Every finding on record at Union Plaza Care Center

Based on record review and interviews conducted during the Abbreviated (NY#00339083) and Recertification survey from 8/21/2024 to 8/28/2024, the facility did not ensure resident was free from accidents. This was evident in 1 (Resident #26) of 7 residents reviewed for Accident. Specifically, Resident #26 sustained 2 cm skin cut to the eyebrow during toileting when staff assisted without a second staff member. The findings are: The facility's policy titled Abuse, Neglect and Mistreatment reviewed 9/5/2023 documented every resident be free from verbal, sexual, physical, mental abuse, corporal punishment, misappropriation of property and involuntary seclusion. The facility's policy titled Fall Prevention Program reviewed 12/20/2023 documented to identify residents who are at fall risk through use of standardized criteria and to assist interdisciplinary committee in developing a care plan for preventions. Maximize resident's mobility and reduce the threat of injury from falls. Resident #26 was admitted to the facility with diagnosis of Alzheimer's Disease, Diabetes Mellitus, and Hypertension. The Minimum Data Set, dated dated dated [DATE] documented Resident #26 had severely impaired cognition and was dependent for toilet transfer/toileting and resident utilized wheelchair for mobility. The Comprehensive Care Plan for Falls/Injuries initiated 7/1/2019, revised 7/1/2024 documented but not limited to keep Resident #26 in a highly supervised area when awake, encourage, and place resident in common areas, increased observations due to poor safety awareness, non-compliance with transfer, and incontinence care every 2-4 hours. The Nursing Instruction for Certified Nurse Aid revised 5/6/2024 documented Resident #26 is dependent for toileting and incontinent care every 2-4 hours, as needed. The Nursing Note dated 6/21/2024 documented on 6/21/2024 at 2:57PM, Resident #26 in bathroom located inside of the dining room, noted with skin cut on left eyebrow, measured about 2 cm in length with minimal amount of bleeding and redness around left cheek observed. Certified Nurse Aid #13 was also noted next to the Resident #26. Resident is very confused and unable to tell what happened. Family notified and transferred resident to hospital for evaluation to rule out head injury. The Facility's Incident Report completed 6/25/2024 revealed that the Certified Nurse Aid #13 was in the dining room when Certified Nurse Aide #13 noticed Resident #26 attempting to self-propel their wheelchair and made gesture to use the bathroom. Certified Nurse Aid #13 safely transfer Resident #26 to the bathroom and on to the toilet seat. When Resident #26 was bending over to wipe themselves in seated position, losing balance falling forward. Certified Nurse Aid #13 was able to hold resident's trunk and preventing from falling. However, Resident #26's left eyebrow made contact with the edge of leg rest of wheelchair placed next to the toilet. This resulted in a superficial skin cut measuring 2 cm in length and 0.5 cm in depth with minimal amount of bleeding and redness around the area. No other injuries noted. The investigation concluded that there is no reasonable cause to believe that resident was abused, neglected. However, Certified Nurse Aid #13 who was not primary certified nurse aid for Resident #26, assisted toileting without checking resident's plan of care and instructions. Certified Nurse Aid #13 was provided with written warning and education to ensure reviewing plan of care and nursing instructions prior to providing resident care. On 8/27/2024 at 10:52 AM, Certified Nurse Aid #14 stated Resident #26 has been on their assignment for some time now and was assigned to them on 6/21/2024. Resident #26 has been incontinent and is total dependent for incontinent care. Resident #26 is on schedule for incontinent care every 2 to 4 hours, as needed. Certified Nurse Aid #14 recalled Resident #26 was provided incontinent care in the room with another staff's assistance prior to wheeling Resident #26 to the dining room around 2:15PM. Certified Nurse Aid #14 then left work early for a personal matter. On 8/27/2024 at 10:40 AM, Certified Nurse Aid #13 stated they were watching residents in the dining room on 6/21/2024 when Resident #26 gestured to go to the toilet and attempting to wheel to the bathroom located inside the dining room. Certified Nurse Aid #13 wanting to help, transferred resident safely to the bathroom and to the toilet seat. Resident #26 was observe falling forward when resident trying to wipe themselves, so Certified Nurse Aid #13 reacted quickly to prevent resident falling to the floor. However, Resident #26's left eyebrow made contact with the wheelchair leg rest, resulting in a superficial skin cut in the area. Certified Nurse Aid #13 stated they had taken care of Resident #26 previously but did not know Resident #26 required two persons for toileting. Certified Nurse Aid #13 stated that they should have asked the nurse supervisor about resident's care needs but did not do so. On 8/22/2024 at 10:24 AM, Registered Nurse Supervisor #7 stated Resident #26 is confused, forgetful at time and who has been up getting out of bed without assistance. Due to the functional declining, resident doesn't get up as often. Resident #26 had an incident on 6/21/2024 around 3PM when resident had a fall incident during toileting. Resident #26 was assisted in transferring and toileting by Certified Nurse Aid #13. Certified Nurse Aid #13 who was not the primary aid assisted the resident to toileting without checking the nursing instructions. Resident #26 is dependent for toileting at the time of incident on 6/21/2024; had schedule for incontinent care every 2 to 4 hours. Certified Nurse Aid #13 has provided care in the past but not always assigned to cover on this unit. Certified Nurse Aid #13 didn't check Resident #26's plan of care prior to assisting the resident for toileting. Resident #26 has been dependent for incontinent care every 2 hours, placed floor mats, lowered the bed and staff are making rounds every hour for resident's safety. On 8/28/2024 at 10:49 AM, Director of Nursing stated they were not aware of this incident, but Certified Nurse Aid #13 should have asked for Resident #26's care instruction prior to assisting the resident. Staff responded quickly to assist resident for toileting, but resident fell and hit their head on the wheelchair. The incident was not resulted from abuse, or neglect but it was an accident that occurred for this resident on 6/21/2024. 10 NYCRR 415.12(h)(1)

Based on observation, record review and interviews conducted during the Recertification survey from 8/21/2024 to 8/28/2024, the facility did not ensure that, to the extent practicable, the resident or resident representative participated in the development, review and revision of the comprehensive care plan. Specifically, Resident #54 and/or Designated Representative were not afforded the opportunity to participate in quarterly care plan meetings. This was evident in 1 out of 1 residents reviewed for Resident Assessment (Resident #54). The findings are: The facility's policy and procedure titled Care Plan reviewed 4/8/2024 documented: interdisciplinary team will meet to discuss and review the comprehensive care plan of each resident on admission, by 21 day, quarterly, annually for any significant change and as needed. Resident/family/responsible party will be invited to participate in the meeting. Resident #54 was admitted to the facility with diagnosis of Diabetes Mellitus, Hyperlipidemia and Non-Alzheimer's Dementia. The Quarterly Minimum Data Set, dated dated dated [DATE] documented resident has moderately impaired cognition. Resident and family participated in the assessment. On 8/28/2024 at 11:11 AM, Resident #54 stated they do not recall getting invited or participating in a meeting to discuss their treatments/care needs. The Comprehensive Care Plan meeting sign in sheet for Resident #54 contained no signatures from Resident #54 or their representative for the quarterly care plan meeting held on 3/8/2024. A review of Social Service notes revealed care plan meeting for significant change was held for Resident #54 on 3/8/2024. There is no documented evidence Resident #54 and/or their Designated Representative were invited to the quarterly care plan meeting on 3/8/2024. On 8/28/2024 at 11:12 AM, Registered Nurse Supervisor #5 was interviewed and stated, the care plan meeting is held by the interdisciplinary team for initial/annual, significant change or when a psychotropic med is initiated. Resident #54 and/or their Designated Representative are invited to these meetings. Registered Nurse Supervisor #5 stated the interdisciplinary team do not hold care plan meetings quarterly, but every department is responsible to review/update resident's care plans quarterly. Currently, there is no quarterly care plan meeting happening for residents and their designated representatives. On 8/27/2024 at 10:01 AM, the Director of Social Service was interviewed and stated there are no quarterly care plan meetings held by the interdisciplinary team, only when requested. Director of Social Service stated they have not been doing any meetings with the resident/designated representative for quarterly care plan review. It has not been the facility's practice to offer residents to participate every quarter. On 8/28/2024 at 11:07 AM, the Director of Nursing was interviewed and stated, the interdisciplinary team does not have quarterly meetings for care plan review. Resident/designated representative have not been invited to care plan meetings quarterly. However, care plans are reviewed and updated every quarter by the departments. 10 NYCRR 415.11(c)(2)(i-iii)

