**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 9/1/23, the facility did not ensure that a resident, with an indwelling suprapubic catheter (tube inserted into the bladder, through the abdomen, to drain urine), received appropriate care and services to prevent urinary tract infections (UTIs) to the extent possible for one (Resident #69) of two residents reviewed for catheter care. Specifically, there was no documented evidence that the catheter was irrigated when the resident had little to no output and the physician/provider was not notified of complications with catheter and low urinary outputs. The finding is: The policy and procedure (P&P) titled Change in Status Notification effective 6/15/21 documented, the resident's attending physician will be notified by the Nurse Manager/Nursing Supervisor/Designee when: any situation which requires a change in the resident's plan of care, medication, or treatment regimen; including the following - intake and output (I&O). The P&P titled Catheter Care - Male/Female Urinary & suprapubic effective 6/2022 did not include procedures for irrigating the catheter or additional interventions for catheter care. 1. Resident #69 was admitted with diagnoses which included Parkinson's disease, obstructive uropathy (obstruction in the urinary tract), and dementia. The Minimum Data Set (MDS- a resident assessment tool) dated 8/18/23 documented Resident #69 had moderately impaired cognition, required extensive assistance of staff for personal hygiene and toileting and had an indwelling catheter. The comprehensive care plan (CCP) revised on 2/2/23 documented Resident #69 had urinary retention, utilized an indwelling catheter due to bladder outlet obstruction and was at risk for recurrent infection. The CCP documented interventions: monitor intake and output and monitor, document, report to MD as needed for signs and symptoms of UTI: frequency, urgency, malaise, foul smelling urine, suprapubic pain, hematuria (blood in urine), cloudy urine, altered mental status, loss of appetite, behavioral changes. Review of the [NAME] report (a guide used by staff to provide care) dated 8/31/23 documented Resident #69 required extensive assistance with toileting. Additionally, the [NAME] report documented to check catheter tubing for kinks when providing care. There was no documentation on the [NAME] report to monitor output or to notify the nurse. Review of the physician's order and Medication Review Report dated 8/31/23 documented irrigate suprapubic catheter with 120 cc (cubic centimeters) for patency as needed every one hour as needed for suprapubic patency. Review of the Treatment Administration Record (TAR) between dates 8/22/23 and 8/30/23, documented six shifts without any urinary output, five shifts with an output of 10-50 cc, and six shifts without any documentation of output. Additional review of the TAR revealed no documented evidence of irrigation of the indwelling catheter throughout August 2023. Review of the nursing progress note dated 8/25/23 at 3:10 PM, Licensed Practical Nurse (LPN) #3, documented resident continues to have no output noted in tubing or urinal bag from suprapubic catheter site. Noted incontinent of urine from genital region and around stoma site or suprapubic. No hematuria was noted. Will continue to monitor. Review of the nursing progress note dated 8/28/23 at 2:55 AM, documented resident with no complaints of pain/discomfort. Suprapubic leakage continues. Review of the nursing progress note written by Licensed Practical Nurse (LPN) #3, dated 8/28/23 at 4:50 PM, documented suprapubic continues to leak around stoma. Catheter irrigated by writer with no effect. Review of the nursing progress note dated 8/28/23 at 11:41 PM written by Registered Nurse Supervisor (RNS) #1, documented suprapubic continues to leak. There was no further documentation in the nursing progress notes from 8/22/23 to 8/30/23 regarding catheter output or interventions to address the low urinary output/leakage. The 24- Hour Nursing Services Report dated 8/22/23-8/30/23 lacked documentation regarding low to no urinary output and interventions for Resident #69's suprapubic catheter. The Nurse Practitioner (NP) note dated 8/10/23 documented resident had a past medical history of frequent UTIs, acute kidney injury, benign prostatic hypertrophy (enlarged prostate gland), and hydronephrosis (excess fluid in a kidney due to a backup of urine). Additionally, the 8/10/23 NP note documented the suprapubic catheter was functioning well, draining yellow urine. The Nurse Practitioner (NP) notes dated 8/11/23-8/30/23 lacked documentation addressing Resident #69's suprapubic catheter. During a personal care observation on 8/31/23 at 1:06 PM, Certified Nursing Aide (CNA) #1 washed their hands and donned (put on) gloves. CNA #1 placed a barrier on the floor and a clean cylinder on top of the barrier. CNA #1 used an alcohol wipe to wipe the spigot of the urine collection bag prior to opening the spigot. CNA #1 emptied approximately 10 cc of dark colored urine into collection bag and wiped the spigot with an alcohol wipe prior to closing it and placing it back into the holder. During an interview on 8/31/23 at 1:09 PM, CNA #1 stated there was 10 cc of urine collected. CNA #1 stated they knew nobody else had emptied the collection bag. CNA #1 stated Resident #69's catheter was not working, and the brief was saturated with urine earlier in the shift. CNA #1 stated they would tell the nurse when the urine output was low. During a catheter flush observation on 8/31/23 at 1:22 PM, LPN #2 performed hand hygiene and donned gloves. LPN #2 used a large piston syringe filled with normal saline and attempted to flush the catheter. LPN #2 stated there was resistance and the catheter was not flushing. LPN #2 stated they were not told anything in report about catheter issues for Resident #69. LPN #2 stated they were going to tell the Resident Care Coordinator (RCC) that the catheter was not flushing. During an observation on 8/31/23 at 1:26 PM, Registered Nurse (RN) #1 and NP were both at the nurse's station. LPN #2 told both RN #1 and NP Resident #69's catheter was unable to be flushed. RN #1 stated they would change the catheter. NP agreed with RN #1 that the catheter needed to be changed. During an interview on 8/31/23 at 1:29 PM, NP stated they were not aware Resident #69 had little to no output prior to LPN #2 telling them today. NP stated they expected the nursing staff to flush the catheter and if that was unsuccessful then the staff should have notified the physician. NP stated since the brief was saturated there was a problem with the catheter and there would be a potential for infection. During a telephone interview on 8/31/23 at 2:43 PM, LPN #3 stated Resident #69 was at the urologist on 8/1/23 and the catheter was working for while after that appointment. LPN #3 stated they reported to RN #1 that Resident #69's catheter was not draining again on Monday 8/28. LPN #3 stated they had tried to irrigate the catheter and there was resistance. LPN #3 stated they could not remember if they documented the irrigation attempt and that they notified RN #1 in the nursing progress notes. During a telephone interview on 8/31/23 at 2:45 PM, LPN #4 stated Resident #69's catheter has not been working for a while. LPN #4 stated there was a lot of sediment in the catheter and that caused it to occlude. LPN #4 stated they tried to flush it on 8/26/23 but nothing happened. LPN #4 stated RN #1 was aware that it was not working. During an interview on 8/31/23 at 3:13 PM, Registered Nurse Supervisor (RNS) #1 stated Resident #69's catheter constantly clogged. RNS #1 stated they attempted flushing it and sometimes it flushed, sometimes it did not. RNS #1 stated nurses should sign they flushed the catheter in the TAR, but they do not always do that. RNS #1 stated during evening and night shift, they have not notified the on-call physician. RNS #1 stated instead of notifying the on-call physician, they would leave a message for RN #1 on the report sheets, for it to be addressed the next day. During an interview on 9/1/23 at 9:48 AM, RN #1 stated they expected the nurses to follow the orders and to irrigate the catheter when there was little to no output. RN #1 stated the nurses should have signed the TAR and should have written a nursing progress note to indicate the catheter was flushed. RN #1 stated if the TAR was not signed out and there was no nursing progress note, that indicated interventions were not done. RN #1 stated they were not aware there was little to no output from Resident #69's catheter since 8/22/23. RN #1 stated when Resident #69's catheter was not working, they would notify the