Every finding on record at Wellsville Manor Care Center

Based on interview and record review conducted during a Standard survey completed 6/14/24, the facility did not employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service. Specifically, one of one facility reviewed for sufficient staffing did not have a full-time (working 35 or more hours a week) qualified Director of Food and Nutrition services or other clinically qualified nutrition professional. The finding is: The policy and procedure titled Food and Nutrition Services revised 1/2024 did not include qualifications and skills sets for clinically qualified nutrition professionals. Review of the undated job description job title Nutrition Service Director revealed the candidate must provide documentation of registry/certificate upon application for the position, must have training in cost control, food management, and diet therapy. Review of the undated job description job title Diet Tech revealed the purpose of the job position is to oversee nutritional well-being of residents by conducting nutrition assessments, identifying patients at risk, and creating diet plans. Qualifications listed included a two-year associate degree in Dietetics Education or related field. Review of the Facility Survey Report signed and dated 6/13/24 revealed Dietitian #1 was not the full-time dietetic service supervisor and Dietary Supervisor #2 (Food Service Director) was listed as the full-time dietetic service supervisor. Review of timecards dated 3/12/24 through 6/12/24 revealed Dietitian #1, a registered dietician, worked less than 35 hours per week at the facility. During an interview on 6/11/24 at 10:45 AM, Dietary Supervisor #2 stated they were hired as the Food Service Director for the facility this past September. They stated they were the full-time Food Service Director for the facility. They stated they did not have a certificate as a Certified Dietary Manager or a Certified Food Service Manager. They stated they had not completed any course of study in food safety and management. During an interview on 6/11/24 at 10:50 AM, Dietary Supervisor #1 stated they were the full-time Diet Tech at the facility. They stated they did not have any certification in food service management or nutrition and hospitality and had been hired as a Diet Tech three years ago after having been a Certified Nurse Aide at the facility. During an interview on 6/13/24 at 10:28 AM, Dietician #1 stated they did not work full time at the facility and that they worked there two days a week. During an interview on 6/13/24 at 3:41 PM, the Administrator stated the Dietician was available in the building a minimum of 2 days per week. They stated they thought Dietary Supervisor #2 (Food Service Director) and Dietary Supervisor #1 (Diet Tech) were qualified for their positions. The qualifications of the regulations were reviewed with the Administrator, and they stated the Food Service Director was not qualified for the position per the regulations. They stated it was important for Food Service Directors and/or Diet Techs to have the proper certifications, so the residents will receive safe and nutritious food and there will be not food related illnesses. 10NYCRR 415.14(a)(1)

Based on observation, interview and record review conducted during a Standard survey completed 6/14/24, the facility did not ensure provision of a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections, for one (Resident #307) of two residents reviewed for infection control practices during pressure ulcer care. Specifically, staff did not maintain proper hand hygiene during wound care and the resident was not on enhanced barrier precautions (infection control interventions including gown and glove use for high contact resident care activities designed to reduce transmission of multidrug-resistant organisms). The finding is: Review of the policy and procedure titled Hand Washing/hygiene dated 1/24 documented that all personal should follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, resident, and visitors. The use of alcohol-based hand rub or soap and water should be used for the following situations: before handling clean or soiled dressings, gauze pads; before moving from a contaminated body site to a clean body site during care; after contact with blood or bodily fluids; after handling used dressings, contaminated equipment; after contact with objects in the immediate vicinity of the resident; and after removing gloves. The use of gloves does not replace hand washing/hygiene and integration of glove use along with routine hand hygiene was the best practice for preventing healthcare-associated infections. The Centers for Medicare and Medicaid Services Quality Safety and Oversight memoranda QSO-24-08-NH dated 3/20/24, documented enhanced barrier precautions were indicated for residents with wounds even if the resident was not known to be infected or colonized with a multidrug-resistant organism. Examples of wounds included chronic pressure ulcers. Enhanced barrier precautions were to be used when staff performed wound care for any skin opening that required a dressing. Review of the policy and procedure titled Enhanced Barrier Precautions dated 4/24 documented that it was the policy of the facility to adhere to the Centers for Disease Control and Prevention and the Centers for Medicare and Medicaid Services guidelines as related to enhanced barrier precautions to prevent the transmission of multidrug-resistant organisms. Enhanced barrier precautions were a Centers for Disease Control and Prevention recommendation to provide guidance for the use of personal protective equipment in facilities for preventing the spread of multi-drug resistant organisms. The facility would implement enhanced barrier precautions for any resident that had a chronic wound and would remain in effect until the resolution of the wound. Appropriate signage for the type of precaution would be posted on the resident's room door. Gown and gloves would only be needed when providing high-contact resident care activities. Resident #307 diagnoses included pressure ulcer of the sacrum (area above the tail bone on right and left buttocks), adult failure to thrive (a state of decline that is multifactorial) and diabetes mellitus type II. The Minimum Data Set (a resident assessment tool) dated 4/24/24 documented the resident was cognitively intact, had one stage II (shallow open wound when the top layer of skin breaks down and extends into the deeper layer of skin) pressure ulcer upon admission and two stage IV (full thickness tissue loss with exposed bone, tendon or muscle) pressure ulcers upon admission. Review of the Comprehensive Care Plan with problem start date 4/19/24 and resolved on 5/30/24 documented that Resident #307 may have enhanced barrier precautions applied. Interventions included for signage on doors and gowns and gloves to be worn with high contact with affected source. The Comprehensive Care Plan with problem start date of 5/4/24 documented that Resident #307 was admitted with a stage IV pressure ulcer on their coccyx (tail bone). Interventions did not include enhanced barrier precautions. Review of the Physician Order Report dated 6/1/24-6/14/24 documented on 5/7/24, Resident #307 had an order to cleanse the pressure ulcer on their coccyx with soap and water, pat dry, apply hydrogel to wound bed, cover with bordered gauze daily and as needed. The order report documented on 6/13/24, Resident #307 was to have enhanced barrier precautions every shift due to their wound. Review of the Wound Physician Services notes dated 5/9/24-6/13/24, Medical Doctor #2 documented weekly that Resident #307 had a healing stage IV pressure injury to their sacrum. Review of Resident Progress Notes dated 5/30/24 at 3:28 PM, Registered Nurse #3 documented that Resident #307's enhanced barrier precautions were discontinued because the resident's wound was no longer draining. During intermittent observations on 6/10/24 at 12:09 PM and 6/11/24 at 10:04 AM, Resident #307 did not have enhanced barrier precaution signage on their room door. During an observation and interview on 6/12/24 at 1:15 PM, Certified Nursing Assistant #3 stated they wore a gown and gloves while providing incontinent care because Resident #307 was on contact precautions. Certified Nursing Assistant #3 stated they were unsure what Resident #307 was on precautions for, but they knew when a resident was on precautions because the name placard was marked with a green dot and there would be a precaution sign above that. Certified Nursing Assistant #3 observed Resident #307's door did not have a precautions sign and the name placard did not have a green dot. Certified Nursing Assistant #3 stated that Resident #307 was on contact precautions at one point during their stay and was unsure why there was not a green dot or precaution sign now. During a wound care observation on 6/12/24 at 1:41 PM, Licensed Practical Nurse #1 performed hand hygiene and entered Resident #307's room, there was no enhanced barrier precaution signage on the door. They cleansed Resident #307's overbed table with an antibacterial wipe, placed a barrier towel on the table and turned on the hot water in the bathroom. Without performing hand hygiene, Licensed Practical Nurse #1 donned two pairs of gloves and moved the resident's overbed table, wheelchair and rolling walker. Then they placed the dressing change supplies on the table with their gloved hands. Licensed Practical Nurse #1 wet a washcloth with the running sink water and put the washcloth on top of the supplies on the overbed table. Licensed Practical Nurse #1 then grabbed their scissors out of their pocket and cleansed them with an antibacterial wipe. Without changing their gloves or performing hand hygiene, Licensed Practical Nurse #1 applied soap to the washcloth then proceeded to wash, rinse and dry Resident #307's open wound on their coccyx. Licensed Practical Nurse #1 then removed their top layer of gloves, packed the wound with the dressing and covered it with border gauze. Licensed Practical Nurse #1 removed their gloves and placed the dressing wrappers into a garbage bag. They then applied new gloves without performing hand hygiene, repositioned the resident in the bed and then doffed their gloves. Licensed Practical Nurse #1 then donned one glove, picked up the garbage bag with their gloved hand, and exited the room. They applied antibacterial hand rub to their ungloved hand and walked down the hallway to the dirty utility room. Licensed Practical Nurse #1 entered the dirty utility room, threw the garbage bag into the garbage, doffed the one glove, and then performed antibacterial hand hygiene to both hands. Licensed Practical Nurse #1 did not wear a gown during wound care. During an observation of a televisit Wound Rounds with Medical Doctor #2, on 6/13/24 at 8:01 AM, Resident #307's room did not have enhanced barrier precautions signage on their door. Registered Nurse #3 rolled Resident #307 onto their side while the Director of Nursing was holding a cellular phone for Medical Doctor #2 to visualize the coccyx wound. Neither staff had donned a gown for the televisit. During an interview on 6/13/24 at 7:37 AM, Licensed Practical Nurse #1, stated that they were working as a graduate nurse and have completed Resident #307 treatment in the past. Licensed Practical Nurse #1 stated during wound care observation on 6/12/24 they had missed hand hygiene opportunities. Licensed Practical Nurse #1 stated hand hygiene should always be performed in-between doffing and donning of gloves. Licensed Practical Nurse #1 stated they did not change their gloves prior to cleansing Resident #307 wound. They stated that they should have doffed the dirty gloves after touching items in Resident #307's room, then performed hand hygiene prior to donning new gloves to prevent the possible spread infection to the wound. Licensed Practical Nurse #1 stated that the process of double gloving was not taught in the facility but was a process they learned in nursing school. Licensed Practical Nurse #1 stated that Resident #307 was not on enhanced barrier precautions and would be if they had a history of multiple drug resistant organisms. During an interview on 6/13/24 at 10:39 AM, Registered Nurse #3 stated that Resident #307 had a chronic pressure ulcer. Registered Nurse #3 stated that hand hygiene needed to be performed every time a staff member donned or doffed a pair of gloves. They stated prior to the start of cleansing a wound Licensed Practical Nurse #1 staff member needed to perform hand hygiene and don a new pair of gloves to prevent the possible contamination of the wound. Registered Nurse #3 stated the Director of Nursing discontinued enhanced barrier precautions for Resident #307 on 5/30/24 when the wound was no longer draining. During an interview on 6/13/24 at 2:42 PM, Registered Nurse #2 (Infection Control Nurse) stated that it was not facility practice to double glove and that hand hygiene should be performed prior to/after leaving a resident's room and in between glove changes. Registered Nurse #2 stated that a new pair of gloves should be worn, after staff performed hand hygiene, prior to cleansing an open wound to prevent possible cross contamination. Registered Nurse #2 stated that a resident with an open draining wound should be on enhanced barrier precautions to reduce the spread of multiple drug resistant organisms and staff were to wear a gown and gloves when coming into close contact with the open area or bedding. During an interview on 6/13/24 at 3:07 PM, Registered Nurse #2 stated Resident #307 should have been on enhanced barrier precautions because their wound was open and greater than a stage II. During a telephone interview on 6/14/24 at 11:14 AM, Medical Doctor #1 (Medical Director) stated they have followed Resident #307 since they were residing at their previous nursing facility, and they had a chronic pressure ulcer to their sacrum. Medical Doctor #1 stated that any resident that had skin breakdown or a pressure ulcer needed to be on enhanced barrier precautions due to the new federal regulation that was just released. During an interview on 6/14/24 at 11:23 AM, the Director of Nursing stated staff should be preforming hand hygiene in between glove changes. They stated that Licensed Practical Nurse #1 should have doffed old gloves, performed hand hygiene, and donned new gloves prior to cleansing Resident #307's open wound to their sacrum. They stated that touching items in the room without hand hygiene and a glove change could have possibly contaminated Resident #307 open wound. The Director of Nursing stated that any resident that had open, draining wounds would need to be on enhanced barrier precautions that would consist of staff wearing gown and gloves for care. The Director of Nursing stated Registered Nurse #3 nor themselves wore a gown during wound round observation for Resident #307 on 6/13/24. The Director of Nursing stated they discontinued Resident #307 enhanced barrier precautions at the end of May because the wound was no longer draining. The Director of Nursing stated the precautions should not have been discontinued because stage IV pressure ulcers had a possibility of drainage. The Director of Nursing stated that the purpose of enhanced barrier precaution was to prevent the spread of infection, protect the staff and other residents from the spread of infection and any open wound had a higher risk for infection. During an interview on 6/14/24 at 12:07 PM, the Administrator stated they expected staff performed hand hygiene before and after resident interaction, when they touched soiled surfaces and if their hands were visibly soiled. They stated hand hygiene should be performed in between glove changes to mitigate germs being spread. 10NYCRR 415.19(b)(4)

