Every finding on record at Western New York State Veterans Home

Based on observation, interview, and record review conducted during a Standard survey completed on 11/17/23, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for one (Resident #14) of five residents reviewed. Specifically, Resident #14 was care planned to receive a straw lid mug for hot beverages due to a history of spilling hot liquids and on observations, the resident received the mug with a hot liquid in it and there was no lid on the mug. The finding is: The policy and procedure (P&P) titled Food & Nutrition Services- Preparation and Service of Meals revised date 8/2023 documented it is the policy of the facility to maximize an individual's degree of independence in self-feeding. Each resident will be screened by Occupational Therapy (OT) upon admission/ readmission to facility with regards to their self-feeding skills and the need for adaptive devices to facilitate self-feeding. Reassessment at a later date will be done upon referral from the dietitian or nursing, rehabilitation maintenance check, and/or physician's recommendation. Once the OT has assessed the safest, highest practical level of independence able to be demonstrated by each individual resident, the OT will initiate an ADL (activities of daily living) care plan, including functional feeding levels, in addition to adaptive equipment as required to maintain resident goals. Recommendations for adaptive devices will be communicated to the Dietary Department by OT. Nutrition and Food Services will be responsible for placing the assistive device on the resident's tray when the trays are prepared in the Nutrition and Food Service's Kitchen. The P&P titled Adaptive Devices revised date 3/8/17 documented OT shall fabricate and purchase adaptive devices to enhance proper sitting/ supine posture, prevent further contractures or skin break-down, to support upper/lower extremities and to enhance independent function in ADL skills. The OT and/or COTA (certified occupational therapy assistant) will assess and issue adaptive devices to residents as needed. Device are monitored for appropriateness and effectiveness jointly by OT and Nursing Department. Devices are documented in OT evaluations, daily notes, progress notes, nursing assistant and resident chart care plans as needed. 1. Resident #14 has diagnoses including dysphagia (difficulty swallowing), Alzheimer's disease, and dementia. The Minimum Data Set (MDS- a resident assessment tool) dated 11/16/23 documented Resident #14 was understood, usually understands and severely cognitively impaired. Resident's functional status with eating was supervision with set- up help. The comprehensive care plan titled Plan of Care dated 3/4/23 documented resident had a potential for alteration in nutrition, hydration, and impaired skin due to hot beverage spills with incident dates of 4/8/21, 10/28/22, 12/15/22, and 4/21/23 all with no injuries. Under ADL function resident was self-care deficit with an intervention for adaptive feeding equipment recommendation of a straw lid mug with no straw for hot beverage- resident has history of removing lids. If falls asleep during meal, please remove cup from hand to prevent spilling. Review of the CP (care plan) Tasks dated 11/16/23 revealed under ADL Eating: Straw lid mug with no straw for hot beverage- resident has history of removing. If falls asleep during meals, please remove cup from hand to prevent spilling. During a lunch observation on 11/13/23 between 12:00 PM and 1:15 PM in the [NAME] (Unit 2) dining room Resident #14 was sitting at the table. The tray was served to the resident who received a plastic blue handled mug with a dark hot liquid in it. There was no cover on the mug or on the tray. The meal ticket with Resident #14's name on it documented Regular Diet-Pureed Honey and Straw Lid Mug for hot beverages. During a lunch observation on 11/16/23 between 12:00 PM and 12:35 PM in the [NAME] (Unit 2) dining room Resident #14 was sitting at their table and Licensed Practical Nurse (LPN) #1 brought over their tray and assisted them with set-up. Resident #14 received a blue plastic handle mug with hot liquid in it and no cover. Observation of the tray itself had no cover on it. Review of the resident's meal ticket revealed Straw Lid Mug for hot beverages. After alerting the staff they place a lid on the mug. Resident was accepting of the lid. Review of the Minor Incident Report dated 12/15/22 revealed Resident #14 spilled coffee on the front of their shirt with no injury noted. Care plan was followed. Resident received a straw lid mug with the lid on and was noted to have removed the cover and attempted to place the cover back on then proceeded to attempt to take a drink spilling coffee on the front of their shirt. Care plan was updated to reflect upright position in wheelchair (w/c). Review of the Minor Incident Report dated 4/21/23 revealed Resident #14 was at breakfast holding their coffee when they fell asleep, and the coffee spilled onto their upper thighs. Mug w/ lid noted to be on, some spilled out of the mouthpiece. No injuries were noted. Intervention included therapy referral which indicated resident to be appropriate for mug cups with lids, with no straws for beverages. Care plan modified for table change to move to a more central table. Review of the progress notes titled Occupational Therapy Note dated 5/1/23 revealed Resident #14 continues to be appropriate for mug cups with lids, with no straws for beverages. They continue to be independent following set up for meals. Review of the progress note titled Quarterly Nutritional Review dated 8/18/23 revealed under adaptive equipment; sectional plate, straw lid mug for hot beverages (h/o-history of removing lid), no straw. During an interview on 11/16/23 at 12:38 PM, the Diet Technician (DTR) stated by looking at the ticket I would think the Resident #14 should have a lid on their mug. The resident sometimes removes the lid. The staff preparing the tray and the staff member who was serving the tray should be double checking the ticket making sure the proper equipment was being provided. During an interview on 11/16/23 at 12:51 PM, LPN #1 stated they accidentally missed the cover for the straw lid mug. They stated they should have looked at the ticket and made sure the adaptive equipment matched what was on the tray to possibly help prevent injury. During an interview on 11/16/23 at 2:36 PM, the OT stated they recommended the straw lid mug for Resident #14's hot beverages because the resident has a history of spilling beverages on themselves. They expected the staff to be providing it with all hot beverages as it was to protect the resident from possible injuries. During an interview on 11/16/23 at 3:37 PM, Registered Nurse (RN) #1 Unit 2 Manger stated they would expect their staff to verify the meal ticket with what was on the tray to make sure the resident received the recommended adaptive equipment. They stated Resident #14 should have had a lid on the mug for their safety as there would be a risk of them spilling the liquid and possibly burning themselves. During an interview on 11/16/23 at 3:53 PM, the Director of Nursing (DON) stated they would expect their staff to review the tray ticket for accuracy. They stated the mug should have had a secured lid on it to help prevent spillage and could possibly cause a burn. They stated, It is unacceptable to provide the mug without the lid. 10 NYCRR 415.12(h)(2)

Based on observation, interview, and record review conducted during an Abbreviated survey (Complaint #NY00317141) completed on 9/13/23, the facility did not ensure the resident has the right to exercise his or her rights as a resident of the facility and as citizen or resident of the United States. Specifically, three (#'s 1, 2, and 3) of three residents reviewed were not afforded the right to vote in local elections. The New York State Department of Health (NYSDOH) publication titled, Your Rights As A Nursing Home Resident In New York State, dated 2022, included the right to participate in social, religious, and community activities, including the right to vote. Additionally, residents have the right to send and receive mail without interference. The findings are: 1. Resident #1 had diagnoses including hypertension (HTN), depression, and dementia. The Minimum Data Set (MDS - a resident assessment tool) MDS dated [DATE] documented Resident #1 was cognitively intact. During an observation/interview on 9/13/23, at 10:45 AM, Resident #1 was well kempt, sitting in wheelchair. Resident #1 stated they would be angry if they were not offered to vote by absentee ballot. 2. Resident #2 had diagnoses including dementia, depression, and hypertension (HTN - high blood pressure). The MDS dated [DATE] documented Resident #2 was cognitively intact. During an observation/interview on 9/13/23, at 9:55 AM, the resident was well kempt, lying in the bed. Resident #2 stated they would like to vote. 3. Resident #3 had diagnoses including HTN, dementia, and anemia. The MDS dated [DATE] documented Resident #3 was cognitively intact. During an observation/interview on 9/13/23, at 9:59 AM, the resident was well kempt, lying in the bed, reading the newspaper. Resident #3 stated they would like to vote. Review of a letter dated 5/22/23, provided by the facility addressed to the Administrator documented the following: - RE: Distribution of Mail to VA Residents. - As the chair of the Annual (Name of Library) Budget Vote/Trustee Election, I am reaching out to you in writing per your request. This is regarding the upsetting situation regarding the non-delivery of mail to our veterans residing at the (Facility Name). - Each year I receive the list of permanent absentees from Deputy Election Commissioner of (County Name) Board of Elections. -All our ballots for the May 4th library election were mailed on April 12, 2023, including ballots to the (Facility Name). - I received an email on May 16, 2023, from the Deputy Election Commissioner from the (County Name) Board of Elections that there was an envelope left against their door with ballots addressed to VA residents for both the City Schools and Library votes. During an interview on 9/13/23, at 9:01 AM, the Administrator stated they received a telephone call sometime in May 2023 from the County Board of Elections. The Board of Elections reported absentee ballots, addressed to residents (including Residents #1, 2 and 3) of the facility were left, unopened, outside the door of the Board of Elections. The Administrator stated Social Worker (SW) #1 was responsible for dispersing the absentee ballots to the residents, assisting the residents with absentee voting, and returning the ballots to the County Board of Elections. The Administrator stated SW #1 never dispersed the absentee ballots to the residents, never assisted the residents with voting, and returned the ballots, unopened, to the County Board of Elections. During a telephone interview on 9/13/23 at 11:06 AM, SW #1 refused to discuss the issue regarding the absentee ballots. Based on the following corrective actions it was determined the facility implemented corrective actions to correct the non-compliance. -Social Worker #1 on 5/29/23 was placed on administrative leave. -Arrangements have been made for County Board of Elections to facilitate absentee voting onsite at the facility with administrative oversight. 10NYCRR 415.3(d)(1)(i)

