**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 11/8/23, the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for two (Resident #6 and #66) of seven residents reviewed for quality of care related to accidents and positioning. Specifically, there was lack of assessments and monitoring for Resident #6 after they spilled coffee on themselves, and Resident #66 was not provided with leg rests while they were in their wheelchair. Additionally, while sitting in their wheelchair, Resident #66's feet were hanging down and were approximately six inches from touching the floor for extended periods of time. The findings are: The policy and procedure (P&P) titled Positioning - Chair/Bed dated 8/29/2018 documented adaptations to the wheelchair are provided as needed and noted in the electronic medical record (EMR). Additionally, the P&P documented, if the resident's condition and need for wheelchair changes, the rehabilitation department is notified, and an evaluation will be completed. Appropriate changes will be made and documented on the resident [NAME] (a guide used by staff to provide care)/care plan. Follow up nursing education will be completed based on resident need and condition to maintain safety and optimal functional level. The P&P titled Resident Accident and Incident Reporting dated 1/24/22 documented all resident accidents and incidents were reported to ensure that the residents receive appropriate intervention and care plan updates. The nurse documents the occurrence and necessary treatment in the nurse's notes. 1. Resident #66 was admitted with diagnoses dementia, osteoarthritis (a type of arthritis that causes pain and stiffness in joints), and anxiety. The Minimum Data Set (MDS- a resident assessment tool) dated 10/19/2023 documented Resident #66 was rarely understood, rarely understands and was severely cognitively impaired. The Comprehensive Care Plan (CCP) dated 10/11/2023 documented Resident #66 was at risk for alteration in positioning related to diagnosis of Alzheimer's dementia. Interventions included: for transport and meals only: high back wheelchair (a wheelchair with a higher back than a standard wheelchair) with anti-thrust cushion (a type of cushion with a higher front surface and lower back surface to prevent sliding) with gel overlay on top and bilateral leg rests. The [NAME] (guide used by staff to provide care) dated 11/6/23 documented Resident #66 required for transport and meals only: high back wheelchair with anti-thrust cushion with gel overlay on top and bilateral leg rests. During a continuous observation on 11/6/23 from 9:13 AM until 12:14 PM, Resident #66 was sitting in their wheelchair with their feet dangling unsupported. Resident #66 was sitting in their wheelchair holding on to a table and rocking back and forth. Resident #66's wheelchair did not have leg/footrests and Resident #66's feet were unable to touch the floor. At 9:35 AM, Certified Nursing Assistant (CNA) #1 wheeled Resident #66 to the lounge area. Resident #66 sat in their wheelchair in the lounge area; their feet dangled, unsupported and did not touch the floor (approximately six inches from the floor). Resident #66 continued to rock in their wheelchair. At 12:00 PM, Resident #66 was wheeled back to the dining room. Staff did not attempt to put leg rests/foot support on Resident #66's wheelchair throughout the observation. During a continuous observation on 11/7/23 from 8:00 AM through 10:31 AM, Resident #66 was sitting in their wheelchair with their feet dangling unsupported. Resident #66 was sitting in their wheelchair in the dining room and occasionally rocking back and forth. Resident #66's feet were unable to reach the floor and were approximately six inches from the floor. At times, Resident #66 would move their feet and point their toes downwards. At 10:31 AM, CNA #1 wheeled Resident #66 to the lounge. CNA #1 and CNA #2 transferred Resident #66 to a reclining chair in the lounge area. CNA #1 elevated the leg rests of the reclining chair. Resident #66 placed their feet flat on the leg rest of the reclining chair. During an interview on 11/7/23 at 12:45 PM, CNA #2 stated they checked the [NAME] at least once a week because the [NAME] could change. CNA #2 stated Resident #66 was dependent on the staff for care. CNA #2 stated they were not sure if Resident #66's feet could touch the floor while they were seated in their wheelchair because Resident #66 was fidgety. CNA #2 stated they did not know when the last time Resident #66 had leg rests on their wheelchair and they could have been misplaced. During an interview on 11/7/23 at 12:52 PM, CNA #1 stated Resident #66's feet were able to touch the floor when Resident #66 was in their wheelchair. CNA #1 stated Resident #66 was not supposed to have leg rests on their wheelchair. CNA #1 stated they checked the [NAME] every morning. During an observation on 11/7/23 at 1:01 PM, CNA #1 and CNA #2 transferred Resident #66 into their wheelchair. Resident #66's wheelchair had a cushion in it that had a dip towards the back and was raised approximately 2-3 in the front. When Resident #66 sat in their chair, their feet did not touch the floor and were approximately six inches from the floor. CNA #1 and CNA #2 stated Resident #66's feet did not touch the floor. During an interview on 11/7/23 at 1:03 PM, Occupational Therapist (OT) #1 stated, Oh Resident #66 has foot pedals. OT #1 stated, usually Resident #66 was only in their wheelchair for meals and would have pedals on the wheelchair at that time. OT #1 stated Resident #66 would have the potential for foot drop if they were in the wheelchair for an extended time without the pedals. OT #1 stated Resident #66 was very active so they were not sure how long it would take for foot drop to develop. OT #1 stated they were going to go get new foot pedals for Resident #66. During an interview on 11/7/23 at 1:06 PM, Registered Nurse (RN) #1 stated they expected the CNAs to check the [NAME] every day for new recommendations and they should follow the recommendations on the [NAME]. RN #1 stated it would not be comfortable for Resident #66 to sit for a long period of time without their feet touching the floor or foot pedals. During an interview on 11/8/23 at 10:40 AM, OT #2 stated residents were screened at least four times a year and with any referrals from nursing. OT #2 stated Occupational Therapy was responsible for wheelchair positioning. OT #2 stated Resident #66 had a lot of movement that they considered sensory movement. OT #2 stated an antithrust cushion was added to Resident #66's wheelchair on 10/6/23 to prevent Resident #66 from sliding and Resident #66 had better positioning with the antithrust cushion in their wheelchair. OT #2 stated there should have been foot pedals on Resident #66's wheelchair for foot support. OT #2 stated Resident #66 could potentially have discomfort without the foot pedals. During an interview on 11/8/23 at 10:47 AM, OT #1 stated they usually see Resident #66 during meals, and they have never checked under the dining room table to see if Resident #66 had their foot pedals on the wheelchair. OT #1 stated therapy made the recommendations, and it was expected that nursing follows the recommendations. OT #1 stated if it was noticed the recommendations were not followed, then they would intervene. OT #1 stated Resident #66 could not verbalize when they had pain, but in the past, they either pointed or tapped where they had pain. OT #1 stated, We would hope Resident #66 would point or something to tell us if they were hurting. OT #1 stated they would encourage the use of foot pedals when in the wheelchair for overall security, to keep the feet from dragging and to promote alignment and upright positioning. During a telephone interview on 11/8/23 at 11:22 AM, Hospice RN #2 stated they were concerned about the length of time Resident #66 sat in their wheelchair with their feet hanging down without any support. RN #2 stated they considered that a positioning problem and there was a possibility that Resident #66 had discomfort. During an interview on 11/8/23 at 12:05 PM, the Director of Nursing (DON) stated if it was care planned, it was expected the staff put leg rests on the wheelchair. DON stated the feet should be supported for comfort and to prevent dependent edema. DON stated the CNAs were responsible to look at the [NAME] every day. DON stated the nurses on the unit should make sure the CNAs were looking at the [NAME] and following it. 2. Resident #6 had diagnoses including depression, muscle weakness, and post-polio syndrome (a group of potentially disabling symptoms that appear decades after a polio infection). The MDS dated [DATE] documented the Resident #6 had moderate cognitive impairment. The [NAME] dated 11/8/23 documented Resident #6 needed set up assistance for eating. The CCP dated 9/27/23 documented Resident #6 was at risk for alteration in feeding related to their diagnosis of post-polio syndrome. Interventions included mugs for