Based on observations, interviews, and record review conducted during a Standard survey completed on 6/14/24, the facility did not ensure each resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one (Resident #58) of three residents reviewed for positioning and mobility. Specifically, the staff did not ensure that Resident #58's right hand splint was worn at all times as ordered and care planned. The finding is: The policy and procedures titled Assistive Devices and Equipment, revised on 1/2024, documented that devices and equipment that assist with resident mobility, safety and independence are provided for residents. These include but are not limited to wheelchairs (manual and powered), walkers, canes, adaptive devices etc. Recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the resident's plan of care. Resident #58 had diagnoses of cellulitis (a bacterial skin infection), urinary tract infection, and adult failure to thrive (a state of decline that is multifactorial). The Minimum Data Set (a resident assessment tool) dated 4/4/24, documented Resident #58 had severe cognitive impairment and could not understand others or was not understood by others, and had a right upper extremity functional limitation in range of motion. The Comprehensive Care Plan dated 6/1/24, documented that a right functional hand splint was to be worn at all times during the day and at bedtime. It could be removed for hygiene, range of motion or functional tasks. The staff were to monitor for signs of discomfort every shift. Review of Resident Orders dated 2/2/24, documented a right functional hand splint was to be worn at all times during the day and bedtime. It could be removed for hygiene and range of motion or functional tasks. Staff were to monitor for signs of discomfort every shift, day, evenings, and overnights. During an observation and interview on 6/10/24 at 11:55 AM, Resident #58 was observed in their wheelchair in the hallway with a family member. Resident #58 did not have their functional hand splint on. The family member stated that Resident #58 should wear a splint on their right hand. During an observation on 6/12/24 at 10:47 AM, Resident #58 was in the common area resting in their wheelchair and did not have their functional hand and splint on. The Resident demonstrated the inability to extend their right hand all of the way. During an observation and an interview on 6/14/24 8:47 AM, Resident #58 was in the television room without their functional hand split on. The device was attached to their wheelchair. When asked why they did not have their splint on they stated they never had it on. During an interview on 6/14/24 at 9:37 AM, Registered Nurse #1 stated that Resident #58 should wear a right-hand splint. Registered Nurse #1 observed the resident and stated they were not wearing their hand splint. Registered Nurse #1 checked the residents care plan and stated the resident was care planned to wear the functional splint at all times. Registered Nurse #1 stated this was important because it was a therapy recommendation, and they may have a contracture. During an interview on 6/14/24 9:49 AM, Certified Nursing Assistant #3 stated that Resident #58 was compliant with their plan of care. They looked at the resident's care plan to verify if the resident was care planned for a functional hand splint. They stated that they did see the splint in the resident's chart. They stated the resident once wore a functional splint and but did not think they did anymore. During an interview on 6/14/24 10:09 AM with Certified Nursing Assistant #2, they stated Resident #58 normally wore a wrist splint. Certified Nursing Assistant #2 observed Resident #58 and stated they did not have it on. Certified Nursing Assistant #2 stated they were not familiar with the new kiosk system to look if the Resident had was care planned for a functional hand splint. They stated that they did not think that Resident #58 normally wore the splint. Certified Nursing Assistant #2 stated that it was important to check residents care plans and that the splint should be worn to so that the resident's hand does not further contract. During an interview on 6/14/24 at 10:32 AM with Occupational Therapist #1, they stated that Resident # 58 should be wearing a splint on their right hand and was care planned for this. They stated that Resident #58 could be confused but was compliant with wearing the splint and it was important to make sure they wore their splint to reduce contractures and stop them from getting worse. They stated it was important to not let the contracture get to the point where it closed and would become painful, and the splint was to help preserve the joints. They stated it was the nurse's responsibility to make sure they are following plan of care orders. During an interview on 6/14/24 at 10:57 AM, the Director of Nursing stated they expected that Resident #58 would wear the splint if they should and have staff put it on. They stated that it was the responsibility of the Unit Manager, but it was everyone's responsibility to make sure the resident's care plan was followed. They stated it was important to make sure splints were worn to prevent contractures and to prevent further decline in residents. During an interview on 6/14/24 at 11:04 AM, the Administrator stated staff should be well informed about the care plan of each resident and it was on the kiosk with the resident's profile. They stated all staff have received training on how to find information and utilize the electronic medical record and how to document and chart properly. They stated this was important to ensure that the residents care plan was being met. 10NYCRR 415.12(e)(2)

Based on interviews and record review conducted during a Complaint investigation (Complaint #NY00312806) during the Standard survey completed on 6/14/24, the facility did not the facility did not make prompt efforts to resolve grievances for one (Resident #257) of three residents reviewed for grievances. Specifically, there was lack of follow through and resolution of a resident's report of missing property. The finding is: Review of a facility policy and procedure titled Resident Grievance, revised 1/2024 revealed that the Social Work Department will inform residents and/or designated representatives of their right to express grievances with the expectation of a response and without fear of reprisal. Each and all grievances will be investigated by the Department Head or their designee against which the complaint is made with cooperation and interventions from other disciplines when necessary. The Social Worker will document the complainant's satisfaction with findings and/or any actions taken by the facility. Review of Your Rights as a Nursing Home Resident in New York State dated 2022 documented, Expect the facility to promptly investigate and try to resolve your concerns. Resident #257 had diagnoses which include aphasia (a language disorder that affects a person's ability to communicate), hypertension (high blood pressure), and major depressive disorder. The Minimum Data Set (a resident assessment tool) dated 1/24/23 documented the resident was moderately cognitively impaired. Review of Resident #257's comprehensive care plan dated 5/6/21 revealed the resident needed assistance with activities of daily living (oral care, washing, dressing, repositioning, transferring, ambulation, mobility, toileting, and eating). An intervention dated 5/9/22 documented the resident wore glasses. Review of facility document titled Missing Items Report dated 1/11/23, provided by the Social Work Department Director, documented the resident's eyeglasses with metal frame were missing. The glasses were not found but per resident documents they had readers. The resident was going to be added to the eye doctor list for replacement. There was a handwritten entry along the margin of the document that said, Notified by nursing on 7/11/23 found their glasses. The form was not signed. The Social Work Department Director stated all the documentation on the form was completed by them. Review of an e-mail dated 1/24/23 at 8:27 AM, from the Social Work Department Director to the Director of Medical Records Department documented, (Resident #257) - can they be added to the eye doctor list, apparently they had glasses missing that we have not located. An e-mail dated 1/24/23 at 8:32 AM, from the Director of Medical Records Department to the Social Work Department Director documented, Okay. Review of Resident #257's medical record including nurse progress notes, consult reports and physician notes from 1/1/23 through 7/6/23 revealed no documented evidence the resident was seen for an eye consult or had their glasses replaced. During a telephone interview on 6/12/24 at 8:33 AM, Resident #257's family member stated the facility did not find the resident's glasses and didn't believe the resident was seen by an eye doctor for new glasses. They stated the glasses that were provided to the resident upon discharge in July 2023 were not theirs and they did not accept them from the staff. During an interview on 6/12/24 at 9:11 AM, the Social Work Department Director stated they were unable to find the resident's glasses therefore they sent an email to have the resident seen by the eye doctor for new glasses. The Social Worker Department Director stated they assumed the resident was seen. During an interview on 6/12/24 at 9:49 AM, the Director of Medical Records Department stated the follow up action for the missing glasses was not completed as documented on the missing items report; the resident was not seen by an eye doctor. During an interview on 6/12/24 at 10:12 AM Social Work Department Director stated the follow-up to the missing glasses was not completed, they didn't know the resident wasn't seen by the eye doctor and were not provided glasses and should have been. During an interview on 6/12/24 at 1:57 PM, Unit Manager Licensed Practical Nurse #2 stated the follow up to the grievance for the missing glasses should have been followed through and would have expected the resident to have been seen by the eye doctor so their glasses could have been replaced. During an interview on 6/12/24 at 2:50 PM, the Administrator stated the resident should have been seen by the eye doctor and their glasses replaced. They stated they were responsible to ensure the Social Work Department Director and the Medical Records Department Director provided follow-up and there is a lack of the facility following through to ensure the resident's personal property was replaced. 10 NYCRR 415.3(d)(1)(i)

Based on interviews conducted during the Standard survey completed on 6/14/24, the facility did not assure the residents had the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through a means other than a postal service. Specifically, the facility did not ensure there was postal service available on Saturdays. This involved Resident #s 22, 30, 36, 44, 49, 82, 84, and 258. The finding is: On 6/11/24 at 10:13 AM, the Resident Council attendees (Resident #s 30, 36, 44, 49, 82, 84, and 258) stated they did not receive mail on Saturdays because they believed the facility didn't have staff available to deliver mail on Saturdays. During an interview on 6/12/24 at 10:51 AM, the Activities Department Director stated the United States Postal Service delivered mail to the facility Monday through Friday. They stated the Administrator set up the mail delivery for Monday through Friday only and stated they didn't know the residents should be able to receive mail on Saturdays. During a telephone interview on 6/12/24 at 11:49 AM, the Postmaster from the United States Post Office stated the facility was listed as a business and closed on Saturdays therefore there is no mail delivery on Saturdays, and believed it was because the facility didn't have staff to provide the mail to the residents on Saturdays. The Postmaster stated if the facility wanted the mail to be delivered on Saturdays, the United States Post Office would accommodate the request. During an interview on 6/12/24 at 12:04 PM, Resident #82 stated they would like the facility to have a process to deliver mail on Saturdays and would expect their mail be delivered to them. During an interview on 6/12/24 at 12:05 PM, Resident #49 stated it bothered them that the facility didn't have a process to deliver mail on Saturdays and that they didn't get their mail. During an interview on 6/12/24 at 12:10 PM, Resident #30 stated the facility should have a process for mail delivery on Saturdays as some residents may be waiting for something important and it bothered them. During an interview on 6/13/24 at 1:46 PM, Resident #22 stated they did not get mail on Saturdays, and it bothered them because they needed to ask a friend to go to the United States Post Office to get their mail on Saturdays and bring it into the facility. During an interview on 6/12/24 at 12:23 PM, the Business Office Manager stated the facility received mail Monday through Friday and believed the facility had not received mail on Saturdays in years because they didn't have staff to deliver the mail to the residents on Saturdays. During an interview on 6/12/24 at 12:17 PM, the Administrator stated they didn't know the residents were not receiving mail on Saturdays and it was a resident's right to receive their mail including Saturdays timely. The Administrator stated they were responsible to ensure the mail delivery process was set up between the postal service and the facility. The Administrator stated the facility was not just a business but also the residents' home. The Administrator stated they did not have a written policy and procedure for mail delivery. 10 NYCRR 415.3(e)(2)(i)