Based on observation, record review and staff interviews conducted during the recertification survey from 08/21/2024 to 08/28/2024, the facility did not ensure that a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion. This was evident for 1 (Resident #190) of 2 residents reviewed for Activities of Daily Living out of 38 sampled residents. Specifically, Resident #190 was not provided hand rolls for bilateral hand contractures in accordance with physician's orders. The findings are: The facility's policy and procedure titled Adaptive Devices/Positing Devices revised 12/20/2023 documents that it is the policy of Union Plaza Care Center to provide residents with adaptive/positioning devices as necessary. The device will be checked daily by the nurse aide. If any adaptive or positioning device is malfunctioning or missing, nursing will notify Occupational Therapy using a Nursing to Occupational Department notification form. Resident #190 was admitted to the facility with diagnoses that included Non-Alzheimer's Dementia, frontotemporal neurocognitive disorder, and malnutrition. The Quarterly Minimum Data Set, dated dated dated [DATE] documents that Resident #190 is rarely/never understood by others and is rarely/never able to understand others. Resident #190 has a short-term memory problem, and a long-term memory problem, and their cognitive skills for daily decision making is severely impaired. Resident #190 has upper extremity limitations on both sides and requires dependent level assistance for: eating, oral hygiene, toileting, showering/bathing, upper and lower body dressing, personal hygiene, bed mobility, and transfer. Physician's Treatment Order #289576 initiated 09/20/2023 and renewed on 08/27/2024 documents: Hand roll to both hands. Remove during ADL care to check skin integrity each shift. Care Plan titled Osteoporosis, risk for spontaneous fracture effective 02/10/2022 and updated 08/09/2024 documents an intervention of Hand rolls to both hands. Care Plan titled Self Care Deficit effective 02/10/2022 and updated 08/09/2024 documents an intervention of: Hand rolls to both hands. On 08/21/2024 at 12:55 PM, an interview was conducted with Resident #190's spouse who stated that the resident is supposed to use hand rolls in both hands due to hand contractures but the facility has failed to ensure the resident receives these on multiple occasions. Resident #190's spouse stated that they would alert the staff on the unit when this was observed and the device would be provided daily for a few weeks following the inquiry, but would then fail to be provided again. On 08/21/2024 at 12:55 PM, Resident #190 was observed in bed with both hands clenched in a closed fist position with no hand rolls in place. On 08/27/2024 at 11:16 AM, Resident #190 was observed in bed with both hands clenched in a closed fist position with no hand rolls in place. On 08/27/2024 at 11:17 AM, Registered Nurse Supervisor #1 was interviewed and stated that Resident #190 requires hand rolls in both hands at all times other than during care that involves cleaning the hands. Registered Nurse Supervisor #1 was observed entering Resident #190's room and looking in the resident's bed sheets for the devices. The devices were not located in the bed sheets. Registered Nurse Supervisor #1 left Resident #190's room and returned with two new hand rolls that were then inserted into the resident's hands. On 08/27/2024 at 12:39 PM, Certified Nursing Assistant #1 was interviewed and stated that Resident #190 requires total care assistance with all activities of daily living. Certified Nursing Assistant #1 stated that they gave Resident #190 a shower on 08/27/2024 at around 09:00 AM. Certified Nursing Assistant #1 stated that after giving Resident #190 a shower, they typically wait about 20 minutes to return the hand rolls to Resident #190's hands to give the skin a little rest. Certified Nursing Assistant #1 stated that they had planned to return the hand rolls to Resident #190's hands 20 minutes after the shower on 08/27/2024, but had to assist another resident and was unable to return to Resident #190's room by the time that the observation was made at 11:16 AM. On 08/27/2024 at 12:54 PM, Registered Nurse Supervisor #1 was interviewed and stated that Resident #190 was given a shower by Certified Nursing Assistant #1 earlier in the day on 08/27/2024. Registered Nurse Supervisor #1 stated that they believed that after Certified Nursing Assistant #1 provided Resident #190 with a shower, they may have forgotten to replace the hand devices. Registered Nurse Supervisor #1 stated that the contracture devices should have been replaced as soon as the resident's hands were dried after the shower and should have been returned to the resident's hands before the observation on 08/27/2024 at 11:16 AM. On 08/27/2024 at 3:10 PM, the Director of Nursing was interviewed and stated that Resident #190 requires the use of hand rolls in both hands at all times other than when staff are providing care that is related to the hands, such as showering or hand washing. The Director of Nursing stated that after that care is provided, the hand rolls should be returned to the hands as soon as they are dry, which would typically be within the span of a few minutes. The Director of Nursing stated that if Certified Nursing Assistant #1 showered Resident #190 around 09:00 AM on 08/27/2024, that the hand rolls should have been returned to the resident's hands before the observation on 08/27/2024 at 11:16 AM. On 08/28/2024 at 09:59 AM, the Director of Rehabilitation was interviewed and stated that Resident #190 has very limited mobility and uses hand rolls for contractures in both hands, which were recommended based on the rehabilitation department's evaluation of the resident. The Director of Rehabilitation stated that in rest position, Resident #190 clenches both fists and this can cause skin breakdown on the inner part of the hand due to the fingernails digging into the skin. The use of hand rolls prevents this. The Director of Rehabilitation also stated that hand rolls are used to ensure that the contractures do not become more severe, and to allow the resident to maintain their current functional ability while preventing decline. The Director of Rehabilitation stated that Resident #190 is supposed to use hand rolls in both hands at all times other than when receiving care that affects the hands. The Director of Rehabilitation stated that as soon as that care is completed, the hand rolls should be returned to the hands. 10 NYCRR 415.12(e)(2)