Based on interview and record review conducted during a COVID-19 Focused Infection Control Survey completed on 12/22/20, the facility did not establish and maintain an Infection Control Program to ensure the health and safety of residents to help prevent the transmission of COVID-19. Specifically, the facility did not ensure that four of four employees (Certified Nurse Aide (CNA) #1, 3, and 4) were screened for COVID-19 symptoms (e.g., fever, cough, difficulty breathing, or other respiratory symptoms), including temperature checks every 12 hours while on duty. Additionally, CNA #2 was not checked for COVID-19 symptoms upon the start of a shift and every 12 hours while on duty. The findings are: The NYS DOH (New York State Department of Health) Commissioner of Health letter to Nursing Home (NH) Administrators, dated April 29, 2020, required all staff to be checked for COVID-19 symptoms (e.g., fever, cough, difficulty breathing, or other respiratory symptoms), including temperature checks upon the start of each shift and every 12 hours while on duty. Review of a CMS (Centers for Medicare and Medicaid Services) memorandum (QSO 20-14-NH) updated 9/28/20 documented facilities should screen all staff at the beginning of their shift for fever and respiratory symptoms. Actively take their temperature and document absence of shortness of breath, new or change in cough, or sore throat. The Centers for Disease Control and Prevention (CDC) guidance, Preparing for COVID-19 in Nursing Homes, updated 11/20/20 documented: Screen all healthcare personnel (HCP) at the beginning of their shift for fever and symptoms of COVID-19. Actively take their temperature and document absence of symptoms consistent with COVID-19. Review of the facility policy and procedure titled Employees who may have been exposed or infected with COVID-19 dated 9/17/20 revealed that if an employee was working greater than eight hours, they will need to be re-screened at security and findings will be documented in the designated log. Review of the facility document titled NY State Veterans Home at Batavia (staffing schedule) dated 12/17/20, 12/18/20, 12/21/20, 12/22/20 revealed that CNA #1 worked the 6:15 AM to 2:45 PM shift and the 2:15 PM to 10:45 PM shift. A review of the facility Employees, Vendors, and Visitors COVID-19 screening tool dated 12/17/20, 12/18/20, 12/21/20 and 12/22/20 revealed no date, time, or signature from CNA #1 for the 2:15 PM to 10:45 PM shift. During an interview on 12/22/20 at 9:41 AM, CNA #1 stated that she works doubles but doesn't go and get re-screened between shifts. An additional interview with CNA #1 at 1:40 PM revealed that she did not recall getting any education about being rescreened before starting another shift. Review of the facility document titled NY State Veterans Home at Batavia (staffing schedule) dated 12/16/20, 12/20/20,12/21/20, 12/22/20 revealed CNA #4 worked the 10:45 PM to 6:45 AM shift and the 6:15 AM to 2:45 PM shift. A review of facility Employees, Vendors, and Visitors COVID19 screening tool dated 12/16/20, 12/20/20,12/21/20, 12/22/20 revealed no signatures of CNA #4 being rescreened or rescreened for the 6:15 AM to 2:45 PM shift. During an interview on 12/22/20 at 9:48 AM, CNA #4 stated she has been working since the night shift (12/21/20) which started at 10:45 PM and that she was not screened after the first 8 hours while on duty. She continued to state, she does not get screened at all on her second shift when she works double shifts. An additional interview at 1:35 PM, CNA #4 stated she was mandated to work a double shift on Sunday (12/20/20) into Monday (12/21/20) and then on Monday (12/21/20) into Tuesday (12/22/20). She stated she could not recall if she had any education of the need to be rescreened after 12 hours. CNA #4 also stated, that the nurse on duty used to come around and retake staff temperatures before their next shift. Review of the facility document titled NY State Veterans Home at Batavia dated 12/20/20,12/21/20, 12/22/20 revealed CNA #3 worked the 10:45 PM to 7:15 AM shift and the 6:15 AM to 2:45 PM shift. A review of facility Employees, Vendors, and Visitors COVID-19 screening tool dated 12/21/20 and 12/22/20 revealed no signatures of CNA #3 being rescreened or re-temped for the 6:15 AM to 2:45 PM shift. During an interview on 12/22/20 at 10:58 AM, CNA #3 stated she has been working since the night shift (12/21/20), which started at 10:45 PM and got screened at the beginning of the shift. Screening is done at the main door and included a temperature check and answering questions. During further interview at 2:15 PM, CNA #3, stated she worked double shifts on Sunday (12/20/20) into Monday (12/21/20) and Monday (12/21/20) into Tuesday (12/22/20). She stated the last time she was screened was at the start of her shift the night before (12/21/20). Review of the facility document titled NY State Veterans Home at Batavia (staffing schedule) dated 12/19/20 revealed that CNA #2 worked the 6:15 AM to 2:45 PM shift and the 2:15 PM to 10:45 PM shift. A review of the facility Employees, Vendors, and Visitors COVID-19 screening tool dated 12/19/20 revealed that no date, time, or signature from CNA #2 for the 6:15 AM to 2:45 PM and 2:15 PM to 10:45 PM shifts. An interview with CNA #2 on 12/22/20 at 9:38 AM revealed that she often works doubles (two 8-hour shifts, one after another) because they are shorthanded due to COVID-19. When asked, she stated that she does not get screened before her next shift. During an additional interview at 1:45 PM, CNA #2 stated she did not recall any education about being re-screened prior to working another shift. She said that they receive many read and sign messages (employee education messages) and that she can't remember them all. An interview with the Director of Nursing (DON) on 12/22/20 at 1:10 PM revealed that staff have to be re-screened and re-temped after eight hours if they have to work an additional shift. During an interview on 12/22/20 at 1:17 PM, the Security Guard stated the only way to enter the building is the main door and staff are screened by taking their temperature and signing in on the log sheet. She stated the staff who are working double shifts are supposed to be rescreened at the start of their next shift. An interview with the Infection Preventionist (IP) on 12/22/20 at 1:30 PM revealed there was an education on staff being re-screened before working an additional shift. The IP stated she was unable to locate documentation that she delivered an educational training. She stated that the education may have been a read and sign. During an additional interview at 2:49 PM the IP also stated the supervisor on duty was supposed to ensure that staff were being rescreened per their policy. During an interview on 12/22/20 at 3:00 PM, RN #3 stated every staff member has their temperature taken and are screened for COVID-19 symptoms. She stated if staff work a longer shift or are mandated to stay an additional shift, they should have their temperature retaken then re-sign the logbook. She stated, that staff were educated verbally when this first started. RN #3 stated, that the infection control nurse was responsible to ensure that staff rescreening was completed, and if the infection control nurse is not working, it would be the job of the nursing supervisor to monitor that staff are being rescreened. She stated there was no designated supervisor in the building on the day shift and that being rescreened is the staff's responsibility. During an interview on 12/22/20 at 3:25 PM, Director of Nursing (DON) stated that RN #3 was the day supervisor and she was responsible to make sure that staff were screened and had a temperature taken at the beginning of their next shift. She stated it would be the nurse on the floor's responsibility to take the temperature of the staff, sometimes they are documented and sometimes they are not. It is expected that the supervisor in charge of that shift makes sure the staff are screened. During an additional interview on 12/22/20 at 4:05 PM, the DON stated that she could not find documentation that the staff were screened at the start of their second shift. 415.19(a)(1);400.2

Based on observation, interview, and record review conducted during the COVID-19 Focus Infection Control Survey (Complaint # NY 635) completed on 9/25/20, the facility did not establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections for two of three units (Oneida and Ontario) reviewed. Specifically, the facility did not ensure residents were wearing masks, or maintained social distancing (at least six feet apart) while communal dining. This involved Residents #2-17 and #30-35. The finding is: The Executive Order #202.1 dated March 12, 2020 documented the following: Any guidance issued by the New York State Department of Health related to prevention and infection control of COVID-19 at nursing homes and adult care facilities, including but not limited to guidance on visitation, shall be effective immediately and shall supersede any prior conflicting guidance issued by the New York State Department of Health and any guidance issued by any local board of health, any local department of health, or any other political subdivision of the State related to the same subject. The Health Advisory issued by the New York State Department of Health dated March 13, 2020, documented At this time NHs (Nursing Homes) are required to take the following actions: - If there are confirmed cases of COVID-19 in a NH cancel group activities and communal dining. The Health Advisory issued by the New York State Department of Health dated September 15, 2020, documented Nursing Homes may resume limited activities under the revised guidance beginning September 17,2020 under the following conditions: Small group activities will be permissible when space allows for appropriate social distancing, however, no more than 10 residents and staff will be permitted to engage in such activities at any one time. Review of a CMS (Centers for Medicare & Medicaid Services) memorandum dated September 17, 2020, with Reference ID QSO-20-39-NH documented communal activities and dining may occur. Residents may eat in the same room with social distancing (limited number of people at each table and with at least six feet apart between each person). Facilities should consider additional limitations based on status of Covid-19 infections in the facility. The facility policy and procedure (P&P) titled Social Distancing for Dining Room dated 9/22/20 documented social distancing refers to the practice of keeping space between yourself and others to reduce the chance of contact with those who knowingly or unknowingly carry an illness. During an outbreak of the coronavirus employees must distance themselves at least six feet apart (approximately two arm lengths from others). Employees will always encourage residents to maintain social distancing as well as offer face masks for their protection. Review of an untitled facility document dated 9/18/20 revealed one resident tested positive for COVID-19 on 9/18/20. a.) Review of the Ontario Dining Room seating chart dated 9/15/20 revealed 10 tables with two residents assigned to each table. During observation on 9/25/20 at 12:09 PM the following was observed in the Ontario dining room: Residents #30 and #31 were sitting across from each other at a dining room table, seated in wheelchairs, eating lunch less than 6 feet apart. Resident #32 was sitting in a wheelchair and Resident #33 was sitting in a standard chair and they were sitting across from each other at a dining room table, eating lunch less than 6 feet apart. Resident #34 was sitting in a standard chair and Resident #35 was sitting in a wheelchair and they were sitting across from each other at a dining room table, eating lunch less than 6 feet apart. The Licensed Practical Nurse (LPN) #3 was present in the dining room during the observation. During an interview on 9/25/20 at 12:43 PM, LPN # 3 stated she was told the Infection Preventionist (IP) measured the residents from shoulder to shoulder and they were 6 feet from each other, therefore it was decided to let the residents eat together. During an observation on 9/25/20 at 12:45 PM LPN # 3 used a facility measuring tape to measure the dining room tables and identified the tables were 41 inches (3 feet, 5 inches) by 41 inches. During an interview on 9/25/20 at 12:49 PM the physician stated she didn't check the measurements of the tables but thought the facility had. The physician stated if the residents are fed by staff they are not leaning toward the tables then they would be socially distanced according to the regulations. Upon further discussion of the identified Residents #30, 31, 32, 33, 34, & 35 they each feed themselves. The physician stated if both residents are feeding themselves and leaning forward to eat they would be less than 6 feet socially distanced as required. During an interview on 9/25/20 at 12:51 PM, Registered Nurse Unit Manager (RN UM) #4 stated the IP measured the residents shoulder to shoulder and said the residents were 6 feet apart in distance. RN #4 further stated the identified Residents #30, 31, 32, 33, 34, & 35 feed themselves and when leaning forward to eat, the residents would be less than 6 feet socially distanced as required. RN #4 further stated she was not aware the tables only measured 41 inches x 41 inches. During an interview on 9/25/20 at 12:52 PM the Administrator stated they were trying to allow residents to have some normalcy by letting them eat together, socially distanced. They measured the residents head to head or shoulder to shoulder across the table and they were 6 feet, but if the residents are leaning forward to eat, they would be less than 6 feet apart. They are going back to where only one resident may eat at a table and the rest will have to eat in their rooms or in the hallway. b.) During an observation on 9/25/20 at 12:09 PM, Residents #2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, and 17 were seated in the Oneida dining room waiting for their meal to be served. There were eight 41.5 inch (3 feet by 5.5 inch) by 41.5 inch tables observed with two residents sitting at each table. The residents were not socially distanced (6 feet apart) or wearing face masks. Staff were present in the dining room (DR) and did not encourage any residents to wear masks while waiting for their meal. Residents #8 and #11 were seated at the same table. Resident #8 was sitting in a wheelchair, with chest positioned 6 inches from the table and had right arm from elbow to tips of fingers resting on the table. Resident #11 had right elbow resting on the table while eating. During an interview on 9/25/20 at 12:19PM, Certified Nurse Aide(CNA) #7 confirmed Residents # 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, and 17 were present in the Oneida dining room and seated according to the Oneida Dining Room seating chart. CNA #7 stated resident communal dining started a few months ago. Review of the undated Oneida Dining Room seating chart revealed there were 11 tables with two residents assigned to each table. During observation on 9/25/20 at 1:10 PM the Infection Preventionist (IP) Registered Nurse (RN #2) used a paper measuring tape to measure a table in the Oneida dining room, which measured 41.5 inches x 41.5 inches. RN #2 stated she previously measured residents from head to head to ensure they were 6 feet apart but did not measure all residents. RN #2 had not considered if any residents would lean in on the table or rested elbows or extremities on the table. RN #2 further stated she measured the residents and had no record of which residents she measured. During an interview on 9/25/20 at 12:33 PM, Licensed Practical Nurse (LPN #1) stated communal dining gradually resumed in May and that the table appeared to measure four feet by four feet. The LPN #1 stated the residents in the Oneida dining room were measured head to head by the Infection Preventionist. LPN # 1 further stated the residents could not be 6 feet apart if the table measured 4 feet by 4 feet. LPN #1 stated few residents on the unit can tolerate a mask and had not encouraged the residents to wear a mask. Further interview on 9/25/20 at 3:55 PM the IP RN #2 stated it was a team decision to start communal dining and residents were measured from head and shoulder to head and shoulder. RN#2 stated she received push back from the residents because they wanted to be able to sit together. RN #2 thought the residents were 6 feet apart. During an interview on 9/25/20 at 4:10 PM the Administrator stated she updated the policy and procedure recently to reflect the CDC (Centers for Disease Control) recommendations that social distancing is 6 feet apart (approximately 2 arm lengths from others). The Administrator stated their usual communal dining is with 4 residents at one table and staff were directed to resume dining with two residents at each table on the three units last week. The Administrator stated she thought they were two arm lengths apart. 10 NYCRR 415.19(a)(1)