soups and set up assistance for eating. During a lunch observation on 11/2/23 at 12:35 PM, Resident #6 was seated at a table in the unit dining area and spilled coffee on their lap. The lid on the disposable cup was not secured. Review of the nursing Progress Notes dated 11/2/23 revealed there was no assessment or monitoring of the resident's skin. Review of the Buffalo House report sheets dated 11/2/23-11/3/23 revealed there was no documentation that Resident #6 was assessed or monitored after the coffee spill. During an interview on 11/7/23 at 9:44 AM, CNA #3 stated they remembered Resident #6 spilled coffee on themselves last Thursday (11/2). CNA #3 stated they saw the resident patting themselves off, so they went over to the resident and noticed they had liquid on their clothing. CNA #3 stated the lid for the coffee cup wasn't on all the way and the resident must have spilled it on themselves. CNA #3 stated they reported it to the nurse, they weren't sure their name but thought it was the nurse working today (Licensed Practical Nurse (LPN) #1). During an interview on 11/7/23 at 12:09 PM, LPN #1 stated they left early that day (11/2/23) and didn't recall Resident #6 spilling their coffee on themselves and that nobody reported anything to them. During an interview on 11/7/23 at 12:07 PM, LPN #2 stated they worked on 11/2/23 and at lunch time they stayed on their side during lunch and did not know anything about a resident that spilled coffee on themselves. During an interview on 11/7/23 at 12:51 PM, Registered Nurse (RN) Unit Manager (UM) #3 stated if a resident spilled coffee on themselves there would usually be a note about the skin and to monitor the resident. During a telephone interview on 11/8/23 at 8:56 AM, LPN #1 stated they would expect the CNAs to tell them if a resident spilled coffee on themselves and they would have checked the resident, documented it, and told the supervisor. LPN #1 stated they were not in the dining area on 11/2/23. During an interview on 11/8/23 at 11:04 AM, the Director of Nursing (DON) stated they would consider this an accident and the staff should have told the nurse. There was a miscommunication between the CNAs where each thought the other told the nurse about the spill. The resident should have been assessed for redness and put on report to monitor for any delayed injury or if blister formed. The DON stated for hot drink spills they would fill out and incident report as there was potential for a burn. The DON stated when they found out about this yesterday, they had Occupational Therapy (OT) look at the resident which was routine for any spill during meal. The DON stated the nurse should have been in the dining room during meals to monitor the residents. During a telephone interview on 11/8/23 at 1:24 PM, CNA #4 stated when they were passing lunch trays (on 11/2/23), CNA #3 asked Resident #6 if they were ok, so CNA #4 went to see what happened. CNA #4 stated they didn't tell the nurse because they thought CNA #3 told the nurse. CNA #4 stated they didn't know if the nurse was on the floor when this happened and it was something that normally was reported to the nurse. 10NYCRR 415.12

Based on observation, interview and record review conducted during a Standard survey completed on 1/14/2022, the facility did not ensure that all alleged violations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown origin are reported to the administrator as required for one (Resident #74) of one resident reviewed. Specifically, staff did not report facial bruising to their supervisor, Director of Nursing or the Administrator. The finding is: The facility policy and procedure (P&P) titled, Abuse, Neglect, Mistreatment, Misappropriation of Property or Exploitation: Care - Resident Rights dated 11/1/2016 documented; if a staff member has a concern regarding a resident's care, they will notify their immediate supervisor, the Director of Nursing or the Administrator. All accidents/ incidents involving residents will be assessed by the RN (registered nurse); an incident report and follow up investigation will be completed. The facility P & P titled, Accident /Incident Report- Resident dated 11/1/2017 documented; for any injuries of unknown origin, interviews and statement must be part of the investigation to determine the cause and to rule out abuse/neglect. Registered Nurse (RN) assessment is needed with documentation for injuries of unknown origin with full body assessments. 