Based on interview and record review conducted during an Abbreviated survey (Complaint #NY00338118) the facility did not ensure that all alleged violations including abuse, neglect, exploitation or mistreatment were reported immediately, but not later than two hours after the allegation was made, if the events that caused the allegation involved abuse, to the facility's Administrator and the State Survey Agency for one (Resident #1) of three residents reviewed. Specifically, facility staff did not report an allegation of abuse/mistreatment of a resident to the Director of Nursing or the Administrator which resulted in the alleged abuse not getting reported to the appropriate officials including the New York State Department of Health as required. The finding is: The policy and procedure titled Abuse and Neglect last reviewed/revised: 4/2024 documented the Administrator and Director of Nursing will be immediately informed of any alleged or suspected occurrence of abuse or neglect. The Administrator or designee will provide a 2-hour notification to the New York State Department of Health for any suspected or confirmed case of abuse or neglect. Any licensed person who fails to report shall be guilty of unprofessional conduct in the practice of his/her profession. All employees must report the suspected abuse, neglect to their immediate supervisor or by calling NYS (New York State) Department of Health Office of Health Systems Management. All staff members are responsible for reporting any and all incidences of alleged or suspected abuse. Resident #1 had diagnoses that included Alzheimer's Disease, dementia with agitation, and recurrent depressive disorder. The Minimum Data Set (MDS-a resident assessment tool) dated 2/28/24 documented Resident #1 had severe cognitive impairment. The comprehensive care plan dated 3/14/24 documented Resident #1 needed assistance with Activities of Daily Living due to dementia, depression, psychosis, anxiety, and non-compliance with plan of care. Approaches included to provide total assistance of two with bed mobility, transfers, and maximal assist of 1 for toileting hygiene. May use a higher level of assistance if needed. Additionally, approach indicated that Resident #1 was very sensitive and if touched too quickly will scream out. The Investigation Summary Report effective 4/8/24 signed by the Administrator and Director of Nursing, documented on 4/2/24 during the evening shift Certified Nurse Aides #1 and #2 provided care to Resident #1. Certified Nurse Aide #1 reported that Certified Nurse Aide #2 used a pillow and a stuffed animal to muffle Resident #1's screams by placing them over Resident #1's mouth. Certified Nurse Aide #1 did not report incident to the supervisor, Director of Nursing or Administrator. The investigation documented facility was not made aware of the incident regarding Resident #1 and Certified Nurse Aide #2 until 4/4/2024; when the scheduler received an email dated 4/3/24 at 10:31 PM from Certified Nurse Aide #1 describing the incident. This incident was reported to the New York State Department of Health on 4/4/24 by the Administrator. Review of email sent 4/3/24 at 10:31 PM to the scheduler documented message was received from Certified Nurse Aide #1 stating something happened on 4/2/24 when they were in Resident #1's room. Certified Nurse Aide #1 stated they visibly saw Certified Nurse Aide #2 put pillow and stuffed animal over Resident #1's mouth while doing care. Certified Nurse Aide #1 stated they didn't feel comfortable telling the nurse and didn't know who else to tell. Certified Nurse Aide #1 stated they should have reached out sooner because they felt it was abuse but didn't know who to go to. Review of a written statement included with the facility's investigation, signed by Certified Nurse Aide #1 dated 4/4/24, documented on 4/2/24 between 7:40 PM-8:30 PM they witnessed Certified Nurse Aide #2 holding a pillow over Resident #1's mouth with force to muffle Resident #1's yelling. Certified Nurse Aide #1 documented they removed pillows from bed, then Certified Nurse Aide #2 took a stuffed animal off Resident #1's bedside stand and used it to cover Resident #1's mouth. Certified Nurse Aide #1 documented they didn't report incident on 4/2/24 because they didn't trust the nurse that was on the unit to do something about it and didn't know who else to go to at that moment. Certified Nurse Aid #1 documented they should have reached out to somebody, but they were uncomfortable and had only been at facility for three weeks. During an interview on 4/15/24 at 2:33 PM, the scheduler stated they received email from Certified Nurse Assistant dated 4/3/24 at 10:31 PM upon looking at their emails the morning of 4/4/24 around 9:45 AM. The scheduler stated they immediately printed email and gave it to the Director of Nursing because abuse had to be reported. During a telephone interview on 4/15/24 at 2:47 PM, Certified Nurse Aide #1 stated on 4/2/24 while providing care with Certified Nurse Aide #2 to Resident #1, who likes to scream during care, they noticed Resident #1's screams sounded muffled. Certified Nurse Aide #1 stated they witnessed Certified Nurse Aide #2 holding a pillow over Resident #1's mouth. Certified Nurse Aide #1 stated they moved the pillow off the bed; then Certified Nurse Aide #2 took Resident #1's stuffed animal and held it over Resident #1's mouth. The Certified Nurse Aide #1 stated they did not tell the nurse about this, and they didn't know how to get ahold of the supervisor. Certified Nurse Aide #1 stated they received education on abuse, who and when to report abuse. Certified Nurse Aide #1 stated they're supposed to report abuse immediately when it happens for the safety of the residents. The Certified Nurse Aide #1 stated they reported it on 4/3/24 at 10:28 PM via a texted email to the scheduler. During a telephone interview on 4/15/24 at 4:45 PM, Licensed Practical Nurse #3 stated they worked 6:00 PM to 6:00 AM on 4/2/24. Licensed Practical Nurse #3 stated they were not made aware of any abuse allegations by Certified Nurse Aide #1. Licensed Practical Nurse #3 stated they would immediately report abuse allegations to the nursing supervisor. Licensed Practical Nurse #3 stated they were able to get a hold of the nursing supervisor by calling their office, cell phone, by overhead page and during the nurse supervisor's rounds. During a telephone interview 4/15/24 at 5:16 PM, Registered Nurse Supervisor #1 stated there were no concerns of abuse brought to their attention when they worked on 4/2/24. Registered Nurse Supervisor #1 stated they would expect staff to tell them right away if they witnessed any abuse so they could make sure the resident was safe, get facts and report immediately to the Director of Nursing and/or Administrator. During an interview on 4/16/24 at 10:14 AM, the Director of Nursing stated Certified Nurse Aide #1 should have reported the incident immediately to their nurse or supervisor (on 4/2/24). Director of Nursing stated it was important to report immediately so an investigation can be implemented, and they only have 2 hours to report it. During an interview on 4/16/24 at 10:29 AM, the Administrator stated Certified Nurse Aide #1 didn't report this allegation immediately as required and should have to assure the safety of the residents. Administrator stated it was important that abuse allegations were reported right away because that was the facility policy, an investigation could have been started immediately and Certified Nurse Aide #2 would have been removed from schedule. 10 NYCRR 415.4(b)(2)

Based on interview and record review completed during the Standard survey conducted 7/18/22 through 7/22/22, the facility did not ensure the providers made actual face to face contact with the residents at required visits for 3 of 9 residents (Resident #s 314, 55, and 82) reviewed. Specifically, provider visits were completed via telehealth (delivery of health care via remote technologies) and not in person (face to face) as required. The findings are: The policy and procedure (P&P) titled Provider Visits with a revised date of 1/22 documented the attending physician will visit residents in a timely fashion, consistent with applicable state and federal requirements, and depending on the individual's medical stability, recent and previous medical history, and the presence of medical conditions or problems that cannot be handled readily by phone. The P&P documented the NP (nurse practitioner) may preform required visits by state and federal regulations. Review of a hand written note provided by the Director of Nursing (DON) documented the MD provided in the facility visits on April 29, 2022, April 30, 2022, June 23, 2022, and June 24, 2022. Additionally, it was documented that other visits were completed via telehealth on Thursdays. 1. Resident #314 admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-a resident assessment tool) dated 7/12/22 documented Resident #314 was cognitively intact, understood and understands. The electronic medical record (EMR) documented Patient Encounters on the following dates: 6/10/22 Initial NP visit; 6/16/22 Initial MD visit; 7/6/22 Return from hospital stay visit completed by the NP; and 7/15/22 Initial MD visit. Review of the Facility Activity Report (progress notes) documented on 7/15/22 Resident #314 was assessed by the MD via telehealth. During an interview on 7/21/22 at 1:18 PM, Resident #314 stated they have never seen the MD in person and have had only telehealth visits. Resident #314 stated they would have preferred to see the MD in person because it is more personal, the MD would have heard better, and if they did not understand what the MD said they could have asked the MD to repeat it. During an interview on 7/22/22 at 8:29 AM, Registered Nurse (RN) Unit Manager #1 stated the MD comes into the building monthly for a two-day time span and then will round on weekly on Thursdays via telehealth. RN #1 stated the NP completes telehealth visits Monday through Fridays. RN #1 stated they did not know if Resident #314's initial visits were completed in person by the MD. 2. Resident #55 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident #55 was understood and understands with severe cognitive impairment. The EMR documented Patient Encounters on the following dates: 5/25/22 60-day visit were completed by the NP. During interviews on 7/21/22 at 8:50 AM and 10:07 AM, RN #3 Unit Manager stated that Resident #55 had a 60-day provider visit on 5/25/22 completed by the NP. The NP does not do in person visits, and completes all their provider visits Monday through Friday via telehealth. RN #3 stated they have no interaction with the MD. 3. Resident #82 admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident #82 had severe cognitive impairment, the physician (or authorized assistant or practitioner) did not examine the resident in the 14 days prior, and the physician (or authorized assistant or practitioner) changed the residents orders on 4 of the 14 days prior. The EMR documented Patient Encounters on the following dates: 5/11/2022 Initial NP Visit; 5/12/22 Initial MD Visit; and 6/7/22, a 30-day visit completed by the NP. During an interview on 7/21/22 at 9:59 AM, Licensed Practical Nurse (LPN) Assistant Director of Nursing (#1) stated they were responsible for scheduling provider visits. The MD completed telehealth visits on Thursday and would come into the building once or twice a month. LPN #3 stated the MD would have a face-to-face visit with a resident if they were due for their 60-day visit at the time the MD was in house. LPN #1 stated that all NP visits were completed via telehealth Monday through Friday. During a telehealth interview on 7/22/22 at 10:14 AM, the NP stated that all their resident visits (initial, 30-day, 60-day, 90-day and acute visits) were completed via telehealth, and they do not come to the building. The NP stated they were unaware that a resident needed to be seen in-person for a 60-day routine visit. During a telephone interview on 7/22/22 at 10:40 AM, the MD stated that they had to see resident's face-to-face every two months and that initial visits were completed via telehealth. The MD stated the last face-to-face visit for Resident #55 was on 11/23/21 and any further face-to-face MD visits were missed. Resident #314 was seen via telehealth for their initial visits on 6/16/22 and 7/15/22, and Resident #82 was seen via telehealth on May 12, 2022, for their initial visit. During an interview on 7/22/22 at 11:41 AM, the DON stated the NP visits are done via telehealth and the MD visits are done via telehealth unless the MD is in the building. The DON stated they were unsure if a resident's initial visit needed to be completed in person. 415.15 (b)

