Every finding on record at Woodland Pond At New Paltz

Based on observation, interview, and record review during the abbreviated (NY00370838 and NY00371165) and recertification surveys from 4/21/2025-4/24/2025, the facility did not ensure sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, 1). multiple residents and family members complained about long wait times after initiating the call bell, 2). Resident #28 had to wait 66 minutes on 2/1/2025 to receive incontinence care, 3) Resident Council attendees reported long wait times to receive assistance from staff for activity of daily living, and 4) Resident #6 was observed waiting an extended period of time for assistance with morning care due to staff inability to manage their assignment, refer to F677. The findings included: The policy titled Staffing documented provide adequate staffing to meet needed care and services for resident population. 1) The Call Bell Logs from October 2024-January 2025 documented 196 alarms in October, 104 alarms in November, 178 alarms in December, and 151 alarms in January took more than 30 minutes for a response. Call bell Logs included but were not limited to the following examples: Friday October 11, 2024 at 8:53 AM, the call bell in room [ROOM NUMBER] was answered after 56 minutes, Saturday October 26, 2024 at 7:43 PM the call bell in room [ROOM NUMBER] was answered after 78 minutes, Thursday October 31, 2024, at 7:29 PM, the call bell in room [ROOM NUMBER] was answered after 72 minutes, Saturday November 2, 2024 at 7:06 AM, the call bell in room [ROOM NUMBER] was answered after 73 minutes, Sunday November 3, 2024 at 8:04 PM, the call bell in room [ROOM NUMBER] was answered after 77 minutes ,Thursday November 7, 2024 at 05:18 AM the call bell in room [ROOM NUMBER] was answered after 74 minutes, Thursday December 5, 2024, at 7:33 PM the call bell in room [ROOM NUMBER] was answered after 74 minutes, Friday December 13, 2024 at 10:01 AM the call bell in room [ROOM NUMBER] was answered after 117 minutes, Thursday December 19, 2024 at 04:20 AM the call bell in room [ROOM NUMBER] was answered after 82 minutes, Monday January 19, 2025, at 6:26 PM the call bell in room [ROOM NUMBER] was answered after 71 minutes, and Wednesday January 22, 2025 at 10:38 AM the call bell in room [ROOM NUMBER] was answered after 74 minutes. 2) A facility investigation dated 2/1/2025 documented that on 2/1/2025 at 2:22 PM Administration was notified by the Certified Nursing Aide, assigned to Resident #28, that Resident #28 was crying, in need of incontinence care, and stated that they were not tended to in a long time. The timeline provided from the investigation documented that Resident #28 initiated the call bell at 10:53:55 AM and the bell was answered at 12:00:52 PM after ringing for 66 minutes and 57 seconds. Incontinence care was provided at approximately 12:20 PM. (See F677) 3) During the Resident Council meeting on 4/22/2025 at 11:10 AM, Residents #9, #15, and #30 stated the night shift had problems as 40 residents was too much for 2 Certified Nurse Aides. All residents in attendance reported the night shift staff were not able to attend to resident activity of daily living needs and that many waited until 7 AM-7 PM to receive assistance with incontinence care and to be transferred to bed. During the Resident Council meeting on 4/22/2025 at 11:51 AM Resident #15 stated during the overnight shift there have been 2 Certified Nurse Aides and during the day shift there were 3 Certified nurse Aides. They stated the day shift staff were used to get them in bed because they would have to wait a very long time to go to bed with the night shift starting at 7 PM. During the Resident Council meeting on 4/22/2025 at 11:51 AM, Resident #19 and Resident #33 stated residents were told to urinate in their brief because they had not had a bowel movement. During an interview on 4/23/2025 at 12:08 PM, the Director of Nursing stated that they felt staffing numbers were adequate to provide the care needed for their residents. The stated Resident #28 had to wait for 66 minutes to receive incontinence care and that a wait time of more than 20-25 minutes was unreasonable and was the cut off for their audit. During an interview on 4/24/2025 at 10:33 AM Resident #18's family member expressed concern over the time it took for staff to answer call bell/s. They stated when staff answered they frequently stated they needed a second person, left and did not return for 20-30 minutes. During an interview on 4/24/2025 at 11:57 AM Certified Nursing Assistant #8 stated there were usually 3 Certified Nurse Aides on the unit during evening/night shift, occasionally there there were only two. They stated when there was only two, the assignment was not easy, but doable, especially with all the residents that required a lift for transfers. They stated nurses assisted with resident care and answering call bells, but the extra nurse was not given an aide assignment to make it a three-way split, it remained a two-way split. 10 NYCRR 415.13 40686

Based on observation, interview, and record review conducted during the recertification survey from 4/21/2025 to 4/24/2025, the facility did not ensure the resident's right to be notified of facility's grievance official and of their right to obtain a copy of their grievance decision in writing. This was evident for 7 (Resident #30, #15, #4, #12, #18, #9 and #7) Resident Council attendees out of 38 total residents. Specifically, Resident #30, #15, #4, #12, #18, #9, and Resident #7's Family Representative did not know the Grievance Official for the facility and were unaware of their right to receive written copy of grievance investigation decisions. The findings are: On 4/22/2025 at 11:10 AM, a Resident Council meeting was held with Resident #30, #15, #4, #12, #18, #9, and Resident #7's Family Representative in attendance. All attendees stated they were unaware of who held the title of Grievance Official for the facility, and they could receive a copy of their grievance investigation decision in writing. On 4/24/2025 at 12:13 PM, Resident #7's Health Care Agent was interviewed and stated they agreed with Resident #7's Family Representative and was unaware of who was the Grievance Official for the facility. Resident #7's Health Care Agent also stated they communicated several concerns to the facility and were not made aware of the facility's formal written grievance investigation process or that they were able to obtain a written copy of the facility's decision regarding their grievances. During observation of the facility front entrance, lobby, and resident unit on 4/24/2025 at 2:19 PM, there were no postings identifying the facility's Grievance Official or providing information on the facility's grievance process. On 4/24/2025 at 2:29 PM, the Administrator was interviewed and stated the facility's Grievance Official, the Director of Social Work, was currently unavailable for an interview. The Administrator stated they were aware of the facility's grievance process. Residents and their representatives were made aware of the grievance process and were aware of how to file grievances regarding missing items. The facility conducted grievance investigations and informed the residents of the outcomes of their investigations. The Administrator stated the residents knew who the Grievance Official was, and they believed this information was posted throughout the facility. The Administrator stated staff attempted to address all resident concerns, requests, and suggestions and did not know of any unresolved resident or representative concerns that required a formal written grievance investigation. 10 NYCRR 415.3(c)(1)(i)