Based on observation, record review, and interviews conducted during the Abbreviated survey (NY00320628 and NY00346784) and Recertification survey from 8/21/24 to 8/28/24, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, and mistreatment, are reported immediately, but not later than 2 hours after the allegation is made. This was evident in 3 out of 38 residents sampled (Residents #22, #147, and #44). Specifically, on 07/21/2023 approximately 5 minutes apart, Resident #22 and Resident #147 (who are roommates) reported that they were rough handled and hit by Certified Nursing Assistant #1. The facility did not report the allegations of abuse within 2 hours to New York State Department of Health. 2) Resident #44 reported an allegation of abuse that was not reported within 2 hours to the New York State Department of Health. The Facility's Policy and Procedure on Resident Freedom from Abuse, Neglect, and Mistreatment revised 09/05/2023, documented that it is the policy of this facility to ensure that every resident be free from verbal, sexual, physical, and mental abuse. The policy further documented if, at any point during the investigation, a determination is made that there is reasonable cause, sufficient evidence for a prudent person to believe that abuse occurred, the Administrator/Designee will immediately report the allegations to the Department of Health. The Facility's Policy and Procedure on Accident/Incident Reporting Protocol revised 12/21/2023, documented that it is the policy of this facility to ensure an environment that is free from accidents, hazards, and provides supervision and assistive devices to each resident to prevent avoidable accidents. The policy further documented to report of an alleged violation involving abuse OR resulting in serious bodily injury immediately, but not later than two hours after the allegation is made, to the administrator of the facility and to other officials, including to the State survey and certification agency. 1) Resident #22 was admitted to the facility with diagnoses including Heart Failure, Respiratory Failure, and Diabetes Mellitus. The Minimum Data Set (an assessment tool), dated 06/24/2023, documented Resident #22 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information) score of 12 associated with moderately impaired cognition. A Comprehensive Care Plan for abuse dated 05/27/2023, documented interventions to provide supportive services and emotional reassurance as needed and encourage resident to promptly report any negative interactions with peers, staff , or family. Resident #147 was admitted to the facility with diagnoses including Coronary Artery Disease, Non-Alzheimer's Dementia, Heart failure, and Depression. The Minimum Data Set (an assessment tool), dated 06/05/2023, documented Resident #147 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information) score of 11 associated with moderately impaired cognition. A Comprehensive Care Plan for abuse dated 04/26/2023, documented interventions to provide supportive services and emotional reassurance as needed and encourage resident to vent/verbalize feelings. The facility's Investigation Summary dated 07/25/2023 documented that at approximately 7:20 am Resident #22 reported to Registered Nurse Supervisor that the night shift (11:00 pm-7:00 am shift) Certified Nursing Assistant was rough during care and hit them in their buttocks and face. On 07/21/2023 at approximately 7:25 am, Resident #147 (roommate of Resident #22) reported to Registered Nurse Supervisor that Certified Nursing Assistant #1 was rough during care and hit them in the face and shoulder. The investigation documented that Resident #22 and Resident #147 were assessed. There were no visible injuries noted. The investigation concluded that the allegation could not be verified because of insufficient information. During an interview on 08/23/2024 at 3:18 pm, Administrator stated any abuse allegation should be reported within two hours. Administrator stated they do not know why the incident was not reported within the time frame. During a telephone interview on 08/26/2024 at 1:45 pm, Registered Nurse Investigator stated they were under the impression that if there is bodily injury, an allegation of abuse should be reported to New York State Department of Health within 2 hours. Registered Nurse Investigator stated they reported the incident to New York State Department of Health within 24 hours of being aware. ) 44842 2) Resident #44 was admitted to the facility with diagnoses including Diabetes Mellitus, Cerebral Infarction, and Age-related cognitive decline. The Minimum Data Set (an assessment tool), dated 06/30/2024, documented Resident #44 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information) score of 13 associated with intact cognition. A Comprehensive Care Plan for abuse dated 06/23/2024, documented interventions to provide supportive services and emotional reassurance as needed and encourage resident to promptly report any negative interactions with peers, staff, or family. The facility's Accident/Incident Summary dated 07/08/2024 documented that Resident #44 reported on 06/29/2024 that two different black men on two different occasions touched their shoulders and breast. The investigative findings documented that Resident #44 was assessed and there were no visible injuries or emotional distress noted. The investigation concluded that the allegation could not be verified because there was not sufficient evidence to support that abuse occurred. During an interview on 08/28/2024 at 9:51 am, the Director of Nursing stated the abuse allegation was reported 2 hours late and it should have been reported within 2 hours. The Director of Nursing further stated they do not know why the incident was reported late since the Administrator conducted the investigation. During an interview on 08/30/2024 at 1:02 PM, the Administrator who is also the Investigator stated they reported the sexual abuse allegation late because they were on site in Resident #44's room spending time with Resident #44, their offspring, and the police officers. The Administrator stated next time they will notify the New York State Department of Health immediately with whatever information they have. The Administrator further stated staff has been inserviced that abuse allegations have to be reported within two hours. 10 NYCRR 415.4(b)

Based on record review and interviews conducted during the Recertification survey from 8/21/2024 to 8/28/2024, the facility did not ensure Minimum Data Set 3.0 (MDS) comprehensive and non-comprehensive assessments were submitted and transmitted into the Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system timely. This was evident in 1 (Resident #54) out of 1 resident reviewed for Resident Assessment. Specifically, the quarterly Minimum Data Set 3.0 assessment for Resident #54 was not submitted and transmitted within 14 calendar days from the assessment complete date. The findings are: The facility's policy and procedure titled MDS Assessment/Submission revised 12/21/2023 documented on a quarterly basis, a MDS assessment is to be completed by appropriate interdisciplinary clinicians in accordance with Federal and State regulations. Resident #54's quarterly Minimum Data Set 3.0 with assessment reference date of 6/2/2024 and completion date of 6/9/2024. The assessment was not submitted as of 8/26/2024. On 8/27/2024 at 11:03 AM, Minimum Data Set Coordinator was interviewed and stated, that the computer software automatically schedules the assessment in the system for every resident. The Minimum Data Set Coordinator stated department staff will complete their part of the assessment within the due date and upon completion. The Minimum Data Set Coordinator will submit it within 14 days. The Minimum Data Set Coordinator stated Resident #54's quarterly assessment was last submitted on 3/12/2024. Upon reviewing, the assessment did not populate in the scheduler for Resident #54. The Minimum Data Set Coordinator further stated the assessment should have been completed and submitted every three months, which is overdue now. On 8/28/2024 at 11:07 AM, Director of Nursing was interviewed and stated, the assessment is scheduled automatically for every resident and staff are responsible to complete their section in the assessment in a timely manner. The Minimum Data Set Coordinator ensures the assessment is completed and submitted in a timely manner. Director of Nursing further stated the system did not populate an assessment for Resident #54's scheduler; therefore, staff were not aware that assessment was not submitted until it was pointed out by the surveyor. 10 NYCRR 415.11

Based on interviews and record review conducted during the Recertification survey from 03/21/23 to 03/28/23, the facility did not ensure all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, to the New [NAME] State Department of Health (NYSDOH), if the events that cause the allegation involve abuse or result in serious bodily injury. This was evident for 1 (Resident #224) of 4 residents reviewed for Accidents out of 40 total sampled residents. Specifically, the facility did not report an incident where Resident #224 was found on the floor with rib fractures to NYS DOH. The findings are: The facility policy titled Accident/ Incident (A/I) Reporting Protocol last revised 11/22/22, documented that if an A/I occur, Injuries in serious bodily injury must be reported within 2 hours after forming the suspicion. All other incidents must be reported within 24 hours. Resident #224 had diagnoses of diabetes mellitus and Alzheimer's disease. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #224 had severely impaired cognition and required the extensive assistance of 1 person for activities of daily living. A Nursing Note dated 2/28/23 documented Resident #224 was found lying on the floor and was transferred to the hospital for cat scan and x-rays. A Nursing Note dated 03/01/23 documented Resident #224 was readmitted to the facility with diagnosis of fracture to the left 4th 5th and 7th ribs. The A/I Summary dated 03/03/23 documented Resident #224 could not provide an account of the occurrence. The A/I concluded Resident #224 attempted to get up without assistance and fell , sustaining fractures to the left ribs. The criteria was not met for reporting. There was no documented evidence the facility reported Resident #224's incident involving serious bodily injury, rib fractures, to the NYSDOH within 2 hours of occurrence. On 03/27/23 at 03:30 PM, the Registered Nurse (RN) Supervisor, RN #1, was interviewed and stated they saw Resident #224 on the floor on the side of their bed, and the resident was very confused and could not say what transpired. RN #1 informed the Medical Doctor (MD). On 03/28/23 at 09:25 AM, the Director of Nursing (DON) was interviewed and stated the interdisciplinary team, including the Risk Manager and the Assistant Administrator (AA), reviews the A/I Investigations and determines which incidents are reported to the NYSDOH. Resident #224 had an injury on 2/28/23 that was not reportable to the NYSDOH because they concluded that it was from an unwitnessed fall. On 03/28/23 at 09:46 AM, the AA was interviewed and stated falls resulting in fractures will be discussed by the team and if there is anything the team is not sure about, the incident will get reported to the NYSDOH. Resident's #224's rib fracture was not reported because the investigation ruled out abuse or care plan violation and it was not considered a reportable incident. 415.4(b)2

