00-07 severe impairment, 08-12 moderate impairment & 13-15 cognitively intact). A Discharge Care Plan initiated on 1/27/2018 documented that the goal was to discharge Resident #1 to the community within 30 days. The interventions were to evaluate community resources, coordinate with the team regarding his progress and to refer him for home care services as needed. A SW's Progress Note dated 2/2/2018 documented that Resident #1 was scheduled to be discharged on [DATE] to the shelter where he previously resided. The shelter informed the SW that a bed was not available and that Resident #1 would be bused out to whatever shelter had an open bed. In addition, she was informed that Resident #1 had to be ambulant before he could be accepted back to the shelter. A SW's Progress Note dated 2/6/2018 at 4:25pm documented that the SW reached out to the Physical Therapist and that Resident #1 ambulated 50ft, took 5 steps with assistance and complained of back pain. Resident #1 had a rolling walker ordered and delivered to the facility. The note documented that the SW touched based with the shelter regarding Resident #1's upcoming discharge and was told that a discharge summary was needed. The SW informed Resident #1 of the discussion she had with his previous shelter. Resident #1 informed the SW that he did not want to return to his previous shelter and that he needed to be discharged to a medical shelter that can accommodate his medical needs. The SW explained to Resident #1 that the shelter he came from would help him find an appropriate shelter with an open bed. A SW's Progress Note dated 2/6/2018 documented that the SW consulted with the case manager and Resident #1's insurance extended his therapy to 2/9/2018. Discharge was on hold. A SW's Progress Note dated 2/13/2018 documented that a care plan meeting was held and Resident #1 was informed that his insurance last day of coverage was 2/20/2018. The resident stated that he is trying to make an effort in rehab and that he would appeal. A SW's Progress Note dated 2/18/2018 at 11:24am documented that Resident #1's appeal was denied and that the resident was notified that he was scheduled to be discharged on [DATE] and reported that the Director of Social Service (DSS) may help him discharge to Bellevue Shelter in Manhattan. The SW informed Resident #1 that Father Smith Shelter was already notified of the upcoming discharge. The resident was encouraged to speak with the DSS for assistance. A note with pharmacy information (HomeMeds) was put in the resident's chart and documented that the resident can call the pharmacy to notify them of his whereabouts. A Physical Therapy Discharge Summary dated 2/20/2018 documented that Resident #1 could ambulate 100ft with set-up assistance, was independent with bed mobility and moderately independent with transfers. The Discharge Status and Recommendations of the discharge summary documented community mobility not applicable at this time. A rolling walker was recommended. A Social Worker's Progress Note dated 2/21/2018 at 10:43am documented that Resident #1 was going to the Assessment Shelter for an assessment so that they could find him a shelter that accommodates his medical needs. It further stated that transportation was arranged. A Discharge Summary Note dated 2/21/2018 at 4:22pm documented that Resident #1 was discharged to the Bellevue Assessment Shelter with his belongings. Prescriptions will be submitted electronically by the doctor to the pharmacy, whose contact person was notified of resident's destination. It documented that it was explained to the resident multiple times that Bellevue will assess him in order to find an appropriate shelter accommodating his medical needs. A Facility Discharge Summary document dated 2/21/2018 documented that Resident #1 performs bed mobility and transfers with moderate independence and ambulates 15ft with rolling walker and moderate assistance. The resident is safe for discharge and rolling walker has been ordered. The Social Worker (SW) was interviewed on 5/11/2018 at 11:55am and stated that she did not send a discharge summary or had any communication with the receiving institution. The Director of Social Service was interviewed on 5/11/2018 at 1:20pm and stated that Resident #1 changed his mind at the last minute and requested to be discharge to the Bellevue Assessment Shelter. The Physician was interviewed on 5/24/2018 at 10:57am and sated that Resident #1 was discharged after completing Physical and Occupational therapy with improvement in functional status. He stated that wound was healed and the right leg swelling was less. Resident #1 was fully ambulant, could walk but also used a wheelchair. The Physical Therapist (PT) was interviewed on 6/6/2018 at 3:31pm and stated that Resident #1 was transferred with a rolling walker. Resident #1 could ambulate 100ft with the rolling walker and set-up assistance. The PT explained that set-up means that someone would have to put the walker in-front of the resident. A follow-up interview was conducted with the SW on 6/6/2018. She stated that Resident #1 was discharged with a rolling walker and that his prescriptions was electronically sent to the pharmacy. The resident did not receive the prescription because he was transferred from the receiving shelter to the hospital. She was unable to answer questions about the receiving shelter as she did not speak to anyone at the shelter. A follow-up interview was conducted with the DSS on 6/6/2018 at 4:15pm. He stated that Resident #1 has a right to go wherever he wants to go and that the resident wanted to go to the