Based on observation, interview, and record review conducted during the recertification and abbreviated (NY00371165 and NY00370838) survey from 4/21/2025 to 4/24/2025, the facility did not ensure a resident unable to carry out activities of daily living received the necessary services to maintain good personal hygiene. This was evident for 2 (Resident #6 and #28) of 3 residents reviewed for activities of daily living. Specifically, 1) Resident #6 reported long wait times to receive assistance with incontinence care and personal hygiene, and 2) Resident #28 was dependent on assistance for activities of daily living and had to wait 66 minutes on 2/1/2025 to receive incontinence care. The findings are: The facility policy titled Activities of Daily Living dated 4/22/2025 documented resident activities of daily living performance skills would be assessed and a care plan would be completed. 1) Resident #6 had diagnoses of left femur fracture and altered mental status. The Quarterly Minimum Data Set (resident assessment) dated 1/16/2025 documented Resident #6 had moderately impaired cognition, required 1-person assistance with toileting and was always incontinent. The Significant Change Minimum Data Set, dated dated dated [DATE] documented Resident #6 had moderately impaired cognition, and was totally dependent on 1 to 2 staff for assistance with incontinence care. The Comprehensive Care Plan related to activities of daily living initiated 4/2/2025 documented Resident #6 required assistance with incontinence care, dressing, and personal hygiene due to a recent left hip fracture and would remain clean, neat, dressed appropriately, and free of body odor. The Nursing Instructions as of 4/2025 documented Resident #6 was dependent on staff for clothing management and post-voiding hygiene during incontinence care. On 4/21/2025 at 3:35 PM, Resident #6's Designated Representative was interviewed and stated there were not enough staff to attend to Resident #6's activity of daily living needs in a timely manner. They stated Resident #6 rang the call bell for assistance and waited over 30 minutes at times for assistance, especially on the overnight shifts. On 4/21/2025 at 5:10 PM, Resident #6 was observed in bed in their room. The call bell button was observed on their recliner out of reach. Resident #6 stated their care was inconsistent and they had to wait extended periods of time to have their call bell answered or to receive incontinent care. The 7 PM to 7 AM shift was short of staff and were unable to provide care timely. Resident #6 stated they were placed in bed today after they received physical therapy and had not received care from a Certified Nurse Aide since then. On 4/24/2025 at 10:45 AM, Resident #6 was observed in their room in bed wearing an incontinence brief and t-shirt. Resident #6 stated the Certified Nurse Aide stopped by to introduce themselves this morning and stated they would be back to provide them with care. Resident #6 stated they did not receive assistance with incontinence care, personal hygiene, or dressing yet for the day. On 4/24/2025 at 11:04 AM, Certified Nurse Aide #9 was interviewed and stated they started their shift at 7 AM and were assigned to Resident #6. Certified Nurse Aide #9 stated they went to introduce themselves to Resident #6 and stopped by the resident's room but have not been able to provide the resident with activity of daily living care including toileting, grooming, or personal hygiene. Certified Nurse Aide #9 stated they were assigned 9 residents and 7 residents on their assignment required the assistance of 2 people to perform activities of daily living. The night shift was assigned to make sure 1 resident on Certified Nurse Aide #9's assignment received morning cares and was transferred out of bed. Certified Nurse Aide #9 stated they had to provide morning cares and get up 8 residents this morning, including Resident #6, and assist with breakfast service. Certified Nurse Aide #9 stated they were assigned to the dining room to assist with feeding residents for breakfast. They were unable to provide care to 3 of their assigned residents, including Resident #6, yet today. Incontinent residents who require assistance with toileting and/or changing their incontinence brief should be checked by staff every 2 to 4 hours. Certified Nurse Aide #9 stated they communicate with the night shift when they start their shift to receive report about residents but did not know when Resident #6 last had their incontinence brief changed. Certified Nurse Aide #9 stated there were 2 Certified Nurse Aides staffed on the night shift and more tasks and work were placed on the day shift aides when they started their shifts in the morning. On 4/24/2025 at 12:47 PM, Licensed Practical Nurse #10 was interviewed and stated they were 1 of 2 medication nurses for the unit. The facility used to staff 3 medication nurses for the day shift but now the facility only staffed 2 medication nurses. There were 4 aides assigned to the day shift. The licensed nurses on the unit tried to help the aides with attending to residents when they were able to, but the licensed nurses needed to ensure that medications were given on time. Licensed Practical Nurse #10 stated they answered call bells but if a resident needed activity of daily living assistance, Licensed Practical Nurse #10 would let the resident know they needed to wait for when their aide had time to come assist them. Licensed Practical Nurse #10 stated they would assist the aides when they could if they had time after their assignment was completed. Licensed Practical Nurse #10 stated Resident #6 required the assistance of 2 people for cares and used a mechanical lift to transfer out of bed. Resident #6 also needed 2 people to assist when turning and positioning in bed. The unit had 19 residents who required 2 people and a mechanical lift to transfer in and out of bed. The assignment could be overwhelming for the night shift to address everyone since there were only 2 aides assigned to provide care to all the residents on the unit at night. On 4/24/2025 at 3:57 PM, the Director of Nursing was interviewed and stated the 2 Certified Nurse Aides assigned to the night shift were able to address all resident care needs adequately. Any of the licensed nurses assigned to the night shift were able to assist the aides with providing resident care. The licensed nurses were expected assist the aides but were not formerly assigned residents to care for on the overnight shift. It was not acceptable for a resident to still be waiting for morning activity of daily living care at 11 AM. None of the residents have complained that the facility was short of nursing staff or that they have not received care timely. The Director of Nursing and Administrator monitored call bell response times and did not identify any concerns with resident care needs being addressed. None of the staff have complained that their assignment was overwhelming. The Director of Nursing stated they felt it was reasonable for 2 aides to address the needs of 19 residents with total care needs overnight because the licensed nurses assisted with providing residents with care. 51214 2) Resident #28 with diagnoses that included, but not limited to, cerebral infarction, hemiplegia, and aphasia. The Annual Minimum Data Set, dated dated dated [DATE] for Resident #28 documented the resident had moderately impaired cognition, maximum assistance to dependent for activities of daily living. The Activities of Daily Living Care Plan dated 10/7/2024 for Resident #28 documented dependent on staff for incontinence care. The Quarterly Minimum Data Set data set dated [DATE] documented Resident #28 had moderately impaired cognition and required maximum assistance for activities of daily living. A facility investigation dated 2/1/2025 documented that on 2/1/2025 at 2:22 PM Administration was notified by the Certified Nursing Aide, assigned to Resident #28, that Resident #28 was crying, in need of incontinence care, and stated that they were not tended to in a long time. The timeline provided from the investigation documented that Resident #28 initiated the call bell at 10:53:55 AM and the bell was answered at 12:00:52 PM after ringing for 66 minutes and 57 seconds. Incontinence care was provided at approximately 12:20 PM. During an interview on 04/23/25 at 12:08 PM, the Director of Nursing stated that they were currently auditing the call bell response time. They stated Resident #28 had to wait for 66 minutes to receive incontinence care and that a wait time of more than 20-25 minutes was unreasonable. 10 NYCRR 415.12(a)(3)