Based on interview, observation and record review conducted during the Standard survey started on 7/18/22 and completed on 7/22/22, the facility did not ensure that it promoted and facilitated resident self-determination through the support of resident choice for three (Residents #49, 67, and 88) of three residents reviewed. Specifically, preferred number of showers per week were not obtained (#49), preferred wake up time was not obtained (#67), and showers were not provided in accordance with resident wishes' (#88). The findings are: The facility policy and procedure (P&P) titled Accommodation of Resident's Needs revised 1/2022 documented the resident's individual needs and preferences shall be accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. The resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, shall be evaluated upon admission and reviewed on an ongoing basis. 1. Resident #49 admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, a resident assessment tool) dated 5/11/22 documented Resident #49 was cognitively intact, required extensive assistance of two or more staff members with bathing, and there was no rejection of care. The MDS dated [DATE] documented it was very important for the resident to choose between a tub bath, shower, bed bath, or sponge bath. During an interview on 7/18/22 at 10:35 AM, Resident #49 stated they would like two showers per week. During an interivew on 7/20/22 at 9:05 AM, Resident #49 stated staff never asked them their preferred shower day, time, nor frequency of showers per week. The undated CNA (certified nurse assistant) assignment sheet documented Resident #49's scheduled bath day was Thursdays on the evening shift. The assignment sheet documented do not change the bath days please! These are set times the Unit Manager has set up and wants left alone. During an interview on 7/20/22 at 10:00 AM, Registered Nurse (RN) #1, Unit Manager, stated bath and shower days and times were on a set schedule based upon the resident's room number. The standard shower schedule was once weekly, and if a resident expresses the preference of more frequent showers the facility would accommodate the preference. Additionally, RN #1 stated residents were not specifically asked their preference on frequency of showers. 2. Resident #67 admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented Resident #67 was cognitively intact, required extensive assistance of one staff member for personal hygiene, and there was no rejection of care. Additionally, it was documented that it was very important to Resident #67 to choose their own bedtime. During an interview on 7/19/22 at 9:06 AM, Resident #67 stated they preferred to go back to sleep after eating their breakfast and preferred to sleep until 11:00 AM. During this interview, CNA #1 was observed entering Resident #67's room at 9:29 AM and the CNA asked the resident if they were ready for AM care, Resident #67 stated not until 11. The undated Kardex (guide used by staff to provide care) documented Resident #67 had no preference for time to get up in the AM. During an interview on 7/20/22 at 10:03 AM, the Director of Recreation Services stated they complete resident preferences based on the MDS questions, and that preferred time to get up in the AM is not specifically asked. Additionally, if a resident expressed a specific preference on a time to get up in the AM the facility would accommodate that request. 3. Resident #88 admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented the resident had moderate cognitive impairment, required total assistance of one staff member with bathing, it was very important for the resident to choose between a tub bath, shower, bed bath, or sponge bath, and there was no rejection of care. During an interview on 7/18/22, Resident #88's responsible party stated Resident #88 had not received a shower since June (2022). The undated CNA (certified nurse assistant) assignment sheet documented Resident #88's scheduled bath day was Mondays on the day shift. Additionally, the assignment sheet documented do not change the bath days please! These are set times the Unit Manager has set up and wants left alone. The (electronic documenting system) (CNA documentation) dated 6/1/22 through 7/20/22 revealed no documented evidence Resident #88 received showers during the time frame. Review of nursing progress notes dated 6/1/22 through 7/20/22 contained no documented evidence Resident #88 refused showers. During an interview on 7/21/22 at 9:31 AM RN #1 Unit Manager stated they were unaware Resident #88 had not been showered. During an interview on 7/22/22 at 9:31 AM the Director of Nursing (DON) stated the CNA's document the type of bath (full, partial, refusal, shower) in the computer system each shift. Additionally, if a shower was missed the facility would attempt to accommodate a shower on the next shift. 415.5 (e)(1)

Based on interview and record review conducted during the Standard survey completed on 8/2/19, the facility did not implement written policies and procedures for screening employees that would prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, the facility did not provide documentation that verified four (Employees #4, 5, 6, 7) of eight employees who were subject to the New York State (NYS) Nurse Aide Registry had not been screened through the NYS Nurse Aide Registry prior to their employment. The findings are: Review of the facility policy titled Employee Files dated 11/2016, revealed all applicants, for all departments, must be screened through Prometric (outside contractor that maintains the NYS Nurse Aide Registry) to confirm if the person in question has ever worked as a Certified Nurse Aide (CNA) and/or ever had any disciplinary actions enforced. A copy of the findings to be reviewed for status and placed in the permanent file. 1. Review of Employee #4's (Human Resources (HR) Coordinator) personnel file on 7/29/19 revealed Employee #4 was hired by the facility on 5/13/19. There was no documentation that the NYS Nurse Aide Registry was checked for Employee #4. 2. Review of Employee #5's (Licensed Practical Nurse) personnel file on 7/30/19 revealed Employee #5 was hired by the facility on 5/14/19. There was no documentation that the NYS Nurse Aide Registry was checked for Employee #5. 3. Review of Employee #6's (Registered Nurse) personnel file on 7/30/19 revealed Employee #6 was hired by the facility on 5/16/19. There was no documentation that the NYS Nurse Aide Registry was checked for Employee #6. During an interview on 7/29/19 at 3:30 PM, the HR Coordinator stated the Nurse Aide Registry is checked and the verification sheet is printed for all new employees by the Receptionist. She further stated around mid-May, there was a new Receptionist and a new HR Coordinator, and there was probably a miscommunication in the training at that time. 4. Review of Employee #7's (CNA) personnel file on 7/29/19 revealed Employee #7 was hired by the facility on 6/24/19. Further review of the file revealed it contained a Pennsylvania State Nurse Aide Registry verification, titled Pulse Portal dated 5/22/19. There was no documentation that the NYS Nurse Aide Registry was checked for Employee #7. During an interview on 7/29/19 at 3:20 PM, the HR Coordinator stated at the time of hire, Employee #7 told her that she was working on getting her Pennsylvania Nurse Aide Certification transferred over to NYS and therefore she only checked the Pennsylvania Nurse Aide Registry for Employee #7. 415.4(b)(1)(ii)(a)(b)

Based on observation, interview and record review conducted during the Standard survey completed 8/2/19, the facility did not ensure that residents who require [MEDICAL TREATMENT] receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan for one (Resident #46) of one resident reviewed for [MEDICAL TREATMENT]. Specifically, there was no collaboration between the facility and the [MEDICAL TREATMENT] center regarding removal of the [MEDICAL TREATMENT] dressing post [MEDICAL TREATMENT]. The finding is: Review of the facility policy and procedure titled [MEDICAL TREATMENT] Documentation with a revision date 5/4/11 revealed under Shunt Care to monitor for bruit (whooshing sound of blood flow) and thrill (a buzzing vibration felt by palpitation) each shift and record in the Medication Administration Record/Treatment Administration Record (MAR/TAR), blood pressure (B/P) readings and blood specimens should not be drawn from the arm with the shunt. Between [MEDICAL TREATMENT] treatment, the skin over the internal AV (arteriovenous) fistula access site (a tube or device surgically implanted to create an artificial connection between an artery and a vein) requires only routine care with soap and water. Topical dressing will be required as per physicians order only. 1. Resident #46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS- a resident assessment tool) dated 5/15/19 documented the resident is understood, understands and is cognitively intact. The MDS further documented under section O the resident is receiving [MEDICAL TREATMENT]. During an observation on 7/31/19 at 8:10 AM, the resident was observed sitting outside of his room eating breakfast fully dressed. On the resident's right forearm was a cotton ball covered with approximately two four-inch crossed pieces of see through tape over his AV fistula site. At the time of the observation the resident stated that the taped cotton ball was from [MEDICAL TREATMENT] yesterday. During an observation on 7/31/19 at 10:53 AM, the resident was lying in bed sleeping. On his right forearm was a cotton ball covered with approximately two four-inch crossed pieces of see through tape over his AV fistula site. Review of the current Care Plan dated 5/29/19 revealed the resident is on [MEDICAL TREATMENT] due to [MEDICAL CONDITION] stage five. The resident is extremely non-compliant with [MEDICAL TREATMENT] and diet with interventions including [MEDICAL TREATMENT] Tuesday, Thursday, Saturday, fluid restriction 1500 ml (milliliters), no B/P or blood draws in arm with shunt and monitor site (fistula) for complications every shift. Review of the [MEDICAL TREATMENT] Logging form (used to communicate between the facility and the [MEDICAL TREATMENT] center) dated 5/11/19 through 5/21/19 documented, Access dressing to come off four hours after treatment. Review of the Physician Order Report dated 7/1/19 through 7/30/19 revealed orders to monitor fistula in right arm every shift for complications, check for bruit and thrill, bruising and bleeding. There was no documented Physician order for [REDACTED]. During an observation on 8/2/19 at 7:43 AM, the resident was sitting outside his room with the AV fistula on the site right forearm with a cotton ball covered with approximately two three-inch crossed pieces of see through tape over the AV fistula site. The cotton ball had a moderate amount of red drainage. At the time of the observation the resident stated that the taped cotton ball was from [MEDICAL TREATMENT] yesterday. During an observation on 8/2/19 at 10:21 AM, revealed AV fistula dressing remained over the resident's access shunt. During an interview on 7/31/19 at 1:05 PM with the [MEDICAL TREATMENT] Center Registered Nurse (RN) revealed the dressing should be removed after 4 hours of treatment. The [MEDICAL TREATMENT] Center RN stated, I do have to say he has come back for his next treatment with the dressing still on. During an interview on 8/2/19 at 10:29 AM, the Licensed Practical Nurse (LPN) #1 Charge Nurse revealed the [MEDICAL TREATMENT] Logging sheet goes with the resident to [MEDICAL TREATMENT]. The nursing home fills out the pre information and the [MEDICAL TREATMENT] center fills out the post information. When the resident returns, the aides get his weight the nurse checks his vital signs and his site. LPN #1 stated, I take off the bandage the next day because it's usually falling off by then. She was not sure when the dressing should be removed or if a physician's order to remove the dressing was needed. During an interview on 8/2/19 at 11:08 AM, the Nurse Practitioner stated she would expect the facility to have instructions from the [MEDICAL TREATMENT] center on how to care for the dressing and when it should be removed. I would expect the staff to let me or the MD (medical doctor) know what the recommendations are for an order. During an interview on 8/2/19 at 11:28 AM, the Director of Nursing stated she would expect the facility to have instructions from the [MEDICAL TREATMENT] center on how to care for the dressing. He's been with us a long time and they've ([MEDICAL TREATMENT] center) never told us what to do with the dressing. 415.12

Based on observation, interview and record review conducted during the Standard survey completed on 8/2/19, the facility did not ensure that residents who have not used anti-[MEDICAL CONDITION] drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record and residents who use anti-[MEDICAL CONDITION] drugs receive gradual dose reductions (GDR) and behavioral interventions, unless clinically contraindicated, in an effort, to discontinue these drugs for one (Resident #75) of five residents reviewed for anti-[MEDICAL CONDITION] medications. Specifically, there was a lack of behavior documentation that warranted the administration of an antipsychotic medication ([MEDICATION NAME]) and a lack of behavior documentation addressing the positive/negative effects of the antipsychotic on the resident. Additionally, there was a delay in acting upon recommendations for a GDR. The finding is: Review of a facility policy titled Antipsychotic Medication Policy dated 2/2018 revealed residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. The staff will observe, document, and report to the attending Physician information regarding the effectiveness of any interventions, including antipsychotic medications. 1. Resident #75 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS-a resident assessment tool) dated 6/10/19 revealed the resident had moderately impaired cognition. Review of a hospital Progress Note dated 4/11/19 documented the resident had voiced complaints of depression and was started on [MEDICATION NAME] (antidepressant)10 milligrams (mg) by mouth daily. Review of a physician's orders [REDACTED]. Review of a physician progress notes [REDACTED]. The staff report he just wants to spend time in bed. He will not participate in physical therapy. He does walk okay but gets agitated and paranoid when he is not in bed. Review of physician's orders [REDACTED]. Review of Facility Activity Report dated 5/1/19 through 5/11/19 revealed documentation that the resident's daily mood was calm and alert; every day through that time frame. There was no documented evidence for the use of the antipsychotic medication. Review of the 24-hour reports dated 5/9/19 through 5/16/19 lacked behavior documentation to support the initiation of the antipsychotic nor had they documented positive/negative effects following administration of the medication except for a Progress Note dated 5/13/19 that indicated no adverse effects. During an interview on 7/31/19 at 10:00 AM, Registered Nurse (RN) #1 stated she believed the [MEDICATION NAME] was started for weepiness and depression but that would be a question for the Physician. She did not know why there were no more behavior notes and stated, I would've been the one writing them and don't know why they weren't done. Interview with the Director of Nursing (DON) on 8/1/19 at 8:50 AM revealed she agreed there should have been more documentation on resident's behaviors to support the use of the antipsychotic. The Physician made the decision to start [MEDICATION NAME] due to a conversation with resident and staff. The resident wanted to spend all his time in bed and was agitated and paranoid when not in bed. He would not participate in therapy. Interview with Social Work (SW) on 8/1/19 at 11:30 AM revealed there are no other notes identifying any behaviors in the resident's medical record. The SW stated, I voiced to the Physician he (resident) felt edgy and the antipsychotic was ordered. During an interview on 8/1/19 at 1:45 PM, the Physician stated, I did not order [MEDICATION NAME] as an antipsychotic but for an adjunct to his depression. He (resident) had good results with [MEDICATION NAME] as an adjunct to antidepressant therapy. He had already been on the [MEDICATION NAME] and was still having depressive behaviors. Review of a Full Psychiatric Evaluation dated 5/26/19 revealed the Psychiatrist visited the resident for his depression. Currently treated with [MEDICATION NAME] 10 mg and [MEDICATION NAME] 5 mg every day. He presents with rapid pressured speech, flamboyant affect, little off, [MEDICAL CONDITION] verses a bit manicky. Mood is euphoric, affect hyperactive, no paranoia noted, no hallucinations (visual or auditory), and no [MEDICAL CONDITION]. Continue medication regimen. Further review of the Facility Activity Reports dated 5/12/19 through 6/28/19 revealed the resident was calm and alert without behaviors except for 6/3/19 when he commented he is unable to do anything. He needs nursing help and help to get his dead wife to heaven. The Physician ordered a urinalysis (urine test) as this was not a usual behavior for the resident. Recommendations from the Pharmacist dated 6/13/19 revealed recommendations for the Physician to review the use of [MEDICATION NAME] 5 mg by mouth daily started 5/12/19 and [MEDICATION NAME] 10 mg by mouth daily started 4/15/19. Review if GDR of the medication would be appropriate. Further review revealed the Physician agreed to the recommendations and signed the form on 6/18/19. During a phone interview on 8/1/19 at 1:48 PM, the Physician stated he would expect the recommendations be acted upon within 7 business days. 415.12(1)(2)(i)