1. Resident #74 was admitted with diagnoses which included dementia, cognitive communication deficit and osteoarthritis. The Minimum Data Set (MDS - a resident assessment tool) dated 10/25/21 documented Resident #74 had moderately impaired cognition, makes self understood and usually understands. The Comprehensive Care Plan (CCP) dated 10/19/21 documented Resident #74 is at risk for falls related to history of falls and on 1/3/22 fell on floor with minor injury. Planned interventions included the Falling Leaf Falls Prevention Program. On 1/10/22 at 1:55 PM Resident #74 was observed with a yellowing bruise above their right eye extending to the right temple approximately 2 inches x 2 inches. During an interview at that time of the observation Resident #74 stated they think they got the bruise from a fall and doesn't recall any specifics. Review of the Progress Notes from 10/18/21 through 1/12/22 revealed there was no documented evidence Resident #74 had bruising above their right eye and temple area. Review of the Nursing RN/ Therapy Skin Assessment from 10/18/21 through 1/12/21 for Resident #74 revealed there was no documented evidence of bruising to the resident's right eye and temple area. Review of the Medication Administration Record and Treatment Administration Records dated 12/1/21 through 1/13/22 revealed there was no documented evidence of neuro checks completed related to the bruise observed above Resident #74's right eye. Review of the Facility Accident/Incident (A/I) Reports provided by the facility dated 10/18/21 through 1/13/22 revealed there was no documented evidence an investigation was initiated related to Resident's #74's bruising above their right (rt) eye. An A/I report dated 1/3/22 revealed at 11:15 PM Resident #74 was found lying on the floor next to the bed on their left side. An RN assessment was completed, and their no visible injuries noted, range of motion (ROM) to all extremities were within normal limits (WNL). Resident offered no complaints of discomfort and denied hitting their head with no visible head injury. In addition, on 1/5/22 Resident #74 complained of left thigh/knee pain with diffuse bruising to the left inner thigh area; doctor was updated, and an x-ray of the left femur and knee were ordered. There was no documented evidence that there was a bruise to Resident #74's right eye and temple. During an interview and observation on 1/13/22 at 10:41 AM, RN #4 stated they were not aware Resident #74 had any bruising on their head or face. During an observation of Resident #74 with RN #4 revealed a yellowing bruise above the resident's rt eye and temple area. During an interview on 1/13/22 at 10:47 AM, Certified Nursing Assistant (CNA) #6 stated they had observed the bruise above Resident #74's right eye on January 4th or January 5th, 2022 and reported it immediately to Licensed Practical Nurse (LPN) #4. CNA #6 stated their responsibility was to report injuries, falls and bruises to the nurse. During interview on 1/13/22 at 10:57 AM RN #4, stated if CNA #6 reported the bruise to a nurse, the nurse should have reported the bruise to supervisor/manager, an RN assessment should have been completed and neuro checks initiated. Additionally, an investigation would have been completed to rule out abuse. During an interview on 1/13/22 at 11:19 AM, LPN #4 stated they recalled observing a bruise above Resident #74's rt. eye with CNA #6 while transferring the resident out of bed either on January 4th or January 5th, 2022. LPN #4 stated they believed the bruise was related to the previous falls but had not looked at the previous A/Is to determine if the bruise was previously noted. LPN #4 stated they didn't document their observation, report it to the Nurse Manger/supervisor or initiate neuro checks and should have. During an interview on 1/14/22 at 11:56 AM, the Director of Nursing (DON) stated they would have expected LPN #4 to have reported Resident #74's bruise to RN #4, and initiated neuro checks. The DON stated an investigation should have been initiated to determine the cause of the bruise and to rule out abuse. During an interview on 1/14/22 at 11:57 AM, the Administrator stated they would have expected the nurse to report the bruise to their Nurse Manager or Nursing Supervisor, an RN assessment completed, and an investigation initiated immediately to rule out abuse. 