Based observations, interviews and record reviews during the COVID-19 Focus Infection Control Survey completed on 11/3/20, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of COVID-19, other communicable diseases and infections. Specifically, the facility did not ensure staff were checked for COVID-19 symptoms (e.g., fever, cough, difficulty breathing, or other respiratory symptoms), including temperature checks every 12 hours while on duty. The findings are: Executive Order 202.11, dated March 27, 2020, as codified at 9 NYCRR 8.202.11, documented the following: Any guidance issued by the New York State Department of Health related to prevention and infection control of COVID-19 shall be effective immediately and shall supersede any prior conflicting guidance issued by the New York State Department of Health and any guidance issued by any local board of health, any local department of health, or any other political subdivision of the State related to the same subject. The NYS DOH (New York State Department of Health) Commissioner of Health letter to Nursing Home (NH) Administrators, dated 4/29/20, documented As care pertains specifically to COVID-19, state and federal rules and regulations require nursing homes must adhere to appropriate safety measures including, but not limited to: Requiring all staff to be checked for COVID-19 symptoms (e.g., fever, cough, difficulty breathing, or other respiratory symptoms), including temperature checks upon the start of each shift and every 12 hours while on duty. The NYS DOH DAL (Dear Administrator Letter) NH-20-07, Required COVID-19 Testing for all Nursing Home and Adult Care Facility Personnel, dated 5/11/20, documented This Directive supplements the prior (DOH) Health Advisory concerning hospital discharges to nursing homes (NHs) . as well as the DAL sent on April 29, 2020. The directive documented With respect to COVID-19, state and federal rules and regulations require that NHs adhere to appropriate safety measures including, but not limited to: Requiring all staff to be checked for COVID-19 symptoms (e.g., fever, cough, difficulty breathing, or other respiratory symptoms), including temperature checks upon the start of each shift and every 12 hours while on duty. The facility Policy and Procedure titled Protocol for Screening of Employees dated 03/12/2020 documented: Employees are screened via temperature checks upon entrance. Any person with a fever will be sent home immediately. Department Heads are responsible for reminding their staff not to come to work if they are not well. A screening tool dated 9/22/2020 documented screening questions for signs and symptoms of COVID-19, contact with an infected person, and recent travel. During an observation on 11/02/2020 at 9:10am, in the lobby of the facility a staff member entered the lobby, sanitized their hands, and stepped in front of the temperature scanner for a temperature check. Once the scanner announced, normal temperature and displayed a digital reading of temperature, the staff member proceeded into the facility. During an observation on 11/02/2020 at 9:15am, in the lobby of the facility a staff member entered the lobby and greeted the security guard. The staff member proceeded to use the hand sanitizer and stepped in front of the temperature scanner for their temperature check. Once the scanner announced, normal temperature and displayed a digital reading of temperature, the staff member proceeded to the elevator. There was no documented evidence on the facility screening tool that staff were asked daily screening questions for signs and symptoms of COVID-19 and travel prior to working. Security Guard #1 was interviewed on 11/02/2020 at 3:38pm. She stated her duties are to instruct staff to check their temperature at the scanning machine before they can clock in. If a staff member complains of symptoms, she calls the RN on the staff member's floor to come down to the lobby. After hours, the RN Supervisor is called. A Licensed Practical Nurse (LPN #1) was interviewed on 11/02/2020 at 3:42pm. LPN #1 stated that when walking into the building, staff must be wearing a mask. All staff stop by a temperature check machine where the temperature is taken via a computerized scanner and sanitize their hands. Once this is done, staff proceed to their unit. If your temperature is above the range, you will be asked about symptoms. A Certified Nursing Assistant (CNA #1) was interviewed on 11/02/2020 at 3:51pm. CNA #1 stated that when walking into the building, staff must be wearing a mask and temperatures are taken using the temperature machine. If you are not wearing a mask, the machine will tell you to put one on. She stated that no other questions are asked daily, weekly, or monthly. She stated that there is no questionnaire that must be completed. She stated that following the temperature check, staff proceed to their unit. A Registered Nurse (RN #1) was interviewed on 11/02/2020 at 4:22pm. He explained the screening process. He stated that he checks his temperature with the machine upon entry to the facility. He stated, when he is tested weekly, he fills out a screening questionnaire form about symptoms and travel history. The Infection Control Preventionist (ICP) and Quality Assurance Policy Improvement (QAPI) Coordinator was interviewed on 11/03/2020 at 2:05pm. The ICP-QAPI stated that each Department Head assumes responsibility for their staff by monitoring them on a daily basis to see if they are showing any signs or symptoms of a lower respiratory infection, including fever, shortness of breath, cough, nasal congestion, runny nose, sore throat, nausea, vomiting or diarrhea. The ICP-QAPI was asked about using the screening tool with screening questions, and he stated that the tool was no longer used. The ICP-QAPI replied we trust our staff to notify management if they are symptomatic. 415.19(a)(1) 400.2