Based on observation and interview conducted during the recertification survey from 4/21/25-4/24/25, the facility did not ensure food was stored in accordance with professional standards for food service safety. Specifically, food items were not properly sealed and dated in the main kitchen walk in refrigerator, clean wet pots were stacked on a drying rack and dietary staff were observed without hair nets or beard covers while in the kitchen and while serving food in the dining room at the steam table. The findings include: The policy titled Hygiene Guidelines dated 6/1/2022 documented hair could be both a direct and indirect vehicle of contamination. A hair restraint keeps dislodged hair from ending up in the food. The policy titled Food Labeling and Dating Guidelines dated 12/6/2022 documented labeling requirements for used by date is required. During initial inspection of the kitchen conducted with the Food Service Director on 4/21/25 at 12:30 PM the following was observed: Dietary Staff #4 was not wearing a hair net or beard cover. - The walk-in refrigerator contained roasted peppers in a container with no date, cooked hash on an uncovered tray with no date, unlabeled soup in a plastic container with no date. - The walk-in freezer contained an opened, unlabeled, undated plastic bag with rolls. - The dishwasher had clean wet pots stacked one on top of the other on a drying rack. During interview on 4/21/2025 at 1:00 PM Dietary Staff #4 stated they were aware they should have worn a hair net and stated sometimes they forget. During observation on 04/21/2025 at 5:00 PM staff members serving food from a steam table were not wearing hair nets or beard covers. During observation on 4/22/2025 at 8:40 AM of breakfast in the main dining room, Dining Manager #5 was serving food from the steam table with their hair in a ponytail and without a hair net. During interview on 4/22/2025 at 8:44 AM, Dining Manager #5 stated they were aware they should have worn a hair net, but they were busy and forgot to put it on. During interview on 4/22/2025 at 9:59 AM, the Director of Food Service stated they were aware that staff serving food were required to wear hair nets. They stated they did not believe beard covers were needed if the beard hair was less than a 1/2 inch. During interview on 4/24/2025 a 09:52 AM, the Assistant Director of Dining #6 stated they were responsible for ensuring foods were dated and stored in sanitary conditions. Prepared foods should be dated and discarded after 3 days. They stated they worked Monday but did not know why foods in the refrigerate were not dated. They stated they constantly train and retrain staff on food safety. They stated staff had been trained and required to wear hair nets to cover hair and beard covers to cover any facial hair. 10 NYCRR 415.14 (h)

Based on observation, record review, and interview conducted during a recertification survey from 4/21/2025 to 4/24/2025, the facility did not ensure infection control and prevention practices were maintained. Specifically, Licensed Practical Nurse #1 was observed administering medication to Residents #20 and #28 without performing hand hygiene during administration of eye drops and preparation of medications via gastrostomy tube. The findings include: The facility policy titled Medication Administration last reviewed on 11/2024 documented administer medications safely and appropriately by a licensed nurse to treat, prevent and alleviate symptoms of a disease. Always practice hand hygiene before and after the procedure. During interview and observation of medication administration on 04/23/2025 from 9:05 AM to 10:23 AM, on Unit S1 the following was noted: Licensed Practical Nurse #1 removed eyedrops from the medication cart, held the bottle with their left hand, read the name on the bottle and checked the expiration date. With their right hand holding the computer mouse, checked the physician order and confirmed the resident's name and order on the eyedrop bottle. Licensed Practical Nurse #1 placed the eyedrop bottle on the medication cart, performed hand hygiene and donned a pair of gloves. They picked up the eyedrop medication with their right hand and entered Resident #20's room. Using their left hand, Licensed Practical Nurse #1 removed 2 tissues from a tissue box, administered an eye drop to Resident #20's left eye by touching the lower lid and used 1 tissue to dry the left eye. Licensed Practical Nurse #1 did not perform hand hygiene and proceeded to administer an eye drop to Resident # 20's right eye by touching the lower lid. Licensed Practical Nurse #1 used the second tissue to dry the right eye. Licensed Practical Nurse #1 performed hand hygiene using the hand sanitizer on the cart. They popped the medication in the blister pack into a medication cup, placed the medication in the small plastic bag, touched the pillcrusher and crushed the medication. They poured the medication into the medication cup and touched the inside of the medication cup without performing hand hygiene. Licensed Practical Nurse #1 crushed another medication inside a small plastic container, touched the pill crusher and touched the inside of the plastic container while pouring the medication into a medication cup without performing hand hygiene. Licensed Practical Nurse #1 with bare hands, separated a medication capsule and poured the capsule contents into a medication cup without performing hand hygiene. Licensed Practical Nurse #1 proceeded to administer the medication via gastrostomy tube. Licensed Practical Nurse #1 was interviewed after the medication administration and stated they should have performed hand hygiene during eye drop administration. Licensed Practical Nurse #1 stated they were aware of infection control and prevention practices and should not have touched the medication capsule with bare hands. Licensed Practical Nurse #1 stated they were aware of the infection control and prevention practices and forgot to do so during medication administration. During an interview on 04/24/25 at 10:14 AM the Director of Nursing stated nurses should follow infection control practices during medication administration particularly hand hygiene. They further stated nurses should not touch medication capsules with bare hands. They stated Licensed Practical Nurse #1 did not follow infection control practices during medication administration. 10 NYCRR 415.19 (b) (4)