Based on observation, interview and record review conducted during an Abbreviated Survey (Complaint #NY 760) completed on [DATE], the facility did not ensure that personnel provide basic life support, including cardiopulmonary resuscitation (CPR), to a resident requiring such emergency care subject to related physician orders [REDACTED].#1) of nine residents reviewed for advance directives. Specifically, when found unresponsive nursing staff did not verify the resident's wristband code status of DNR (Do not resuscitate) against the resident's advanced directives including the MOLST (Medical Orders for Life Sustaining Treatment) in the medical record which resulted in the resident not receiving basic life support, including CPR in accordance with the physician orders [REDACTED]. In addition, the facility did not have a process to check resident wristbands to ensure the proper code status was indicated. The finding is: Review of a facility policy and procedure (P&P) titled Blue Alert with AED (automated external defibrillator) last reviewed on [DATE] revealed to use the term Blue Alert to summon help in the case of a life-threatening medical problem which cannot be handled by staff on the scene without assistance. The licensed/ Medical/ Nursing staff responds to the emergency and assesses person for need for medical assistance. Staff checks the resident's code status from wristband, obtains medical record to ensure emergency care provided correlates with resident's Advanced Care Directives. Review of a facility P&P titled Resident Wristbands last reviewed on [DATE] revealed all residents will wear a wristband for personal identification and to assure that each resident's wishes regarding CPR are known to staff responders. The wristband is to have the following information visible on the outside of the wristband: the facility name and phone number, resident's name, cottage and room number. The inside of the band is to contain the resident's wishes regarding CPR. The Social Worker will inform all new residents that it is the policy of the facility that all residents wear a wristband for personal identification, to safely administer medications and assure that each resident's wishes regarding CPR are known. The Nursing Station Clerk/Designee prepares the resident's identification bracelet. The Licensed Nurse places the wristband on the resident. 1. Resident #1, an [AGE] year-old male, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- a resident assessment tool) dated [DATE] documented the resident had intact cognition. The resident's MOLST signed by the resident on [DATE] and signed by the physician on [DATE] revealed CPR order: Attempt Cardio-pulmonary resuscitation. Additional review revealed the MOLST was signed by the medical provider on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] with no change to the code status. Social Work (SW) notes from (MONTH) 2019 through [DATE] documented the resident's MOLST was reviewed on [DATE], [DATE], [DATE], and [DATE]; the resident remained a Full Code (to provide CPR). The Physician order [REDACTED]. Review of a SOAP (subjective, objective, assessment, and plan) note dated [DATE] at 12:30 PM written by the Nurse Practitioner (NP) documented the resident was seen due to reported worsening of respiratory symptoms. Resident has a history of asthma. On [DATE] the on-call provider ordered a chest x-ray (CXR) and a one-time dose of [MEDICATION NAME] [MEDICATION]). The CXR was reviewed and revealed cardiomegaly (enlarged heart) without [MEDICAL CONDITIONS], no evidence of acute cardio-pulmonary pathology and no significant change from prior CXRs of [DATE] and [DATE]. The resident was trying to eat some lunch but admitted poor appetite. On physical assessment the resident had rhonchi (sounds heard when lungs are partially obstructed) and wheezes ([MEDICATION NAME] sounds when breathing) throughout the lung fields; airflow maintained throughout and bilaterally. Unable to hear heart sounds due to lung sounds. The Assessment/ Plan documented by the NP was acute respiratory symptoms consistent with upper respiratory infection. Concern for aspiration (taking foreign matter into the lungs) and illness was complicated by asthmatic component. Not likely [MEDICAL CONDITION]. Resident has remained afebrile (without fever). Plan was to give another dose of [MEDICATION NAME] 60 milligram now and start a [MEDICATION NAME] taper tomorrow. Plan to re-evaluate the resident on [DATE] to see how he responded to the [MEDICATION NAME] dose. To continue nebulizer (breathing treatment) treatments and [MEDICATION NAME] (medication to thin mucous). Resident will need close monitoring for near future including vital signs every shift and as needed. A Nursing Progress Note dated [DATE] written at 3:21 PM by Registered Nurse (RN) #1 documented that she assessed the resident for not breathing. The resident was cyanotic (bluish discoloration of the skin due to decreased oxygen in the blood) and had no spontaneous respirations. He was cool-warm to touch. On auscultation (listening to heart and lung sounds with stethoscope) there was no spontaneous respirations and no apical pulse for greater than two minutes. Resident was pronounced dead at 2:24 PM. The facility investigation dated [DATE] included the following staff written statements; -Certified Nurse Aide (CNA) #1's written statement dated [DATE] documented she was in Resident #1's room to transport his roommate out of the room. As she passed by Resident #1, she heard him gurgling. She commented to another aide that Resident #1 sounded terrible. CNA #1 walked back into Resident #1's room to check on him and he was gray. She walked out of the room, the Assistant Director of Nursing (ADON) was walking by so she informed the ADON of the resident's condition. The ADON told CNA #1 to get RN #1 who came to the room. -ADON's written statement dated [DATE] documented while going up the hallway CNA #1 stopped her and stated she thought Resident #1 was dead. The ADON entered the room and found the resident upright in his bed leaning to the right side. He was blue/gray in color and cool to the touch. No notable breathing was seen. The ADON took the resident's pulse and told CNA #1 to get RN #1. The ADON checked the resident's wristband which had DNR written across the back of the band. RN #1 entered the room and asked what time the ADON found him. -RN #1's written statement dated [DATE] documented she was called to the resident's room by CNA #1 because we think he is dead. RN #1 got her stethoscope and went to the room. The resident was warm but not really cool. The resident had one movement of his mouth. On auscultation there was no spontaneous respiration and apical pulse for greater than two minutes. RN #1 was informed that the resident was a DNR per his wristband and pronounced him dead. RN #1 went to the chart and the MOLST read CPR. The resident was cyanotic at the time of RN #1's response to the information. Administration was notified. During an interview on [DATE] at 10:00 AM, the Administrator stated that upon entering the resident's room for assessment of his unresponsiveness the ADON and RN #1 did not follow the facility policy for verifying a resident's code status that was in place at the time. The policy was to check the wristband for code status but verify the code status by reviewing the resident's MOLST in the medical record. The policy to verify code status was changed on [DATE] after the incident. The only way nurses may check a resident's code status currently is to review the MOLST in the medical record. Wristbands will no longer be used to identify code status. On [DATE] all current wristbands were removed from all residents and replaced with a wristband that will only be used to identify the resident's name and room number for medication administration purposes. In addition, on [DATE] all residents advance directives were audited to ensure they were accurate. No other issues were identified. During an interview on [DATE] at 12:10 PM, the SW stated that the process upon admission is that the SW, physician or NP would complete the MOLST with the resident/ family. Whoever completes the MOLST would inform the ward clerk or nursing supervisor of the code status and they would make a wristband with the code status. Nursing would place the band on the resident. The SW stated she did not know who made the wristband for Resident #1 with the incorrect code status or if/how the incorrect code status was communicated. Resident #1 had a MOLST completed prior to admission to the facility and was a Full Code upon admission. His code status did not change during his stay. The SW stated that the facility policy was now changed. Staff are no longer to use the wristband for identify code status. The only place to confirm code status is to review the MOLST in the resident's chart. During a telephone interview on [DATE] at 1:00 PM, RN #1 confirmed the contents of her written statement and clarified that she was informed by CNA #1 that they thought Resident #1 was dead. CNA #1 told her the ADON wanted her to come to the room to pronounce him dead. RN #1 got her stethoscope and proceeded to the room. The ADON was there and told her that the resident is a DNR. RN #1 took the ADON's word that resident was a DNR and did not check the resident's chart. RN #1 assessed the resident; he was cyanotic from the mid-chest up and moved his mouth a bit, his temperature was cool/warm, and his left forearm was white on the top and purple on the bottom. RN #1 auscultated the resident's chest for greater than two minutes and there were no respirations and no apical pulse. She pronounced the resident dead at 2:34 PM. Less than 10 minutes later while reviewing the resident's medical record she discovered the resident's MOLST which documented he requested CPR. She returned to the room to check the resident and he was completely purple at that point. Administration was notified of the occurrence. RN #1 said that the procedure for checking any resident's code status was to check the resident's wristband first which had the code status printed on the back then to always check the resident's chart for the MOLST to verify. During a telephone interview on [DATE] at 1:25 PM, the ADON confirmed the contents of her written statement. She stated that on [DATE] as she was walking up the hall CNA #1 stopped her and said that she thought the resident was dead. She entered the room. The resident was in bed, was blue/gray in color and was not breathing. The ADON checked the resident's wristband and it stated DNR on the back. She told CNA #1 to get RN #1. The ADON stated that she assumed RN #1 would check the resident's chart for the resident's code status. The ADON said she did not check the resident's chart. While waiting for RN #1 to come to the room the ADON had her hand on the resident's chest to see if she felt any movement which she did not. RN #1 entered the room at 2:35 PM and said that she needed to know what time to pronounce him. RN #1 assessed the resident and pronounced him dead. Several minutes later while RN #1 was reviewing the resident's medical record she discovered the resident's MOLST which stated he was a Full Code. The incident was reported to the SW and Administration. The ADON returned to the resident's room and the CNAs were providing post mortem care. The resident was completely blue and not breathing. The ADON stated that the procedure for checking a resident's code status is to check the wristband. She stated that the new policy is to only check the resident's MOLST. During a telephone interview on [DATE] at 12:00 PM, the Physician stated that she was in the facility on [DATE] to confirm the resident's death. Due to the resident's age and medical condition CPR more than likely would not have been successful. During an interview on [DATE] at 9:45 AM, CNA #1 stated that she was not assigned to care for Resident #1 on [DATE] but was in the room caring for his roommate. Resident #1 was in bed all day because he did not feel well. He was making noises all day. He ate lunch in bed. CNA #1 took his lunch tray away at 12:30 PM and the resident apologized for not eating much. At approximately 2:30 PM as she wheeled Resident #1's roommate out of the room into the hallway she heard Resident #1 make a gurgling sound. After taking the roommate into the hallway she returned to the room [ROOM NUMBER] seconds later to check on Resident #1. He was gray with no movement and appeared dead. CNA #1 immediately informed the ADON who entered the room to check on the resident. The ADON told her to get RN #1 to the room. CNA #1 informed RN #1 who immediately came to the room. During an interview on [DATE] at 10:30 AM, the Administrator stated she was not aware of any process or policy that was in place prior to the incident of [DATE] to audit resident wristbands to ensure that it contained the correct code status. During an interview on [DATE] at 11:35 AM, the SW stated that prior to [DATE] there was no formal process in place to audit resident wristbands to ensure that the correct code status was identified. During a telephone interview on [DATE] at 3:00 PM, RN #1 clarified that upon entering the resident's room on [DATE] he was cool to the touch but not cold. His arms were white on top and cyanotic on the bottom. The entire chest was cyanotic and cool. The face, lips and ears were cyanotic and cool to the touch. She knew he was beyond the point of being resuscitated. RN #1 auscultated the chest for greater than two minutes and there were no respirations or apical pulse. She pronounced him dead after the assessment. 2. Resident observations on [DATE] revealed all wristbands were removed and replaced on [DATE] by 5:30 PM with wristbands that only identify the resident's personal identification to safely administer medications. Review of a facility policy titled Blue Alert dated [DATE] revealed licensed medical/Nursing staff checks resident's code status from the medical record to ensure emergency care provided correlates with resident's Advanced Care Directives. Review of in-service records dated [DATE] revealed Nursing staff were educated on the policy titled Blue Alert dated [DATE] that the only place to identify a resident's code status is the medical record on the MOLST and that wristbands are no longer used to identify code status. Review of facility wide audits dated [DATE] revealed audits were conducted to review all resident's Advance Directives to ensure accuracy; they were reviewed by the physician within the expected time frame. No issues were identified. Interviews conducted on [DATE] revealed the Nursing staff had received education on [DATE] regarding the Blue Alert policy. 483.24(a)(3)