415.4 (b)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during the Standard survey completed on 1/14/22, the facility did not store all drugs and biologicals in locked compartments and permit only authorized personnel to have access for two of two medication storage cabinets ([NAME] and [NAME] Units) observed for safe medication storage. Specifically, two medication cabinets located in common areas were observed unlocked with over-the-counter medication bottles ([NAME] and [NAME] Units) and one medication cabinet contained 21 prescription blister packs and two prescription nebulizer (inhaled) medications ([NAME] Unit). The finding is: 1. Review of the facility policy titled Medications Administering-Equipment & Supplies effective 1/8/09 revealed the facility maintains equipment and supplies necessary for the preparation and administration of medications to residents. The following equipment and supplies are acquired and maintained by the facility for the proper storage, preparation, and administration of medications include: Lockable medication carts and medication cabinets, drawers or rooms with well-lit dose preparation areas. a. During an observation on 1/12/22 at 7:53 AM on the [NAME] Unit, the medication storage cabinet located in the common area near the resident dining room was observed unlocked and unattended by staff. At 7:54 AM Registered Nurse (RN) #4 stated they had the medication cabinet keys and the medication cabinets were to be locked at all times when not attended by a nurse. RN #4 also stated they had just retrieved medications from the cabinet and did not lock it. On 1/12/22 at 7:57 AM, RN #4 was observed to walk away from the unlocked medication cabinet to answer a call light. During an observation from 7:57 AM until 8:03 AM the medication cabinet was unlocked and no facility staff was in the area. During another observation at 8:18 AM, the medication cabinet was unlocked and unattended. During an interview on 1/12/22 at 9:32 AM, RN #4 stated they broke the key in the cabinet door, called maintenance to fix it, and should have maintained the medication cabinet within visual sight to ensure residents and others did not have access to the medications. Observation on 1/12/22 at 9:32 AM, in the presence of RN #4 and RN #5 revealed the following over-the-counter medications were located in the [NAME] Unit medication cabinet: · Aspirin 325 milligram (mg) 2 bottles, 100 tablets each · Enteric Coated Aspirin 325 mg 2 bottles, 100 tablets each · Aspirin chewable 81 mg 1 bottle, 36 tablets · Aspirin 81 mg 1 bottle, 300 tablets · Acetaminophen (pain reliever) 325 mg 1 bottle, 100 tablets · Acetaminophen 500 mg 1 bottle, 100 tablets · Calcium (dietary supplement) 600 mg 1 bottle, 180 tablets · Thera-M multivitamin/multimineral supplement 2 bottles, 100 tables each · Ferrous Sulfate (iron supplement) 325 mg 2 bottles, 100 tablets each · Lactobacillus (dietary supplement) 2 bottles, 50 tablets each · Senna (laxative) 8.6 mg 4 bottles, 100 tablets each · Stool Softener 100 mg 2 bottles, 100 soft-gels each · Melatonin (sleep aid) 3 mg 1 bottle, 60 tabs · Multi-vitamin 2 bottles, 100 tablets each · Vitamin C 500 mg, 1 bottle, 100 tablets · Vitamin D3 25 mcg 1 bottle, 100 tablets · Ferrous Sulfate Elixir 220mg / 5 milliliters (ML) 473 ml. · Antacid and Anti-gas 1 bottle 355 mL · Antacid tablets 500 mg 1 bottle 150 tablets · Milk of Magnesia (laxative) 1 bottle 473 mL · Polyethylene Glycol 3350 (powder laxative) 17.9 ounces b. During an observation on 1/12/22 from 8:45 AM until 8:48 AM on the [NAME] Unit, the medication storage cabinet located in a common area near the resident dining room was observed to be unlocked and unattended by staff with bottles of over-the-counter medications and prescription medication blisters packs. During an interview on 1/12/22 at 8:48 AM, RN #1 stated they had the keys to the medication cabinet and didn't know if the cabinet was to be locked. RN #1 asked Licensed Practical Nurse (LPN) #4 if the cabinet should be locked and LPN #4 stated yes. During an interview on 1/12/22 at 8:50 AM, LPN #4 stated medication cabinets were always to be locked when not attended by the nurse to prevent residents and others from opening and having access to the medications. LPN #4 stated the cabinet should have been locked. Observation on 1/12/22 at 8:50 AM, in the presence of RN #1 and LPN #4 revealed the following over-the-counter medications were located in the [NAME] Unit medication cabinet: · Aspirin 325 milligram (mg) 4 bottles, 100 tablets each · Enteric Coated Aspirin 325 mg 1 bottle, 100 tablets each · ASA Chewable 81 mg 1 bottle, 36 tablets · Acetaminophen 325 mg 4 bottles, 