Based on observation and staff interview conducted during the recertification survey it could not be ensured that the facility maintained a safe, functional, sanitary and comfortable environment for residents, staff and the public. Specifically, (1) the facility did not have enough water sampling points on Legionella tests done in 3/2019 and 4/2019, (2) facility water supply has tested positive for Legionella on tests done in 7/2019 and 8/2019, and (3) no water sampling was done from 9/2019 to 2/28/2020. The findings are: 1. Review of the Facility Water Analysis Results dated 3/21/2019 and 5/15/2019 revealed that 11 sample sites were tested for Legionella. Additional testing sites (16) are indicated. Of note, 3 of 11 (27.27%) sample sites showed positive Legionella results. An interview was conducted on 2/26/2020 at 03:18PM with the Director of Facilities (DOF) where he stated that on 4/15/2019 after he attended a Department of Health (DOH) Legionella Training Session, he became aware that they should increase water sampling points in the facility from 11 to 16. 2. Review of the Facility Water Analysis Result dated 8/15/2019 (samples collected 7/29/2019) revealed that 11 out of 16 (68.75%) sample sites tested positive for Legionella. An interview was conducted on 2/28/2020 at 12:18PM with the DOF where he confirmed that 11 of 16 sites sampled, had positive results for Legionella. Review of the Facility Water Analysis Result dated 9/17/2019 (samples collected 8/28/2019) revealed that 11 out of 16 (68.75%) sample sites tested positive for Legionella. An interview was conducted on 2/28/2020 at 12:18PM with the DOF where he confirmed that 11 of 16 sites sampled, had positive results for Legionella. 3. There was no documentary evidence available for review to show that the water system testing was completed from 09/18/2019 to 02/28/2020. An interview was conducted with the DOF on 2/28/2020 at 12:18PM. He stated that the facility is following the engineering consultant's advice after the positive tests to flush the facility water system and to resample. He stated that the facility stopped water resampling after 8/28/2019 because 11 out of 16 water sample sites were positive again. The engineering consultant advised the facility that they need to install a chlorination system to re-chlorinate and wait for an 0.08mg/L residual chlorine level to redo another water resampling. He stated that they have not resampled since 8/2019 because they have not reached 0.08 mg/L residual chlorine level. 415.29

Based on observation, interview and record review conducted during a recertification survey, it was determined that the governing body did not implement policies regarding the management and operation of the facility Water Management Plan. Specifically, the facility Legionella Sampling and Management Plan. The findings are: The facility did not adhere to the recommended water sampling points on the water sampling tests done in 3/2019 and 4/2019. Review of the Facility Water Analysis Result dated 03/21/2019 revealed that 3 out of 11 (27.27%) sample sites tested positive for Legionella. Review of the Facility Water Analysis Result dated 5/15/2019 revealed that 3 out of 11 (27.27%) sample sites tested positive for Legionella. The facility water supply has tested positive for Legionella in 7/2019 and 8/2019. Review of the Facility Water Analysis Result dated 8/15/2019 showed that 11 out of 16 (68.75%) sample sites tested positive for Legionella. Review of the Facility Water Analysis Result dated 9/17/2019 showed that 11 out of 16 (68.75%) sample sites tested positive for Legionella. There was no documentary evidence that further water system resampling was completed from 9/18/2019 to 2/28/2020. An interview was conducted with the facility Administrator on 2/26/2020 at 4:18PM who stated that they informed the New York State Department of Health (NYSDOH) on 8/19/2019 after the more than 30% positive Legionella result. He stated that all technical questions about Legionella should be directed to the Director of Facilities. An interview was conducted on 2/26/2020 at 03:18PM with the Director of Facilities who stated that the first 2 water samplings were conducted on 3/06/2019 and 4/25/2019. He stated that 3 out of 11 sample points were positive for Legionella at both tests. He stated that the results were not more than 30% so they did not report it. He stated that on 4/15/2019 after he attended a NYSDOH Legionella Training Session, he became aware that the facility should increase water sampling points in their facility from 11 to 16. He stated that on 7/29/2019 they took water samples from 16 sites and 11 came out positive, and the Administrator reported it to the NYSDOH. A second interview was conducted with the Director of Facilities on 2/28/2020 at 12:18PM. He stated that the facility is following the engineering consultant's advice to flush the facility water system and to resample. He stated that the facility stopped water resampling after 8/28/2019 because 11 out of 16 water sample sites were positive again. The engineering consultants advised them that the facility needs to install a chlorination system, to re-chlorinate and to wait for a 0.08 mg/L residual chlorine level to redo another water resampling. He stated that the facility has not resampled since 9/2019 because they have not reached the 0.08 mg/L residual chlorine level. 415.26 (b)(3)(1)

Based on observation, interview and record review conducted during the recertification survey, the facility did not ensure foods were stored in accordance with professional standards for food service safety to ensure prevention of foodborne illness. Specifically, opened and/or expired potentially hazardous foods (beef, chicken) were observed to be stored in a refrigerated unit. The findings are: The facility policy dated [DATE] and titled, Ground Beef Policy documented that the shelf life of the product is 21 days from manufacturer's pack date. The facility policy dated [DATE] and titled CVP (Cryovac: a way of vacuum sealing meat to keep harmful bacteria out and to extend the shelf life of the meat by keeping it fresh longer) Fresh Chicken Guidelines documented that the shelf life of product is 14 days from the manufacturer's pack date, frozen items must be used within 48 hours after thawing and that staff are to use opened packages of CVP chicken within ,[DATE] days of opening. 1. The initial tour of the kitchen was conducted on [DATE] at 11:10AM with the Dining Director (DD) in attendance. The surveyor observed in a refrigerated unit one box with a manufacturer's label documenting: Ground Beef Bulk .4 / 5 lb. packages .keep refrigerated .packed on [DATE] (26 days prior to observation date) .use or freeze by [DATE]. The box was dated ,[DATE] and contained 20 pounds of uncooked ground beef. The Utility Aide (UA) responsible for receiving and storage of the beef was interviewed on [DATE] at 11:20AM and reported that he took delivery of the beef on ,[DATE] and stored it in the refrigerator; he is supposed to watch for expiration of foods; and the beef should have been used or frozen by [DATE]. The Chef Manager (CM) was interviewed on [DATE] at 2:25PM and said that he had frozen the ground beef on the date of delivery but could not recall the date of the delivery. He stated that he had pulled 2 cases of ground beef on [DATE] and dated the bottom of the box. The DD was present at that time and when asked if she was aware of the food storage practices stated by the CM, responded she did not know the CM moves deliveries from the refrigerator to the freezer or that he was labeling the boxes on the bottom when the foods were pulled from the freezer and returned to the refrigerator. At that time, neither the CM nor the DD were able to provide evidence that the ground beef with a received date of [DATE] had been frozen then returned to the refrigerator on [DATE]. 2. The initial tour of the kitchen was conducted on [DATE] at 11:10AM with the DD in attendance. The surveyor observed in a refrigerated unit one box dated ,[DATE] contained an opened, partially used, approximately half-full, 10-pound bag of diced chicken which was not labeled with an opened date. The Utility Aide (UA) responsible for receiving and storage of the chicken was interviewed on [DATE] at 11:20AM and reported that he took delivery of the diced chicken on ,[DATE]. He reported that it came in frozen and he stored it in the refrigerator. The DD was interviewed on [DATE] at about 11:30AM and reported that all Chef Managers should be checking for expired foods. Furthermore, the opened bag of diced chicken should have been used within 3 days. 3. A follow up tour of the kitchen conducted on [DATE] at 10:48 AM revealed one box containing four, ten-pound packages of defrosted chicken leg quarters was dated with a received date of ,[DATE]. The manufacturer's label on the box documented that the chicken leg quarters were packed on [DATE] (18 days prior to observation date) .keep refrigerated or frozen .vacuum packed. The label did not document a use by date. The DD was interviewed at that time and explained that the chicken leg quarters had been in the refrigerator since the received date of ,[DATE]. She said that after the chicken is defrosted, she has 3 days to use it. She further explained that she did not know when the chicken was defrosted as it was not checked. 415.15(h)