Based on record review and staff interview conducted during the recertification and abbreviated survey, the facility did not ensure needed care and services that are in accordance with the resident's preferences, goals for care and professional standards of practice were provided. Specifically, 1). a resident was administered a dose of insulin without a physician's orders [REDACTED]. This was evident for 2 of 9 residents reviewed for Unnecessary Medications out of a sample of 35 residents (Resident # 401-Complaint #NY 392 and Resident # 245) The findings are: 1. Resident #401 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medication Administration Record [REDACTED]. Accident/Incident Report dated 9/14/18 documented that resident was administered [MEDICATION NAME] 7 units at 9:15 PM. There was no documented evidence that the resident had a physician order [REDACTED]. ED Patient Discharge Instructions dated 9/15/2018 documented blood glucose was assessed via meter at 2:19 AM. The blood glucose level was 168 mg/dL. On 9/15/18 at 2:35 AM, a Basic Metabolic Panel (BMP) was done in the hospital, the blood glucose level was 179 mg/dl. Nursing progress notes dated 9/15/18 at 1PM documented a call was received from a Nurse Manager at the hospital indicating the resident is stable to return. There were no episodes of [DIAGNOSES REDACTED] and blood glucose via fingerstick was 168mg/dL. Attempts to contact the Licensed Practical Nurse via telephone for interview were unsuccessful. LPN is no longer employed at the facility. On 3/6/2020 at 11:38 AM, the resident's primary physician (MD #4) was interviewed. MD #4 stated the resident did not have an order for [REDACTED].#4 also stated the resident's daughter requested the resident be transferred to the hospital for evaluation. On 3/6/2020, at 11:50 AM, an interview was conducted with the RN Supervisor (RN #3). RN #3 stated when she reviewed the resident's record, there was no insulin order noted on the Medication Administration Record. 2. Resident # 245 was admitted to facility with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS dated [DATE] documented resident as cognitively intact. Physician order [REDACTED]. Medication Administration Record [REDACTED]. MAR dated March 2020 documented resident received the medication on the following dates at 9:30am: 3/1/2020, 3/2/2020, 3/3/2020, 3/4/2010 and 3/5/2020. Medication was administered to the resident on a daily basis and not every other day as ordered by the physician. On 03/06/20 at 01:34 PM, an interview was conducted via telephone with Licensed Practical Nurse (LPN #2). LPN #2 stated when administering medications, she normally follows the five rights of medication administration and according to the physician's orders [REDACTED]. LPN #2 also she read the order but did not check the scheduling of the order because the wording was correct. LPN #2 further stated she thought she did the correct thing when administering the medication. On 03/05/20 at 02:03 PM an interview was conducted with Licensed Practical Nurse (LPN #3) LPN #3 stated she is the regular medication nurse for the unit and administered this medication to the resident on 2/29/20, 3/1//20, 3/3/20, 3/4/20 and 3/5/20. LPN #3 stated she read the orders and I administered medications as they as it appeared in the MAR. LPN #3 also stated she is not allowed to enter orders but has to confirm orders placed before giving medication. LPN #3 further stated she saw the initial order last week, confirmed the order was for every other day but did not check the schedule of the order because she assumed it was correct as the wording in the order was correct. On 03/05/20 at 12:04 PM, an interview was conducted with Unit Manager (RN #2). RN #2 stated she is responsible for entering and reviewing all orders in the computer. RN #2 stated she received a telephone order from the Medical Doctor (MD) to decrease [MEDICATION NAME] from 20 mg daily to [MEDICATION NAME] 20 mg every other day which was confirmed by MD on 2/27/2020. She then changed the wording to [MEDICATION NAME] 20mg every other day but forgot to change the schedule of the order so that it would show in the MAR indicated [REDACTED]. RN #2 further stated when a new order is entered in the system, two other nurses also confirm that the order is correct. 415.12

Based on observations, record review, and staff interviews conducted during the re-certification survey, the facility did not ensure a resident received and consumed foods in the appropriate form as prescribed by a physician. Specifically, the CNA did not provide the resident the correct consistency diet as prescribed. This was evident for 1 of 3 residents reviewed for Nutrition out of an investigation sample size of 38 residents. (Resident#171) The finding is: The most recent Minimum (MDS) data set [DATE] documented resident has a [DIAGNOSES REDACTED]. On 3/2/2020 at 12:45 PM, resident was observed coughing in the dining room during lunch service. CNA #1 walked over to resident and held a cup of thin water to the resident while she drank. Tray ticket for the resident documented nectar thick liquids. physician's orders [REDACTED]. Speech Language Pathology (SLP) screen dated 2/10/20, SLP evaluation dated 1/6/20, and Nutrition assessment dated [DATE] all documented the resident is prescribed nectar thick fluids. On 3/05/2020 at 2:34 PM, an interview was conducted with LPN#1. LPN#1 stated the trays got switched. One resident gets thin liquids and the other gets nectar thick. Initially the trays were placed in front of the wrong residents. The cups of water were given out to the residents that receive thin liquids. Before the residents started eating, I switched the trays back to the appropriate resident, however I forgot to place the thin water back in front of the resident who receives thin liquids. Then when resident #171 started coughing, the CNA seeing the thin liquids in front of her gave it the resident. On 3/11/2020 at 2:51 PM, an interview was conducted with RN Supervisor #1. RN #1 stated We don't necessarily encourage staff to memorize diet orders since they should always be checking what is on the ticket. This is especially important since residents may be upgraded or downgraded in consistency. We don't have a list or any other documents with diet orders in the dining room, staff relies on the tray tickets. The nurses have access to the diet orders in Sigma which helps us stay up to date on diet changes. At meal times there is always a nurse present. Dispensing of water can be completed by either a CNA or a nurse. On 03/11/2020 at 2:24 PM, an interview was conducted with CNA #1 via telephone. CNA #1 stated when it is mealtime, I look at the tray ticket. If I see a patient with thickened water, I won't give them water and I will tell whoever is giving out the water not to give it the resident. CNA #1 stated she doesn't know why she had given the resident thin liquids because she always follows what is on the tray ticket. 415.14(e)

Based on observation and staff interview conducted during the Recertification survey, the facility did not ensure that an infection prevention and control program was established and maintained a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Specifically, oxygen tubing connected to resident from a Bi-pap machine was observed touching the floor and a resident's nasal cannula was found attached to a portable oxygen tank uncovered and touching the floor. This was evident in 1 of 3 residents reviewed for Infections out of sample size of 38 residents. (Resident # 304) The finding is: The undated policy titled Oxygen Therapy documented if oxygen is to be used for greater than 24 hours, the mask and or cannula and humidifier will be replaced weekly. The tubing is to be dated when first used and the 11-7 staff is responsible for setting up the new system. Resident #304 was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented resident with intact cognition and required extensive assistance of staff with Activities of Daily Living. On 03/06/2020 at 11:00 AM, resident was observed in bed asleep with oxygen mask with ongoing treatment. The tubing from the oxygen concentrator was observed touching the floor from the concentrator to the resident. In addition, a wheelchair in the resident's room was observed with an attached oxygen tank and the nasal cannula tubing was coiled around the wheelchair with no cover. The tubing was dated 02/21/2020, indicating the tubing had not been changed for two (2) weeks. Review of the physician's orders [REDACTED]. On 3/06/2020 at 11:20 AM, Registered Nurse (RN) #8 was interviewed. RN # 8 stated she was unsure of the facility policy on changing oxygen tubing and would check and get back to the surveyor. On 3/06/2020 at 11:20 AM, RN # 9 was interviewed. RN #9 stated tubing is changed weekly by the night shift and should be dated. On 03/06/2020 at 3:45 PM, Infection Control Coordinator (ICC) was interviewed. The ICC stated nasal tubing are change weekly and dated and there is a specific staff person assigned to this task. The ICC also stated the resident's family takes the resident out of the room and this may contribute to tubing touching the floor. The ICC further stated re-education and reminders to staff about different practices including tubing of oxygen and catheter is ongoing and family members would be re-educated. 415.19 (a)(1-3)