Based on interview during a Standard Survey completed on 1/23/18, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The facility did not conduct or complete a Legionella risk assessment of the facility to identify where Legionella and other opportunistic pathogens could grow and spread in the facility's water system and the facility did not have a water management plan in place for the facility to reduce the risk of growth and spread of Legionella and other opportunistic pathogens. This affected the entire building including three (Erie Cottage, Oneida Cottage, and Ontario Cottage) of three resident units. 1. Interview with the Administrator and the Health Program Administrator 1 on 1/16/17 at approximately 3:11 PM and 3:50 PM revealed the following: -The facility had not conducted or completed a Legionella risk assessment for the facility. -The facility did not have a water management plan in place. - Outside consultants had informed the facility's previous Administrator that since the facility did not have cooling towers the facility did not have to conduct a Legionella risk assessment. Review of the Centers for Medicare & Medicaid Services Survey and Certification Letter S & C 17-30 subject: Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires' Disease (LD) dated 6/2/17 revised 6/9/17 with an effective date of Immediately on 1/16/18 revealed: Healthcare Facilities must conduct a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system. Healthcare Facilities must have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in the building water systems. 415.19(a)(1)

Based on observation, interview, and record review conducted during the Standard survey completed on 1/23/18, the facility did not ensure that each resident's drug regimen is free from unnecessary drugs without adequate indications for its use. Specifically, one (Resident #77) of three residents reviewed for unnecessary antipsychotic medications underwent a gradual dose reduction (GDR) without documented evidence non-pharmacological interventions were individualized or revised during the GDR process. Additionally, there was lack of documented specific behaviors that led to a failed GDR. The finding is: 1. Resident #77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident received routine antipsychotic medications and has severe cognitive impairment. Review of the physician's orders [REDACTED]. Review of the Plan of Care, dated 9/1/17 (identified as current by staff) revealed the following: - Resident utilizes [MEDICATION NAME] for [DIAGNOSES REDACTED]. - 11/1/16 it was 0.5 mg twice daily - 7/14/17 a GDR was done and the dose was decreased to 0.5 mg at bedtime. - 7/31/17 GDR failed increased back to 0.5 mg twice daily - 10/27/17 GDR was done, dose to 0.5 mg at bedtime - Potential for behavior - Since 10/21/16 resident has been very anxious about his admission to this facility, states he is going to leave the facility and is going home, wander guard placed on left ankle. States going to call sheriff's because he cannot be held against his will. Has been on 1:1 monitoring, will continue until mental health evaluation is completed. Recommendations from neuropsychologist resident was started on [MEDICATION NAME]. Follow up with neuropsychologist will be 10/25/16 - 11/3/16 continued delusional thinking and wanting to go home - 11/15/17 was exit seeking and thinking he had to get on the lawn mower and mow the lawn. Kept telling aides his friend was picking him up and trying to get out of the doors - 1/5/18 behavior logged being verbally abusive to staff and being resistive on standing lift, [MEDICATION NAME] increased Review of physician progress notes [REDACTED]. - 7/14/17 medications included [MEDICATION NAME] 0.5 mg twice daily for dementia with delusions and the plan was to decrease the [MEDICATION NAME] dose today - 7/21/17 medication included [MEDICATION NAME] 0.5 mg at bedtime, [MEDICATION NAME] in small dose at bedtime should continue, has seemed calmer and less agitated on it Review of nurse's Progress Notes revealed the following: - 7/15/17 2:12 AM, cooperative with meds and care, easily re-directed when exit seeking, [MEDICATION NAME] 0.5 mg at bedtime as ordered, sleeping at long intervals - 7/15/17 10:21 AM, easily re-directed when exit seeking, no agitation noted - 7/16/17 1:12 AM, cooperative with care this shift - 7/17/17 12:07 AM, cooperative with care this shift, new order hydrogen peroxide foot soaks and triple antibiotic ointment to right great toe, sleeping at long intervals - 7/18/17 2:23 AM, resident out of bed (OOB) one time, up making bed. Did redirect at this time, no paranoia or hallucinations noted - 7/18/17 2:08 PM, cooperative and pleasant with care - 7/18/17 9:36 PM, restless at times, difficult to redirect at times - 7/19/17 4:16 AM, apprehensive about toe - 7/19/17 2:18 PM, no hallucinations, no paranoia, alert and cooperative - 7/20/17 4:07 AM, can be sarcastic with staff, fairly cooperative - 7/20/17 9:40 PM, no agitation noted, no paranoia observed - 7/21/17 1;44 PM, no issues related to mood or agitation, no reported hallucinations - 7/21/17 10:13 PM, observed ambulating out of room after being put to bed, without walker. Escorted back to bed but appears agitated, placed in wheelchair by nurse's station, PRN (as needed) [MEDICATION NAME] (hormone that regulates sleep) given at 9:00 PM, was effective. - 7/22/17 4:03 AM, resting in shorter intervals, ambulating to bathroom without regards to safety, needs reminders to use walker - 7/22/17 10:21 AM, no agitation noted, pleasant and cooperative - 7/23/17 9:56 PM, cooperative with meds and care - 7/24/17 3:45 AM, restless at start of shift, easily agitated and sarcastic with staff. Ambulating up and down halls looking for a gun because I'm no coward resident believes we are in a war. Unable to redirect, complaints right toe pain, prn medication given with good effect - 7/24/17 1:43 PM, cooperative with staff, no agitation, paranoia or hallucinations - 7/25/17 1:02 AM, cooperative with care, no hallucinations noted, no paranoia - 7/25/17 2:33 PM, hard to redirect during lunch, alert and confused, pleasant and cooperative once redirected - 7/25/17 9:49 PM, argumentative at times with staff but is able to be redirected with humor and 1:1 - 7/26/17 3:53 AM, restless at times, always needing to do some task. Easily agitates with staff. Found ambulating in room without regards to bed alarm sounding, no complaints of pain - 7/26/17 2:05 PM, cooperative with staff, complaints of toe pain, prn medication given with positive effect. No hallucinations or agitation noted - 7/27/17 1:24 PM, wanted to leave with another resident difficult to redirect, no participation in day treatment, in a good mood no paranoia or hallucinations - 7/27/17 9:22 PM, cooperative, wandering at times. 1:1 and redirection as needed - 7/28/17 3:44 AM, awake on and off throughout shift, worrisome about a friend driving to take him out. Able at times to redirect, agitated at times when he thinks staff is telling him what to do, with redirection - 7/28/17 10:28 AM, cooperative with staff and care, no hallucinations or paranoia present this shift - 7/29/17 1:10 AM, no paranoia or hallucination so far this shift, sleeping at long intervals - 7/29/17 9:46 PM, alert, confused, cooperative prn Tylenol for toe pain with effect pending - 7/30/17 2:02 AM, no paranoia or hallucinations so far this shift, sleeping in long intervals - 7/30/17 12:19 PM, no behavior issues - 7/30/17 10:21 PM, resident up and down OOB (out of bed) many times this shift - 7/31/17 2:33 PM, some paranoia and exit seeking after breakfast. 1:1 with effect noted, then daughter came to visit. No further issues at this time, Bactrim continues for toe infection Review of Nurse Practitioner (NP) progress note dated 7/31/17 revealed the unit manager and staff report increasing agitation and aggressive behaviors lately. At the last RV (routine visit) it was noted that [MEDICATION NAME] had been decreased to one time per day instead of BID (twice daily). Consider decrease in [MEDICATION NAME] a failed GDR, will place back on twice daily. During an interview on 1/19/18 at 2:30 PM, Registered Nurse Unit Manager (RN UM #1) stated that the resident was started on the medication prior to moving to his current unit and he was seen by the neuropsychologist a couple times because of his behaviors. The RN UM further stated she does think he was residing on this unit in July, at one point the resident was on a twice daily dose, right now it's once per day. When asked why the resident was on the [MEDICATION NAME], the RN stated he would call his family and say he was locked in prison, that would upset the family a lot and he would get them all revved up in there. When asked what non- pharmacological interventions are done with the resident the RN stated, diversionary things were done in day treatment, he has his guys that visit every week and when they are here he is totally with it. When asked what care plan changes were made while the resident was undergoing a GDR in July, the RN stated, typically the changes you make are to the medications and you are hoping it works for them, you don't know what needs to be changed until it happens; the day treatment room is a big example of what we do for the residents, if something specifically helps a resident we would do that, unfortunately it's a new day every day for some residents. Staff have undergone training, deescalating residents, and just trying different things with them, like the Snoezelen room (therapeutic environment to provide stimulation to different senses), tv sometimes, one on one, and socialization. Since the negative behavior notes, we have had more interventions that staff use documented. When asked why the resident failed the GDR in July, the RN looked at the notes in the electronic medical record (EMR) and stated, they wrote a note on the 31st, staff report increased agitation and aggressive behaviors. They have documentation of paranoia and exit seeking after breakfast. When asked if exit seeking is a reason for someone to be on an antipsychotic the RN stated, no, but if they think they are in a prison, it is delusionary behavior. When asked if his behaviors were a threat to himself or others the RN looked at more notes in the EMR and stated she didn't see it in there, whether it happened or not and staff didn't express their concerns about it, I'm not sure. The RN further stated, the family was getting frustrated that he was calling them because they couldn't console him, but I'm not sure if it was during that time or not. When asked how it's decided that a resident failed a GDR the RN stated, what we have been doing lately, we have behavior reviews at morning report, we look at the meds and go from there, as for who decides what, she does not decide what's prescribed, they are doing telepsych (telepsychiatry, the delivery of psychiatric assessment and care through telecommunications technology, usually videoconferencing) now but I do not believe he has seen telepsych, we give it time, we don't like residents to be on meds if they don't need them. During an interview on 1/19/18 at approximately 3:15 PM, the Administrator stated they have made some changes to how they are tracking behaviors. They are using behavior logs, which started in November. During a telephone interview on 1/22/18 at 1:35 PM, the attending Physician stated she's not an employee of the facility, she's a contractor that comes to the facility on ce per week. The Physician stated she did not have access to the medical record for this interview and that she is listed as the resident's attending, but if the resident needed something between her visits, the staff would contact the Medical Director or another provider for orders. The Physician did state she thinks the resident was very problematic when he first came to the facility in the Fall of 2016. He was agitated and he saw the neuropsychologist who recommended the [MEDICATION NAME]. He was so agitated, wasn't eating much, was wandering. The Physician state she doesn't remember specific dates but does know they decreased the medication, then had to increase it again. She doesn't specifically remember what behaviors caused them to have to increase it. But she knows the staff work with the residents and try redirection, music sometimes, singing with the residents. During an interview on 1/23/18 at 11:05 AM, the NP (who wrote 7/31/17 note) stated the resident's attending does her own regulatory visits, I saw him for his toe, then on 7/31/17 was notified that he had increased behaviors, they told me more agitation and aggressive behaviors. When asked if she considered any medical reasons for his behaviors the NP stated, no he's had behaviors since he's been here, you always rule it out but I don't think the toe was the problem. When asked if she knows what his specific behaviors were, the NP stated she can't remember, it was in July. When asked about how they decide if a resident fails a GDR the NP stated, we have meetings to discuss the GDRs, get most of the team together that you can and discuss it. When asked why the resident is on the medication, the NP stated, I will look at (attending physician's) note. When asked, since the Physician was the person to decrease the dose, should she have been notified of the need to increase it, the NP stated, she's here one day per week, that's why they told me about it. The NP further stated the resident is on the medication for dementia with behaviors and [MEDICAL CONDITION]. The NP stated, there would have been behavior charting for him if she decreased it on the 14th and if she didn't agree with increasing the medication back again, she could have changed it the next time she saw the resident. Observation of resident transfer/toileting on 1/22/18 at 10:22 AM revealed the LPN #2 and CNA #1 used the sit to stand lift to transfer the resident from his chair onto toilet. The resident did state, I hate this thing while the staff were applying the sling to the lift. The staff provided encouragement and the resident was cooperative during the transfer to the toilet. During an interview on 1/22/18 at 10:33 AM the CNA #1 stated the resident has gotten better with using the lift and when they first started using it he would get frightened. She usually works night shift, but stated no when asked if the resident hits or kicks during care. During an interview on 1/23/18 at 10:09 AM, the Director of Nursing (DON) stated that when someone undergoes a GDR they do behavioral charting, then the unit manager or whomever revisits it with the Medical Director. When asked how it's decided if a GDR is failed, they would bring it back the next month to review if it's a failed GDR or not. During further interview at 12:23 PM, the DON stated we expect them to have documented interventions tried before indicating that they had a failed GDR. 415.12(l)(1)