Based on observation, record review and interview conducted during the recertification survey, the facility did not ensure that proper hand hygiene was performed during wound care for 2 of 2 residents (#2 and #13) reviewed for pressure ulcers. The findings are: Review of the Wound Dressing Policy revised on 11/2019 documented that after removing the old dressing, staff must remove gloves, wash hands and apply a clean pair of gloves. Review of an undated Competency Dressing Change Checklist documented that for both sterile and non-sterile dressing changes, staff must remove gloves and perform hand hygiene after removing old and / or soiled dressings. 1. Resident #2 was admitted with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS; a resident assessment tool) dated 2/26/2020 documented a Brief Interview for Mental Status (BIMS) score of 3, denoting severe cognitive impairment. Section M of the MDS documented that the resident was at risk for developing pressure ulcers and had one unhealed and one unstageable pressure ulcer. Review of the 2/27/2020 physician's orders [REDACTED]. Cover silver alginate with an [MEDICATION NAME] heel cup. Place an abdominal pad (ABD) on the shin area and top of foot, then wrap loosely with kling. Change daily and as needed. The order also documented an order for [REDACTED]. A wound treatment observation for Resident #2 was conducted on 2/27/2020 at 09:39AM with Registered Nurse (RN #1) who was assisted by Certified Nursing Assistant (CNA #1). RN #1 removed the soiled dressing on the right heel then proceeded to cleanse the wound, pat dry and apply Silver Alginate. RN #1 completed the dressing to the right heel and then applied Sureprep to the resident's left heel without changing the soiled gloves or washing her hands. An interview was conducted with RN #1 on 02/27/20 at 09:52 AM who stated that she washes her hands before and after a wound treatment, but not in the middle of the procedure. 2. Resident #13 was admitted with [DIAGNOSES REDACTED]. The Significant Change MDS dated [DATE] documented a BIMS score of 9, denoting moderate cognitive impairment. Section M documented that the resident is at risk for developing pressure ulcers, had an unhealed and an unstageable pressure ulcer. Review of the 02/27/20 physician's orders [REDACTED].#13 should have the left heel gently cleansed with wound cleanser and have an Opti-foam heel cup applied to the left heel. Allow the Slipper Sock to secure the heel cup; changing every three days. The order also documented to cleanse the right calf area with wound cleanser, apply a whole piece of silver foam securing with minimal amount of Mediflex tape, change daily and as needed. A wound care observation was conducted on 2/27/2020 at 09:54AM with RN #1 who was assisted by CAN #1. RN #1 removed the resident's left heel dressing and completed the entire procedure without removing her soiled gloves or washing her hands. Before proceeding to the resident's right calf, RN #1 removed her gloves, used alcohol hand rub, then donned new gloves. RN #1 was observed to remove the soiled dressing on Resident #13's right calf then complete the treatment without changing her soiled gloves or washing her hands prior to donning new gloves. An interview was conducted with RN #1 on 2/27/2020 at 09:52 AM who stated that she washes her hands before and after a wound treatment, but not in the middle of the procedure. An interview was conducted with the Infection Control Nurse (ICN) on 02/27/20 at 10:49 AM. The ICN stated that after removing the old and / or soiled dressing, the nurse must remove her gloves and perform hand hygiene. 415.19(b)(4)

Based on observation, record review and interview conducted during the recertification survey, it could not be ensured that the facility stored medications under proper temperature controls. Specifically, the temperature in the facility medication refrigerator was noted to be below the manufacturers' specifications during two observations. The findings are: The facility policy on refrigerated medications revised on 2/2019 documented that the medication refrigerator temperatures are to be checked daily and documented. The temperature range should be between 36° Fahrenheit (F) and 41° F. If refrigerator temperatures are above or below this range, maintenance is to be notified immediately. An observation was conducted on 2/25/2020 at 12:58PM with LPN #2. The medication refrigerator was observed via a thermometer to be at a temperature of 32° F. An interview conducted with LPN#2 at that time revealed that the LPN did not know the correct temperature range for the refrigerator nor does she know what actions to take should the temperature be out of range. An observation was conducted on 2/26/2020 at 9:40AM with LPN #1. The medication refrigerator contained medications such as insulin, vaccines and eye drops. The thermometer in the medication refrigerator was observed to read a temperature of 28°F. An interview was conducted with LPN #1 who revealed that she does not know the correct temperature range for the refrigerator and does not know what actions to take should the temperature be out of range. An interview was conducted with RN #1 on 2/26/2020 at 09:45AM and revealed that RN #1 does not know the correct temperature range for the refrigerator and does not know what actions to take should the temperature be out of range. An interview was conducted with the Unit Manager (UM) on 2/26/2020 at 10:15AM. She stated that they will discard all the medications (which included insulin, vaccines and eye drops) in the refrigerator and replace the refrigerator with a new one. An interview was conducted with the Nurse Educator on 2/28/2020 at 10:20AM. She stated that she has not trained the facility nurses on monitoring the medication refrigerator temperatures. An interview was conducted with the Director of Nursing (DON) on 2/28/2020 at 10:33 AM. She stated that they have discarded all the medications in the refrigerator since they cannot determine how long the temperature has been out of range. 415.18(3) (1-4)