assessment shelter. He stated that he received a call from a SW in hospital on [DATE] noting that Resident #1 was in the hospital and that they needed the discharge summary and referral for the resident. He faxed the documents to the hospital. He added that the assessment shelter is supposed to find an appropriate shelter for the resident and that Resident #1 did not want to go back to his original shelter in the Bronx. The Program Director of Department of Homeless Shelter for Single Men was interviewed on 6/8/2018 at 2:26pm and stated that before a nursing home or hospital discharges a client to the shelter, an institutional referral form containing information on the client's medical condition must be submitted to the shelter. The shelter reviews the institutional form within 24 hours and notify the facility if a shelter is appropriate for the client. She stated that on 2/21/2018, a van brought Resident #1 and dropped hin off in the shelter. Someone called her to the front of the shelter to see the resident who was shaking very badly, could hardly stand and was complaining of severe pain. She asked why was the resident dropped off at the shelter and the driver responded, the nursing home said to drop him off and don't bring him back. The shelter did not receive a call or any paperwork from the facility. The shelter does not have medical staff onsite and 911 was called and Resident #1 was taken to the hospital the same day (2/21/2018). She further stated that the Department of Homeless Shelter for men does not have a medical shelter and that the resident was not appropriate for shelter. She added that Resident #1 informed her that he told the facility that the shelter was not appropriate for his condition and the SW told him that the shelter would deal with it. 415.3(e)(2)(ii)(d)

Based on observation and staff interview, the facility did not ensure that housekeeping and maintenance services were maintained to provide a sanitary interior. Specifically resident care equipment such as; Tube feeding pumps, poles and attached cords on multiple units were found to be soiled. This was evident for 12 of 19 feeding pumps observed in multiple rooms throughout the facility. The facility policy titled Feeding Pumps/Poles (Care of Equipment) dated 11/2017 documented maintenance of the pump/poles is the responsibility of the nurse, administering the feed. Spillage must be wiped up immediately. The findings are: On 1/24/18 at 12:03 PM, a feeding pump in room [ROOM NUMBER] was observed with a dried, beige substance on the console. There was no feeding in progress. On 1/25/18 at 4:17 PM, another observation was made of the feeding pump in room [ROOM NUMBER] which was found to have a dried beige colored substance on the console. Feeding was in progress. Observation of other feeding pumps revealed the following: On 01/26/18 at 12:12 PM, the feeding pump in room [ROOM NUMBER] B with a dried brown substance on the console and base of the monitor. On 01/26/18 at 12:15 PM, the feeding pump in room [ROOM NUMBER] A with a dried, brownish substance on the monitor, pole and electric cord. On 01/26/18 at 12:18 PM, the feeding pumps on Rooms 825 A and 827 B with a dried beige colored substance on the console. In room [ROOM NUMBER] A, there was a dried beige colored substance on the console and the pole. On 01/26/18 at 12:23 PM, the feeding pump in room [ROOM NUMBER] A with a beige colored substance on console. On 01/26/18 at 12:34 PM, the feeding pumps in Rooms 606 B, 608 A and 623 B with a dried beige colored substance on the console. In room [ROOM NUMBER] B the feeding pump, console, pole and cord were noted with a dried beige colored substance On 01/26/18 at 12:43 PM, the feeding pump in room [ROOM NUMBER] A with a dried beige colored substance on the console. On 01/26/18 at 05:24 PM, the feeding pump in room [ROOM NUMBER] with a dried beige colored substance on the console. There were no feedings in progress during the above observations. On 01/26/18 at 04:16 PM, in room [ROOM NUMBER] B the feeding was in progress, however the pump had not been cleaned. On 01/26/18 at 05:28 PM, in Rooms 623 B and 608 B feedings were in progress, however the pumps had not been cleaned On 01/26/18 at 05:31 PM, in Rooms 825 A and 813 A feedings were observed in progress, the pump had not been cleaned. On 01/26/18 at 05:31 PM, an interview was conducted with LPN #1 assigned to Unit 8 who stated that the nurse is responsible for making sure the feeding pumps are clean before hanging feedings and stated that the pumps were cleaned today. LPN inspected the feeding pumps with State Agent (SA) and stated that the pumps were not properly clean. On 01/26/18 at 05:42 PM, LPN #2 assigned to Unit 9 was interviewed and stated that she cleans the pumps sometimes and sometimes housekeeping staff would clean them every so often whenever asked. LPN #2 stated that she had checked the pump today before hanging the feed today and it was clean. LPN inspected the pump with SA and stated the pump was not clean and she would clean it now. On 01/26/18 at 05:49 PM, an interview was conducted with LPN #3 assigned to Unit 11 who stated that she had hung feeding earlier in the shift. LPN #3 stated that pumps are supposed to be checked and cleaned before the feeding is hung. LPN #3 also stated that she always cleans the pumps and had done so today. LPN inspected the pump with SA and stated that pump was not completely clean. On 01/26/18 at 05:54 PM, an interview was conducted with LPN # 4 assigned to Unit 6 who stated that part of her responsibility is to make sure the pump is clean. LPN #4 also stated that sometimes pumps are cleaned by the nurses and other times housekeeping staff cleans it. LPN#4 further stated that she did not clean the pumps today before hanging the feedings, and she does not look at the poles or electric cord when cleaning the pump. On 01/30/18 at 11:04 AM, Housekeeper (HSK) #1, who stated that he is not assigned to any unit and floats to several units, stated that feeding pumps are cleaned when they are messy. HSK #1 also stated that feeding tubes are cleaned on a regular basis and the poles are taken downstairs and cleaned if feeding gets on them. HSK #1 further stated that everything is cleaned when we clean the room. On 01/30/18 at 11:06 AM, an interview was conducted with HSK #2 assigned to Unit 6 who stated we clean the poles if they are messy, and if really messy we take them downstairs to clean. HSK #2 also stated that there is no schedule and he cleaned poles on the unit yesterday. On 01/30/18 at 11:24 AM, an interview was conducted with HSK #3, who floats on several units and was assigned to Unit 8 today, who stated that he only clean pumps if they are dirty. HSK #3 also stated that there was no schedule for cleaning of feeding pumps. On 01/30/18 at 11:34 AM, an interview was conducted with HSK #4, regularly assigned to Unit 9, who stated that feeding pumps are cleaned every day. HSK #4 also stated that cleaning of the pump includes the top, the pole and wire and the bottom. HSK #4 further stated that when he cleans the room he cleans everything in the room. On 01/30/18 at 11:41 AM, in room [ROOM NUMBER] A, the feeding pump console was observed with a dried beige colored substance. On 01/30/18 at 11:50 AM, the Operation Manager (OM) who is responsible for housekeeping staff was interviewed and stated that rooms are cleaned on a two cycle basis, meaning that 2 rooms are selected each day for terminal cleaning and pumps would be cleaned at that time. The OM also stated that if the pumps are heavily soiled they are switched out so they can be cleaned downstairs at night. The OM further stated that the nursing staff will let them know if pumps need to be cleaned but he had not received any notification regarding cleaning of feeding pumps until late last week. On 01/30/18 at 11:57 AM, an interview was conducted with the Assistant Director of Nursing (ADN) who stated that nursing staff are responsible for cleaning of the feeding pumps. The ADN also stated that it is expect if there is spillage it would be cleaned immediately, and the pump should always be cleaned when hanging and taking down feeds. The ADN further stated that floor RN's should check to ensure this is done, as should the supervisor when making rounds. 415.5(h)(2)

Based on record review and interviews, the facility did not ensure that a residents total program of care was reviewed thoroughly by the physician at each visit. Specifically, the hearing needs of the resident was not assessed or addressed. (Resident #324). This was evident for 1 of 2 resident reviewed for Communication and Sensory out of 35 Sampled residents. The findings are: The facility Policy and Procedure titled Physician Services dated 9/2017 documented the physician will (a) perform pertinent, timely medical assessments; (b) prescribe an appropriate medical regimen; provide adequate, timely information abut the resident's condition and medical needs. Resident is an [AGE] year old admitted to facility 10/20/16 from an acute hospital with [DIAGNOSES REDACTED]. The Annual Minimum Data Set 3.0 assessment dated [DATE] documented that the resident had intact cognition, required the limited assistance of one staff with Activities of Daily Living (ADL's), and had moderately impaired hearing with no hearing aid. On 01/24/18 at 11:00 AM, the resident was interviewed and observed to have difficulty hearing surveyor. The State Agent had to speak loudly and sit very close to the resident, speaking directly into resident's ears on both sides. The resident was not wearing a hearing aid. During the interview, the resident stated he is hard of hearing in both ears. He also stated that he had gotten his ears cleaned in the past but was not given any hearing aids. The resident further stated If I get one, (hearing aid) I would be glad. The Comprehensive Care Plan (CCP) Potential for Communication Deficit r/t (related to) hearing is moderately impaired was initiated on 11/8/16, and revised 1/22/17 and documented the following interventions: ENT (Ear, Nose, Throat) f/u (follow-up) PRN (as necessary), repeat, rephrase message PRN (as necessary), face resident during conversation, allow time to respond, adjust volume and tone of voice. The Nursing Admission/Readmission Screen dated 10/20/16 documented hearing loss (right), hearing loss (left). The Physician History and Physical dated 10/21/16 documented poor vision in rt (right) eye and did not document the status of the resident's hearing. The Physician Monthly/Admission Progress Notes dated 10/20/16 to 12/29/17 did not document the resident's hearing status. The Physician Monthly/Admission Progress Notes dated 1/25/18 documented pt noted with decrease hearing-right ear mostly-was referred to ENT, denies pain in the ear. The Nursing Progress Notes dated 2/23/17, 4/28/17, 5/18/17, 6/19/17, 8/16/17, 11/8/17 documented HOH (hard of hearing) right ear. The Multidisciplinary Rehab Screening Form dated 11/3/17 documented notably, pt is hard of hearing; utilize increased volume and speak closely to patient. Review of the record document that a consult for Ear, Nose, and Throat (ENT) was initiated for the resident on 1/25/18 