Based on interview and record review during the Standard survey completed on 1/23/18, the facility did not implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The facility did not provide documentation that verified two (Food Service Worker 1(5A) and Food Service Worker (6A)) of two agency employees, that worked in the facility during the last four months and were subject to the New York State Nurse Aide Registry, had been reviewed through the New York State Nurse Aide Registry prior to their employment. The findings are: Review of employee time sheets and assignment sheets, provided for agency employees on 1/18/18 and 1/22/18, revealed the facility did not have documentation that showed a New York State Nurse Aide Registry check had been conducted on the following agency employees, prior to their employment at the facility. - Employee #5A, an agency Food Service Worker 1, worked at the facility for 36 days between 10/26/17 and 12/17/17 on three of the facility's three units. - Employee #6A, an agency Food Service Worker, worked at the facility for 68 days between 10/13/17 and 1/16/18 on three of the facility's three units. Interviews with the facility's Administrator (Authorized Person) and the Human Resources Director (Authorized Person) on 1/18/18 at approximately 9:10 AM revealed an Administrative Assistant, that formerly worked at the facility, had conducted the New York State Nurse Aide Registry checks on Employee #5A and Employee #6A and the facility was unable to find the documentation that verified these checks had been conducted, prior to their employment at the facility. Review of the Abuse, Neglect, Mistreatment Policy and Procedure (revised 11/7/17) on 1/22/18 revealed: The facility, through the Human Resources Department, screens potential employees, contractors who have resident contact, and volunteers against the RHCF Home Nurse Aide Registry. Reference checks are requested for employees according to Human Resources Policies. It is the responsibility of all Department Heads/Supervisors to notify Human Resources of new or changes in employees, contractors, and volunteers and that clearance of the Nurse Aide Registry has occurred. 415.4(b)