Based on record review and interview conducted during a recertification survey, the facility did not ensure that its potable water system was tested , as required by public health laws and regulations, to determine the presence of Legionella and/or other opportunistic waterborne pathogens, that could grow and spread in the water system and affect the health of the residents, staff, and visitors. Legionella can cause a serious type of pneumonia in persons at risk. Outbreaks have been linked to poorly maintained water systems in buildings with large or complex water systems including long-term care facilities. The Public Health Law Section 225(5)(a) Subpart 4-2.4 Sampling and Management Plan states that all covered facilities shall adopt and implement a legionella culture sampling and management plan for their potable water systems. The findings are: Review of the facility's 11/2017 policy and procedures, and water management plan revealed that the facility did not ensure that its portable water system was tested , as required by public health laws and regulations, to determine the presence of Legionella and/or other opportunistic waterborne pathogens. These include Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, Microbacteria and Fungi, that could grow and spread in the water system, and affect the health of the residents, staff, and visitors. The Director of Plant Operation (DPO) was interviewed on 4/24/18 at 2:23 PM and stated that the Legionella Disease Prevention Plan/Policies were initiated in (MONTH) (YEAR). The DPO stated that water testing was never done. The DPO stated that he had no explanation why testing was never done. The facility administrator was interviewed on 4/25/2018 at 11:00 AM and stated that the water management policy was put in place in (MONTH) (YEAR), but the facility did not get around to test the water supply. In a follow up interview with the DPO on 4/25/18 at 11:15 AM, he stated that testing was never done on the ice machines or water supply for Legionella or other bacteria. Following surveyor intervention, the facility submitted verbal and written evidence on 4/25/18 that showed 10 water samples were collected and submitted to an outside company for testing, with results pending. 415.19(a) (1-3)

Based on observation and interviews conducted during a recertification survey, the facility did not ensure that nourishing snacks were provided to residents. Ten out of 14 residents interviewed stated they were either not given or were not made aware that they could ask for evening snacks. The findings are: A resident council meeting was conducted on 4/20/18 at 10:50 AM. At this meeting, four residents in attendance (#19, #23, #32 and #37) were asked if they were offered evening snacks. Resident #19 stated she's a diabetic and she receives her prescribed snack. Resident #37 stated she gets enough food at mealtimes and did not want an evening snack and did not know that she could ask if she wants one. Residents #23 and #32 stated they were not offered evening snacks. An observation was conducted on 4/24/18 at 4:00 PM of the unit pantry and revealed that the refrigerator and cabinet drawers were stocked with food items such as cookies, yogurt, pudding and various fluids. Further resident interviews were conducted starting at 2:00 PM on 4/25/18. Eight additional residents were interviewed (#1, #12, #14, #15, #24, #35, #188, and #238) and were asked whether or not they received or offered evening snacks. Each of these residents stated that they were not being offered evening snacks. The Registered Dietitian (RD) was interviewed on 4/25/18 at 2:40 PM and stated that after the evening meal is over at about 7:00 PM, evening snacks are supposed to be offered to residents at 8:00 PM by the Certified Nurse's Aides (CNAs). The RD stated further that snacks for residents are stored in the unit pantry. Two evening shift CNAs were interviewed on 4/25/18 at 3:09 PM and 3:15 PM, respectively, regarding the offering of evening snacks to residents. Both CNAs stated that they offer residents snacks on the evening shift. Both CNAs stated that the snacks which they offer to residents included items like cookies, coffee, and yogurt which are kept in the unit pantry. 415.14(f)(1)(2)(3)(4)

Based on observation, interview, and record review conducted during a recertification survey, the facility did not ensure that its medication error rate did not exceed five percent for 3 of 4 residents (Residents #69, #38, and #14), observed for medication pass for a total of 27 observations. This resulted in a medication error rate of 18.5% percent. The findings are: 1. Resident #69 has [DIAGNOSES REDACTED]. A medication observation was conducted on 1/13/17 at 9:30 AM on the First Floor unit. The Licensed Practical Nurse (LPN#1) administered medications including [MEDICATION NAME] Eye Vitamin [MEDICATION NAME], 1 soft gel oral for [MEDICATION NAME] eye vitamins and minerals supplement and Complete Omega 565 mg Omega-3 + 70 mg Gla oral capsule. The current physician orders [REDACTED]. Review of the medication bottles, online literature, and physician orders [REDACTED]. The current medication orders of January 2017 revealed that the resident was to receive his own stock medication. The facility's Medication Administration Policy revealed no documented evidence on how the medication nurses would handle medications that were brought to the facility by residents and their families. The medication LPN was interviewed on 1/13/17 at 2:51 PM, following a review of the physician's orders [REDACTED]. The LPN stated when families bring in medications from the outside, we administer the medications. The LPN further stated that these medications were not checked by the facility pharmacist. The LPN stated he should have made sure the medications and the doses matched the physician's orders [REDACTED]. 2. Resident # 38 has [DIAGNOSES REDACTED]. A medication observation was conducted on 1/13/17 at 9:52 AM on the First Floor unit. LPN #1 administered one Aspirin 81 mg chewable tablet in its whole form. The current January 2017 physician orders [REDACTED]. This order further indicated an instruction to chew the medication before swallowing and to take it with food. LPN #1 was interviewed on 1/13/17 at 2:51 PM, following review of the physician's orders [REDACTED]. 3. Resident #14 has [DIAGNOSES REDACTED]. A medication observation was conducted on 1/13/17 at 10:02 AM on the First Floor unit. LPN #1 administered medications [MEDICATION NAME] soft gel 50+150-30-6 oral capsule and Fish Oil Omega-3 [PHONE NUMBER] mg oral capsule. The current physician orders [REDACTED]. The current physician orders [REDACTED]. LPN #1 was interviewed on 1/13/17 at 2:51 PM following review of the physician orders, and stated the doses of the medication are not the same. LPN #1 stated he did not realize the doses were not the same. 415.12 (m) (1)