Based on record review, resident and staff interviews during the Recertification Survey the facility did not ensure that all residents received dentals services to meet the needs of each resident for 1 of 1 resident reviewed for Dental services from a total Stage 2 sample of 25 residents. Specifically, Resident #356 was identified by the Dentist to have loose partial upper dentures; however, there was no documented evidence that the facility addressed the loose partial upper dentures. The finding is: Resident #356 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 1/5/2017 Admission Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 15, indicating that the resident was cognitively intact. The MDS documented that the resident had broken or loosely fitting full or partial denture and needed extensive assistance for personal hygiene. A Comprehensive Care Plan (CCP), titled Dental/Oral Needs related to Dentures Partial Upper/Partial Lower, dated 12/29/2016, had an intervention to check to see that the dentures fit properly. A Dental consult, dated 1/4/2017, documented that the resident had partial upper and partial lower dentures. A question mark was placed by the Dentist as to whether the dentures were functional or not, and the Dentist documented the word loose next to the upper dental diagram. There were no documented interventions or follow-up in the consult to address the loose partial upper dentures. There were no nursing notes documenting the Dental consult or that the partial upper dentures were loose. On 2/13/2017 at 11:34 AM Resident #356 was interviewed with the Registered Dietician who translated. The resident stated that his partial upper denture was loose because of his age and that it had been loose since before his admission to the facility while he was still in the community. He stated, I did not report it, but nobody asked me. The Dental CCP was updated on 2/14/2017, which documented that the resident complained of a loose partial denture prior to admission in the community; Fixodent applied and to be as necessary; dental consult ordered. On 2/15/2017 at 12:04 PM Resident #356's Certified Nursing Assistant (CNA) was interviewed. She stated that the resident had dentures and he had been complaining of looseness since yesterday (2/14/2017). She stated that she started applying Fixodent yesterday (2/14/2017) and that the resident says the denture fit is much better. Review of the CNA Accountability Record (CNAAR) for February 2017 revealed that upper and lower dentures were checked off and that the CNA was to provide assistance for oral care. There was a hand written special care note stating to provide Fixodent if resident asks for partial (denture). Review of the January 2017 CNAAR revealed no such note regarding Fixodent. On 2/15/2017 at 1:42 PM the Dentist was interviewed via telephone. He stated that he did not recall the consult for Resident #356, but that if there was a concern regarding dentures he would communicate with the nursing staff because the resident could lose the denture. He stated that there are different factors related to the teeth and gums that can cause dentures to be loose, and these factors would have to be assessed. On 2/16/2017 at 8:08 AM Resident #356 was re-interviewed with the Licensed Practical Nurse (LPN) who translated. The resident said the dentures fit better now. The LPN stated the staff started using Fixodent when the resident started complaining. She said she thinks it was Monday (2/13/17). On 2/16/2017 at 8:20 AM the Registered Nurse (RN) Unit Supervisor was interviewed. She said she was not aware of the loose dentures until the resident started complaining this week. She stated that she added the hand written note to the February 2017 CNAAR regarding the Fixodent this week. On 2/16/2017 at 10:03 AM the LPN MDS nurse was interviewed. This LPN had completed the Dental section of the 1/5/2017 Admission MDS. He stated that the Dentist did not indicate any interventions regarding the dentures in the 1/4/2017 consult and that he just transcribed what the Dentist wrote in the consult to the MDS. He stated the resident did not complain about the dentures, but denture cream is part of the facility's protocol. On 2/16/2017 at 12:15 PM the Director of Nursing Services (DNS) was interviewed. She said denture cream is protocol and does not need to be put on the CNAAR. On 2/16/2017 at 1:02 PM Resident #356 was re-interviewed with the Registered Dietician who translated. He stated that the staff started applying the denture cream to his dentures this week and that it was not being applied before. The facility's undated policy on Dental Services-Oral Hygiene states that when applying dentures to apply a small quantity of denture adhesive to front and sides of dentures as needed or requested by the resident and to place dentures in resident's mouth and assess proper alignment. 415.17(a-d)

Based on observations and record review, the facility did not ensure that garbage and refuse were disposed of properly. Specifically, the garbage compactor was leaking liquid, and the garbage disposal area was not free of foul odors. This was evident during observations conducted during the Kitchen Tour. The findings are: An observation of the garbage disposal area was conducted on 12/14/15 at 9:37 AM and the following was observed: A strong foul odor was noted at the entrance and surrounding areas to the garbage disposal and garbage compactor. Liquid was observed leaking from the right side of the garbage compactor, a solidified yellow and green puddle was in the front of the compactor, and garbage debris were observed around the garbage compactor. On 12/16/15 at 11:32 AM, a follow up observation was made. There was a foul odor upon entrance to the garbage disposal area as well as surrounding garbage compactor area. Liquid was observed leaking from the left side of the compactor. On 12/14/15 at 9:37 AM, the Food Service Director (FSD) was interviewed and observation made. The FSD stated that this is the first time he had seen this and that maintenance is responsible for cleaning the area. On 12/16/15 at 11:35 AM, the Director of Housekeeping was interviewed. He stated that he is responsible for cleaning the outside area of the compactor and that he had someone assigned to clean the area but pulled him away to do work inside. He further stated that there is a staff member assigned everyday to clean the area. On 12/16/15 at 1:50 PM, the housekeeper responsible for cleaning the garbage compactor area was interviewed. He stated that he cleans the area everyday as part of his duties but was not able to clean it earlier this week because he was re-assigned to work inside the building. He also stated that he sweeps, hoses, and puts germicide in the area to clean it. He further stated that he will report to his supervisor if the compactor is not working or leaking so the supervisor will call the company. The facility policy for Disposal of Waste and Trash was reviewed. .the housekeeping department is responsible to maintain the cleanliness of the area surround the trash compactor . 415.14(h)

Based on observation, record review, and interview, the facility did not ensure that services provided were in accordance with the resident's written plan of care. Specifically, a resident was observed without a wheelchair head support in place. This was evident for 1 of 1 residents reviewed for Positioning. (Resident #190). This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. The finding is: Resident #190 is a [AGE] year-old with [DIAGNOSES REDACTED]. On 12/04/14 at 9:58 AM the resident was observed sitting in her wheelchair (w/c) in her room. The Certified Nursing Assistant (CNA) was in the room with the resident and had just completed morning care. The resident's neck was tilted forward and to the right. There was no head support on the resident's w/c. Additional observations of the resident were made on 12/04/14 at 11:28 AM, 11:54 AM, and 12:14 PM. The resident was observed without the head support in place on the w/c, and the resident's head was leaning forward and to the right. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] and 11/7/14 documented the resident had severely impaired cognition and no speech. The MDS further documented the resident required extensive assist of 2 persons for bed mobility and transfer. The MDS also documented the resident had range of motion (ROM) impairment on both sides of her upper and lower extremities. The Comprehensive Care Plan (CCP) for Potential/Actual Contractures dated 4/11/13, last reviewed 11/14/14, included an intervention to: "Use positioning devices...". The CCP for Risk for Poor Postural Alignment dated 9/9/14, last reviewed 11/14/14, documented the intervention: " Mobility/Positioning: High Back semi recliner w/c, gel cushion c(with) dycem, head support, eggcrate back cushion, B (Bilateral) arm lateral pads, a leg extender". The Occupational Therapy Annual Screen dated 9/9/14 documented the resident had no change from previous status, and required positioning with a High Back semirecliner w/c c gel cushion c dycem, a head support, eggcrate back cushion, B arm lateral pads and a leg extender. The screen also documented the resident was not a candidate for restorative OT. The CNA Accountability dated December 2014 (signed by the Registered Nurse 11/28/14) documented the resident should have a High Back semi-recliner w/c with gel cushion, eggcrate cushion, bilatateral arm, double leg extender, and head support. On 12/04/14 at 11:36 AM and 2:14 PM, the CNA was interviewed and stated that the resident used to have a different w/c with a higher back and a curved cushion behind her head. The CNA further stated that the w/c was changed a few months ago. The CNA stated that the head support is documented on the CNA Accountability, but she did not ask about the missing head support. She stated that if a device on the accountability is missing, she should ask the nurse about the missing item. The CNA stated that the resident had been leaning her head forward and to the side for about a month, and she reported it to the previous Registered Nurse (RN) Supervisor who is no longer employed at the facility. On 12/04/14 at 12:20 PM and 2:23 PM, the RN Supervisor was interviewed and stated she does review the CNA Accountability and discusses it with the CNA. She further stated that she was not aware of anything missing on the w/c, and the CNA did not report any issues to her. The RN also stated that she reviewed the CCP in November, but she did not check the resident herself to see if all the devices were in place. On 12/04/14 at 12:14 PM and 2:19 PM, the Occupational Therapist (OT) was interviewed and stated that the resident had been provided with a head support for her w/c. She further stated that the head support was provided to enhance the residents comfort and seating balance due to her balance deficit. The OT also stated that she did not know when the head support went missing, and that she had not received any requests for a replacement head support. 415.11(c)(3)(ii)