urologist. During a telephone interview on 9/1/23 at 10:15 AM, Medical Director (MD) stated Resident #69 had a history of problems with their catheter. MD stated they have not been notified by nursing staff within the past couple of weeks regarding low to no output. MD stated they expected the staff to notify the physician when there was no output from the catheter, even if the brief was saturated with urine. MD stated they expected a notification if the catheter was not irrigating, as well. MD stated there was a potential for the resident to go into renal (kidney) failure or heart failure. During an interview on 9/1/23 at 10:54 AM, Director of Nursing (DON) stated they expected the CNAs to report little to no urinary outputs to the LPN, even when the brief was saturated. DON stated the LPN should let the RCC or Supervisor know there was a problem and catheter should have been irrigated. DON stated if the nurses were unable to irrigate the catheter, that should have been reported to the RCC or Supervisor. DON stated they expected the RN to follow up and do an assessment of the resident. DON stated their assessment should have included checking for bladder extension and signs of infection. DON stated they expected the irrigation to be documented and signed out in the TAR and the nurse should have written a nursing progress note also. DON stated if the irrigation and follow up assessments were not documented, that means they were not done. DON stated the physician should have been made aware. DON stated when there was little to no catheter output, that would identify a problem such as an occlusion. DON stated an occlusion in a catheter could mean an infection was brewing. 10NYCRR 415.12 (d)(1)

Based on observation, interview, and record review conducted during a Standard survey completed 9/1/23, the facility did not provide food and drink that were prepared by methods that conserved flavor, and appearance, were palatable and at a safe and appetizing temperature, for two (Units 2 [NAME] and 2 East) of two test trays. Specifically, food and beverages were served at suboptimal temperatures and were not palatable. Residents #26, #52, #72, and #91 were involved. The findings are: The policy and procedure titled Food Preparation and Service dated 5/2/23 documented that the danger zone for food temperatures is between 41 degrees (°) Fahrenheit (F) and 135°F. Therefore, foods must be maintained below 41°F or above 135°F. The policy and procedure further documented the temperatures of foods held in steam tables were monitored throughout the meal. The facility Recipe Card for Macaroni Salad documented to chill the macaroni in a 2 (inch) deep container to 41ºF or below. The recipe card then documented to hold on ice for service, maintaining temperature at 41ºF or below for up to 1 hour and to discard any product that exceeded 41ºF during service. During an interview on 8/28/23 at 11:30 AM, Resident #26 stated that sometimes the food was just thrown together and one had to guess what it was. Resident #26 also stated that sometimes hot food was not hot enough and that trays never arrived on the unit at a consistent time. During an interview on 8/28/23 at 12:03 PM, Resident #72 stated that the food at the facility was not good. They stated that the food was bland, and the hot foods were served cold. 1.During a continuous lunch meal observation the main dining room (MDR) on 8/30/23 at 12:02 PM to 1:31 PM, revealed at 12:02 PM, the steam table contained a serving pan with broccoli with cheese sauce and at 12:18 PM the remainder of the hot food items arrived from the kitchen. Tray line service began at 12:29 PM. [NAME] #1 pulled plates from the plate warmer to serve food. The plate warmer was not warm. During an interview at the time of the observation the Food Service Director (FSD) #1 stated the plate warmer had not worked in a long time. The second 2 [NAME] dietary cart left the MDR at 1:13 PM and the 2 East dietary cart left at 1:26 PM. During a lunch meal observation on 8/30/23 at 1:09 PM, the first dietary cart for 2 [NAME] arrived, and the second dietary cart arrived at 1:18 PM. All residents on 2 [NAME] were served their meals by 1:28 PM. The test tray temperatures were taken by Diet Tech #1 at 1:29 PM using the facility's digital thermometer. The results were as follows: -BBQ chicken breast 123.1°F, tasted dry, bland, and lukewarm -Baked Beans 119.3°F, tasted lukewarm -Broccoli with cheese sauce 122.3°F, tasted mushy, bland, and lukewarm -Milk 52.2°F, tasted warm and was not palatable -Apple juice 55.8°F, tasted warm and was not palatable During an interview on 8/30/23 at 1:39 PM, Diet Tech #1 stated that hot foods should be served above 130°F, and cold foods should be served below 45°F. During a lunch meal observation on 8/30/23 at 1:30 PM, the 2 East unit dietary cart arrived on the unit. Staff completed the tray pass at 1:40 PM. The test tray temperatures were obtained at 1:40 PM with the FSD #1 using the facility's thermometer. The FSD #1 stated that the hot food temperatures should be above 145°F and the cold food temperatures should be below 41°F. The results were as follows: -BBQ chicken breast 120°F, the chicken tasted dry, the barbeque sauce tasted watery, and it was cold -Baked Beans 127°F, were cool to taste -Broccoli with cheese 128°F, tasted mushy and cool -Canned pears 66.4°F, tasted warm and bitter -Apple juice 59.2°F, tasted warm and unappetizing -Milk 55.6°F, tasted warm and unappetizing During an interview at 8/30/23 at 1:50 PM, Resident #91 stated the chicken was dry and did not taste good. Resident #91 stated their food was cold and their drinks were warm. During an interview at 8/30/23 at 1:55 PM, Resident #52 stated they were served barbeque chicken, baked beans and sauerkraut for their lunch meal and it was an odd combination of food items. Resident #52 stated their hot food items tasted cold. During an interview on 8/31/23 at 7:24 AM, Resident #72 stated that on 8/30/23 they had the alternate meal for lunch. It was cabbage and it did not taste good. They stated that the cabbage was bland, and they only ate about half of it. 2.During an observation of the MDR on 8/31/23 at 12:27 PM, an uncovered, clear plastic full size 4 (Inch) deep food service pan containing macaroni salad was on a cart in the servery. [NAME] #2 was just beginning to plate the meals and the macaroni salad was part of the lunch meal to be served. When the FSD #1 took the temperature of the macaroni salad, it was 60ºF. During an interview on 8/31/23 at 12:30 PM, FSD #1 stated the macaroni salad could not be served, as it was too warm and should have been kept on ice. During an interview on 9/1/23 at 11:15 AM, [NAME] #2 stated they should have taken the macaroni salad temperature before beginning meal service and they should have kept the macaroni salad on ice when setting up for meal service. 10 NYCCR 415.14(d)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Standard survey completed on 9/1/23, it was determined that the facility did not ensure that the resident environment remains as free of accident hazards as is possible. Specifically, three (1 West, 2 East, 2 West) of three resident units had water temperatures that exceeded 120 degrees Fahrenheit (°F). The findings are: The policy and procedure titled Daily Domestic Hot Water Testing effective date 2017, with a reviewed date of 8/2023 documented this policy outlines the daily testing of the domestic hot water supply to ensure it is regulated within 90 - 120 °F. Maintenance staff shall perform daily testing at all floors using a correctly calibrated thermometer. This gauge may be a digital or dial type and shall be tested weekly by comparison to other known correctly calibrated gauges. Water temperatures are to be taken on each resident unit daily, at varying times, at two separate locations. One at the beginning of the hot water circuit and one at the end of the circuit. Turn on hot water faucet and let the water run for approximately 10 seconds. Grasp the thermometer by the gauge ensuring that you are not touching the probe and insert the probe on the thermometer into the water stream. Keep the probe immersed in the water for 10 - 15 seconds. Record temperature at this time on a log sheet. Allow water to run for an additional 2 to 2 ½ minutes (3 minutes total) and retest the water temperature by inserting the thermometer probe into the water for 10 - 15 seconds. Record this temperature on the log sheet. Temperature on mixing valve should be checked and adjusted as needed if water temperatures fall marginally outside the parameters during tests. Thermometers can be checked for calibration using the following method: Calibration in ice water. 