Based on observation, interview, record review conducted during a recertification survey, the facility did not ensure that for 1 of 4 residents (Resident #69) observed during a medication pass, medications brought into the facility by the resident's family accurately matched or complied with the physician's orders [REDACTED]. The findings are: Resident #69 has [DIAGNOSES REDACTED]. A medication observation was conducted on 1/13/17 at 9:30 AM on the First Floor unit. The Licensed Practical Nurse (LPN#1) administered medications including Preservision Eye Vitamin Areds2, 1 soft gel oral for Ocuvite eye vitamins, and minerals supplement and Complete Omega 565 mg Omega-3 + 70 mg Gla oral capsule. The current physician orders [REDACTED]. Review of the medication bottles, online literature, and physician orders [REDACTED]. The current medication orders of January 2017 revealed the resident was to receive his own stock medication. The facility's Medication Administration Policy revealed no documented evidence on how the medication nurses would handle medications that are brought to the facility by residents and their families. The medication LPN was interviewed on 1/13/17 at 2:51 PM, following a review of the physician's orders [REDACTED]. The LPN stated when families bring in medications from the outside, we administer the medications. The LPN further stated these medications were not checked by the facility pharmacist. The LPN stated he should have made sure the medications and the doses matched the physician's orders [REDACTED]. The Director of Nursing (DON) was interviewed on 1/17/17 at 12:40 PM and stated that residents and their families were allowed to bring in medications from the outside. The DON stated that it is the nurses responsibility to make sure that medications administered matched the same information as the physician's orders [REDACTED]. The pharmacy consultant from the vendor pharmacy was interviewed on 1/17/17 at 3:47 PM and stated he reviews residents' medications at the facility on a monthly basis and he was not aware that residents' families bring medications to the facility from the outside. The pharmacy consultant stated the pharmacy do not condone families to bring in medications from the outside and were encouraged to use the vendor pharmacy. The pharmacy consultant stated the facility should have informed him of this practice. 415.18(a)

Based on record review and interview conducted during a recertification survey, the facility did not ensure that care plans with measurable objectives, time frames and interventions to meet each resident's medical, nursing and psychosocial needs were initiated for 2 out of 11 sampled residents (Residents #41 and #63) reviewed in Stage 2 of the survey. The findings are: 1. Resident #41 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission MDS (Minimum Data Set; a comprehensive resident assessment tool) dated 11/23/16 indicated the resident had a BIMS score of 15 out of 15 (Brief Interview for Mental Status; used to measure orientation and memory recall) which suggested that the resident had no cognitive impairment. Review of the most recent physician's orders [REDACTED]. The orders revealed the resident's blood sugar level was to be checked by nursing four times daily and was to receive insulin coverage for an elevated blood sugar per sliding scale. The current MAR (Medication Administration Record) used to record the resident's blood glucose levels, revealed the blood glucose levels varied widely and the resident was administered insulin on numerous occasions during her stay at the facility. The CCP (Comprehensive Care Plan) revealed no evidence of a care plan with measurable objectives, timeframes and interventions to address that care of this resident with Diabetes Mellitus. The Licensed Practical Nurse (LPN) was interviewed on 1/17/17 at 2:00 PM and stated she could not locate a care plan for the resident related to Diabetes Mellitus. 2. Resident #63 has [DIAGNOSES REDACTED]. The resident's current physician's orders [REDACTED]. There was no documented evidence that a comprehensive care plan with measurable objectives, timeframes and interventions, was initiated to address the use of these medications for the medical problems or conditions for which they were prescribed. The unit Registered Nurse manager, who was responsible for developing the residents' care plans, was interviewed on 1/17/17 at 1:20 PM, and stated there was no need for a care plan to address the use of the above-mentioned medications because the resident had no problems with sleeping, constipation and pain. 415.11(c)(1)

Based on interview and record review conducted during a recertification survey, the facility did not ensure that a comprehensive assessment conducted for 1 of 3 residents (Resident #20) reviewed for urinary incontinence accurately reflected the resident's urinary status. The findings are: Resident #20 is a [AGE] year old female and was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS; a comprehensive resident assessment tool) dated 8/15/16 revealed that the resident had no significant cognitive impairment, required extensive assistance for toileting, used a walker and a wheelchair for locomotion and was continent of bowel and bladder (urine). The Quarterly MDS dated [DATE] showed that the resident had experienced a decline in bowel and bladder incontinence in that this MDS showed that the resident was now always incontinent of bowel and bladder. The resident's medical record showed no documented evidence of an assessment conducted to determine the reason for the change or decline in the resident's status in order to assist the resident regain as much bowel and bladder function as possible. The MDS Registered Nurse Coordinator was interviewed on 1/17/17 at 11:07 AM regarding why the resident had experienced a decline in her level of continence. The MDS Coordinator stated that after reviewing the resident's record she concluded that she had made a mistake in coding the resident to show that she was continent when the resident was actually incontinent. The incorrect coding resulted in the resident not being assessed to determine the specific reasons for her incontinence, which would then assist the care planning team in determining the appropriate goal and developing interventions to address the resident's current incontinency level. 415.11(b)

Based on record review and interview conducted during a re-certification survey, the facility did not ensure that treatment and services were provided to one of three residents reviewed for urinary incontinence (Resident #30) to assist the resident restore as much bladder function as possible. The findings are: Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS; a comprehensive resident assessment tool) of 9/12/15 indicated that the resident scored 12 out of 15 on the BIMS test (Brief Interview of Mental Status; used to measure orientation and memory recall) which suggested that the resident was cognitively intact with daily decision making; and was occasionally incontinent of urine (the resident was incontinent less than seven episodes during the seven-day look-back period at the time of assessment, and includes incontinence of any amount of urine sufficient to dampen undergarments, briefs, or pads during daytime or nighttime). The subsequent comprehensive Significant Change MDS assessment of 10/15/15 indicated that the resident's BIMS score was 6 out of 15, which suggested that the resident's cognitive status remained to be severely impaired with daily decision making and that the resident's urinary status showed a decline from occasionally incontinent to frequently incontinent. The resident was again assessed on the Quarterly MDS of 1/15/16 and revealed that the BIMS score was 7 out of 15 which suggested that the resident's cognitive level remained to be severely impaired. This MDS showed that the resident was always incontinent of urine (the resident had no continent voiding). A review of the Activities of Daily Living Tracking Form, used by the CNAs (Certified Nursing Assistants) to track the progress of a resident, revealed that the resident had approximately six episodes of urinary incontinence during the month of September 2015. The tracking form for October 2015 revealed that the resident experienced approximately thirty episodes of urinary incontinence. The tracking form for March 2016 revealed no episodes of urinary continence. The Comprehensive Care Plan of 10/1/15 states that the resident is at risk for changes in urinary continence secondary to limited mobility, acute pain in his right hip, arthritis, and [MEDICAL CONDITION]. The goal of this care plan stated that the resident will be clean, dry and odor-free during the next 90 days. The care plan/interventions initiated on September 2015 through February 2016, remained unchanged. There was no documented evidence that appropriate measures were put into place to address various changes in the resident's urinary status from October 2015 to January 2016. The assigned CNA was interviewed on 3/1/16 at approximately 11:00 AM and stated that the resident has become increasingly incontinent during the time he has been in the facility. The Unit Registered Nurse Manager was interviewed on 3/1/16 at approximately 11:30 AM and stated that the resident's continence level had decreased but could not explain as to why the care plan had not been revised to address the progressive decline in the resident's urinary continence. The resident's clinical record was reviewed with the unit manager and was unable to locate documented evidence that appropriate interventions were put into place to assist the resident restore his usual bladder function, to the extent possible. 415.12(d)(2)