Based on observation, interview, and record review conducted during the Standard survey completed on 3/2/18, the facility did not ensure that the resident environment remains as free of accident hazards as possible and that each resident receives adequate supervision and assistance devices to prevent accidents. One (Resident #112) of seven residents reviewed for accidents lacked evidence that planned interventions were implemented or revised. The finding is: The facility policy and procedure entitled Care Plans, Nursing dated 1/2018 revealed the Kardex Care Plan is to be completed and will act as a Care Plan which will reflect current day to day needs. Changes and Updates will be completed by the Unit Manager, Supervisor or Nurse. 1. Resident #112 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Date Set (MDS - a resident assessment tool) dated 2/8/18 documented the resident had severe cognitive impairment, usually understands, is usually understood. Additionally, the MDS documented the resident required the assistance of two people for bed mobility, transfer, dressing, toilet use and personal hygiene. The MDS documented the resident had two or more falls. An Incident Report dated 2/1/18 at 7:50 PM documented the resident was found on the floor in her room next to her bed. The planned intervention was for floor mats to both the left and right sides while the resident was in bed. An Incident Report dated 2/2/18 at 1:15 AM documented the resident sustained [REDACTED]. An Admission assessment dated [DATE] revealed the resident was at risk for falls. The Fall Risk Assessment Tool & Guidelines dated 2/22/18 and 2/28/18 documented the resident had a score of 13. A score of 12 or above indicated a greater risk of falling. The current Comprehensive Care Plan (CCP) dated 2/19/18 documented the resident was at risk for falls related to cognitive impairments, unsteady gait, weakness and [DIAGNOSES REDACTED]. Interventions included, to see Kardex (guide used by staff to provide care) for preventative and protective devices for falls. The current undated Plan of Care, used by Certified Nurse Aides (CNAs) to provide care, documented instructions for floor mats to the left and right side of the bed for safety. Additionally, Geri-gloves (hand/ arm protectors) or long sleeves were to be worn at all times (AAT). During an observation on 2/27/18 at 9:26 AM with CNA #5, the resident was wearing a short-sleeved gown with arms exposed during a transfer from the wheel chair to the toilet. Steri-strips were observed on the resident's left forearm. During an observation on 2/28/18 at 7:38 AM, the resident was sleeping in bed without floor mats on either side of the bed. During an observation on 2/28/18 at 7:59 AM, CNA #5 was washing and dressing the resident's upper body. The resident was not wearing Geri-gloves and had a short-sleeved gown on with arms exposed. During an observation on 2/28/18 at 2:25 PM, the resident was sleeping in bed without floor mats on either side of the bed. During an interview and observation on 2/28/18 at 3:09 PM, CNA #2 stated she is assigned to the resident and was not familiar with the resident. The CNA did not know if the resident was care planned for floor mats. The CNA reviewed the Kardex (Care Plan) and revealed the resident was to have floor mats on the left and right side of the bed. The CNA walked into the resident's room, the resident was in bed without floor mats on either side of the bed. She stated if the floor mats are in the room and not on the floor, they are stored against the wall. The CNA stated the floor mats were not in the room. During an interview on 2/28/18 at 3:15 PM, Registered Nurse (RN) Nurse Manager (RN #3) stated the floor mats were necessary for safety related to the resident's history of falls. The floor mats were not in the resident's room because while the resident was in the hospital the floor mats were taken for another resident. The resident had not had floor mats since her readmission on 2/22/18 because of there were not any floor mats available. RN #3 stated that she had contacted the Maintenance department a couple of times and believed the mats have been ordered. RN #3 also stated the Maintenance department and the Director of Nursing (DON) were made aware there were no floor mats available. During an interview on 2/28/18 at 3:32 PM, the DON stated floor mats are kept in the clean utility rooms for the staff to obtain as needed for residents. The DON stated that she was not aware floor mats were not available. The Maintenance department was responsible to order them and does not have any knowledge of how floor mat usage was tracked. During an interview on 2/28/18 at 3:36 PM, the Maintenance Department Director stated he was aware there may be a shortage of floor mats because of the increase usage and he was in the process of replacing old torn floor mats with new floor mats. He revealed he does not have a tracking system and does not know how many floor mats are in use or how many are available. He said he was not aware there were not mats available for this resident and that the last time he ordered floor mats was about three months ago. He said he would place a floor mat order today and they would be delivered in a couple of days. During an observation of morning care on 3/1/18 at 7:35 AM with CNA #3 and CNA #4, the resident did not have long sleeves or Geri-gloves on prior to initiating AM care, and a short-sleeved gown was removed. During an interview on 3/1/18 at 8:22 AM, CNA #3 revealed the resident was supposed to wear long-sleeves or Geri-gloves on AATs. The reason for the long-sleeves or Geri-gloves was because the resident had fragile skin and a history of skin tears. The CNA did not believe the facility had long sleeved gowns and had not seen Geri-gloves on this resident. During an interview on 3/1/18 at 8:28 AM, RN #3 Nurse Manager said the resident should have had either Geri-gloves or long sleeves on at all times for her fragile skin, and did not recall seeing Geri-gloves on this resident while wearing a short-sleeved gown. During an interview on 3/2/18 at 9:58 AM, CNA #5 stated he works the day shift and this resident is usually on his assignment. He has not seen floor mats in the resident's room for this resident since her readmission and did not recall removing long sleeves or Geri-gloves from this resident during morning care. CNA #5 stated the resident should have had Geri-gloves on during the night for her fragile skin. 415.12(h)(1)

Based on interview, and record review conducted during the Standard survey completed on 3/2/18 the facility did not assure that each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas and are knowledgeable about the resident's status, needs, strengths, and areas of decline. Four residents (Residents #11, 73, 98 and 102) of 26 residents reviewed for accuracy of the Minimum Data Set (MDS - a resident assessment tool) had issues. Specifically, the lack of an accurate assessment to reflect a fall (Resident #11), lack of an accurate assessment to reflect the most recent gradual dose reduction GDR of [MEDICAL CONDITION] medications (Resident #73, 98) and the inaccurate coding of the use of a restraint (Resident #102). Review of the policy and procedure entitled MDS 3.0 Care Area assessment dated ,[DATE] revealed after MDS completion the MDS will be printed by the Unit Manager, for the initial Admission, quarterly, and annual reviews. The responsible discipline will then address the pertinent area of concern. The findings are but not limited to: 1. Resident #11 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed the resident was cognitively intact, understood and understands. The MDS documented the resident had no falls since admission, entry or reentry or the prior assessment. A Facility Accident/ Incident Report dated 2/6/18 documented the resident was found on the floor on her knees in the bathroom sustaining a scratch and abrasion to the nose. The Comprehensive Care Plan (CCP) dated 2/6/18 identified as current documented the resident was at risk for falls related to an unsteady gait and was found on the bathroom floor by staff. The plan was to never leave the resident unattended in the bathroom. The undated Kardex (guide used by staff to provide care) identified as current revealed a revision that included, Do not leave alone on toilet. During an interview on 2/28/18 at 11:49 AM, MDS Nurse (LPN #1) stated when completing a MDS assessment she would review the clinical record and visually inspect the resident. LPN #1 is responsible to complete the fall section of the MDS. The MDS is signed off by the Registered Nurse (RN) Unit Manager for completion, but for not accuracy. She did not identify the fall on the assessment and should have coded the MDS to reflect a fall with injury. During interview on 2/28/18 at 12:15, RN Unit Manager (RN #1) stated he signs the MDS for completion and does not review every section. During interview on 2/28/18 at 1:01 PM, the RN MDS Coordinator stated she would expect all members of the interdisciplinary team to make sure assessments are completed accurately and the fall should have been captured on the MDS. During an interview on 3/2/18 at 10:47 AM, the Director of Nursing (DON) stated she would expect a nurse doing any kind of resident assessment, look at the resident, review the clinical record and code the assessment accurately. 2. Resident #98 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] revealed the resident was severely cognitively impaired, usually understood and understands. The MDS documented the last GDR of a [MEDICAL CONDITION] medication was on 9/9/17. The CCP revised 12/27/17 documented the use of [MEDICAL CONDITION] drugs related to [MEDICAL CONDITION]. The CCP documented the medication [MEDICATION NAME] (antipsychotic) was successfully discontinued. Review of the Medication Administration Record [REDACTED]. Review of the current physician's orders [REDACTED]. During interview on 2/28/18 at 11:49 AM, the MDS Nurse (LPN #1) stated she only had access to the last 14 days of the Medication Administration Record [REDACTED]. During an interview on 3/2/17 at 10:47 AM with the Director of Nursing (DON) stated she was unaware the MDS Nurse (LPN #1) did not know how to access the MAR indicated [REDACTED]. 3. Resident #102 was admitted into the facility on [DATE] and has [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed that the resident was moderately impaired and is understood and understands. The MDS Section P (Restraints and Alarms) was coded as a 2, indicating the resident had a limb restraint and was used daily in the chair or out of bed. Physician order [REDACTED]. The Comprehensive Care Plan dated last Care Conference 1/24/18 and CNA (Certified Nurse Aide) Plan of Care revealed there was no indication that a restraint was being used for Resident #102. During an interview on 2/28/18 at 3:11 PM, LPN #1 stated the MDS dated [DATE] was marked wrong for the use of a restraint. The resident did not have a restraint and this was an error. LPN #1 stated that they sent in a correction for this yesterday 2/27/18. LPN #1 stated that she completed the section for restraint use (Section P). Additionally, once all the sections are completed the MDS is then signed by the RN Unit Manager. LPN #1 stated that the RN does not review her work. They just sign off on the MDS. 415.11(b)