after State Agency was on-site at the facility. There was no documented evidence that the physician reviewed the resident's total program of care, specifically, the resident's hearing status was not addressed during visits. On 01/26/18 at 11:24 AM, an interview was conducted with the Registered Nurse (RN) who stated that the resident stays on the unit most of the time and is hearing impaired. The RN stated that the resident does not have a hearing aid and has not been referred for evaluation of his hearing. The RN stated that she does discuss care of the resident with the physician however could not recall discuss the residents hearing status. The RN also stated that she could not recall whether there had been any discussion with the resident about the possible use of a hearing aid. On 01/26/18 at 11:52 AM the Assistant Director of Nursing (ADN) was interviewed. The ADN stated that the resident's hearing status should have been evaluated upon admission. The ADN also stated that the resident's hearing status may have been evaluated prior to admission so she would need to review the admission documents. The ADN further stated that physicians are required to examine the resident and review the resident's records, laboratory results, medications and treatments to determine if current plan of care is still appropriate. On 01/30/18 at 10:23 AM an interview was conducted with the Attending Physician via telephone. The physician stated that the resident does have some hearing deficit and was able to communicate with staff. The physician stated that the resident has a chronic hearing deficit, and during her examination of him she does not recall having to raise her voice; the resident may have been reading her lips. She further stated that neither the staff or the resident voiced any concerns about the resident's hearing in the past and only recently had staff communicated increased hearing deficit. The physician also stated that there was no particular reason that the resident had not been referred for evaluation of his hearing status. 415.15(b)(2)(iii)

Based on interview and record review, the facility did not ensure that a resident received proper treatment and assistive devices to maintain hearing ability. Specifically; Resident #242 who has impaired hearing was provided with an evaluation by a specialist to evaluate the resident for potential assistive device to aid in hearing. This was evident for 1 of 2 resident reviewed for Communication and Sensory out of 35 sampled residents. The findings are: Resident is an [AGE] year old admitted to facility 10/20/16 from an acute hospital with [DIAGNOSES REDACTED]. The Annual Minimum Data Set 3.0 assessment dated [DATE] documented that the resident had intact cognition, required the limited assistance of one staff with Activities of Daily Living (ADL's), and had moderately impaired hearing with no hearing aid. On 01/24/18 at 11:00 AM the resident was interviewed and observed to have difficulty hearing surveyor. The State Agent had to speak loudly and sit very close to the resident, speaking directly into resident's ears on both sides. The resident was not wearing a hearing aid. During the interview, the resident stated he is hard of hearing in both ears. He also stated that he had gotten his ears cleaned in the past but was not given any hearing aids. The resident further stated If I get one, (hearing aid) I would be glad. The Comprehensive Care Plan (CCP) Potential for Communication Deficit r/t (related to) hearing is moderately impaired was initiated on 11/8/16, and revised 1/22/17 and documented the following interventions: ENT (Ear, Nose, Throat) f/u (follow-up) PRN (as necessary), repeat, rephrase message PRN (as necessary), face resident during conversation, allow time to respond, adjust volume and tone of voice. The Nursing Admission/Readmission Screen dated 10/20/16 documented hearing loss (right), hearing loss (left). The Physician History and Physical dated 10/21/16 documented poor vision in rt (right) eye and did not document the status of the resident's hearing. The Physician Monthly/Admission Progress Notes dated 10/20/16 to 12/29/17 did not document the resident's hearing status. The Physician Monthly/Admission Progress Notes dated 1/25/18 documented pt noted with decrease hearing-right ear mostly-was referred to ENT, denies pain in the ear. The Nursing Progress Notes dated 2/23/17, 4/28/17, 5/18/17, 6/19/17, 8/16/17, 11/8/17 documented HOH (hard of hearing) right ear. The Multidisciplinary Rehab Screening Form dated 11/3/17 documented notably, pt is hard of hearing; utilize increased volume and speak closely to patient. Review of the record document that a consult for Ear, Nose, and Throat (ENT) was initiated for the resident on 1/25/18 after State Agency was on-site at the facility. There was no documented evidence that the resident received proper treatment and assistive devices to maintain hearing ability. On 01/26/18 at 10:37 AM, and interview was conducted with the assigned Certified Nursing Assistant (CNA) who stated that the resident is hard of hearing, and you have to go close when speaking or stand in front of him. The CNA also stated that the resident does not have a hearing aid and has not had one. The CNA further stated that the resident did not tell her he wanted a hearing aid. On 01/26/18 at 11:24 AM, an interview was conducted with the Registered Nurse (RN) who stated that the resident stays on the unit most of the time and is hearing impaired. The RN stated that the resident does not have a hearing aid and has not been referred for evaluation of his