Based on record review and interview conducted during a re-certification survey, the facility did not provide the necessary care and services based on a written plan of care for one of five residents reviewed for unnecessary medications (Resident #24). Specifically, monitoring was not consistently conducted for this resident who is at risk for bleeding. The findings are: Resident #24 has active [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. Eliquis is used to reduce the risk of stroke and blood clots in people who have [MEDICAL CONDITION] Fibrillation and reduce the risk of forming a blood clot in the legs and lungs of people who have just had hip or knee replacement surgery. The concomitant use of both oral Eliquis and [MEDICATION NAME] increase the risk of side effects and cause bleeding or bruising. The evaluation section of the care plan for [MEDICAL CONDITION] Fibrillation dated 11/2/2015 indicated that the resident was seen by his attending physician on 10/30/15 and ordered to discontinue Xarelto, a blood thinner used to treat and prevent blood clots and to initiate Eliquis. On 12/30/15, the care plan for [MEDICAL CONDITION] Fibrillation was updated to include an intervention to monitor for effectiveness and adverse effects of Eliquis and to report to the attending physician signs and symptoms, including but are not limited to bleeding, [MEDICAL CONDITION], and nausea There was no documented evidence in the resident's clinical record, including but are not limited to nurses' notes and Medication Administration Records that ongoing monitoring was being conducted for this resident while using the above medications since 10/30/15 when Eliquis was initiated. The surveyor and the unit Registered Nurse manager reviewed the resident's comprehensive care plan and other clinical notes in the morning of 3/1/16. The unit RN manager stated that there was no documented evidence that ongoing monitoring of the resident was being conducted while undergoing treatment with the above medications to include observation for bleeding or bruising and other side effects. 415.11(c)(3)(ii)

Based on record review and interview conducted during a re-certification survey, the facility did not review and revise a comprehensive care plan with measurable objectives and time frame to address an assessed decline in urinary continence and to potentially restore previous urinary continence status to the extent possible for one of three residents reviewed for urinary incontinence (Resident #30). The findings are: Resident #30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS; a comprehensive resident assessment tool) of 9/12/15 indicated that the resident scored 12 out of 15 on the BIMS test (Brief Interview of Mental Status; used to measure orientation and memory recall) which suggested that the resident was cognitively intact with daily decision making; and was occasionally incontinent of urine (the resident was incontinent less than seven episodes during the seven-day look-back period at the time of assessment, and includes incontinence of any amount of urine sufficient to dampen undergarments, briefs, or pads during daytime or nighttime). The subsequent comprehensive Significant Change MDS assessment of 10/15/15 indicated that the resident's BIMS score was 6 out of 15, which suggested that the resident's cognitive status remained to be severely impaired with daily decision making and that the resident's urinary status showed a decline from occasionally incontinent to frequently incontinent. The resident was again assessed on the Quarterly MDS of 1/15/16 and revealed that the BIMS score was 7 out of 15 which suggested that the resident's cognitive level remained to be severely impaired. This MDS showed that the resident was always incontinent of urine (the resident had no continent voiding). A review of the Activities of Daily Living Tracking Form, used by the CNAs (Certified Nursing Assistants) to track the progress of a resident, revealed that the resident had approximately six episodes of urinary incontinence during the month of September 2015. The tracking form for October 2015 revealed that the resident experienced approximately thirty episodes of urinary incontinence. The tracking form for March 2016 revealed no episodes of urinary continence. The Comprehensive Care Plan of 10/1/15 states that the resident is at risk for changes in urinary continence secondary to limited mobility, acute pain in his right hip, arthritis, and [MEDICAL CONDITION]. The goal of this care plan stated that the resident will be clean, dry and odor-free during the next 90 days. The care plan/interventions initiated on September 2015 through February 2016, remained unchanged. There was no documented evidence that appropriate measures were put into place to address various changes in the resident's urinary status from October 2015 to January 2016. The assigned CNA was interviewed on 3/1/16 at approximately 11:00 AM and stated that the resident has become increasingly incontinent during the time he has been in the facility. The Unit Registered Nurse Manager was interviewed on 3/1/16 at approximately 11:30 AM and stated that the resident's continence level had decreased but could not explain as to why the care plan had not been revised to address the progressive decline in the resident's urinary continence. The resident's clinical record was reviewed with the unit manager and was unable to locate documented evidence that appropriate interventions were put into place to assist the resident restore his usual bladder function, to the extent possible. 415.11(c)(2)(i-iii)

Based on observation, interview and record review conducted during a recertification survey, the facility did not ensure that all essential equipment was functioning appropriately. Specifically, (1.) the temperature gauge on the rinse cycle of the dishwasher in the main kitchen did not register accurate temperatures when in use; and (2.) no corrective actions were taken by the dietary staff to ensure that the problem was promptly addressed. This had the potential of resulting in more than minimal harm that was not immediate jeopardy. The findings are: The Dishmachine Temperature Record for the month of February was reviewed on the afternoon of 2/6/15 and showed that temperatures were monitored and recorded twice daily (at lunch and at dinner time). The required temperature for the rinse cycle is 180 degrees Fahrenheit (F). The record of temperatures observed on the gauge and documented in the record showed that, on one occasion at lunch time on 2/4/15, and on four occasions at dinner time on 2/1/15, 2/2/15, 2/4/15 and on 2/5/15, the recorded temperatures were in the range of 160 - 168 degrees F. There was no documented evidence in the area designated on the form that a paper test strip was used as a method to determine if the water temperature was appropriately effective for sanitization at the times when the low temperatures were obtained. Immediately following review of the temperature record, the Food Service Manager turned on the dishwasher to determine if the rinse cycle was achieving the required temperature and if the temperature gauge was reflecting the necessary 180 degrees F or above. The test strip demonstrated that appropriate hot water temperature was reached. However, the temperature gauge registered 160 degrees F. The Food Service Manager then stated that the low temperatures in the range of 160 - 168 degrees F noted on the gauge and documented in the record above were not reported to a supervisor for corrective action. (The employees who documented the low temperatures were not available for interview). 415.29 (b)