1. Add crushed ice and cold tap water to a clean container to form a watery slush. 2. Place thermometer probe into slush for at least one minute taking care to not let the probe contact the container. 3. If the thermometer does not read 30 °F to 34 °F adjust to 32 °F. Non-adjustable thermometers should be removed from use until they have been professionally serviced. Temperatures exceeding 120 degrees °F: If a component of the domestic hot water system fails allowing unsafe hot water temperatures; the following procedure will remove the risk to residents, staff, and visitors. Activation Protocol: In the even that water supply temperature(s) are found to be excessively hot; notify a department manager or nursing supervisor on duty immediately. Review the following plan and start the initiate. Plan of Action: Department Manager or Nursing Supervisor will be notified to direct staff to shut off all water supplies at the bathrooms and dining rooms on the resident units. Staff shall utilize the under-sink supply valves, turning them slowly so as not to damage the valve assembly or cause possible injury. Maintenance staff will coordinate this effort. Water shall remain off until corrective action has been taken and maintenance staff confirm that water temperatures are safe. Observation in the Basement in the Boiler room on 8/28/23 at 12:58 PM revealed the building had two hot water tanks that supplied water to the building's domestic hot water system. The thermometer for one of the hot water tanks read 110 °F and the thermometer for the second hot water tank read 130 °F. The domestic hot water system also had a mixing valve (mechanical device that mixes cold water with hot water to deliver mixed, or tempered, water downstream in the system) and the thermometer for the mixing valve read 118 °F. During an interview at the time of the observation on 8/28/23 the Environmental Services Director stated the building's domestic hot water system had two hot water tanks and a mixing valve. The hot water tanks for the building's domestic hot water system were not labeled or identified other than the tanks for the building's domestic hot water system. They also stated the thermometer for one of the hot water tanks read 110 °F, the thermometer for the second hot water tank read 130 degrees °F and the thermometer for the mixing vale read 118 °F. The Environmental Services Director stated the thermometers for the two hot water tanks and the mixing valve, and the mixing valve were in place since they started working at the facility in 2019 and the thermometers and mixing valve had not been recalibrated or replaced since 2019. The Environmental Services Director stated they had noticed the temperature of the domestic hot water in the building creeping up close to 120 °F over the last couple of months, so they adjusted the mixing valve to lower the temperature. They also stated a contractor had worked on the mixing valve a year ago and the facility did not have any documentation for the work that was completed. The Environmental Services Director stated the facility took random daily water temperatures Monday through Friday in resident rooms, shower rooms, and the Kitchen and the temperatures were recorded on the Water Temperature logs. The water temperatures for resident rooms were taken from the room of the day and a random resident room. The room of the day was chosen for water temperatures checks because this room was a resident room that the facility chose daily to conduct extra cleaning and checks in. During an interview on 8/29/23 at 2:11 PM, the Environmental Services Director stated that they or the Maintenance Assistant took the daily water temperatures in the building. They stated water temperatures in resident rooms and shower rooms cannot be higher than 120 °F. The Environmental Services Director stated they and the Maintenance Assistant used the Eco Lab CDN Model Q2-450X digital thermometer to take water temperatures in the building. This was the thermometer the facility was using to take water temperatures when they started working at the facility in 2019 and this thermometer had never been recalibrated or replaced since 2019. During an interview on 8/29/23 at 2:14 PM, the Maintenance Assistant stated that they or the Environmental Services Director took the daily water temperatures in the building. They stated water temperature in resident rooms and shower rooms cannot be higher than 120 °F. The Maintenance Assistant also stated the thermometer they used to take water temperatures in the building was the same thermometer that the Environmental Services Director used, and they had not recalibrated it. Review of water temperature logs from March 2023 through August 2023 revealed the highest temperatures recorded on the resident units ranged from 117°F to 119 °F. Further review of the logs revealed water temperatures were taken on the 1 [NAME] Unit, 1 [NAME] Unit Tub room, 2 [NAME] Unit, 2 [NAME] Tub room, 2 East Unit, 2 East Tub room, and the Kitchen. The resident room(s) where water temperatures were taken were not listed on the logs. Review of the Company Design Northwest, CDN Model Q2-450X Pro Accurate Pocket Thermometer instructions documented, Self- Calibration, 1. Place the stem into a mix of 3 parts ice and 1 part water. 2. Press the CAL button for 2 seconds. The display will be blank for 2 seconds. Release the CAL button and a 32.0 °F/ 0 °C appears. Note to avoid accidental recalibration, this function only works when the water temperature is 30 to 34 °F/ -1 to +1 °C. ERR will appear for 2 seconds if the water is not within this range and then return to the temperature display mode. Important: Do not immerse thermometer head in water. 2. Observations on 8/28/23 between 1:00 PM and 2:00 PM with calibrated thermometers, [NAME] Model 9840N and [NAME] Model 3519T21 on Unit 1 West; [NAME] Model 9840N and [NAME] Model 9842 on Unit 2 [NAME] and Unit 2 East; and [NAME] Model 9842 on Unit 2 West: Unit 1 West Resident room [ROOM NUMBER] - 122.3 °F Resident room [ROOM NUMBER] - 123.3 °F Resident room [ROOM NUMBER] - 121.6 °F Resident room [ROOM NUMBER] - 122.0 °F Resident room [ROOM NUMBER] - 122.4 °F Resident room [ROOM NUMBER] - 122.1 °F Resident room [ROOM NUMBER] - 122.3 °F Unit 2 [NAME] Resident room [ROOM NUMBER] - 123.1 °F Resident room [ROOM NUMBER] - 124.7 °F Resident room [ROOM NUMBER] - 123.3 °F Resident room [ROOM NUMBER] - 121.3 °F Resident room [ROOM NUMBER] - 122.0 °F Resident room [ROOM NUMBER] - 124.9 °F Resident room [ROOM NUMBER] - 123.9 °F Resident room [ROOM NUMBER] - 124.5 °F Unit 2 East Resident room [ROOM NUMBER] - 122.3 °F Resident room [ROOM NUMBER] - 123.5 °F Resident room [ROOM NUMBER] - 123.3 °F Resident room [ROOM NUMBER] - 124.3 °F Resident room [ROOM NUMBER] - 124.6 °F Observations on 8/28/23 between 2:30 PM and 3:30 PM with a calibrated thermometer [NAME] Model 9842 with the Director of Environmental Services: Unit 1 West Resident room [ROOM NUMBER] - 127.0 °F Resident room [ROOM NUMBER] - 125.2 °F Resident room [ROOM NUMBER] - 123.8 °F Resident room [ROOM NUMBER] - 123.4 °F Unit 2 [NAME] Resident room [ROOM NUMBER] - 124.0 °F Resident room [ROOM NUMBER] - 124.0 °F Resident room [ROOM NUMBER] - 124.1 °F Resident room [ROOM NUMBER] - 125.3 °F Resident room [ROOM NUMBER] - 122.4 °F Resident room [ROOM NUMBER] - 121.5 °F Unit 2 East Resident room [ROOM NUMBER] - 121.3 °F Resident room [ROOM NUMBER] - 120.6 °F Resident room [ROOM NUMBER] - 122.4 °F Resident room [ROOM NUMBER] - 122.0 °F Resident room [ROOM NUMBER] - 121.5 °F During an interview on 8/28/23 at 3:27 PM, the Environmental Services Director stated they had no idea what would make the water temperatures vary. They stated that if they turn down the temperature of the water then the shower temperature would become cold. During an interview on 8/31/23 at 7:58 AM, Licensed Practical Nurse (LPN) #1 stated that if the temperature of the hot water seemed to hot, they would contact maintenance and would turn on the cold water to lower the temperature, so the resident would not get scalded. During an interview on 8/31/23 at 12:03 PM, the Director of Nursing (DON) stated they were not aware that hot water temperatures were over 120 °F. The DON stated they would expect staff to lower the water temperature by mixing in the cold water and for staff to contact maintenance for any issues concerning hot water. During an interview on 9/1/23 at 11:00 AM, the Administrator stated that they expected maintenance to do regular temping of the hot water. The Administrator stated that Maintenance was on call 24 hours a day, 7 days a week so they can be contacted any time for water temperature issues. 10 NYCCR 415.12(h)(1)