The facility did not ensure that the necessary care and services were provided to attain or maintain the highest practicable physical wellbeing in accordance with the plan of care. Specifically, a resident with impaired body alignment did not receive the appropriate adaptive devices to maintain proper positioning. This was evident for 1 of 1 residents reviewed for Positioning. (Resident #190). This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. The finding is: Resident #190 is a [AGE] year-old with [DIAGNOSES REDACTED]. On 12/04/14 at 9:58 AM the resident was observed sitting in her wheelchair (w/c) in her room. The Certified Nursing Assistant (CNA) was in the room with the resident and had just completed morning care. The resident's neck was tilted forward and to the right. There was no head support on the resident's w/c. Additional observations of the resident were made on 12/04/14 at 11:28 AM, 11:54 AM, and 12:14 PM. The resident was observed without the head support in place on the w/c, and the resident's head was leaning forward and to the right. On 12/5/14 at 10:36 AM, a follow-up observation was conducted during an Occupational Therapy evaluation. The resident was not able to actively participate in the evaluation or follow commands. When the Occupational Therapist (OT) lifted the residents head into an upright postion, the resident was unable to maintain her head in an upright position without assistance. The residents head returned to leaning forward and to the right when released. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] and 11/7/14 documented the resident had severely impaired cognition and no speech. The MDS further documented the resident required extensive assist of 2 persons for bed mobility and transfer. The MDS also documented the resident had range of motion (ROM) impairment on both sides of her upper and lower extremities. The Comprehensive Care Plan (CCP) for Potential/Actual Contractures dated 4/11/13, last reviewed 11/14/14, included intervention: "Use positioning devices...". The CCP for Risk for Poor Postural Alignment dated 9/9/14, last reviewed 11/14/14, documented the interventions: "OT evaluation-Annual....Mobility/Positioning: High Back semi recliner w/c, gel cushion c(with) dycem, head support, eggcrate back cushion, B (Bilateral) arm lateral pads, a leg extender". A Rehabilitation Department Consult Form dated 9/4/13 documented the resident was re-screening was conducted for w/c positioning and support of head in w/c. The consult further documented: "...A/P (Assessment/Plan)...Res (Resident) tends to sleep while in w/c- head backward...P (Plan): Apply an eggcrate back cushion. Apply a head support for extra support. Replace gel cushion cover...". The Occupation Therapy Positioning Evaluation Form dated 11/6/13 documented: "Reason for referral: Decline Neuromuscular control/Decrease postural alignment...Res displays a posterior pelvic tilt. Kyphotic posture & uneven W.B. (weight bearing) distribution... Additional items:...head support/eggcrate back cushion...Res requires skilled OT services to assess the need for w/c adaptation/modification, AD (Assistive Devices) to facilitate postural control, develop proper position in w/c and facilitate sitting tolerance in order to enhance res' quality of life by improving ability to decrease risk for falls and risk of skin breakdown". The Seating/Position D/C (Discharge) OT Note dated 11/14/13 documented: "Resident seen by OT at least 3x (times) for a week (secondary to) decline neuromuscular control, decrease postural alignment...Res able to maintain upright posture while in w/c for about...4 hrs without sliding and displaying proper body alignment, (increased) sitting tolerance and more UE (upper extremity)/trunk extension...A/P Res displays symmetrical & neutral trunk & extremities alignment while in w/c. P: Educate res' caregivers on equipment/modification of w/c...Encourage res to maintain upright posture to facilitate even WB distribution in order to prevent falls and protect skin...". The Occupational Therapy (OT) Screens dated 5/l9/14, 7/24/14, and 9/9/14 (Annual) documented the resident had no change from previous status, and required positioning with a High Back semirecliner w/c c (with) gel cushion, dycem, a head support, eggcrate back cushion, Bilateral arm pads and a leg extender. The screens also documented the resident was not a candidate for restorative OT. The CNA Accountability dated December 2014 (signed by the Registered Nurse 11/28/14) documented the resident should have a High Back semi-recliner w/c with gel cushion, eggcrate cushion, bilat arm, double leg extender, and head support. The Rehab Rounding Schedule for November & December 2014 documented that rehab rpounds were conducted on 11/6/14 at 12:14 PM. The OT Referral for W/C positioning dated 12/5/14 documented: Resident displays a posterior pelvic tilt with pelvic rotation, Kyphotic posture with head forward/tilt right side and uneven WB distribution. Res appears weak, unable to maintain upright posture while in w/c without continuous reposition (secondary to) medical status and decreased neuromuscular control (head) and (decreased) postural alignment. W/c evaluation/position...Cushion and dycem to be evaluated as soon res OO (out of) w/c. A/P w/c evaluation/position. P: Res will be observed for the next 2 to 3 days while in w/c (secondary to) res's fluctuating medical status. Res may benefit from B adjustable armrests and a full lapboard c one side strap to promote more upright posture/trunk extension. Res can continue with present w/c/ leg extender/ a head support. Res would benefit...to improve body alignment, balance postural alignment and UE/trunk extension". There was no documented evidence in the medical record that the staff reported the head support missing prior to 12/5/14. On 12/04/14 at 11:36 AM and 2:14 PM, the CNA was interviewed and stated that the resident used to have a different w/c with a higher back and a curved cushion behind her head. The CNA further stated that the w/c was changed a few months ago. The CNA stated that the head support was documented on the CNA Accountability, but she did not ask about the missing head support. She stated that if a device on the accountability is missing, she should ask the nurse about the missing item. The CNA stated that the resident has been leaning her head forward and to the side for about a month, and she reported it to the previous Registered Nurse (RN) Supervisor who is no longer employed at the facility. On 12/04/14 at 12:20 PM and 2:23 PM, the RN Supervisor (working in facility since October 2014) was interviewed and stated she reviews the CNA Accountability records and discusses the care to be provided with the CNA. She further stated that she was not made aware of any adaptive devices missing. The RN also stated that she reviewed the CCP in November, but she did not check the resident herself to see if all the devices were in place. The RN stated that she had noticed the resident was leaning more to one side lately, but she had not spoken to the physician about requesting an OT referral to determine if the resident would benefit from a recliner. Interviews were conducted on 12/04/14 at 12:14 PM and 2:19 PM and on 12/05/14 at 10:21 AM and 11:58 AM with the Occupational Therapist (OT). The OT stated that she had provided the resident with a head support for her w/c. She further stated that the head support was provided to enhance the residents comfort and seating balance due to her balance deficit. The OT also stated that she did not know when the head support went missing, the device was initially provided on 9/4/13 and that she had not received any requests for a replacement head support. The OT also stated that she had not seen the resident since November 2013, and the OT and PT screens are conducted by having a discussion with the nurses on the units with no resident contact. The Screen form is then completed based on the information provided from the discussion. She stated that the therapists used to see the residents for quarterly and annual assessment screens, but the policy was changed when the therapists began working for an agency and were no longer employed by the facility. After evaluating the resident, the OT stated that the resident was more kyphotic and less responsive than she was on prior evaluations. She further stated that the resident had a decline in muscular control and postural alignment, and her balance had decreased due to increased weakness. She stated that she will need to observe the resident for a week to determine what would be best for her positioning. The OT stated that they did begin Rehab Rounds last month, but she did not see the resident. Rehab Rounds are conducted during lunch twice per week on different units. During the rounds, they ask the CNAs if there are any changes in ADL (Activities of Daily Living) function or mobility, but they do not personally evaluate the residents for changes. She stated that residents are seen if a rehab referral is made, but if she happens to notice something about a resident during rounds, she will ask the staff about it. She stated that she will check any residents that staff brings to her attention during rounds. On 12/05/14 at 11:23 AM, the MDS Coordinator was interviewed and stated that Rehab evaluations are done after a nursing referral is generated. She further stated that there were times when the nursing staff missed information about changes in the residents' condition, and that is why the facility implemented Rehab Rounds in November to address the issue. The MDS Coordinator stated that the purpose of the rounds is to make sure all the residents are seen by the therapists, and the CNAs are interviewed to make sure any changes are noted and followed-up on. She stated that she compares the resident's ADL status to the previous MDS for changes. She stated that rehab is looking for positioning, eating, and ambulation changes. On 12/5/14 at 2:00 PM, the Director of Nursing (DON) was interviewed and stated that if there is a change in the resident's ADL status or positioning that cannot be attributed to an acute illness or condition, the CNA should inform the nurse. She further stated that the nurse should contact the physician so a rehab referral can be ordered. The DON stated that she was unable to determine why the resident's head support was not in place. She stated that the previous supervisor on the resident's unit left in August 2014. She stated that the Rehab Rounds were implement to make sure that each resident is seen by rehab to assess for changes that may require intervention. The facility policy and procedure for Rehabilitation Department Evaluation and Screening dated 1/2000 documented: "Upon readmission to the facility and annually, a screen is completed for the resident. The Screen is the gathering of information by the therapist to determine the need for evaluation for possible therapeutic intervention...In the event that it is determined that further Evaluation is needed, the therapist will obtain an order and will conduct the Evaluation...". The facility policy and procedure for Reab Rounds dated 11/2014 documented: "Rehab Rounds function as an additional method of identifying residents who may require therapy to address functional decline...The Physical and Occupational Therapist will observe the residents and interview the residents' Primary Caregivers...The therapists and RN Supervisor will review the information gathered...Orders for an Evaluation will be generated, as needed". 415.12