100 tablets · Acetaminophen 500 mg 4 bottles, 100 tablets · Calcium 600 mg 2 bottles, 180 tablets · Thera-M multivitamin/multimineral supplement 1 bottle, 100 tables each · Ferrous Sulfate 325 mg 3 bottles, 100 tablets each · Lactobacillus 10 bottles, 50 tablets each · Senna 8.6 mg 6 bottles, 100 tablets each · Stool Softener 100 mg 7 bottles, 100 soft-gels each · Multi-vitamin 3 bottles, 100 tablets each · Vitamin C 500 mg, 2 bottles, 100 tablets · Vitamin D3 25 micrograms (mcg) 1 bottle, 100 tablets · Acetaminophen Suppositories 650 mg, 1 box 12 suppositories · Antacid and Anti-gas 1 bottle 355 mL · Milk of Magnesia 1 bottle 473 mL · Polyethylene Glycol 3350 17.9 ounces In addition, the following resident specific blister pack medications were on the top shelf in the [NAME] Unit medication cabinet: · Acetaminophen 325 mg, 18 tablets · Albuterol neb (increases airflow to lungs) 2.5 mg - 3mL, 15 vials · Augmentin (antibiotic) 500 mg, 4 tablets · Aspirin chewable 81 mg, 44 tablets · Docusate Sod Cap (stool softener) 100 mg, 22 tablets · Doxycycline HYC (antibiotic) 100 mg, 6 tablets · Eliquis (blood thinner) 2.5 mg, 18 tablets · Eliquis 5 mg, 18 tablets · Famotidine (antacid) 20 mg, 30 tablets · Galantamine (used for dementia) 8 mg, 53 tablets · Guaifenesin (cough medicine) 200 mg, 162 tablets · Ibuprofen (pain reliever) 600 mg, 36 tablets · Iprat - albut (Duoneb) (increases airflow to lungs) 0.5-3mg / 3mL, 15 vials · Loratadine (allergy medication) 10 mg, 29 tablets · Memantine HCL (used for dementia) 5 mg, 30 tablets · Metoprolol Tartrate (antihypertensive) 25 mg, 11 tablets · Metoprolol Tartrate 100 mg, 11 tablets · Potassium Chloride (supplement) 10 MEQ ER, 28 tablets · Quinapril/HCTZ (antihypertensive) 20-25 mg, 30 tablets · Rosuvastatin (high cholesterol) 10 mg, 30 tablets · Sodium Bicarb (antacid) 650 mg, 22 tablets · Trazodone (antidepressant) 25 mg, 8 tablets · Vitamin D3 1000IU (25 mcg), 30 tablets During an interview on 1/12/22 at 9:13 AM, RN #7 Assistant Director of Nursing (ADON) stated the medication cabinets in the common areas should always be locked if unattended by a nurse to prevent residents and others from having access to the medications for resident safety, and it was the responsibility of the nurse who had the keys for the cabinet to ensure the cabinet was locked. During an interview on 1/14/22 at 11:08 AM, the Pharmacy Consultant stated they would have expected all medications cabinets in common areas to be securely locked at all times when unattended by a nurse to prevent access for the safety of the residents. During an interview on 1/14/22 at 11:54 AM, the Director of Nursing (DON) stated they expected all medications cabinets in the common areas to be locked when unattended by a nurse for the safety of the residents. The DON stated it was the responsibility of the nurse to ensure the cabinets were locked. 415.18 (c)(1-4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review conducted during the Standard survey, completed on 5/9/19, the facility did not ensure that a resident who is fed by enteral means (method of feeding that uses the gastrointestinal (GI) tract to deliver part or all of a person's caloric requirements) receives the appropriate treatment and services to prevent possible complications for one (Resident #218) of two residents reviewed for feeding tubes. Specifically, the facility did not provide tube feed formula as ordered by the physician. In addition, the nursing staff documented the formula was administered as ordered. The finding is: 1. Resident #218 was admitted [DATE] and has diagnoses that included a gastrostomy tube (GT, tube feed), throat cancer, protein calorie malnutrition, and borderline gluten intolerance (wheat allergy). The Minimum Data Set (MDS-an assessment tool) dated 4/16/19 documented the resident was cognitively intact. Review of an Order Summary Report (physician's orders) dated 4/14/19 revealed an order for Jevity 1.5 (tube feed formula) via PEG (percutaneous endoscopic gastrostomy tube-feeding tube inserted into the stomach) with instructions to infuse at 50 cc (cubic centimeters) per hour, continuously for 24 hours. During an observation of the resident on 5/3/19 at 11:45 AM revealed the resident's tube feed formula, Jevity 1.5 was running via PEG at 50 cc per hour. During an observation on 5/7/19 at 8:05 AM revealed the resident's tube feed formula, Impact 1.5 was running via PEG at 50 cc an hour. During an interview on 5/7/19 at 12:00 PM the resident stated