Based on observation, interview, and record review conducted during a Standard survey completed on 9/1/23, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one Main Kitchen. Specifically, the dishwasher was not functioning properly and there was a lack of proper hand hygiene. The policy and procedure titled FOOD PREPARATION AND SERVICE dated 5/2/23 documented that appropriate measures were used to avoid cross contamination, including cleaning and sanitizing food-contact equipment between uses, and that food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illnesses. The policy and procedure also documented that bare hand contact with food was prohibited. Gloves were worn when handling food directly and changed between tasks. Disposable gloves were single-use items and discarded after each use. The policy and procedure PREVENTATIVE MAINTENANCE dated 6/2022 documented only routine maintenance safety inspections to ensure resident safety and to check work order books on units and in the kitchen daily. An observation of the main kitchen and dish washing area adjacent to the kitchen on 8/28/23 at 9:57 AM revealed the dish machine which was running at the time of observation, was not displaying temperatures for the wash and rinse cycles. The gages did not move during the observation. There was no sanitizer connected to the dishwasher. During an interview on 8/28/23 at 10:00 AM, the Food Service Director (FSD) #1 stated the temperature gages on the dish machine had just been looked at by maintenance and they were not aware the gages were still not working correctly. During an interview on 8/28/23 at 3:00 PM, FSD #1 stated they had hooked up the sanitizer to the dish machine, to use the dish machine for low temperature operations. During an observation on 8/28/23 at 3:00 PM, FSD #1 ran three separate items through the dish machine and used test strips to test for sufficient levels of sanitization. The test strips did not detect sufficient sanitizer levels. During an interview on 8/28/23 at 3:03 PM, Dietary Aide #1 stated they would call maintenance when there were issues with the dish machine and maintenance would fix when they had time. Dietary Aide #1 stated there had been issues with the dish machine for a while and there was a red light blinking that they had told maintenance about. During an observation of the lunch service on 8/30/23 from 12:02 PM to 1:31 PM in the main dining room/servery, the following observations were made: -Cook #1 was wearing one blue disposable glove on their left hand for the and no glove on their right hand for the entire meal service. [NAME] #1 used both hands to periodically look through meal tickets, to grab plates, to tear open a bag of prepared lettuce, and to adjust to adjust their personal clothing. [NAME] #1 also on two occasions placed fabric oven mitts on both hands during meal service to change serving pans on the steam table. [NAME] #1 used the gloved left hand to grab lettuce and shredded lettuce by hand and placed it into bowls, used the left gloved hand to place cucumber pieces and other cut up items on the salads, then continued to use the soiled left gloved hand to serve/plate food. [NAME] #1 did not change their glove or wash hands during the meal service. During an interview on 8/30/23 at 1:32 PM, [NAME] #1 stated they had received all their food service training from FSD #1 and DT #1. When asked about their glove use, [NAME] #1 stated they were instructed to put on gloves and rotate them between stuff and to wash their hands. They stated wearing only one glove was the way they do it and that the ungloved hand did not touch food and the ungloved hand made it easier to look through meal tickets. During an interview on 8/30/23 at 4:04 PM, Registered Dietician (RD) #1 stated their expectations for hand hygiene and infection control during meal service was for the cook to wear gloves on both hands, wash both hands when soiled, change the gloves frequently, and when visibly soiled. The RD stated when the cooks touch other items, and inside the oven mitts, they should also change their gloves. During an interview on 8/31/23 at 8:00 AM, the ADON (Assistant Director of Nursing)/ IP (Infection Preventionist) stated salads should not be plated by hand, but using utensils, as there was a possibility of cross contamination if gloves were not changed, and food was touched. 10 NYCCR 415.14 (h) 14-1.80, 14-1.31 (a) and (b), 14-1.110 (b), 14-1.116, 14-1.171, 14-1.113 (a) and (b)

Based on interview and record review conducted during an Abbreviated survey (NY00310681) completed on 6/14/23, the facility did not ensure that they immediately inform the resident's representative when there is a significant change in the resident's health, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening changes or clinical complications) for one (Resident #1) of three residents. Specifically, Resident #1's representative was not notified regarding the resident's hyperglycemia (high blood sugar levels) and new physician orders for insulin (a hormone that helps regulate blood sugar levels) injections subcutaneously (injections underneath the skin). The finding is: The policy and procedure titled Change in Status Notification dated 11/8/23 documented the resident's responsible party will be notified by the nurse manager, nursing supervisor, or designee when there is a sudden or unexpected change or deterioration in the resident's physical, mental, or psychosocial/emotional status; or any situation which requires a change in the resident's plan of care, medication, or treatment regimen. 1. Resident #1 was admitted with diagnoses of diabetes mellitus (a disorder where there are high blood sugar levels for prolonged periods of time), cerebral infarction (a stroke), and dementia. The Minimum Data Set (MDS - a resident assessment tool) dated 5/4/23 documented Resident #1 was severely cognitively impaired, understood, and usually understands. The MDS documented the resident received insulin injections. Resident #1's Comprehensive Care Plan (CCP) dated 8/21/2020 documented the resident had diabetes mellitus, was to use diabetic medication as ordered. Additionally, the resident had impaired cognitive function and impaired thought processes due to their dementia and stroke. The physician's orders dated 2/5/23 documented an order for subcutaneous injection of insulin of 20 units at 3:00 PM and an additional injection of 30 units at 5:30 PM. The physician's orders also documented a one-time order for a blood sugar check at 5:00 PM. During an observation on 6/14/23 at 9:30 AM, Resident #1's glucometer (a device that measures a person's blood sugar level through a test strip) was an (Brand Name) glucometer. Review of the undated owner's guide to the (Brand Name) glucometer documented the glucometer measured blood sugar from a value of 20 to 600 (normal blood sugar levels are from 70 to 100). Additionally, the owner's guide documented that if the glucometer reads high, the person's blood sugar was over 600. An Order Note dated 2/5/23 at 2:52 PM documented that Resident #1's blood sugar was running high, the physician was notified, and new orders were received to give 20 units of lispro insulin now and check blood sugar in two hours. The Order Note revealed no there was no documented evidence that Resident #1's responsible party was notified about the new order or the high blood sugar. A Nurses Note dated 2/5/23 at 5:57 PM documented that Resident #1's blood sugar was high, the physician was notified, and new orders to give 30 units of Humalog insulin subcutaneously now. Further review of the Nurses Note documented the resident was responsive but lethargic, and that the resident's blood sugar will be rechecked at 7:30 PM. There was no documentation the resident's responsible party was notified of the new orders or change in condition. During an interview on 6/13/23 at 1:00 PM, Registered Nurse (RN) #1 stated that if they didn't write in in a progress note, then they did not notify the responsible party of the resident's changes. RN #1 recalled notifying the physician concerning Resident #1's blood sugar after the glucometer was read high. RN #1 stated they should have let the nursing supervisor know and called the resident's responsible party. During an interview on 6/13/23 at 1:16 PM, RN #2 Nursing Supervisor stated that they did not recall notifying the responsible party concerning a change of condition. RN #2 Nursing Supervisor stated that if there was a change of condition or a problem, they should notify the physician and the resident's responsible party. RN #2 stated the person notifying the responsible party should document it in the progress notes. During an interview on 6/14/23 at 10:00 AM, the Director of Nursing (DON) stated the process was that if there was a new order, a change of condition, or an incident, the resident's physician, or responsible party was to be notified right away. They stated they expected the nurses to document in the progress notes the notification of family, physician, or responsible parties. The DON stated they expected nurses to do a follow up for any change of condition or anything else concerning the residents. During an interview on 6/14/23 at 10:07 AM, the Administrator stated they expected staff to notify the resident's responsible party if there was a change of condition with the resident and staff to document in the progress notes that the family and the physician were notified about a change in condition. 