Based on observation and staff interview, the facility did not ensure that food was stored to prevent food-bourne illness. Specifically, prunes were observed stored in the refrigerator for fourteen days after the container was opened. This resulted in no actual harm with potential for more than minimal harm. The finding is: On 11/13/13,at approximately 9:50 AM, the initial tour of the kitchen was conducted. In the walk-in refrigerator, there were approximately 16 (sixteen) individual plastic containers with prunes in liquid, covered with lids and dated 10/30/13. The Food Service Director (FSD) was present and was interviewed immediately. He stated that the prunes were opened on 10/30/13 and that the prunes were good for 15-20 days. On 11/14/13 at approximately 1:15 PM, the FSD was interviewed and stated that opened canned foods were safe for 48-72 hours. He further stated that the prunes were discarded and the kitchen staff were in-serviced on safe handling of opened canned food products. 415.14(h)

Based on observation and staff interviews during the Recertification survey, the facility did not ensure that a Gastrostomy tube GT (a tube surgically inserted in the stomach for delivery of nutrition and hydration) fed residents receive the appropriate treatment and services to complications including aspiration, diarrhea, vomiting. This was noted for one of one GT fed residents (#188) observed during medication administration. Specifically, Resident #188 was observed to have medications administered via a GT without the Licensed Practical Nurse (LPN) having checked the placement appropriately as per standards of practice. This resulted in no actual harm with the potential for more than minimal harm that is not an immediate jeopardy. The finding is: Resident #188 has [DIAGNOSES REDACTED]. The resident also receives nutrition, hydration, and medications via a GT due to Dysphagia (swallowing difficulty). Physician orders [REDACTED]. On 8/17/11 at 10:15 AM, the LPN medication nurse was observed as a part of the medication observation to administer medications to Resident #188. The LPN prepared the medications, instilled 30 cc of air into the GT and proceeded to administer the medications as prescribed by the Physician. The LPN was interviewed immediately after the medication administration (8/17/11 at 10:30 AM). The LPN stated that she should have used a stethoscope to verify the placement of the tube and that she forgot. The RN Supervisor responsible for the unit where Resident #188 resided was interviewed on 8/17/11 at 1:10 PM. The RN stated that the LPN should have verified the placement of the GT prior to administration of the medications with a stethoscope. The RN stated further that the LPN just forgot. The Facility Policy and Procedure dated 9/10 titled Medications: Administration of medications via Gastrotomy tube documented, " if using a GT ascertain that the tube is in the stomach by injecting 10 (cubic centimeters) of air into the stomach and simultaneously ausculating with a stethoscope. 415.12 (g)(2)

Based on observations and staff interviews during a Recertification survey, the facility did not ensure that all information contained in the resident's medical record is kept confidential and safeguards are maintained against the unauthorized use of a resident's clinical record information, regardless of the storage method of the records. Specifically, during the Dietary storage area tour in the basement, it was observed that the Medical Records Cage which was located within the Dietary Storage Cage was unlocked. Several Dietary, Maintenance and Housekeeping personnel were observed working in the vicinity. This resulted in no actual harm with a potential for minimal harm. The finding is: During Food Storage Area tour on 8/17/11 at 9:00 AM to 9:30 AM the following was observed and staff interviews conducted. The Dietary Storage area was located in the basement. It was observed that the basement had multiple Department's ( Nursing, Dietary, Medical Records) storage cages. The Dietary Cage was unlocked and a Dietary Aide was observed working there. A Medical Records Storage cage was observed to be located within the Dietary Storage Cage. The door to Medical Records cage was ajar, an opened lock was hanging by the hook. The Food Service Director (FSD) stated that the Medical Records Cage door is normally locked, and that it might have been opened this morning. A Dietary Aide working in the area stated that some one from the Administration might have come to retrieve something from the Medical Records Cage. The Dietary Aide stated further that the Medical Records Director has a keys to both, the Dietary Cage and the Medical Records cage. The Dietary Aide also stated the he is mostly in charge to retrieve the food storage items but in emergency any kitchen staff can come. On 8/17/11 at 10:30 AM a tour of the storage area was conducted with Director of Medical Records. The Dietary Cage and the Medical Records Cage was observed to be unlocked. Two Maintenance and one House Keeping employees were observed working in the vicinity. The Director of Medical Records stated that there are approximately 100 boxes of resident's medical records stored in this area. Regarding the area being unlocked this morning, she explained that the Administration may have required some record in the morning before she arrived. She stated that the House Keeping Director and her Assistant have a key to the Cage and that "Who ever opened it should have closed it." The Medical Records Assistant was interviewed on 8/17/11 at 11:00 AM. The Assistant stated that the Medical Records Cage was opened yesterday. She added that the Director of House Keeping or his Assistant had required the key from her. She stated that, "I don't know what happened, I have to speak to them about it." The Medical Records Director stated on 8/17/11 at 12:00 noon that at 8:00 AM this morning the Nursing Assistant had obtained the master key to her office from the Security, and retrieved the keys to the Medical Record Cage. The Medical Records Director stated further that,"the Nursing Assistant was in a hurry and she forgot to lock it. It was just an over sight." 415.22(b)