the feed was on continuously except during therapy and care. The Impact 1.5 formula was still running at 50 cc/hr. at that time. Review of the Order Summary Reports and Interdisciplinary Team Notes (IDT) dated 5/6/19 through 5/7/19 revealed a lack of documented evidence for a change in formula. Review of the Medication Administration Record (MAR) dated 5/1/19 through 5/31/19 revealed on 5/7/19 the nurses signed that Jevity 1.5 was administered as ordered. During an observation on 5/7/19 3:10 PM in the presence of the Registered Nurse (RN) Unit Manager #4 revealed the resident still had the Impact 1.5 formula running via a pump through the PEG tube. Interview with the RN #4 at the time of the observation stated she was unaware of any formula changes for the resident. During an interview on 5/8/19 at 7:35 AM, RN #4 stated the wrong formula order was placed in the resident's closet. The nurse didn't look at the tube feeding when she hung it. The resident now has the correct formula. Additionally, a medication error report form was completed for the night nurse for hanging the wrong formula and the day nurse who didn't identify it was the wrong formula. During an interview on 5/8/19 at 8:15 AM, RN #4 stated generally the Unit Clerk signs the invoice for the formula and the delivery person puts the formula in the resident's closet in their room. It was the nurse's responsibility to check the packaging of the product to make sure it's the right formula before hooking it up (providing the formula to the resident). During an interview on 5/9/19 at 6:24 AM, the night shift Licensed Practical Nurse (LPN #5) stated she hung the bag of Impact 1.5. She stated there was a big box of the Impact 1.5 formula instead of the Jevity formula in the resident's closet and assumed there was a new order for that formula. The LPN stated she should have checked the order or verified the order with the physician if she was not sure. During a telephone interview on 5/9/19 at 1:00 PM, the day shift LPN #6 stated she did not hang the bag of Impact 1.5 formula, so she didn't check it. 415.12 (g)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 5/9/19, it was determined that the facility did not maintain all mechanical, electrical and patient care equipment in safe operating condition. Specifically, ten (Arms, [NAME], [NAME], Eschelman, Harmony, [NAME], Horizon, Hospice, [NAME], [NAME]) of 15 resident household washing machines reviewed for safe operating condition had black debris on the rubber door gaskets and stale mildew odors in the washers. The findings are: 1. During an interview on 5/6/19 at 11:30 AM, a family member of Resident A revealed that the frontloading washing machine on the [NAME] Household had a smell to it and had a black ring around the inside of the door. Observations of the facility's frontloading washing machines between 5/7/19 and 5/9/19 revealed the following: - 5/7/19 at 8:11 AM - [NAME] Household - the washing machine had the door closed. The Surveyor opened the door and observed black debris all around the inside rubber gasket. The washer had a slight mildew odor on the inside. A note taped to the front of the door read to leave the door open between cycles and clean gasket with Affresh wipes every Tuesday. Interview with a Registered Nurse (RN #5) at the time of the observation revealed that bibs/clothing protectors, bedspreads, or residents' clothing at the request of family, are washed in the washer. - 5/8/19 at 3:31 PM - Horizon Household - the washing machine in the soiled utility room had a large amount of black debris along the bottom of the gasket. The washer and the soiled utility room had a musty, mildew odor. The washer contained an unidentified green clothing item which was dry to the touch. - 5/9/19 at 6:34 AM - Harmony Household - the door of the washing machine, located next to the servery area, was closed. A note affixed to the door stated it was to be kept open between cycles and to be wiped with a cleaning wipe every Tuesday. There was a slight mildew odor on the inside of the machine. Interview with a Licensed Practical Nurse (LPN #1) revealed that clothing protectors, slings for the sit to stand lift, and residents' soiled personal clothing are washed in this washer. The LPN could not confirm who was responsible for the care and upkeep of the washer. - 5/9/19 at 6:39 AM - [NAME] Household - the washing machine door was closed. A note affixed to the door stated that the door should be kept open and wiped with a