10 NYCRR 415.3(f)(2)(ii)(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during an Abbreviated survey (Complaint #'s NY00297795 and NY00298518) completed on 6/14/23, the facility did not ensure that each resident receives adequate supervision to prevent accidents for two (Resident #11 and #12) of three residents reviewed. Specifically, the facility did not provide adequate supervision to prevent the residents from eloping from the facility. Resident #11 eloped from the facility on 7/5/22 and was found by staff off facility grounds and Resident #12 eloped from the facility on 6/21/22 and was found outside by a family member on the front patio. The findings are: The policy and procedure (P&P) titled, Elopement Prevention and Search for Missing Resident, dated 3/10/21, documented the purpose is to safeguard the health and welfare of those residents who are cognitively impaired, wander, have emotional disturbances, or any resident who leaves the facility without notification/ approval of the staff and the physician. Residents will be assessed for potential for elopement on admission, re-admission, quarterly and upon significant change, adhering to the MDS (minimum data set - a resident assessment tool) assessment process, and if an attempted elopement occurs. If residents are identified as being a wanderer and/ or exhibit the potential for elopement, a behavior management plan shall be developed by the interdisciplinary team. Additionally, the facility utilizes environmental strategies to prevent/ deter elopement, including a code system on exit doors, stairwells, and elevators. The P&P titled, Security Considerations, effective 4/21/22, documented physical and/ or electronic security is essential in providing security, access, and protection to residents, personnel, equipment, buildings, and resources. Diligent control of electronic access devices (keypads) and building keys will help provide a safe and secure environment. Only authorized individuals will be provided with door/ elevator keypad codes and building keys. In the event of an electronic device breech (unauthorized individual has accessed the code), the code will be changed immediately, and an investigation will be implemented to determine how/ why the breech occurred. 1. Resident #11 had diagnoses which included secondary Parkinsonism, anxiety disorder, schizophrenia, major depressive disorder, and obsessive-compulsive disorder. The MDS dated [DATE] documented Resident #11 was moderately cognitively impaired, was usually understood. The Elopement Evaluation dated 4/7/22 documented the resident had a score of one, which was categorized as At Risk. Additionally, it documented Resident #11 had a history of or attempted leaving the facility without informing staff. The clinical suggestions were to apply an identification bracelet and notify staff of elopement risk. The comprehensive care plan dated 6/7/22 documented Resident #11 was at risk for elopement, and an orange wrist band was utilized, and their photo was placed by main entrance. The resident ambulated independently to all destinations. The electronic medical record (EMR) Progress Notes for Resident #11 documented the following: - 1/14/22 1:43 PM - Resident is telling staff that their sister is coming to pick them up this morning and take them home, repeatedly asking for backpack. - 2/24/22 10:53 AM - On 2/23/22, resident's sister signed resident out of the facility at 12:45 PM. At approximately 1:15 PM, sister came back into facility and stated resident was attempting to get out of car. Sister pulled into facility parking lot and resident refused to get out of car. Sister came into facility to ask for help. While sister was in facility, resident got out of car and walked toward street. Social Worker and other staff members followed resident and got into their car and brought resident back. - 7/5/22 6:00 PM - a CNA (Certified Nurse Aide) had come through the interior locked doors into the hallway when they saw a shadow. The CNA turned back to look, and the resident was running though the outer doors and could not be persuaded to come back inside and continued to run away from the building. Based on the CNA's description, the resident was in the lobby out of sight when the CNA entered. There was no receptionist on duty at that time. - 7/6/22 8:58 PM - Resident has attempted to leave many times, stands near door to Solarium watching the stairway and elevator. Watches for someone to put the code in. - 7/8/22 11:13 AM - Activities Aide got into elevator and resident swiftly got in as the door was starting to close. Resident angrily mumbled for about three minutes, but finally got out of the elevator. Resident then swiftly turned and tried to rush into the elevator but was blocked by staff member. - 7/8/22 8:17 PM - When dinner carts were being delivered to units, resident attempted to get onto elevator numerous times, but was blocked by staff members. - 7/9/22 9:09 PM - Resident attempted to force way onto elevator by pushing past staff members. Resident finally turned around and began pushing elevator code buttons after door had closed. The Investigation Summary dated 7/5/22, completed by the Former Director of Nursing (DON), documented Resident #11 was hiding around the corner in the front lobby area when a staff member came back into the building, the resident ran through the locked door and out of the building, running away from the facility. Upon completion of interviews of all staff members, none brought the resident down the elevator, opened the elevator door for the resident, or gave the resident the code to use. It is believed that the resident did have the code and used the code to let themselves down the elevator. The resident may have received the code from another resident who frequently goes outside to water flowers and feed the birds. Staff does not give residents the codes, but this resident sees the codes being inputted at times. This resident was able to get themselves to the lobby, lookout the front window and see when staff was coming up the sidewalk to re-enter the building. There was no Receptionist on duty that evening to monitor the front entryway. The staff member who entered the building saw a shadow out of the corner of their eye and turned to see the resident run out the door and was unable to persuade the resident to come back into building. The resident was located and returned to facility. The facility's investigation documented Resident #11 resided on the facility's second floor at the time of the elopement, in the 2 [NAME] Unit. During a telephone interview on 6/14/23 at 1:45 PM, CNA #3 stated on the date of Resident #11's elopement, they were just coming into work at the main entrance, and they did not see anyone inside until they turned to go down the hall toward Dietary, they thought they saw a shadow out of the corner of their eye. CNA #3 stated they turned around and saw Resident #11 exiting out of the main entrance doors and tried to stop them and coax them back in. At that time, Resident #11 had just passed through the outer door and pushed CNA #3. CNA #3 stated they did not want anyone to get hurt, so they immediately went to find a supervisor, and at that time, they saw Resident #11 run away from the building. CNA #3 stated the front doors had an approximate five to ten second delay in closing, and they believed Resident #11 could have been waiting in the cubby corner of the lobby until the doors opened and they had that long to get out of the front doors before they closed. They further stated they believed no one else was nearby at the time and no one was sitting at the front reception desk. There was usually someone at the front desk until 8 PM and they were not sure why no one was at the desk at the time of the incident. CNA #3 further stated they believed the Receptionist was in the building, but not sitting at the