Based on observation and interview during the Standard survey completed on 11/18/16, the facility did not store, prepare, distribute, and serve food under sanitary conditions. Issues included cleaned and sanitized pot, pans, pan lids, plate covers, bowls and plastic bins that were ready for use, were stacked together wet and not air dried after being sanitized. Pans, pan lids, pan handles, and plate covers that were ready for use, were soiled with food debris, grease, greasy substances, and/or rust. A plastic bin containing cleaned and sanitized pan lids, contained food debris and crumbs. Cleaned and sanitized knives and spatulas were stored in a drawer that was soiled with food debris and crumbs. Cleaned and sanitized knives and a spatula were stored in a cardboard box that was solied with food debris and crumbs. This affected one (Main Kitchen) of one Main Kitchen. The findings are: 1. Observation in the Main Kitchen on 8/15/16 at approximately 8:36 AM revealed the following: - Ten cleaned and sanitized pots and pans were stored on a clean pot and pan rack, wet stacked together and unable to individually air dry. Water was observed dripping from them when they were pulled apart. Further observations at this time revealed that six of the pans were soiled with white and tan colored food debris and grease. - 20 cleaned and sanitized plate covers were stored on the counter top, wet stacked together and unable to individually air dry. Three of the plate covers were soiled with white colored food debris. - Two pan lid handles were rusted. The screws on the interior of pan lids, that connected the handle to the pan, were rusted. - Ten cleaned and sanitized pan lids stored in a plastic bin on the clean pot and pan rack, were soiled with greasy substances, brown, red, tan, and yellow colored food debris. The bottom of the plastic bin was also soiled with brown, red, yellow and tan colored food debris and crumbs. - Cleaned and sanitized knives and spatulas were stored in a drawer, where the bottom of the drawer was soiled with brown and tan colored food debris and crumbs. 15 knives and one spatula were stored in an open cardboard box, inside the drawer, that was falling apart, partially tapped together with clear colored tape, and soiled with brown and tan colored food debris and crumbs. - Six cleaned and sanitized plastic bins, stored under the counter at the Cook's station, were wet stacked together and unable to individually air dry. Water was observed dripping from them when they were pulled apart. Interview with the Director of Nutritional Services at the time of theses observations revealed the pots, pans, pan lids, plate covers, knives, spatula, and plastic bins were ready for resident use. 415.14(h) New York State Sanitary Code Subpart 14-1 14-1.110(b) 14-1.110(c) 14-1.110(d) 14-1.116

Based on observation, record review, and staff interview during a complaint investigation (Complaint #NY 340) during the Standard survey completed 11/18/16, the facility did not ensure that residents were provided with adequate supervision to prevent accidents and that the resident environment remains as free of accident hazards as possible. Two (Residents #7, 51) of five residents reviewed for accidents had issues involving the lack of adequate supervision for the prevention of falls in accordance with the care plan (#7) and the lack of adequate supervision after a resident was found with plastic bags over his head and covering his face (#51). In addition, one (Activity room) of two electric fireplace heaters rooms observed for safe operating temperatures had a metal vent that was very hot to touch and not shielded from resident access. The findings are: 1. Resident #7 has [DIAGNOSES REDACTED]. Review of the quarterly MDS (Minimum Data Set - a resident assessment tool) dated 11/4/16 revealed that the resident has severe cognitive impairment, understands, and is understood. Review of the Comprehensive Care Plan (CCP) dated 8/9/16 revealed the resident was identified at risk for falls related to unsteady gait and weakness. Review of Incident Reports revealed the resident had two falls during October 2016 as follows: - 10/23/16 at 4:45 PM - The resident was sitting on the edge of the bed and slid to the floor. The care plan was updated to keep the resident up in the wheelchair during the day to watch TV. - 10/28/16 at 4:20 PM - The resident requested to lay down for a nap. The bed alarm was sounding and the resident was found on the floor next to the bed. The resident sustained [REDACTED]. The care plan was changed to place the resident at the Nurses' Station during the day and add a floor mat at the right side of the bed. Additional review of the CCP revealed the care plan was updated on 10/23/16 to include keeping the resident up in the wheelchair during the day to watch TV versus being in bed. It was further updated on 10/28/16 to place the resident at the Nurses' Station during the day. Review of the CCP dated 11/8/16 revealed the resident was identified at risk for falls related to unsteady gait and weakness. The previously updated interventions were not carried over to the current CCP. Review of the Pocket Care Plan, used by certified nurse aides (CNAs) to provide care, dated 11/11/16 included plans for the use of chair and bed alarms and a left orthopedic shoe out of bed. The current Kardex included an additional intervention to keep the resident at the Nurses' Station during the day. Intermittent observations from 11/14/16 through 11/16/16, between the hours of 9:00 AM and 3:00 AM revealed Resident #7 was sitting in her room, unsupervised, watching TV. Interview with a Registered Nurse (RN #1) on 11/17/16 at 9:33 AM revealed the resident is to be in view of the Nurses' Station. The RN stated that the resident self-propels her wheelchair at times and ends up in her room. During an interview on 11/17/16 at 11:28 AM, a Certified Nurse Aide (CNA #1) stated that the resident sits at the Nurses' Station during the day. The CNA stated that the resident can only wheel her wheelchair a very short distance and not far enough to get to her room. Review of an undated policy and procedure entitled Accident/Incident Investigation Report revealed the resident's risk factors are to be discussed at the next CCP meeting. Reviews/revises interventions accordingly. 2. Resident #51 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is cognitively intact, understands, and is understood. Further review of the MDS revealed there were no reported mood or behavior symptoms. Review of a Nursing Progress Note, written by RN #5, dated 8/21/16 at 7:14 PM, revealed the resident was found in his room lying in bed with two small plastic garbage bags over his head and the RN promptly removed the bags. The resident stated that his ex-wife was out to get him and was calling the cops to have him arrested. The RN reassured the resident that he was safe in the building and the Nursing Supervisor was notified immediately. The RN documented that the resident's garbage can was removed from the room and the resident was moved to the lounge for supervision. The next Nursing Progress Note was written by the RN (#4) Nursing Supervisor and dated 8/22/16 at 6:16 AM. The Nursing Supervisor documented that she was made aware of increased confusion of resident at 7:14 PM on 8/21/16. The resident was placed on q (every) one hr (hour) safety checks; plastic trash bags were removed from the resident's room; and the resident was moved to the resident lounge area for closer supervision. The RN Nursing Supervisor documented that she checked on the resident at 11:00 PM on 8/21/16, at 2:00 AM on 8/22/16, and at 4:00 AM on 8/22/16. The resident was in his room lying in bed with his eyes closed,for all three checks. Per conversation with overnight staff,the resident did not present with an increased level of confusion on overnights and staff did perform q one hr safety checks as per facility policy. Review of entire medical record, including Nursing Progress Notes, revealed there was no further RN documentation between 7:14 PM on 8/21/16 and 6:16 AM on 8/22/16. Review of a CNA Safety Checks - q (every) 1 hour Whereabouts sheet dated August 2016 revealed the resident's whereabouts were documented hourly from 8/21/16 at 7:00 PM through 8/22/16 at 12:00 PM. Review of the 24 Hour Report dated 8/22/16, from 10:00 PM to 6:00 AM revealed the resident was on hourly checks. Review of an Incident Report, signed by the RN (#3) Unit Manager on 8/22/16 revealed Recommendations for preventive measures not already in place/additional corrective measures taken included Q one hour safety checks initiated. Resident sent to hospital for evaluation. All items removed from room that would cause a safety hazard and kept safe until he left. Review of the comprehensive Care Plan, Next Care Conference - 10/14/16, revealed the following: - Problem: 8/21/16, Res (resident) found in room with bags over his head. Unsure of what/why he was doing this d/t (due to) his recent change in behaviors and d/t he likes to cover his head with blankets. - Approach: 8/21/16, remove bags from room as well as garbage cans. Place on 1:1 (one person assigned to observe/supervise resident at all times) safety checks x (times) 48 hours - then continue q one hr safety checks. Bring res out of room for closer supervision. Interview with the Director of Nursing (DON) on 11/17/16 at approximately 2:57 PM revealed Staff did monitoring and safety checks. Staff should have placed the resident on 1:1, do suicide precautions, call the MD, call the family, get orders, and keep plans in place to maintain safety. The interview further revealed that the Care Plan Problem and Approach dated 8/21/16 were handwritten on the Care Plan by the DON on 8/22/16. During a telephone interview on 11/17/16 at approximately 2:39 PM, the RN (#4) Nursing Supervisor stated I went to the unit, he was in no distress so we moved him to the lounge. He was in the lounge with 1:1 for a good while. Without being there to see the Incident) Report, I can't say how long he was on 1:1. Interview with RN #5 on 11/17/16 at approximately 7:14 PM revealed I was going in to give the resident his medications and he had two plastic bags over his head with his hands at his neck holding the bags. I immediately removed the plastic bags from his head and threw the garbage can towards the door. I talked to him for a few minutes and got a CNA to stand at the door when I went and called the supervisor. The supervisor said to bring him to the lounge area and to start q one hour safety checks. There was no 1:1 on the 2-10 (2:00 PM -10:00 PM) shift. My thought was he needed to be evaluated, needed to be sent out. I kept my med (medication) cart at the Nurses' Station and ran to rooms to give meds so I could keep an eye on him. Interview with the RN (#3) Unit Manager on 11/18/16 at approximately 7:59 AM revealed When I came in (on 8/22/16 - 6:00 AM - 2:00 PM), he was calm and seemed fine, he was in bed curled up under a blanket. He was not on 1:1, he was on the q one hr safety checks and was easily redirected. The Social Worker came in that morning and was upset that she had not been called the night before when all of this was happening. The Social Worker called the hospital and arranged transportation for the resident to be evaluated at the hospital. Review of a facility policy and procedure entitled Suicide Prevention Protocol dated 5/96 revealed staff are to Closely observe the resident, including safety checks at intervals determined by charge nurses. 3. Observation of the main Activities Room on 11/15/16 at approximately 10:02 AM revealed an electric fireplace-style heater was plugged into a power strip that was plugged into a duplex electrical outlet in the room. The heater was on and running. Further observation at this time revealed an approximate two foot long by three inch wide metal vent on the front of the fire place was hot to the touch and the following was written on the front of the heater to the left of the vent: Caution - High Temperature risk of fire, keep electrical cords, drapery, furnishings, and other combustibles at least three feet from the front of the heater and away from the sides and rear. Continued observation revealed the temperature setting of the heater was set on high and the temperature control knob was missing. Continued observation revealed the following: - The metal vent was approximately two feet from the floor's surface and there was no barrier between it and the front of the heater. The vent was easily accessible to a person standing or sitting in front of the heater. - A wooden shelving unit was stored directly against the left and right hand sides of the heater and both of the shelving units had holiday decorations stored on them. - No residents or Activities staff were in the Activities room at the time of the observation. Interview with the Maintenance Supervisor at the time of the observation revealed he was not aware that the metal vent got hot and thought the electric fireplace-style heater had a light bulb in it for atheistic purposes only. Further interview with the Maintenance Supervisor at the time of the observation revealed he was not aware the electric fireplace-style heater had a heating element and that it functioned as a heater. Observation on 11/15/16 at approximately 10:12 AM revealed the metal vent on the front of the electric fireplace-style heater had a temperate of 250 degrees Fahrenheit (°F) when the Maintenance Supervisor took its temperature with an infrared laser thermometer from approximately one foot from the front of the heater. Interview with the Director of Recreation on 11/15/16 at approximately 10:15 AM revealed she turned the fireplace on at approximately 8:30 AM on 11/15/16 by turning on the power strip that the fireplace was plugged into. Further interview with the Director of Recreation at this time revealed she usually plugged the fireplace in when she can, into the building in the morning to heat up the Activities room. Interview with the Director of Recreation on 11/15/16 at approximately 10:26 AM revealed she had been working at the facility for [AGE] years, she had no documentation for the fireplace, and the electric fireplace was in the Activities room when she started working at the facility. Review of the User's Operating Manual provided by the facility on 11/17/16, for the electric fireplace-style heater that was located in the Activities room, revealed the following: Important Instructions: When using electrical appliances, basic precautions should always be followed to reduce the risk of fire, electric shock, and injury to persons, including the following: - Extreme caution is necessary when a heater is used by or near children or whenever the heater is left operating and unattended. - Always unplug the heater when not in use. Safety Information: - Caution: High temperatures! Keep draperies, electrical cords and other furnishings at least three feet (0.9 meters) from the front and away from the sides and rear of the heater. - Warning: 1. Risk of fire - keep combustible material away from the front of the electrical fireplace. - 9. Never leave the appliance unattended while it is in use. - 11. Always remove the plug from the socket when the appliance is not in use and each time before it is cleaned. - 12. Danger! Nominal voltage is still present in the appliance as long as the appliance is connected to the electrical source. Special Security Advice: - The warm air vent becomes very hot during operation. During operation, only touch the appliance's switches and handles. - The appliance must not be moved when hot. Never touch the hot parts with your bare skin. Review of information provided by the facility on 11/17/16 for the infrared laser thermometer that was used to take the temperature of the metal vent on the front of the electric fireplace-style heater revealed the following: Instant Temperature Measurement - This handy household tool also features laser visual guidance, so you'll always know you're scanning the right spot. It makes for better accuracy and easier operation. - Safely measure extreme temperatures ranging from -58 degrees Fahrenheit (°F) (-50 degrees Celsius) (°C) to 1022 degrees Fahrenheit (°F) (550 degrees Celsius) (°C) without ever needing to come in contact. Use the infrared temperature scanner for a high range applications, from internal components to oven temperatures. With a temperature range that surpasses the boiling points, the possibilities are endless. Note - For best accuracy, the distance between the thermometer and the object should be approximately 14.17 inches (36 centimeters). Simple operation - Point and Click! -It turns on and begins reading temperature with one press of the trigger. 415.12(h)(1,2)