hearing. The RN stated that she does discuss care of the resident with the physician however could not recall discuss the resident's hearing status. The RN also stated that she could not recall whether there had been any discussion with the resident about the possible use of a hearing aid. On 01/26/18 at 11:43 AM, an interview was conducted with the RN Supervisor who stated that he is relatively new to the unit and not yet familiar with the resident. The RN Manager stated that care of a resident with hearing impairment should include use of a communication board if indicated and an Audiology consult should have been obtained. On 01/26/18 at 11:52 AM, the Assistant Director of Nursing (ADN) was interviewed and stated that the resident's hearing status should have been evaluated upon admission. The ADN also stated that the resident's hearing status may have been evaluated prior to admission so she would need to review the admission document. The ADN subsequently stated that the resident had not had a hearing evaluation, should have had an evaluation, and that this was apparently overlooked and would be corrected promptly. On 01/30/18 at 10:23 AM, an interview was conducted with the Attending Physician via telephone who stated that the resident does have some hearing deficit and was able to communicate with staff. The physician stated that the resident has a chronic hearing deficit and during her examination of him she does not recall having to raise her voice and the resident may have been reading her lips. She further stated that neither the staff or the resident voiced any concerns about the resident's hearing in the past and only recently had staff communicated increased hearing deficit. The physician also stated that there was no particular reason that the resident had not been referred for evaluation of his hearing status. 415.12(3)(b)

Based on interviews and record review, the facility did not ensure that necessary care and services were provided to enhance a resident's communication abilities. Specifically, a hearing impaired resident did not receive services or evaluation for use of a hearing aid. (Resident #324). This was evident for 1 of 2 residents reviewed for Communication and Sensory out of 35 Sampled residents. The findings are: Resident#324 is an [AGE] year old admitted to facility 10/20/16 from an acute hospital with [DIAGNOSES REDACTED]. The Annual Minimum Data Set 3.0 assessment dated [DATE] documented that the resident had intact cognition, required the limited assistance of one staff with Activities of Daily Living (ADL's), and had moderately impaired hearing with no hearing aid. On 01/24/18 at 11:00 AM the resident was interviewed. The resident was observed to have difficulty hearing surveyor. The SA (State Agency Surveyor) had to speak loudly and sit very close to the resident, speaking directly into resident's ears on both sides. The resident was not wearing a hearing aid. During the interview, the resident stated he is hard of hearing in both ears. He also stated that he had gotten his ears cleaned in the past but was not given any hearing aids. The resident further stated If I get one, (hearing aid) I would be glad. The Comprehensive Care Plan (CCP) Potential for Communication Deficit r/t (related to) hearing is moderately impaired was initiated on 11/8/16, and revised 1/22/17 and documented the following interventions: ENT (Ear, Nose, Throat) f/u (follow-up) PRN (as necessary), repeat, rephrase message PRN (as necessary), face resident during conversation, allow time to respond, adjust volume and tone of voice. The Nursing Admission/Readmission Screen dated 10/20/16 documented hearing loss (right), hearing loss (left). The Physician History and Physical dated 10/21/16 documented poor vision in rt (right) eye and did not document the status of the resident's hearing. The Physician Monthly/Admission Progress Notes dated 10/20/16 to 12/29/17 did not document the resident's hearing status. The Physician Monthly/Admission Progress Notes dated 1/25/18 documented pt noted with decrease hearing-right ear mostly-was referred to ENT, denies pain in the ear. The Nursing Progress Notes dated 2/23/17, 4/28/17, 5/18/17, 6/19/17, 8/16/17, 11/8/17 documented HOH (hard of hearing) right ear. The Multidisciplinary Rehab Screening Form dated 11/3/17 documented notably, pt is hard of hearing; utilize increased volume and speak closely to patient. Review of the record document that a consult for Ear, Nose, and Throat (ENT) was initiated for the resident on 1/25/18 after State Agency was on-site at the facility. There was no documented evidence that the resident received the necessary care and services to maintain or improve his ability to carry out the activities of daily living, specifically, in the area of communication (hearing). On 01/26/18 at 10:37 AM and interview was conducted with the assigned Certified Nursing Assistant (CNA). The CNA stated that the resident is hard of hearing, and you have to go close when speaking or stand in front of him. The CNA also stated that the resident does not have a hearing aid and has not had one. The CNA further stated that the resident did not tell her he wanted a hearing aid. On 01/26/18 at 11:24 AM an interview was conducted with the Registered Nurse (RN). The RN stated that the resident stays on the unit most of the time and is hearing impaired. The RN stated that the resident does not have a hearing aid and has not been referred for evaluation of his hearing. The RN stated that she does discuss care of the resident with the physician however could not recall discussing