desk at that time. CNA #3 also stated orange wrist bands were for elopement risk, but they could not remember if Resident #11 wore an orange band at the time. During a telephone interview on 6/14/23 at 2:00 PM, Dietary Employee #1 stated they were working in the kitchen when a Dr. Wander (code for a resident elopement) was called. They further stated upon hearing Dr. Wander, they jumped in their car, cruised a couple of close streets, and found Resident #11 one or two streets over from the facility. Dietary Employee #1 also stated Resident #11 kind of knew them, so they were able to get Resident #11 to come into their car, and they drove Resident #11 back to the facility. They further stated Resident #11 did not say much of anything while in the car and was annoyed at the fact that they were found. After Dr. Wander was called, Dietary Employee #1 stated it was about 15 minutes or less before Resident #11 was returned to the facility. They stated they did not recall if Resident #11 was wearing an orange bracelet at the time of the elopement. We are not citing the issue about the orange wrist band. During an interview on 6/13/23 at 12:06 PM, Registered Nurse (RN) #4 stated prior to the 7/5/22 incident, in April 2022, Resident #11 scored a one on the Elopement Evaluation and a score of greater than one was classified as At Risk. They stated Resident #11 would not have had an orange bracelet at the time of their elopement on 7/5/22. During an interview on 6/14/23 at 10:25 AM, Licensed Practical Nurse (LPN) #2 stated Resident #11's mobility had declined since July 2022, but they were still an elopement risk. Observations on 6/12/23 through 6/14/23 revealed there were no locked or access-controlled doors between the 2 [NAME] Unit and the elevator and multiple stairways on the second floor. The elevator door and all stairway doors on the second floor were access-controlled by electronic keypads that required a numeric code. Observation at the main front entrance on 6/14/23 at 3:00 PM revealed the main entrance consisted of two sets of double doors. At this time, the front desk Receptionist hit the button located behind the desk to release the main entrance doors' magnetic door lock, the front inner door opened electronically, and the front outer door opened electronically five seconds later. Twenty- five seconds after the button was pushed, the inner door closed electronically and 30 seconds after the button was pushed, the outer door closed electronically. During an interview on 6/13/23 at 11:25 AM, the Environmental Services Director stated the facility's lockdown system consisted of key coded locked doors. The exterior doors and stairway doors had magnetic locks that were controlled by numeric codes and a numeric code was needed to get in or out of the building. The Environmental Services Director also stated a numeric code was also needed to access the elevator, and different doors had different codes. The codes were changed periodically and in case someone happened to catch the code being used. The Environmental Services Director stated the Receptionist could buzz people in or out of the main entrance and the facility had a full time Receptionist from 7:00 AM - 3:30 PM daily Monday through Friday and part-time people who worked reception in the evenings. When no one was at the reception desk, the 1 [NAME] Nurses' Station had a monitor that was linked to a camera at the main entrance. The camera activated when the facility's doorbell was rung. This monitor was the same camera feed that the front reception desk had on their monitor. Additionally, on 6/14/23 at 9:15 AM, the Environmental Services Director stated the doors equipped with magnetic locks and keypad codes were checked by maintenance staff daily and there were no malfunctions with the system in June or July of 2022. Review of front reception desk coverage schedule revealed the schedule for 7/5/22 (Tuesday) indicated the reception desk would be covered from 7:00 AM to 3:00 PM. Review of the Receptionist job description called, Administrative Assistant, dated 4/1/98, revealed the Administrative Assistant assumed responsibility for the clerical operations of the facility, which included overseeing front desk operations. The job description did not address security items such as the key coded locked door system or access into and out of the building. During an interview on 6/13/23 at 9:20 AM, CNA #1 stated the were working at the front desk at this time because the front desk Receptionist, who usually worked 7 AM to 3 PM, was on vacation this week. CNA #1 stated the front reception desk was occupied usually until 8 PM. When the usual Receptionist went on break, they would sit at the reception desk until the Receptionist returned from break if they were working that day, and if they weren't working that day, CNA #1 stated they did not know who covered the Receptionists' breaks. CNA #1 also stated the Explorers Club poster was at the front door and there were currently seven residents' pictures there. The purpose of the poster was to alert people to which residents were an elopement risk. CNA #1 stated the keypads on the exterior doors, stairway doors, and the elevator kept doors locked and they had to buzz people in and out. Employees knew the codes, which were different at each door, and they could let themselves in and out by entering the numeric code into the keypad. Additionally, at this time, CNA #1 stated they were going to leave the facility momentarily and an Activities Assistant would take over for them while they were out. Continual observation on 6/13/23 between 10:00 AM - 10:10 AM revealed the front reception desk was unoccupied. Additionally, the front reception desk was observed to be unoccupied on 6/13/23 at 10:39 AM and 11:15 AM. During an interview on 6/13/23 at 11:18 AM, Activities Assistant #1 stated they started covering the front reception desk today at around 10:45 AM or 11:00 AM because they were told to come to reception at that time. During an interview on 6/14/23 at 9:20 AM, the Administrator stated the hours of front reception desk coverage were 7 AM to 3 PM and 3 PM to 8 PM on Mondays through Fridays. There was also weekend front desk coverage from 8 AM to 4 PM and 4 PM to 8 PM. The Administrator also stated the usual Receptionist was on vacation this week, and when that happens, a light duty CNA or Activities staff or others as needed could cover the front reception desk. During the Receptionist's breaks, the facilities outside phone line was forwarded to all other office phones. The Administrator also stated there was a doorbell system with a camera that turned on when doorbell was rung. If anyone other than a staff member wanted to get out of the facility, such as residents' family members, and no one was at the front reception desk, they are told to go to the 1 [NAME] Nurses' Station and a staff member there will assist them. Residents' family members never get the keypad codes for doors. They must be walked to the elevator and let in and let out of the front entrance by staff. 2. Resident #12 had diagnoses which included Alzheimer's Disease. The MDS dated [DATE] documented Resident #12 was severely cognitively impaired, sometimes understood others, and was sometimes understood by others. The Elopement Evaluation dated 6/15/22 documented Resident #12 had a score of two, which was categorized as At Risk. The evaluation documented the resident wandered and the wandering behavior was likely to affect the privacy of others. There were no clinical suggestions check marked on the evaluation. Resident #12's comprehensive care plan dated 6/16/22 documented resident's ambulation was limited assist of one staff member with gait belt and rolling walker to all destinations. This version of the care plan did not mention a risk for elopement. The focus of Resident is at risk for elopement related to cognitive impairment was initiated on the care plan on 6/22/22. The EMR Progress Notes for Resident #12 documented the following: - 6/15/22 6:38 PM - Resident just admitted , wanders to door and out in hall in evening, but unsure of during night. - 6/17/22 3:50 PM - Orange elopement band applied to resident's wrist and DON made aware of possible elopement risk. Resident was with a visitor and stated they were leaving the facility. It was explained to resident that they needed to stay at the facility. Resident seemed to think they were at a hotel and for the remainder of the shift, they tried to turn in keys and packed things over and over throughout the shift. - 6/17/22 8:10 PM - Resident wandered out of room and down to the other end of the unit before staff found resident attempting to enter another