Based on observation, interview, and record review conducted during the Standard survey completed on 11/3/16, the facility did not ensure residents received services in the facility with reasonable accommodation of individual needs and preferences, except when the health or safety of the individual or other residents would be endangered. Two (Residents #32, 77) of two residents observed for reasonable accommodation of needs had issues involving: Resident #32 was unable to go freely into and out of his room and Resident #77 was left in his room on several occasions without the call light within reach. The findings are: 1. Resident #32 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 9/7/16 revealed that the resident is cognitively intact, is understood, and understands. During an interview on 11/2/16 at 9:59 AM, Resident #32 stated I am unable to go into and out my room freely. Where my room is situated, the big TV is there and staff place other residents in my way and I cannot come and go to my room as I please. I have talked to the Administrator, the Director of Nursing (DON) and the Unit Manager about this. They say they will figure something out, but they haven't because it is still happening. Or it will improve for a day or two and then it is right back to the same thing. They did offer me another room, but I said no because I like my room and my roommate, we get along well. It also doesn't solve the issue, because it will be the same situation for the next guy that moves in there. Sometimes I have to go get staff to move someone so I can get into my room and that is really a pain because it sometimes takes me a while to find someone to move them. This really bothers me a lot. Intermittent observations on the Oneida Unit High Side on 11/1/16 at approximately 10:00 AM, 1:30 PM, and 3:00 PM revealed there was a group of five to six residents sitting in wheelchairs watching a television that was mounted on the wall just outside of Resident #32's room (the room is a semi private room). One of the residents was positioned in a manner that blocked the doorway entrance to Resident #32's room, leaving no space for wheelchairs or staff to get through without having to move the resident. During an observation on the Oneida Unit High Side on 11/2/16 at approximately 10:25 AM, a group of six residents were again sitting in wheelchairs watching television just outside of Resident #32's Room. There was approximately a two foot wide pathway into Resident #32's. This left no room for a wheelchair to get through the doorway, without having to move someone. Review of a Directives (activities of daily living care plan) document for Resident # 32 printed on 11/3/16 revealed the resident transfers independently in and out of bed and is independent with wheelchair mobility both on and off the unit. Review of the Oneida High Side Safety Care Checklist Pod 1 (guide used by staff to provide care) dated 11/3/16 revealed there were no instructions for keeping the pathway to Resident #32's room clear. Review of the Plan of Care printed 11/3/16 revealed there were no care plan interventions for keeping the pathway to Resident #32's room clear. During an interview on 11/3/16 at approximately 10:52 AM, the Registered Nurse (RN #2) Unit Manager stated Personally, I have not heard that the resident (#32) was having problems getting in and out of his room until recently. It was brought to my attention the other day and we are working with him on the matter. Often other residents are placed in the pathway to his room so that they can watch television. They are placed too close to his doorway and it does not leave him access to his room, unless we move one of the residents for him. We were just recently told that every time staff goes by the area we have to watch to make sure other residents are not placed in the pathway to his room. Also, if the residents that are in front of the television are sleeping we were told to ask them if they would like to go lay down in their room. This is so Resident #32 can go in and out of his room without any problems. There was a sign there to alert staff; not to block the pathway but it is gone now. We were told we cannot hang any signs. I have offered him a room change at least two times and he did not want it. He said he likes his room. I did not document that I offered him a room change, I know I should have. This is a legit request. The residents should be able to go to and from their rooms freely, without having to get someone to move another resident out of their way. During an interview on 11/3/16 at 11:05 AM, the Social Worker stated Yes, Resident #32 did complain to me that the pathway to his room is usually blocked with other residents, and that he cannot get into or out of his room freely. I have talked to him about this approximately two to three times. The first time was about two to three weeks ago. I met with the Administrator about this and we decided to put a piece of tape on the ground and a sign stating not to put anybody past the tape line. This was so the pathway would not be blocked. I did not document anything about this though. I know I should have written a note, but I didn't. During an interview on 11/3/16 at approximately 11:42 AM, the DON stated Resident #32 spoke to me about this two days ago. I went over by his room and found that there was a piece of tape on floor and I was told that it was to keep residents from touching the equipment. I later found out that the Administrator and the Social Worker put up the tape and a sign so that the pathway would be clear for him to freely go to and from his room. That night, I immediately put out an email about this not blocking his pathway because I fully agree with the resident. He should be able to get in and out of his room freely. I use the analogy of how would you feel if you get home and were unable to get into your house. During an interview on 11/3/16 at 12:56 PM, the Administrator stated We are trying to come up with a solution, we had a piece of tape on the floor, and we had a sign but it was misinterpreted. Staff didn't know where to place residents (in front of or behind the tape). We are trying to come up with a way. It's a work in progress. The resident doesn't want to move his room, they had a private room that was available and offered it to him but he declined. We would love for him to go to the private room. He is the only resident that has voiced this concern, it's not widespread or a pattern. Review of a policy and procedure entitled Program Overview dated 12/23/96 revealed the Department of Social Work Services staff shall protect and promote the rights of each resident to ensure that they are afforded their rights to a dignified existence, self-determination, respect, full recognition of their individuality. In addition, the Department of Social Work Services shall provide services that include advocating for residents with personal and social problems involved with institutionalization. 2. Resident #77 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed that the resident has moderate cognitive impairment, understands and is understood. The MDS documented that the resident requires extensive staff assistance for dressing, toilet use, personal hygiene and limited staff assist for wheelchair mobility. The resident has an indwelling catheter (tube inserted into the bladder to drain urine and is frequently incontinent of bowel. Review of a Safety Care Check List dated 10/28/16 revealed the resident is incontinent of bowel and requires extensive assistance with toileting and staff are to anticipate the resident's needs. Observation on 11/1/16 at approximately 10:20 AM revealed the resident was in his room sitting in a Broda (specialized wheelchair)chair by the bedside and the call light was not within reach, it was approximately five feet away on the bed. At the conclusion of a resident interview, the resident asked the surveyor to get staff to assist him with positioning. Additional observation on 11/1/16 at approximately 2:11 PM revealed the resident was sitting in the Broda chair by the bed and asked for assistance to the bathroom; the resident's call light was on the floor and not within the resident's reach. The surveyor turned on the call light for the resident and a Licensed Practical Nurse (LPN # 1) entered the resident's room to provide toileting assistance, then transferred the resident back to the bedside to watch television. Observation on 11/2/16 at approximately 2:05 PM revealed the resident was seated in the Broda chair at the bedside and the call light was on the floor; not within the resident's reach. The resident again asked the surveyor to provide bathroom assistance, and the surveyor activated the call light for the resident. LPN #2 entered the room and provided toileting assistance for the resident. During an interview on 11/2/16 at approximately 2:14 PM, LPN #2 stated that the resident was capable of using the call light, he just called for assistance, didn't he? During an interview on 11/3/16 at approximately 12:30 PM, LPN #3 stated the resident is usually pretty alert and is able to use the call light; in addition staff perform rounds every two hours to ensure that the resident's needs are met. It is expected that all residents who use call lights, have them available. 415.5(e)(1)

Based on observation, interview, and record review conducted during the Standard survey completed on 11/3/16 the facility did not ensure that services provided or arranged by the facility were provided by qualified persons in accordance with each resident's written plan of care. One (Resident #8) of sixteen resident's reviewed for care plan implementation was not transferred by staff using a gait belt (used to provide weight bearing support) and limited staff assistance as planned. The finding is: 1. Resident #8 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 9/23/16 revealed the resident has severe cognitive impairment, is usually understood and sometimes understands. Review of the undated Safety Care Check List (guide used by staff to provide care) revealed the resident requires limited assist of one person with a gait belt for transfers. Review of the current Plan of Care revealed the resident requires a gait belt with limited assistance of one staff personfor transfers and has history of falls. Observation on 11/3/16 at approximately at 8:12 AM, CNA #1 assisted the resident to a seated position at the edge of the bed and stated to the resident; We can't walk to the bathroom now because I don't have a gait belt, so we'll have to use your wheelchair. CNA #1 instructed the resident to grab onto the wheelchair arm rests, pull herself up, turn, and to sit down into the wheelchair. The CNA transported the resident into the bathroom in her wheelchair. During continued observation at approximately 8:21 AM, CNA #1 instructed the resident to place her hands on the bathroom wall mounted assist bar and pull herself up. CNA #1 assisted the resident to a standing position by holding onto the side of the resident's hips. There was no gait belt used by CNA #1 during the transfers. Interview on 11/3/16 at approximately 7:48 AM CNA #1 stated, We usually do use a gait belt, but I didn't have one in here. I should have: double checked the care plan, stopped what I was doing, went to get a gait belt, or put the call bell on and had someone bring me one. She (the resident) has been pretty stable with her transfers, that's why I felt that she was safe and I didn't need one. CNA #1 then stated that gait belts are used for anyone who requires a limited assist. If the care plan says she requires a gait belt, then I should have used one. Interview on 11/3/16 at approximately 9:00 AM the Lead Physical Therapist stated, residents requiring limited assist or more for transfers are to use a gait belt if that is what is stated on the care plan. Interview on 11/3/16 at approximately 1:03 PM the Director of Nursing (DON) stated Our facility policy states; residents requiring a limited assist for transfers must have a transfer belt on unless otherwise contraindicated. I would expect my staff to use a gait belt for the safety of our resident's if it's on the Care Plan. Review of the facilities policy and procedure entitled Zero Manual Lift/ Safe Resident Handling dated 4/14/2008 revealed the use of a transfer/ gait belt provides a firm, grasping surface for the caregiver, protects the residents from accidental trauma to the skin, provides a sense of security to the resident, and protects the care giver from injury while transferring or ambulating a resident. Before assisting the resident in transfer or ambulation, make sure the belt is properly positioned and that the buckles are securely fastened. 415.11(c)(3)(ii)

Based on observation, interview and record review during the Standard survey completed on 11/3/16, the facility did not ensure that each residents' drug regimen was free of unnecessary medications. One (Resident #97) of five residents reviewed for unnecessary medications had issues involving the continued administration of an antipsychotic medication without an attempt of a gradual dose reduction (GDR) to attempt to discontinue the medication, unless clinically contraindicated. The finding is: 1. Resident #97 has a [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Review of the current Plan of Care printed 11/3/16 revealed documentation that on 12/9/15 [MEDICATION NAME] 12.5 mg was started twice daily for hitting and yelling at staff. Further review revealed documentation that on 12/17/15 the dose of [MEDICATION NAME] was increased to 25 mg twice daily for a [DIAGNOSES REDACTED]. Review of Physician's Progress Note dated 12/9/15 revealed the resident has a known history of dementia with behaviors/ agitation/ aggression and [MEDICAL CONDITION]. The resident is combative and verbally abusive to others. The documented assessment plan included to trial [MEDICATION NAME] 12.5mg twice daily, continue with 1:1 and behavior monitoring. Review of a Physician's Progress Note dated 12/22/15 revealed the resident still has agitated and aggressive periods where she will try to hit but these have decreased. Review of Physician's Progress Notes dated 1/27/16 through 10/11/16 revealed the resident's symptoms stabilized,GDR not indicated as her behaviors have stabilized. The Progress Notes do not provide documentation of a risk benefit rational for why the continued medication, dose or duration is appropriate. Review of the Medication Administration Records (MAR) dated 12/9/15 through 11/3/16 revealed documentation that the resident was administered [MEDICATION NAME] as ordered by the physician. Observation on 11/1/16 at approximately 11:15 AM the resident was sitting in a Broda chair watching television. The resident was alert and attentive but did not verbally respond to the Surveyor. Observation on 11/3/16 at approximately 11:00 AM the resident was in the Day Treatment Program attending an activity, the resident was alert and attentive to her surroundings. During an interview on 11/3/16 at approximately 1:50 PM, the Director of Nursing (DON) stated that a GDR should have been discussed and the contraindications should have been clearly documented by the Physician. 415.12(I)(1)

Based on interview and record review during the Standard survey completed on 11/3/16, the facility did not ensure the drug regimen review be reviewed at least once a month by a Licensed Pharmacist and the Pharmacist must report any irregularities to the attending Physician, and the Director of Nursing (DON) and these reports must be acted upon. One (Resident #97) of five residents reviewed for unnecessary medications had issues involving the lack of Consultant Pharmacist identification and recommendations regarding ongoing physician's orders [REDACTED]. The finding is: 1. Resident #97 has [DIAGNOSES REDACTED]. Review of a physician's orders [REDACTED]. Review of the current Plan of Care printed 11/3/16 revealed documentation that on 12/9/15 Seroquel 12.5 mg was started twice daily for hitting and yelling at staff. Further review revealed documentation that on 12/17/15 the dose of Seroquel was increased to 25 mg twice daily for a [DIAGNOSES REDACTED]. Review of a Physician's Progress Note dated 12/9/15 revealed the resident has a known history of dementia with behaviors/ agitation/ aggression and psychosis. The resident is combative and verbally abusive to others. The documented assessment plan included; to trial Seroquel 12.5mg twice daily, continue with 1:1 and behavior monitoring. Review of a Physician's Progress Note dated 12/22/15 revealed the resident still has agitated and aggressive periods where she will try to hit but these have decreased. Review of Physician's Progress Notes dated 1/27/16 through 10/11/16 revealed the resident's symptoms stabilized, GDR not indicated as her behaviors have stabilized. The Progress Notes do not provide documentation of a risk benefit rational for why the continued medication, dose or duration is appropriate. Review of the Medication Administration Records (MAR) dated 12/9/15 through 11/3/16 revealed documentation that the resident was administered Seroquel as ordered by the physician. Review of the monthly Pharmacist Review Summary dated 11/15 through 11/16 revealed no documented evidence that recommendations were made regarding the use of Seroquel or that a GDR was recommended unless documented clinically contraindicated. During an interview on 11/3/16 at 11:48 AM, the Pharmacist stated that during the monthly drug regimen review, the Pharmacist would review the psychotropic medications for a GDR. The Pharmacist stated they might not recommend a GDR if the Physician documented contraindications and/ or behaviors in the nurses notes. The Pharmacist stated he did not see a recommendation for a GDR in the resident's medical record. He was not sure that the resident was appropriate for a GDR and he does not recall discussing this issue with the interdisciplinary team during their monthly meetings. The Pharmacist further stated the resident should have had two attempts of a GDR within the last year if the Seroquel was initiated last December. We will review her medications at our next meeting. During an interview on 11/3/16 at approximately 1:50 PM, the Director of Nursing (DON) stated that a GDR should have been discussed and the contraindications should have been clearly documented by the Physician. We don't have a policy on Gradual Dose Reductions, we follow the rules of the SOM (State Operations Manual). Therefor a GDR should have been attempted at least in two separate quarters, with at least one month in between, unless clinically contraindicated. 415.18(c)(2)