Based on interview and record review conducted during a Complaint investigation (Complaint #NY 340) during the Standard survey completed on 11/18/16, the facility did not ensure that each resident received the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being. One (Resident #51) of five residents reviewed for quality of care related to accidents lacked a comprehensive Registered Nurse (RN) assessment of physical and mental status when the resident was found in his room with two plastic bags over his head, covering his face. The finding is: 1. Resident #51 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 7/1/16 revealed the resident is cognitively intact, is understood and understands. Further review revealed no reported mood or behavior symptoms. Review of a Progress Note dated 8/21/16, written by RN #5, revealed the following: -7:14 PM Nursing: Resident found in room lying in bed by writer with two small plastic garbage bags over his head. Writer promptly removed the bags. Spoke with resident who stated that his ex-wife was out to get him and calling the cops to have him arrested. Writer reassured the resident he was safe in the building. Nursing Supervisor notified immediately. Resident's garbage can removed from the room as well as resident moved to lounge for supervision. Review of the next Progress Note dated 8/22/16, written by RN #4 Nursing Supervisor, revealed the following: -6:16 AM Nursing: Writer made aware of increased confusion of resident at 7:14 PM on 8/21/16. Resident placed on q (every) one hr (hour) safety checks, plastic trash bags removed from resident's room, resident moved to resident lounge area for closer supervision. Writer checked on resident at 11:00 PM on 8/21/16, at 2:00 AM on 8/22/16, and at 4:00 AM on 8/22/16. Resident in room with eyes closed and lying in bed for all three checks by writer. Per conversation with overnight staff, resident did not present with an increased level of confusion on overnights. Staff did perform q one hr safety checks as per facility policy. Review of Search Vitals Results, Vital Signs: Temperature, Pulse, Respirations, Blood Pressure, O2 (oxygen saturation), Blood Sugar (BS), Vitals Taken From 8/1/16 to 8/31/16 revealed the following documented vital signs for 8/21/16 through 8/22/16: -8/21 at 7:05 AM BS 125 (normal 60 -120) -8/21 at 7:04 PM BS 155 -8/22 at 7:01 AM BS 118 Review of entire medical record revealed no evidence the resident's temperature, pulse, respirations, blood pressure, O2 saturation were monitored after the two plastic bags were removed from over the resident's head. Review of entire medical record revealed no evidence the resident's mental status to include harm, anguish, and /or lethality were monitored. Review of entire medical record revealed no further RN documentation between 7:14 PM 8/21/16 and 6:16 AM on 8/22/16. Interview with the Medical Director on 11/17/16 at approximately 4:07 PM revealed the Medical Director's expectation would be for nursing to complete a full assessment of the resident, to include vital signs, a physical assessment, and a mental assessment to see where the resident is at mentally. Assess pulse ox (pulse oximetry - amount of oxygen in the blood), if everything is completely normal, follow protocol, and ship them out. Review of facility policy entitled Accident/ Incident Investigation Report included to assess for injury - physical or mental harm/anguish. 415.12

Based on observation, interview, and record review conducted during a Standard survey completed on 11/18/16, the facility did not periodically review and revise the Comprehensive Care Plan. Two (Residents #19 and #123) of three residents reviewed for dental status lacked care plan revisions to reflect that the family declined the dental consult recommendations (Resident #123) and dental recommendations to improve the resident's oral hygiene (Resident #19). The findings are: 1. Resident #123 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 8/4/16 revealed the resident is understood, understands, and is moderately impaired in daily decision making. During an observation on 11/15/16 at approximately 9:44 AM the resident was noted to have several missing and broken teeth. Review of Dental Consult dated 7/20/16 included the following: - Resident has upper and lower natural dentition in fair/poor condition. Pt (patient) has gingivitis (form of gum disease that causes inflamed gums), staff needs to brush teeth along the gum line better. Schedule Pt in my office for x-rays and possible extractions. Affixed to the 7/20/16 Dental Consult was an undated, unsigned sticky note with the following written: - Talked to wife and son, did not want to go for f/u (follow-up) with x-rays and extraction. Review of facility Plan of Care, last updated 9/7/16, included the resident required extensive assistance with personal hygiene and has natural teeth. Review of Care Plan, Last Care Conference: 11/10/16, included the resident requires assistance with ADL's (activities of daily living) including oral care. The documented care plan goal is for the resident to maintain current ADL status for three months. Care Plan approaches included assist with ADL's, including oral care per CNA (certified nurse aide) Kardex (care guide used by staff to provide care). Further review of Care Plan, Last Care Conference: 11/10/16, included the Problem: Family dynamics/ conflicts. Review of the Care Plan Problem, Goal, and Approaches revealed no documentation in the Care Plan of the family refusal to comply with the 7/20/16 Dental Consult recommendations. Interview with Registered Nurse (RN #3) Unit Manager on 11/17/16 at approximately 12:37 PM revealed, We don't have a specific dental care plan, if there were recommendations from the dental consult I guess it could go on the ADL care plan, but right now we don't have that care planned. During an interview with the Director of Nursing (DON) on 11/18/16 at 8:11 AM, the DON stated that if there was a resident or family refusal to comply with dental recommendation, it would be documented in a non-compliance or family dynamics comprehensive care plan (CCP), depending on the situation. The DON further stated that if the concern was the resident not wearing dentures than that situation could be included in the dental status section of Activity of Daily Living CCP. Review of facility policy entitled Dental Policy, updated 8/19/2011, included the following: - A Comprehensive Care Plan will be established to include dental treatment goals for each resident and based on individual need. - Every resident will receive oral hygiene care, as permitted by the resident, on a regular as needed basis as described in his/her care plan and/or as prescribed by a physician or dentist. 2. Resident #19 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is cognitively intact, understands and understood. Review of the Dental Consult form revealed on 10/26/16 the dentist documented, Patient has sore 'upper right hand side'. Exam does not show any problem. Told patient to brush gums better. Review of the CCP revealed the problem area dated 6/15/16, that the resident needs assistance with the following ADL's; oral care, washing, dressing, repositioning, transferring, ambulation, mobility, toileting and eating. Review of the undated Kardex revealed in the area of personal hygiene that the resident requires limited assistance of one person to encourage the resident to complete oral care. The CCP does not include the dental recommendations for the resident to brush the gum better. During an interview with the RN #1 Unit Manager on 11/17/16 at 11:42 AM, the RN #1 stated that the Quality Assurance Assistant to the Director of Nursing keeps all Dental Consult forms in a binder in a front office of the facility. The RN Unit Manager stated she was told that the resident had gingivitis and needed to brush better. The RN stated there was not a specific care plan for dental status and did not know if she should include the dental recommendations in the resident's comprehensive care plan. Interview with the DON on 11/18/16 at 8:11 AM, the DON stated that the Kardex should include every day dental care issues for the resident. 415.11 (c)(2) (iii)

Based on interview and record review conducted during a complaint investigation (Complaint # NY 823) during the Standard survey completed on 11/18/16, the facility did not provide pharmaceutical services to meet the needs of each resident. One (Resident #159) of one resident reviewed for pain management had an issue involving the lack of timely acquisition and administration of ordered pain medications. The finding is: 1. Resident #159 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS- a resident assessment tool) Entry Tracking Record revealed the resident was admitted to the facility on [DATE]. Review of a Physician order [REDACTED]. - Lyrica (Pregabalin) - a Schedule V controlled substance with low potential for abuse - used to treat nerve and muscle pain and seizures) capsule 100 mg (milligrams) twice a day at 8:00 AM and 8:00 PM. - Morphine - (Schedule II controlled substance with high potential for abuse) tablet extended release; 60 mg; one tab; oral for pain twice a day at 8:00 AM and 8:00 PM. Review of a Medications Administration History dated 9/23/16 to 10/1/16 revealed the Lyrica and Morphine were both scheduled to be administered twice a day at 8:00 AM and 8:00 PM, beginning on 9/23/16 at 8:00 PM. Review of a Physician Telephone Order dated 9/23/16 revealed an order to Hold Lyrica and Morphine until available from pharmacy. Further review of the Medications Administration History dated 9/23/16 to 10/1/16 revealed the Lyrica and Morphine were not signed as administered at 8:00 PM on 9/23/16 with Special Instructions to Hold until available from pharmacy. Review of a Physician Telephone Order dated 9/24/16 revealed the following order: - Ok to use home medications of Morphine extended release 60 mg po (by mouth) bid (twice a day) and Lyrica po 100 mg bid from home until available from pharmacy. Interview with a Registered Nurse (RN #5) on 11/17/16 at approximately 7:29 PM revealed The resident was very upset about his meds not being available from pharmacy. He was requesting the medications during the shift and questioning when the meds would be delivered from the pharmacy. He wasn't really in pain, more anxious about not having the meds to prevent pain. His next door neighbor brought the medication to the facility around midnight and the 8:00 PM doses of Morphine and Lyrica were given then. Interview with the Director of Nursing (DON) on 11/17/16 at approximately 1:55 PM revealed We met with pharmacy about four to six weeks ago to come up with a better plan for these instances. Medications sometimes don't arrive from the pharmacy until two or three in the morning. We are still working on some sort of plan to get medications to the facility quicker. Review of an undated facility policy entitled Delivery of Medications from Satellite (Back-Up) Pharmacy revealed the purpose of the policy is to provide medications in a timely manner by utilizing satellite (back-up) pharmacies to dispense medications that are needed by a facility sooner than the facilities regularly scheduled delivery. The procedure documented that Controlled Medications (all schedules) may not be called into a back-up pharmacy. 415.18(a)

Based on observation, interview and record review conducted during the Standard survey completed on 11/18/16, the facility did not maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. One (West Unit) of three resident units observed for infection control practices had an issue involving the lack of proper disinfection of a blood glucose meter after resident use. The finding is: 1. Resident #163 has [DIAGNOSES REDACTED]. Review of a Physician order [REDACTED]. During an observation on the West Unit on 11/14/16 at approximately 8:11 PM, a Licensed Practical Nurse (LPN #1) entered Resident #163's room with a portable glucose meter obtained from the top drawer of the medication cart and requested permission from the resident to obtain a blood glucose level. The observation revealed that LPN #1 entered the resident's room with one disposable lancet (a device used to puncture the skin to obtain a small blood sample), one pre-packaged alcohol pad, one glucose monitor test strip, and the portable blood glucose meter. With gloved hands, the LPN inserted a test strip into the blood glucose meter; cleansed Resident #163's fingertip with the alcohol pad; punctured the fingertip; and obtained a sample of blood. The LPN then picked up the blood glucose meter and touched the tip of the blood glucose test strip to the droplet of blood on the resident's fingertip. Once a glucose reading was obtained on the meter, the nurse disposed the test strip and lancet into a red sharps container on the medication cart; placed the blood glucose meter onto the top of the medication cart; removed her gloves; and washed both hands. LPN #1 then removed a disposable hand sanitizing wipe from a container on her medication cart and proceeded to wipe the blood glucose meter for approximately 30 seconds; she placed the blood glucose meter into a storage container; and placed the container into the top drawer of the medication cart. Interview with LPN #1 on 11/14/16 at approximately 8:28 PM revealed Usually I have antiviral wipes on my cart and wipe the glucose meter with them, but I don't have any on my cart tonight. I don't know if the hand wipes are effective for cleaning everything but I figured it was better than nothing. Interview with the RN Assistant Director of Nursing on 11/17/16 at approximately 10:45 AM revealed The glucometers (glucose meters) are supposed to be wiped with antimicrobial wipes and they should be wiped after every use. I expect the staff to clean it after every use like they are supposed to. I haven't had any cross contamination so far. Review of a facility policy and procedure (P&P) entitled Glucometer Monitoring Blood Glucose Test dated 6/16 revealed the following instructions: - Cleanse glucometer with Germicidal Wipes - Set cleaned glucometer on a clean barrier (another clean paper towel) - Let dry for two minutes - Place glucometer back in box, and store in med cart or in medication room. 415.19(a)(1)