resident's room. - 6/18/22 1:09 PM - Resident alert with some confusion, ambulating in room and within the unit. - 6/18/22 8:26 PM - Resident alert with some confusion, continues to ambulate unassisted in the halls and attempts to go into other residents' rooms at times. - 6/19/22 1:00 PM - Resident alert with confusion, wandering halls today looking for son to take them home. Review of the facility's Investigation Summary, written by the Former DON, dated 6/21/23 documented the resident used a rolling walker to ambulate to all destinations on care plan, but frequently ambulated out of room without assistance and without roller walker and had to be assisted back to room. Resident was well-groomed and can speak, although unable to carry on a normal conversation due to deteriorating mentation. On the date of the incident, the resident was last seen sitting across from the Nurses' Station at 10:50 AM and ten minutes later, resident's sister reported resident was seen on the patio outside of the front of the building. Between 10:50 AM and 11:00 AM, no staff was around to let the resident out of the building. There was a resident that was transferring to another facility leaving at that time with family. It is suspected that the family member had the code to the front door and let themselves and the resident out the front door. At time of admission, because of the Elopement Evaluation, an orange band was placed on the resident's wrist, to denote elopement risk. Staff were alerted to elopement status. The resident resided on 1 West, which was ground level of the building, no second-floor rooms were available, and resident needed to be on quarantine upon admission and the only rooms available for quarantine were on the 1 [NAME] Unit. The resident was reportedly wearing an orange bracelet at the time of the elopement, but a long sleeve shirt covered it. The written Employee Statement signed by the Assistant Director of Nursing (ADON), dated 6/21/22, documented they observed the resident sitting in a chair in the hallway at 10:50 AM and at that time, they informed staff that the resident should be in their room, and they went to their break. The written Employee Statement signed by RN #5, dated 6/21/22, documented they were notified by the resident's sister that the resident was on the front patio walking away from facility still on the patio. The resident's sister stated someone was at the front desk who let the resident out of the facility but was unclear who exactly let the resident out. Resident did have an orange elopement band on. The written Employee Statement signed by the Receptionist, dated 6/21/22, documented the resident's sister came inside to get someone to get the resident off the front porch. Review of the Visitor Sign In log dated 6/21/22 revealed it did not have a separate column for time in and time out, but only one column labeled Time. There were eleven entries on the log, and only the first entry was highlighted. The column labeled Time for the first entry was 9:17. Review of front reception desk coverage schedule revealed the schedule for 6/21/22 (Tuesday) indicated the reception desk would be covered from 7:00 AM to 3:00 PM and 3:00 PM to 8:00 PM. Observations made on 6/12/23 and 6/13/23 revealed numeric code access keypads were located at the elevator and stairway at the front/ center of the building as well as exit doors on the first floor. A numeric code access keypad was also observed at the main entrance and at all second- floor stairway doors and elevator. During a telephone interview on 6/14/23 at 3:20 PM, the former DON stated they were the DON at the time of the elopements of Residents #11 and #12. They stated an elopement investigation always started with interviews with all staff to find out how the person got out of the building. The former DON also stated some residents did not look like residents and another residents' family members could let a resident out of the building thinking they were not a resident. The former DON also stated the facility got rid of cameras during the remodeling about two years ago and because there were no cameras left in the facility, it would be hard to know who would have let Resident #12 out. The front main doors close slowly, which could allow enough time for someone to possibly get out. Family members are not supposed to get the door codes, but some family members hear or see staff members punch in the door codes. The staff are asked to block the view of the keypad while they are punching in the codes as much as possible. Families may overhear staff saying door codes out loud to each other. If the facility knows that a family has a code, we will change codes. The former DON also stated the potential safety concerns related to elopement of a resident with limited capacity included the busy road out front of the facility and the nearby creek. The Former DON also stated new interventions should have been put in place for Resident #12 when they were observed to be packing on 6/17/22 and if they personally didn't know about it, the Resident Care Coordinator should have been notified. Resident #12 should have been moved upstairs, but at that time, there was no room upstairs as this resident was under quarantine for COVID-19 as a new admission. Orange bracelets alert everyone that that resident is an elopement risk, so they are aware to monitor closely. 10 NYCRR 415.12(h)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during an Abbreviated survey (Complaint #NY00313271) completed on 3/29/23, the facility did not ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, and the comprehensive person-centered care plan for one (Resident #1) of three residents reviewed. Specifically, the facility inaccurately documented the use of a non- invasive mechanical ventilator as a CPAP (continuous positive airway pressure) machine and on 3/22/23 the non-invasive mechanical ventilator was removed from Resident #1's use. The finding is: The facility provided a policy for CPAP (machine that uses mild air pressure to keep breathing airways open while you sleep) and did not have a policy specifically for the (brand name) Ventilator (a non-invasive mechanical ventilator). The (brand name) 100 Clinical Manual provided to the facility by the vendor on 3/28/23 documented the machine was a (brand name)100 system that provided continuous or intermittent ventilatory support for the care of individuals who require mechanical ventilation. This ventilator provides both pressure control and volume modes of therapy. The device can provide non-invasive or invasive ventilation. It can be used to provide total therapy to patients as they progress from non-invasive to invasive ventilation. Resident #1 was admitted with diagnoses including chronic obstructive pulmonary disease (COPD), anxiety disorder and depression. The Minimum Data Set (MDS - a resident assessment tool) dated 2/20/23 documented Resident #1 was cognitively intact. The undated Comprehensive Care Plan (CCP) documented Resident #1 had COPD, chronic respiratory failure with hypoxia (low oxygen levels in the blood). The CCP inaccurately documented the use of a CPAP versus the non-invasive mechanical ventilator. The undated Closet Care Plan (a guide used by staff to provide care) documented oxygen (O2) at 3 liters continuous via nasal canula. The Hospital Discharge summary dated [DATE] documented Resident #1 used a nighttime Trilogy in ventilator mode and was encouraged to use the machine during daytime naps. The Nursing Comprehensive Assessment dated 1/13/22 documented acute and chronic respiratory failure with hypoxia, and COPD exacerbation. Respiratory treatments and devices included a ventilator and continuous oxygen. The resident has own ventilator type machine they take care of. The Physician's Orders dated 1/14/22 revealed an order for a CPAP. The physician's order documented CPAP on at HS (hour of sleep), off in am. There were no settings listed. There was no physician's order for the Non-Invasive Mechanical Ventilator ((brand name) Ventilator) as per the hospital discharge summary and comprehensive nursing assessment. The orders inaccurately documented the use of a CPAP versus the non-invasive mechanical ventilator Review of the Treatment Administration Record (TAR) from 1/14/22 through 3/22/23 documented CPAP on at HS, off in am. Resident does like to place on by themselves, every day and night shift and had a start date of 1/14/22 and discontinued date of 3/22/23. The treatment record inaccurately documented the use of a CPAP versus the non-invasive mechanical ventilator. The Nursing Progress Notes dated 3/22/23 documented the Administrator informed Registered Nurse (RN) #1 the