Based on interview and record review conducted during the Standard survey completed on 11/3/16, the facility did not develop a Comprehensive Care Plan (CCP) for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing and mental and psychosocial needs that are identified in the CCP assessment. One (Resident #31) of three residents reviewed for care plans related to antipsychotic medications did not have a care plan to address the use of an antipsychotic medication. The finding is: 1. Resident #31 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 9/29/16 revealed the resident is cognitively intact, sometimes understands, is sometimes understood, and receives an antipsychotic medication. Review of physician's orders [REDACTED]. Review of Medication Administration Records (MARS) dated 8/6/16 through 11/2/16 revealed that the resident was administered [MEDICATION NAME] 25 mg daily at 8:00 PM, as ordered by the physician. Review of a Physician's Progress Note - Regulatory Visit dated 9/14/16 revealed that the resident was started on [MEDICATION NAME] for hallucinations. The resident will continue on [MEDICATION NAME], and there will be no GDR (gradual dose reduction) at this time as the resident's symptoms are recently controlled. Review of the resident's current, undated Plan of Care printed on 11/3/16 revealed there was no care plan developed to address the use of an antipsychotic medication, to include measureable goals and interventions. Interview with Registered Nurse (RN #1) Unit Manager on 11/3/16 at approximately 9:20 AM revealed the Social Worker would update the care plan if a resident is started on an antipsychotic medication. Interview with the Social Worker on 11/3/16 at approximately 9:25 AM revealed that Social Work updates the care plans within two or three days of a resident starting a new [MEDICAL CONDITION] medication. She also stated that there is a section in the care plan to add [MEDICAL CONDITION] medications, such as [MEDICATION NAME]. The Social Worker then stated I don't see it here on her (the resident's) care plan. Interview with the Director of Social Work (DSW) on 11/3/16 at approximately 9:40 AM revealed that she did not update the care plan for Resident #31 related to the use of [MEDICATION NAME]. She also stated that it should be on the care plan. Review of a facility policy and procedure entitled Care Plan Process dated 5/5/15 revealed that even though a care area assessment may not have been triggered in the assessment process, the ICPT (Interdisciplinary Care Plan Team) will address, in the Care Plan any resident problem or concern if clinically warranted. 415.11(c)(1)

Based on observation, interview and record review conducted during the Standard survey completed on 9/28/15, the facility did not promote care for residents in a manner that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. One (Resident #17) of 17 residents observed for dignity had issues that involved two certified nurse aides (CNA) discussing another resident's response to care, while providing care to Resident #17. The findings are: 1. Resident #17 has [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS - a resident assessment tool) dated 8/12/15 revealed the resident is cognitively intact, understands and is understood. The resident requires the physical assistance of one person for bathing. Review of the electronic Plan of Care, printed on 9/28/15, revealed the problem area of ADL's (activities of daily living) Self Care Deficit. The interventions included that the resident required extensive assistance for bathing. During an observation of the resident's shower on 9/25/15 at 10:09 AM, CNA #3 entered the shower room. CNA #3 called out to CNA #1 and opened the privacy curtain to allow her head to be exposed to the resident and CNA #1. CNA #3 continued by telling CNA #1 and Resident #17 about another (stating the resident's name) and the resident's behavioral reaction when she was providing care to that resident. CNA #1 and Resident #17 audibly chuckled to the comments made by CNA #3. During the observation, CNA #1 did not attempt to stop CNA #3's disclosure of information about another resident while showering Resident #17. Review of facility policy, Philosophy of Nursing Department, dated 9/30/96 revealed, We believe that each resident be ensured privacy and that all information is treated in a confidential manner. During an interview with the Director of Nursing (DON) and the covering Registered Nurse (RN) Unit Manager on 9/28/15 at 10:46 AM, the DON stated that it is not acceptable to discuss another resident in front of a resident. The DON stated the person listening should have quieted the person speaking about another resident. 415.5(a)

Based on observation, interview and record review conducted during the Standard survey completed on 9/28/15, the facility did not store food under sanitary conditions. One (Erie Servery) of four food preparation areas observed for sanitary conditions did not maintain refrigerated potentially hazardous foods at or below 41 degrees Fahrenheit. The finding is: 1. Observation in the Erie Servery on 9/28/15 at approximately 11:36 AM revealed the thermometer inside the small stainless steel cooler registered at 45 degrees Fahrenheit (F) and at approximately 11:40 AM the thermometer registered at 50 F. At this time, temperatures of potentially hazardous foods in this cooler were taken as follows: - Approximately 1 1/2 half cups tuna: 52.8 F - Approximately 1 1/2 half cups cups egg salad: 54.0 F - Approximately 1 pound of sliced cheese: 49.6 F Continued observation at this time revealed the following potentially hazardous foods were also stored in this cooler, but temperatures were not taken: Approximately 45 ounces canned whipped non-dairy topping with keep refrigerated on the label. Interview with the Director of Food and Nutrition at this time revealed the tuna had been in this cooler since last night and the remainder of the food items had been in this cooler for greater than 24 hours. The Director of Food and Nutrition stated the food in this cooler should not be served, and she will voluntarily discard all items in this cooler, and call maintenance immediately. Review of the facility policy and procedure entitled Prevention of Cross Contamination revised 2/17/12, revealed cold foods are to be held at 40 degrees Fahrenheit or below. 415.14(h)

Based on observation, interview and record review conducted during a Standard survey completed on 9/28/15, the facility did not establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. One (Resident #17) of three residents observed for infection control practices during resident care had issues with staff not completing proper hand hygiene after providing fecal incontinence care; after transferring the resident out of bed; after emptying the resident's urinary drainage bag and disposing of urine; and before touching common resident areas. Staff allowed Resident #17's urinary drainage bag to lay on the floor during transport and during the resident's shower. Staff handled clean linens while wearing soiled gloves. The findings are: 1. Resident #17 has [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS - a resident assessment tool) dated 8/12/15 revealed the resident is cognitively intact, understands and is understood. The resident requires the physical assistance of one person for bathing. During an observation on 9/25/15 at 9:52 AM of the preparation and shower of Resident #17, certified nurse aide (CNA) #1 and CNA #2 were placing a shower transfer sling under the resident while rolling the resident side to side in bed. When the resident was rolled to the right side, the resident released flatulence (gas) with watery discharge and pieces of stool. With gloved hands, CNA #2 used a cleanser moistened washcloth to clean the resident's soiled buttocks and rectum. Without removing the soiled gloves, CNA #2 touched the resident's left shoulder and hip to guide the resident onto his back. CNA #2 then handled the ceiling lift control mechanism to bring the lift over the resident and connected the left side of the sling to the lift bar. CNA #2 continued to handle the ceiling lift controls to transfer the resident out of bed and into a Broda shower chair. Once the resident was seated in the shower chair, CNA #2 handled the ceiling lift controls to move the lift bar away from the resident. CNA #2 disposed of the soiled linens and washed his hands in the dirty utility room. CNA #2 went to assist another resident. Also observed during transferring the resident out of bed to the Broda shower chair, CNA #1 was wearing gloves while turning the resident in bed to place the shower sling under the resident. Without removing the gloves, CNA #1 attached the right side of the sling to the lift bar, stabilized the resident while transferring out of bed into the Broda shower chair, placed a clean towel at the resident's perineum (the area between the anus and genitalia), moved the urinary drainage bag to the foot rest of the shower chair and unclipped the sling from the ceiling lift bar. CNA #1 then transferred the resident out of his room to the shower room, touching the shower chair hand grips and the shower room door knob while wearing the soiled gloves. While wheeling the resident into the shower room, the urinary drainage bag began to fall off the foot rest and was observed to be dragging on the floor. The urinary drainage bag remained on the floor for the duration of the shower and was observed to be sitting in a pool of water during the shower. CNA #1 obtained towels and washcloths from a cabinet in the shower room while wearing the soiled gloves and provided physical assistance to wash the resident's hair and body wearing the gloves used to transfer the resident out of bed. On two occasions during the shower, CNA #1 was observed to reposition the shower chair and looked at the front wheels with the urinary drainage bag positioned on the floor, within 1-2 inches of the front wheels. CNA #3 entered the shower room, donned gloves and assisted with positioning the resident for complete bathing. Upon completion of the shower, CNA #3 opened the shower room door while wearing the soiled gloves used during the resident's shower. CNA #3 immediately entered the clean linen room and handled the door knob while wearing the soiled gloves. CNA #3 immediately exited the clean linen room without wearing gloves. After completing the resident's shower, CNA #1 emptied the incontinence basin at the base of the shower seat and repositioned the urinary drainage bag onto the shower chair foot rest. CNA #1 wheeled the resident into his room, wearing the soiled gloves, and placed clean bath blankets on the resident's bed. CNA #3 followed into the room and put on clean gloves without washing her hands. While wearing the contaminated gloves, CNA #1 handled the ceiling lift controls. CNA #3 obtained a urinal and emptied the urinary drainage bag. CNA #1 cleaned the tip of the drainage spout with an alcohol wipe before securing the drainage spout. Both CNAs entered the resident's bathroom. CNA #1 removed the gloves and washed her hands for no more than 10 -15 seconds. CNA #3 removed her gloves and washed her hands for no more than 10 seconds after disposing the urine into the toilet and rinsing the urinal. Both CNAs donned clean gloves. Review of facility policy entitled Hand Hygiene dated 5/2/12, revealed the indication for handwashing during resident care is: - Prior to and after having direct hands on contact with resident. - When moving from a contaminated body site to a clean body site during resident care. - Prior to donning gloves and after removal of gloves. Further review of the Hand Hygiene policy revealed instruction in the section Hand Hygiene Techniques to rub hand together vigorously creating friction for a minimum of 15-20 seconds. Review of a poster entitled, How to Handwash? provided with the policy, listed the duration of the entire (handwashing) procedure: 40-60 seconds. Review of a facility policy entitled, Universal Steps for Nursing Procedures dated 4/22/13 revealed that CNAs are to wash hand and don clean gloves prior to a procedure. The policy revealed that post procedure, the CNA is to remove gloves and wash hands. During an interview with the Director of Nursing (DON) and Registered Nurse (RN) covering Unit Manager (UM) on 9/28/15 at 10:46 AM, the DON stated that gloves are to be removed immediately after incontinence care, staff should not touch common areas with gloves worn during hands on resident care, hands are to be washed more than 10 -15 seconds and should be washed before and after glove removal. The DON stated that a urinary drainage bag should not be laying on the floor while transporting or showering the resident. The RN UM stated that the clean linen room does not have a sink for handwashing. 415.19 (a)(1-3)