the resident's hearing status at any time. The RN also stated that she could not recall whether there had been any discussion with the resident about the possible use of a hearing aid. On 01/26/18 at 11:43 AM, an interview was conducted with the RN Supervisor who stated that he is relatively new to the unit and not yet familiar with the resident. The RN Manager stated that care of a resident with hearing impairment should include use of a communication board if indicated and an Audiology consult should have been obtained. On 01/26/18 at 11:52 AM, the Assistant Director of Nursing (ADN) was interviewed and stated that the resident's hearing status should have been evaluated upon admission. The ADN also stated that the resident's hearing status may have been evaluated prior to admission so she would need to review the admission document. The ADN subsequently stated that the resident had not had a hearing evaluation, should have had an evaluation, and that this was apparently overlooked and would be corrected promptly. On 01/30/18 at 10:23 AM, an interview was conducted with the Attending Physician via telephone who stated that the resident does have some hearing deficit and was able to communicate with staff. The physician stated that the resident has a chronic hearing deficit and during her examination of him she does not recall having to raise her voice and the resident may have been reading her lips. She further stated that neither the staff or the resident voiced any concerns about the resident's hearing in the past and only recently had staff communicated increased hearing deficit. The physician also stated that there was no particular reason that the resident had not been referred for evaluation of his hearing status. 415.12 (a)(2)

Based on record review and interviews, the facility did not ensure that the residents CCP (comprehensive care plan) are reviewed and revised in accordance with residents assessments; that cognitively intact residents were invited to participate in the development of their plan of care. Specifically: 1) Resident #324 was assessed with [REDACTED]. The resident's CCP was not reviewed to determine effectiveness of interventions and CCP was not revised to include evaluation for hearing aid device. 2) Resident #7 was assessed with [REDACTED]. This was evident for 2 out of 35 residents reviewed for adequate Care Planning and participation. The findings are: The facility Policy and Procedure titled Comprehensive Care Plan dated 11/2017 documented the CCP team will review the interventions for each problem identified in order to ensure applicable disciplines are participating in achieving the established goals. In addition, the policy documented resident/patient and designated representative will be notified of CCP (Comprehensive Care Plan) meeting. 1. Resident #324 is an [AGE] year old admitted to the facility on [DATE] from an acute hospital with [DIAGNOSES REDACTED]. The Annual Minimum Data Set 3.0 assessment dated [DATE] documented that the resident had intact cognition, required the limited assistance of one staff with Activities of Daily Living (ADL's), and had moderately impaired hearing with no hearing aid. On 01/24/18 at 11:00 AM the resident was interviewed. The resident was observed to have difficulty hearing SA (State Agency Surveyor). The SA had to speak loudly and sit very close to the resident, speaking directly into resident's ears on both sides. The resident was not wearing a hearing aid. During the interview, the resident stated he is hard of hearing in both ears. He also stated that he had gotten his ears cleaned in the past but was not given any hearing aids. The resident further stated If I get one, (hearing aid) I would be glad. The Comprehensive Care Plan (CCP) initiated on 11/8/16 identified the resident's Potential for Communication Deficit r/t (related to) hearing is moderately impaired and revised 1/22/17 and documented the following interventions: ENT (Ear, Nose, Throat) f/u (follow-up) PRN (as necessary), repeat, rephrase message PRN (as necessary), face resident during conversation, allow time to respond, adjust volume and tone of voice. The Nursing Admission/Readmission Screen dated 10/20/16 documented hearing loss (right), hearing loss (left). The Physician History and Physical dated 10/21/16 documented poor vision in rt (right) eye and did not document the status of the resident's hearing. The Physician Monthly/Admission Progress Notes dated 10/20/16 to 12/29/17 did not document the resident's hearing status. The Physician Monthly/Admission Progress Notes dated 1/25/18 documented pt noted with decrease hearing-right ear mostly-was referred to ENT, denies pain in the ear. The Nursing Progress Notes dated 2/23/17, 4/28/17, 5/18/17, 6/19/17, 8/16/17, 11/8/17 documented HOH (hard of hearing) right ear. The Multidisciplinary Rehab Screening Form dated 11/3/17 documented notably, pt is hard of hearing; utilize increased volume and speak closely to patient. Review of the record document that a consult for Ear, Nose, and Throat (ENT) was initiated for the resident on 1/25/18 after State Agency was on-site at the facility. There was no documented evidence that interventions on the resident's care plan had been reviewed and revised to reflect the resident's current status. On 01/26/18 at 10:37 AM, an interview was conducted with the assigned Certified Nursing Assistant (CNA) who stated that the resident is hard of hearing, and you have to go close when speaking to him or stand in front of him. The CNA also stated that the resident does not have a hearing aid and has not had