wipe every Tuesday. The washer had a very slight mildew odor when the door was open. The washer contained slings and clothing protectors. Interview with a Certified Nurse Aide (CNA #2) revealed that staff put clothing protectors, slings, and residents' clothing in this machine. She was not sure who was responsible for the washing machine. - 5/9/19 at 6:44 AM - [NAME] Household - the washing machine door was closed. A note affixed to the door stated it is to be kept open and wiped every Tuesday. The Surveyor opened the door and observed black debris all around the rubber gasket and the washer had a mildew odor. Interview with CNA #3 revealed that they wash clothing protectors, but she was not sure if they washed anything else in it. She was not sure who was responsible for the cleaning of the washer. - 5/9/19 at 6:49 AM - Arms Household - the washing machine door was open with a note affixed to it for the door to be kept open and wiped with a wipe every Tuesday. Inside the washing machine there was a strong mildew odor and the gasket had a heavy coating of black debris all around it. - 5/9/19 at 6:54 AM - [NAME] Household - the washing machine was located in a separate closet type room. The door of the machine was closed with a note affixed to it for the door to be kept open after cycles and wiped with a wipe every Tuesday. The washer had a mildew odor. Interview with CNA #4 revealed that residents' clothes are washed in this machine if they or their families do not have a washing machine. She cleans it when she is finished with it. - 5/9/19 at 7:37 AM - [NAME] Household - the washing machine was located next to the server. The washer door was closed with a note affixed to it for the door to be kept open after cycles and wiped with a wipe every Tuesday. The Surveyor opened the door and there was an area of black debris on the bottom of the gasket, three inches long and one inch wide, with a mildew odor. Interview with Homemaker #4 at revealed that she only puts clothing protectors in the washer. She cleans it after she is done with the washer. - 5/9/19 at 7:46 AM - Hospice Household - the washing machine door was open. There was a note affixed to it for the door to be kept open after cycles and wiped with a wipe every Tuesday. The Surveyor opened the door and there was a mildew odor. Interview with CNA #1 revealed that she washes clothing protectors and slings in the machine. She was not sure who is in charge of maintenance of the washers. - 5/9/19 at 7:58 AM - [NAME] Household - the washing machine door was open. There was a note affixed to it for the door to be kept open after cycles and wiped with a wipe every Tuesday. The gasket around the opening had black debris and a strong mildew odor. Interview with Homemaker #1 revealed that clothing protectors, shower robes, and residents' personal clothing gets washed in the machine if they become soiled. - 5/9/19 at 8:16 AM - [NAME] Household - the washing machine door was open. The gasket around the opening had black debris all around it and there was a strong mildew odor. There was a small puddle of water at the bottom of the gasket. Next to the washer, there were folded clothes and clothing protectors that appeared to be freshly washed and dried. Interview on 5/9/19 at 9:28 AM with the RN Infection Preventionist revealed that she expects that staff not use a washing machine if there is black debris on the gasket and is smelly. She said that staff should clean it or report it to housekeeping. Interview on 5/9/19 at 9:46 AM with the Facilities Director revealed that he was not aware of the issue. He stated that there needs to be staff education about the washers even though there are notes about the front loader door needing to be left open and the washer needs to be wiped down. He will have maintenance staff replace what gaskets they can now, and they will have new gaskets for the other washers in a few days. He will have residents' personal clothing go to laundry and the clothing protectors should be washed in the household washers. Review of a facility policy and procedure (P&P) entitled Household Washing Machine Cleaning Procedures dated April 2015 revealed that staff are to maintain overall cleanliness and sanitation of washing machines on the households and must do the following: 1. After completed wash, remove items, and then use the machine cleaning wipes. 2. Wipe thoroughly the machine door gasket. 3. Leave washing machine door open after each use and when not in use. 415.29(b)