Based on observation, interview and record review conducted during the Standard survey completed on [DATE], the facility did not maintain clinical records on each resident in accordance with acceptable professional standards and practices that are complete; accurately documented; readily accessible; and systematically organized. Three (Residents #4, 23, 81) of 18 resident's medical records reviewed for complete and accurate documentation had issues. Specifically, the lack of correct laboratory (lab) Physician's Orders for Resident #4; a medication that had been discontinued remained on the medication administration record (MAR) with medication administered [DATE] through [DATE] for Resident #81 and lack of documentation lab work was not obtained per Physician's Order and the Physician's direction to obtain the lab work two days later for Resident #23. The findings are: 1. Resident #4 has [DIAGNOSES REDACTED]. The resident is cognitively intact, understands and is understood. Review of the Rheumatologist Consultant request dated [DATE] revealed the resident is to have monthly lab work including a CBC (complete blood count), AST ([MEDICATION NAME] transaminase - a test for liver damage), ALT ([MEDICATION NAME] transaminase - a test for liver damage), ESR (erythrocyte sedimentation rate- a test to measure inflammation), and CRP (C - reactive protein - a test for inflammation). Review of a Physician's Verbal Order dated [DATE] revealed CBC, AST, ALT, ESR, and CRP to be drawn monthly. Review of the Physician's Orders dated [DATE] and [DATE] revealed a CBC, and CMP is to be drawn every three months. Review of Physician's Orders dated [DATE] through [DATE] revealed no documentation regarding monthly labs per the Rheumatologist Consultant request and Physician's Orders on [DATE]. Interview with the Oneida Unit supervising Licensed Practical Nurse (LPN) on [DATE] at approximately 1:30 PM revealed the resident was seen by her Rheumatologist on [DATE] and an order was written to change some of the resident's labs to monthly. The LPN scheduled the resident to have a CBC, AST, ALT, ESR and CPR monthly. Review of the Oneida Unit Lab Book during the interview revealed the resident is scheduled for a monthly CBC, AST, ALT, ESR, and CRP. The supervising LPN further stated during the interview that upon signing off the Physician's Orders, the nurse is to check and verify that the information on the orders is correct and that all the orders are processed correctly. review of the resident's medical record revealed [REDACTED]. Review of the facility policy and procedure entitled Diagnostic Services- Laboratory Services dated ,[DATE] revealed that all laboratory tests shall be performed only by orders of a Physician or Nurse Practitioner. 2. Resident #81 has [DIAGNOSES REDACTED]. The resident is cognitively intact, is understood and understands. Review of a physician progress notes [REDACTED]. Review of the Physician's Orders dated [DATE] revealed an order to discontinue [MEDICATION NAME] sulfate. Review of the MAR dated [DATE] revealed the [MEDICATION NAME] sulfate 325 milligram (mg) by mouth daily was discontinued on [DATE]. Review of the Physician's Orders dated [DATE] revealed [MEDICATION NAME] sulfate 325 mg by mouth daily was crossed off with a note stating d/c (discontinue) on [DATE]. Review of the MAR dated [DATE] revealed [MEDICATION NAME] sulfate 325 mg daily was administered [DATE] through [DATE]. During an observation of the resident's medication administration on [DATE] at approximately 7:10 AM revealed the Registered Nurse (RN) administered [MEDICATION NAME] sulfate 325 mg to the resident. Interview with the Director of Nursing (DON) and the Consulting Pharmacist on [DATE] at approximately 1:30 PM revealed the Physician's Orders were not followed through on the new orders as the medication remained on the MAR and the medication was given on [DATE] through [DATE]. Review of a facility policy and procedure entitled Physician's Orders - Overview dated ,[DATE] revealed the Registered Nurse or designee is to check and verify all renewals of orders prior to the licensed practitioner's signature. 3. Resident #23 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated [DATE] revealed the resident is cognitively intact, understands, and is understood. Review of a Physician's Orders dated [DATE] revealed an order from the Nurse Practitioner (NP) to obtain a BMP (Basic Metabolic Profile - a blood test to measure basic chemistry components of the blood) on Monday, [DATE]. Review of the Physician's Orders dated [DATE] revealed an order to obtain iron studies (blood test to measure amount of iron in the blood), reticulocyte count (analysis of red blood cells), CBC with diff (complete blood count with differential - blood analysis that includes an analysis of white blood cells) and LDH ([MEDICATION NAME] dehydrogenase - a blood protein that is an indicator of tissue damage). Review of an RN Progress Note dated [DATE] revealed, He also stated he told the girl in the morning she wasn't poking him again cause (sic) she was unable to get his blood (.) Resident did state he would allow me to draw his blood tomorrow morning. Review of the resident's lab reports revealed no documentation the BMP was obtained on [DATE]. Further review of lab reports revealed a BMP, iron studies, CBC with reticulocyte and differential, and LDH were obtained on [DATE]. Interview with the RN on [DATE] at 10:24 AM revealed the resident did not let the nurse draw his blood on [DATE]. The RN spoke with the resident on [DATE] and he agreed to allow the RN to reattempt drawing his blood on [DATE]. On [DATE], the RN informed the NP of the inability to obtain the ordered lab work on [DATE] and received direction to obtain the resident's lab work on [DATE]. The RN stated that this information was not documented in the clinical record. 415.22 (a)(,[DATE])

Based on observations and interviews, it was determined that in one of one kitchen the facility did not maintain all essential equipment in a safe operating condition. The issue was related to the lack of an air gap for the indirect drain on a food preparation sink. This resulted in a pattern of no actual harm with the potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following: On 9/16/14 at approximately 2:50 p.m. during a tour of the kitchen, a single bay sink in the kitchen area did not have an air gap for the indirect drain. The drain plumbing from the sink was below the top of the catch funnel for the sewer plumbing. This created a direct connection to the sewage system. At that time, the Food Service Director (FSD) stated that the sink was used for preparing food and that there was not a direct connection to the sewer system. The FSD was not aware of the requirement for an air gap. Also, the Director of Environmental Services was shown the plumbing and acknowledged that the plumbing from the sink is below the level of the funnel for the sewer. Section 14.140 of Subpart 14-1 of the New York State Sanitary code states that, "There is to be no direct connection between the sewage system and any drains originating from fixtures and equipment used for storage, preparation, or processing of food or drink." (10 NYCRR 415.29(e)(1)(2); Subpart 14-1: 14.140)

Based on observation, interviews and record reviews, it was determined during the Recertification Survey that for one (Resident #87) of one resident reviewed for accommodation of needs, the facility did not provide services to accomodate each resident's individual needs. The issue involved the lack of an available call light. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following: Resident #87 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Assessment, dated 7/5/13, revealed that the resident is able to make decisions. Documentation on the Comprehensive Care Plan (CCP), dated 7/17/13, shows that the resident is at risk for falls and staff are to encourage the resident to use the call light. During an observation on 8/26/13 at 11:03 a.m., the resident was in his room sitting in his wheelchair. The resident's call light was located on the other side of the bed under the bedspread. In an interview at that time, the resident stated that he was not able to reach the call light. During observations on 8/28/13 at 10:00 a.m. and at 10:30 a.m., the resident was seated in a recliner chair in his room. The resident's call light was laying on the middle of the bed out of the resident's reach. When interviewed at 10:30 a.m. that day, the assigned Certified Nursing Assistant stated that the resident prefers the call light in the middle of his bed. When interviewed on 8/28/13 at 10:45 a.m., the Registered Nurse/Nurse Manager stated that the call light should be within the resident's reach at all times while he is in his room. (10 NYCRR 415.5(e)(1))

Based on observations, interviews, and record reviews, it was determined during the Recertification Survey that for one (Resident #1) of three residents reviewed for comprehensive care planning related to nonpressure related skin issues, the facility did not ensure that revisions were made to a resident's care plan. THIS IS A REPEAT DEFICIENCY FROM THE RECERTIFICATION SURVEY OF 8/24/12. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following: Resident #1 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Assessment, dated 7/15/13, revealed that the resident's cognitive skills for daily decision making are intact. Documentation on the Comprehensive Care Plan (CCP), dated 5/13/13, shows that the resident is at high risk for skin impairment related to decreased mobility and the aging process. Approaches are to provide pressure relieving devices in wheelchair and on bed, provide incontinence care as needed, weekly skin assessments, and staff are to assess skin for any redness, irritation, or skin breakdown with care and report to nurse. The Certified Nursing Assistant (CNA) care sheet, reviewed and revised on 8/23/13, includes staff are to report any skin integrity issues to the nurse immediately. The resident is nonambulatory and requires a mechanical lift for transfers. The resident is independent with bed mobility with use of a transfer bar in bed and is able to use a wheelchair independently around the facility. Observations of the resident include the following: a. On 8/26/13 at 10:20 a.m., the resident had numerous bruises on both forearms and a small scabbed area on the left forearm covered with a steri-strip. b. On 8/27/13 at 11:30 a.m., the resident was seated in a powered wheelchair in her room wearing a long sleeved sweater. c. On 8/28/13 at approximately 9:15 a.m., the resident was seated in a powered wheelchair moving around the unit wearing a short sleeved blouse. d. On 8/28/13 at 1:16 p.m., the resident was seated in a powered wheelchair in the Community Lounge visiting with family, wearing a long sleeved sweater. Review of the weekly skin documentation forms, dated from 6/13/13 to 8/22/13, revealed that on 7/18/13, the resident's left elbow was bruised. On 8/1/13, old bruises were present on the resident's left arm. There was no further documentation of bruising in the medical record or on the skin sheets. Interviews on 8/28/13 include the following: a. At 1:45 p.m., the assigned CNA stated that the resident bruises easily and that she has not seen any new bruises that needed to be reported to the nurse. b. At 4:00 p.m., both the Medical Director and the Registered Nurse/Nurse Manager (RN/NM) were not able to provide further information regarding the chronic bruising. The Medical Director stated that staff are so used to the bruising that they do not think to document it. The RN/NM and the Medical Director both said that the CCP needed to be revised to reflect the chronic bruising. After surveyor intervention, the CCP was revised on 8/29/13 to include that the resident is at risk for chronic bruising related to [MEDICATION NAME] and aspirin use, both blood thinning medications. Approaches included to dress the resident with geri sleeves or long sleeved clothing and to note new areas of bruising on skin assessments and progress notes. (10 NYCRR 415.11(c)(3)(ii))