one. The CNA further stated that the resident did not tell her he wanted a hearing aid. On 01/26/18 at 11:24 AM the Registered Nurse (RN) was interviewed and stated that care plans are done by all members of the team. The RN also stated that she is responsible for completing care plans that address the medical and nursing concerns of the resident. The RN further stated that she should have reviewed each intervention to determine if it was still pertinent or being carried out, and revised the care plan so that the interventions would be appropriate to the resident. She also stated that an ENT consult had not been done and this should have been addressed when the care plan was revised. On 01/30/18 at 11:57 AM an interview was conducted with the ADNS (Assistant Director of Nursing). The ADN who stated that on admission, once the assessments and evaluations are complete the care plan is generated by the RN on the floor. She also stated that the RN's are supposed to update and revise the care plan accordingly. She further stated that supervisors can also review and care plans should be reviewed during CCP meetings and interventions reviewed and addressed accordingly. 2. Resident #7 is an [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MD'S) 3.0 Quarterly assessment dated [DATE] documented that resident had intact cognition, was able to understand and be understood by others, and required assistance of one staff person with Activities of Daily Living (ADL's). The Annual MD'S assessment dated [DATE] documented resident with intact cognition. During a Resident Interview conducted on 01/23/18 at 03:06 PM, the resident stated that he had never been asked or attended any meeting relating to his care planning, and he would have gone if he had been informed. The Care Plan Note dated 5/9/17 documented that the resident's sister was informed of the meeting and stated she was not interested in attending because she and the resident do not speak, however she wants to remain as a contact person as she would like to know how he is doing. On 01/26/18 at 10:01 AM an interview was conducted with the Social Worker (SW). The SW stated residents are encouraged to attend Annual CCP meetings and are invited to quarterly meetings if there are changes in the resident's status. She also stated that the resident has a sister who we contact who is not involved in care. She further stated that the sister was contacted to attend the annual CCP meeting but did not want to participate. She also stated that the resident may not have available to attend the meeting as he was at lunch or involved in activities. On 01/26/18 10:16 AM the Director of Social Work (DSW) was interviewed. The DSW stated that when conducting the CCP meeting, the family or the resident is invited to attend. The DSW further stated that alert and cognitively intact residents usually would attend the annual or significant change meetings and if the resident is alert, the resident would be asked first, and then if the resident wants them to attend the family. The DSW also stated that this resident has always been alert and should have been invited to participate in care planning meetings. 415.11( c) (1)

Based on record review and interviews, the facility did not ensure that it promoted and facilitated resident self-determination through support of resident choice. Specifically, the Resident #324 was not scheduled showers according to the resident's stated preferences. This was evident for 1 of 2 resident reviewed for Choices out of 35 sampled residents. The findings are: The facility Policy and Procedure titled Bathing the Resident-Shower dated 10/9/09 did not document the procedure for reporting and documenting a resident's refusal to shower. Resident #324 was admitted to facility on 10/20/16 from an acute hospital with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 assessment dated [DATE] document intact cognition, limited 1 person assist with Activities of Daily Living (ADL's), and for daily preferences that it was somewhat important to choose between tub bath, shower, bed bath or sponge bath. On 01/24/18 at 11:38 AM, the resident was observed sitting on bed in room, neatly dressed and groomed. During an interview the resident stated he cannot recall when last a shower was received. The resident stated that on admission he was informed that showers would be twice weekly, and the resident's preference is to shower twice weekly, however that had not been occurring. The CNA Assignment Accountability Record (CNAAR) for December 2017 and January 2018 documented that the resident required assistance with bathing, and was to receive showers on Monday during the day shift and on Friday during the evening shift. There was no field in which to document that showers had been given or offered. There was no documented evidence that resident had received or been offered showers as scheduled. On 01/26/18 at 10:37 AM, the Certified Nursing Assistant (CNA) assigned to the resident was interviewed and stated that the resident is able to do things for himself and requires minimal assistance with care. The CNA stated that the assigned shower day is Monday, however any time the resident asks for a shower he is assisted. The CNA also stated that on occasion resident will refuse and when that happens the nurse is notified. The CNA stated that the resident received a shower sometime last week. On 01/26/18 at 11:24 AM, the Registered Nurse (RN) was interviewed and stated that shower schedules are checked for residents to ensure that showers are given as scheduled. The RN stated that if a resident refuses to shower the CNA's let me know and I would go talk to the patient and try to encourage them. If they continue to refuse, I document refusals in the medical record. The RN stated that she could recall being notified that the resident had refused showers at anytime. On 01/26/18 at 11:52 AM, an interview was conducted with the Assistant Director of Nursing (ADN) who stated that documentation on showers should be in the record and the CNA's are supposed to be signing on the accountability if showers are given. Upon reviewing the CNAAR, the ADN noted that there was nowhere on the document for CNA's to document whether or not the shower had been given. 415.5 (b)(1-3)