Based on observation, interview, and review of facility records during the Standard survey completed 9/18/15, the facility did not store, prepare, distribute, and serve food under sanitary conditions. One of one Main Kitchen observed for sanitary conditions had issues involving cooked chicken breasts that were not properly cooled and the lack of an indirect drain on the food preparation sink. The findings are: 1. Observation in the Main Kitchen on 9/16/15 at approximately 11:55 AM revealed approximately 20 cooked chicken breasts were located in the walk-in cooler that had an internal temperature of 50.5 *Fahrenheit (F). During an interview on 9/16/15 at approximately 12:52 PM, the Cook stated that the chicken breasts were cooked in the morning and were taken out of the oven around 9:20 AM. The chicken breasts were then left on the counter to cool at room temperature until approximately 11:00 AM. The Cook stated that at 11:00 AM the chicken breasts were covered and placed in the walk-in cooler to finish cooling. When asked what the temperature was when the chicken was placed in the walk-in cooler, the Cook stated that she did not know because no temperature was taken. The Cook stated that the chicken was for lunch tomorrow. The Cook then stated that normally the chicken would be placed in a shallow pan with a pan of ice underneath to cool it. At that time, the internal temperature of the chicken was taken by the Director of Clinical Nutrition and it was found to be 45.9 *F. Review of the facility document entitled Proper Food Cooling Technique revealed that cooked potentially hazardous food must be cooled within 2 hours, from 140*F to 70*F, and within 4 hours, from 70*F to 40*F. The document revealed that the cooling methods to be used are to place the food in shallow pans, separate the food into smaller or thinner pieces, ice water bath, stir, and replenish ice as it melts. The document states to check the cooling temperatures and if the food has not reached 70*F within two hours or 40*F within an additional 4 hours, it may be reheated to the appropriate temperature and then cooled again. 2. Observation in the Main Kitchen on 9/16/15 at approximately 12:49 PM revealed that the sink identified by the Cook as a food preparation sink was located next to the stove and was equipped with a direct drain. Interview with the Food Service Director on 6/17/15 at approximately 9:44 AM revealed that the sink located in the kitchen next to the juice machine is normally used as a food preparation sink. Observation at the time of the interview revealed that the downspout of the sink was below the level of the funnel for the sewer plumbing, providing a potential cross connection between the sink drain and sewage system plumbing. 415.14(h) 14-1.40,14-140

Based on record review and staff interview, the facility did not provide each resident with sufficient fluid intake to maintain proper hydration and health. One (Resident #117) of one resident reviewed for dehydration was identified at risk for dehydration upon admission. The facility did not evaluate the resident's suboptimal fluid intake and did not revise the dietary meal plan to provide additional fluids to maintain adequate hydration. Specifically, Resident #117 received two diuretic (medication to promote the excretion of urine) medications, had ongoing loose bowel movements and did not consume adequate fluids to meet her estimated daily needs. This resulted in actual harm that is not immediate jeopardy. The finding is: 1. Resident #117 has [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] revealed the resident has moderate cognitive impairment, always understands, is understood and receives diuretic (medication to promote the excretion of urine) medication. Review of a hospital Discharge Summary dated 2/16/11 revealed the resident was hospitalized for [REDACTED]. During the hospitalization , the resident experienced perfuse diarrhea secondary to [MEDICAL CONDITION] ([MEDICAL CONDITION] - bacteria in the bowel that may cause diarrhea) colonization and "electrolyte derangement" (imbalance of the chemical composition of the body). Recommendations were to follow-up with the surgeon and institute contact precautions (isolation measures to prevent the spread of infection) for [MEDICAL CONDITION] colonization. Review of Physician admission orders [REDACTED]. Review of an Admission physician progress notes [REDACTED]. The Physician documented that since surgery, the resident "regained her eating" and is having bowel movements. Review of an Admission Nutritional Assessment completed by the Registered Dietitian (RD) dated 2/21/11 revealed the resident weighed 229.2 pounds (#) and estimated nutritional needs included 2200 cubic centimeters (cc) of fluid daily. The Nutritional Assessment documented recent laboratory results (2/15/11) included a BUN (blood urea nitrogen - blood test to determine kidney function and hydration status) of 11 (normal 7 to 17) and a creatinine level of 0.9 (normal 0.7 to 1.1). The Nutritional Assessment documented that the resident was on [MEDICATION NAME] and [MEDICATION NAME]. There was no documentation regarding the resident's history of [MEDICAL CONDITION] and electrolyte derangement. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Review of the 2011 Nursing Drug Handbook revealed the combined use of [MEDICATION NAME] and [MEDICATION NAME] ([MEDICATION NAME]) "may cause (an) excessive diuretic response, causing serious electrolyte abnormalities or dehydration". Review of the Comprehensive Care Plan (CCP) dated 3/3/11 revealed the resident was identified at risk for alterations in fluid/electrolyte balance secondary to daily [MEDICATION NAME] therapy on 2/16/11. CCP approaches included plans to administer medications per MD (Medical Doctor) order and monitor and record intake of food and fluids. Review of Meal Intake sheets dated 2/17/11 through 3/5/11 revealed the resident's fluid intake at meals ranged from 180 cubic centimeters (cc) to 1020 cc. The daily average fluid intake at meals was 535 cc. Review of the Intake/Output sheets dated 2/17/11 to 3/5/11 revealed the resident's total 24 hour fluid intake ranged from 300 cc to 840 cc and the average total fluid intake was 581 cc daily. Review of a facility policy and procedure (P&P) entitled "Intake and Output" dated 12/08 revealed a policy to ensure adequate fluid intake and prevent dehydration. Fluid intake and output is documented in cc's each shift with totals and then a 24 hour total. Licensed nurses and nurse aides are responsible for recording and totaling fluid totals and reporting pertinent findings. Review of a Bowel Monitoring sheet for 2/11 revealed the resident had one to three loose bowel movements on 12 of 13 days from 2/16/11 to 2/28/11. The Bowel Monitoring sheet for 3/11 documented the resident had loose bowel movements daily from 3/1/11 to 3/5/11. Interview with LPN #1 on 6/22/11 at 8:30 AM revealed the bowel sheets are checked by the night nurse and fluid intake sheets are reviewed in the morning by the Unit Managers and Dietary staff. Review of Nutrition Progress Notes revealed the resident weighed 229.2# (pounds) on 2/25/11 and 227.6# on 3/1/11. There was no documentation regarding the resident's suboptimal fluid intake and continued loose stools. Additional review of the 2/25/11 and 3/1/11 Nutrition Notes and the 3/3/11 CCP revealed no documented evidence that revisions were made to the resident's meal plan or that additional fluids were provided. Interview with the Dietary Technician on 6/22/11 at 10:40 AM revealed she had no recollection of Resident #117's low fluid intake and loose bowel movements. The Dietary Technician confirmed there were no changes to the dietary meal plan and that no additional information was available. Review of nursing "Care Notes" dated 2/16/11 through 3/4/11 and the MARs dated 2/11 and 3/11 revealed no documented evidence that additional fluids were encouraged or provided. Additional review of Nurses' Notes and 24 Hour Report Sheets dated 2/17/11 through 3/4/11 revealed no documented evidence the Physician was notified of the resident's low fluid intake and/or ongoing loose stool. During the interview with LPN #1 on 6/22/11 at 8:30 AM, the LPN explained that staff would not normally notify the Physician regarding continued loose stool for a resident with [MEDICAL CONDITION] because staff know that the resident will have loose stool. Review of a nursing Care Note, written by a Licensed Practical Nurse (LPN #1), dated 3/5/11 at 11:00 AM revealed the resident had complaints of abdominal tenderness, the Physician assessed the resident and new orders were obtained for a stool specimen for [MEDICAL CONDITION] and an abdominal x-ray. Review of a Care Note written by LPN #2 dated 3/5/11 at 6:15 PM revealed the Physician was notified of the results of the abdominal X-ray which showed a colonic ileus (disruption of normal propulsive bowel activity). A Care Note written by a Registered Nurse (RN #1) dated 3/5/11 at 7:45 PM revealed the resident took bites of food, tolerated fluids and had two loose stools. Review of a Care Note written by RN #2 dated 3/6/11 at 10:30 AM revealed the resident had increased lethargy and was "not really responding to stimuli or sternal rub" (vigorous rubbing of the sternum/breastbone, using the knuckles of a closed fist). The RN documented that the Physician was called and an order was received to transfer the resident to the hospital. Review of the hospital Admission History and Physical (H&P) dated 3/7/11 revealed the resident was admitted on [DATE] with profound hypokalemia (low potassium level in the blood) secondary to diarrhea, hypovolemia (low blood volume) and acute [MEDICAL CONDITION] secondary to dehydration and diarrhea. The H&P documented that admission laboratory data included a potassium level of 1.6 mEq/L (normal 3.5 to 5.1), a BUN of 51 mg/dL and a creatinine of 2.4 mg/dL. Review of the hospital Discharge Summary dated 3/15/11 revealed the resident was admitted to the intensive care unit (ICU) upon admission and required aggressive potassium supplementation as well as intravenous (IV) fluids to correct her acute [MEDICAL CONDITION]. Interview with the Dietary Technician on 6/22/11 at 10:40 AM revealed dietary staff normally watch laboratory values to monitor a resident's fluid status. The Diet Technician explained that nursing staff are responsible to inform dietary staff if a resident's fluid intake is low. The Dietary Technician stated the resident would certainly have a weight drop and she didn't know if the resident was receiving any fluid from her family. The Diet Technician stated that if the resident consumed less than 50 percent (%) of the recommended fluids, she (the Diet Technician) should have documented it in the 2/25/11 Nutrition Progress Note. The Dietary Technician had no recollection regarding any conversation with nursing regarding the resident's fluid intake. Interview with the RD on 6/22/11 at approximately 9:00 AM revealed the Dietary Technician is responsible to review and follow-up a resident's fluid and meal intake after the initial Nutritional Assessment is completed by the RD. Interview with the RN ADON (Assistant Director of Nursing) on 6/22/11 at approximately 10:30 AM revealed the facility's policy for Intake and Output changed recently. The RN ADON stated there has always been an expectation that any resident taking in 50% or less of their fluids and/or meals for each of three shifts would be reviewed by the Nurse Manager and interventions would be done; now the policy (revised 5/11) formally documents this accountability & responsibility. Interview with the Physician on 6/22/11 at 12:48 PM revealed Resident #117 was a post operative patient who had a stormy post operative course. The Physician stated he typically reviews the hospital discharge summary upon a resident's admission to the facility. When the facility received Resident #117 for rehabilitation, she was still recovering from her surgery, she was weak, and still had [MEDICAL CONDITION] diarrhea. Medically she was a diabetic resident; she required nutrition and he needed to maintain her metabolic status. The Physician stated he continued the resident's current medications to make sure she got better. The Physician revealed he was aware that both diuretic medications ([MEDICATION NAME] and [MEDICATION NAME]) and diarrhea can lead to hypokalemia. The Physician stated he should have made plans to check the resident's metabolic profile (blood work) when she entered the facility. The Physician stated he could not recall the nurses informing him about any low fluid intake regarding this resident. 415.12(j)