Based on observations, record reviews, and staff interviews, the facility did not ensure that the food was maintained at the proper temperature during the tray line service. This was evident for hot and cold foods on tray line observed during the Kitchen Tour. The findings are: On 9/21/16 at 12:15 PM the tray line was observed and temperatures of the hot and cold foods were recorded as follows: 1) Baked Chicken 126-130 Fahrenheit (F). The Baked Chicken was observed in a 2 (inch)shallow half pan and the pan was not covered to minimize heat loss. 2) Brown gravy 126 F. The gravy was in a deep half pan, held close to hot water in the well that registered 181 F which is sufficient to heat the pan if it was kept in contact with water and 3) Vanilla pudding temperature was 58 F and was kept on the counter on a tray. There was no mechanism to maintain the temperature. Orange juice was observed to be 44.4 F. On 9/21/16 at 12:25 PM, the Food Service Worker ( FSW) was interviewed and stated that she set up the foods on the tray line by filling water to half level in the well, then placed the pans in the well and added the chicken which was noted to be at 165 F when placed in the pans. The FSW further stated that she realized the shallow half pan was not touching the well's hot water which would have heated the pan. On 9/21/16 at 12:30 PM, the Assistant Food Service Director (FSD) was interviewed and stated that the pans with foods should be touching the hot water in the well on the tray line in order to maintain the hot temperature. On 9/21/16 at 12:35 PM, the Food Service Supervisor (FSS) who checked the tray line temperatures prior to service was interviewed and stated that she takes temperatures of the lunch food items and documents the temperatures on a form and only checked the main meat entree and not the Baked Chicken, which was an alternate item. The FSS further stated that she did not check the cold food temperatures. She further stated that deep pans need to be used to keep foods hot in the well on the tray line and that all hot foods are required to be over 140F to meet the standard. A review of the Service Line Checklist dated 9/21/16 revealed that the form was incomplete and not specific to food items as the form included categories for starch, meat and vegetables. There were 2 to 3 foods under meat, starch and vegetable on the tray line. There was no documentation of the temperatures of the Baked Chicken or cold foods. The undated facility policy titled Food Temperatures: Keeping Hot Foods Hot and Cold Foods Cold contained a log that documented temperatures to be maintained, specifically Baked Chicken 150-160, Gravies 175, and Cold Dessert at 40 or below. 415.14 (h)

Based on observation, record reviews, and staff interviews, the facility did not ensure that a comprehensive care plan was developed for a resident who developed a change in continence status. This was evident for 1 of 3 residents reviewed for Urinary Incontinence. (Resident #513). The findings are: Resident # 513 is a [AGE] year old admitted on [DATE] with [DIAGNOSES REDACTED]. On 9/22/16 at 1:15 PM observed the resident seated in a wheel chair in the hallway. Through a interpreter the resident stated that he was admitted to the facility with a cast due to [MEDICAL CONDITION] and needed assistance for transfers and toileting. The Nursing Admission Evaluation dated 5/19/16 documented the resident was continent of bladder and bowel. The Minimum Data Set (MDS) Admission assessment dated [DATE] documents the following: Intact cognition, no mood or behavior problems, extensive assist for activities of daily living including toileting and continent of bladder and bowel. The MDS further documented [DIAGNOSES REDACTED]. The Nursing Evaluation dated 8/10/16 documented the resident was incontinent of bladder and bowel. The ADL review nursing progress note dated 8/10/16 documented occasional incontinence with bladder and bowel. The Minimum Data Set Admission assessment dated [DATE] documents the following: severe cognitive impairment, no mood or behaviors problems, extensive assistance for toileting and occasional incontinence of bladder and bowel. The MDS further documented the resident was not on a toileting program. There was no documented evidence that a Comprehensive Care Plan (CCP) was developed after the resident's continence status changed from continent on the MDS dated [DATE], to occasionally incontinent on the MDS dated [DATE]. On 9/22/16 at 1:35 PM the Certified Nursing Assistant (CNA) was interviewed and stated that the resident is occasionally incontinent of urine, wears an incontinent brief and uses the urinal. On 9/23/16 at 9:45 AM the RN (Registered Nurse) Manager was interviewed and stated that she wrote the 8/10/16 progress note that documented that the resident was occasionally incontinent. The RN further stated that a comprehensive care plan had not been developed. 415.11 (c) (i)