vendor was picking up Resident #1's machine on 3/22/23. Resident #1 was anxious about the machine being taken. During observation and interview on 3/28/23 at 11:30 AM, Resident #1 was wearing oxygen via a nasal canula, and the liter flow was set at 3. There was no evidence of a non-invasive mechanical ventilator at the bedside. Resident #1 stated the machine was a ventilator which removed carbon dioxide from their lungs and functioned differently than a CPAP or BIPAP. The vendor took the machine on 3/22/23. During a telephone interview on 3/28/23 at 1:05 PM, the Operations Manager/ Respiratory Therapist for the vending company stated the non mechanical ventilator helped with the removal of Carbon Dioxide (CO2) levels. Resident #1 had a ventilation issue, not an oxygenation issue. The Operations Manager/Respiratory Therapist stated they contacted the Administrator to discuss payment on 2/17/23, 2/21/23, 2/28/23, 3/2/23, and 3/15/22 with no response from the facility. On 3/22/23 the Respiratory Therapist came to the facility and spoke with the Administrator. The Administrator instructed the Respiratory Therapist to take the ventilator. During an interview on 3/28/23 at 2:10 PM, the Administrator stated Resident #1 was admitted with a CPAP machine on 1/13/22. The machine was rented prior to admission and the resident brought it with them. Resident #1 insisted that it was a ventilator. Registered Nurse (RN #1), Resident Care Coordinator, (RCC) determined it was a CPAP. Resident #1 would put it on and take it off on their own. Nursing staff would sign off for accountability on the TAR. The Administrator stated the vendor came to the facility on 3/22/23 and told the vendor to remove the machine. During a telephone interview on 3/28/23 at 2:27 PM, the Corporate Supervising Administrator stated they weren't sure what type of machine Resident #1 used. The machine should not have been removed. The facility was responsible to provide respiratory services for residents. We'll take care of it. During a telephone interview on 3/29/23 at 9:24 AM, RN #1 RCC stated they assumed the machine was a CPAP, until yesterday (3/28). RN#1 stated Resident #1 communicated with the vendor and maintained it on their own. RN# 1 stated they were responsible for inaccurately documenting the CPAP order on 1/14/22. The order should have specified a non-invasive mechanical ventilator. RN #1 stated they should have attempted to contact the vendor on admission and clarified what the machine was but did not. On 3/22/23 the vendor picked up the machine. Resident #1 was anxious and upset the machine was being taken. During a telephone interview on 3/29/23 at 11:05 AM, the Medical Director stated a noninvasive mechanical ventilator provided more inspiratory and expiratory pressure. PCO2 (partial pressure of carbon dioxide- the measure of carbon dioxide within arterial or venous blood) was expelled. The pressure changes on its own and was different from a CPAP/BiPAP (bilevel positive airway pressure). The pressure delivered by the CPAP/BiPAP was much lower. The Medical Director stated they were unaware the machine was a ventilator and had been taken away. Monitoring SPO2 (percentage of oxygen in blood) levels every 4 hours would not be a good indicator for someone with severe COPD. The problem was not getting rid of the CO2. The facility was not capable of monitoring CO2 levels. CO2 levels were obtained through arterial blood gases (ABGs) which the facility was incapable of performing. ABGs were performed in the hospital or Emergency Room. The Medical Director stated the non-invasive mechanical ventilator prevented further hospitalizations and should have not been taken away. 10 NYCRR 415.12(k)(6)

Based on observation, interview and record review conducted during an Abbreviated survey (Complaint #NY00262897) completed during the Standard survey 7/30/21, the facility did not ensure that each resident received adequate supervision to prevent accidents for one (Resident #5) of four residents reviewed. Specifically, the facility did not identify and reassess a resident with exit seeking behaviors and the resident eloped from the facility. The finding is: A facility policy and procedure titled, Elopement Prevention and Search for Missing Resident revised 3/10/21 documented that residents will be maintained in a safe and secure manner and protected from actual harm while encouraging a restraint free environment. Residents will be assessed for potential elopement on admission, re-admission, quarterly and upon significant change, and if an attempted elopement occurs. If residents were identified as being a wanderer and/or exhibited the potential for elopement, a behavior management plan would be developed. All staff would receive elopement prevention in-service upon hire and annually. Staff would be instructed to immediately alert the licensed nurse of any resident displaying an increased risk for elopement including but not limited to: - Displaying exit seeking behaviors - Wandering behaviors - Verbalizing statements that may indicate potential for elopement 1. Resident #5 had diagnoses including metabolic encephalopathy (disturbance in brain function due to disease or toxin in the body), dementia, and restlessness and agitation. The Minimum Data Set (MDS-a resident assessment tool) dated 8/12/20 documented Resident #5 had severe cognitive impairment and required limited assistance of staff for ambulation with no assistive devices. The initial Elopement Evaluation dated 8/5/20 documented Resident #5 was not at risk for elopement. The Comprehensive Care Plan (CCP) dated 8/6/20 documented the resident was independent with ambulation to all destinations. Additionally, on 8/17/20 the CCP documented the resident had impaired cognitive function/dementia or impaired thought processes. Interventions included to cue, redirect, and supervise as needed. There was no CCP developed, or interventions implemented for wandering behaviors or elopement risk. Review of Resident #5's electronic medical record (EMR) interdisciplinary team (IDT) Progress Notes dated 8/6/20 through 8/24/20 revealed the following: - 8/11/20 at 2:55 PM Resident alert with periods of confusion and disorientation noted throughout shift. Required occasional redirection during times when they wandered out of their room and was looking to go home or to find some alcohol. - 8/15/20 at 1:31 PM Continued to have periods of confusion/disorientation at times. Resident told writer this morning that they were (leaving) for a few days. - 8/18/20 at 1:39 PM Occasionally wandered out from room and would usually tell staff they were looking to go somewhere to drink. Staff made resident aware of where they were and gently guided resident back to their room. - 8/22/20 1:10 PM After lunch was given to resident it was noted that resident had ambulated independently out of their room and walked down to the end of the hallway and attempted to open the emergency door. - 8/22/20 at 9:51 PM Alert with confusion, continued to come out of room asking for ETOH (alcohol). Resident asked if ride was here, explained no one was here to pick up resident. - 8/24/20 at 7:31 PM Accident & Incident: Elopement was paged overhead for resident. Resident then asked by writer if anyone let them out, resident stated No. Immediately all staff went to search for resident. Resident was noted to be walking toward the apartment buildings next to the facility. Resident's name was called, resident stopped, and calmly walked back to the facility with writer and another staff member. MD was called and notified of incident. Resident's room was changed to the second floor and an elopement band was placed on the resident. When asked how resident got out the resident stated, I went out of the front door. Review of the facility's Investigation Summary dated 8/24/20 at 5:30 PM revealed the resident eloped from the building. Certified Nurse Aide (CNA) went to deliver dinner tray and the resident was not in their room. Resident was found outside of building in grassy area next to the building. The resident returned to the building without incident. Registered Nurse (RN) assessment documented no injury occurred and the resident was not previously identified as an elopement risk. The investigation summary conclusion documented that the investigation supported the allegation of elopement as defined in the regulations. Attempts to interview the CNA involved in the incident were unsuccessful. During an interview on 7/30/21 at 10:18 AM, Licensed Practical Nurse (LPN) #3 stated that RNs were responsible for elopement assessments on admission and if a resident exhibited signs of wandering. LPN #3 stated Resident #5 would sometimes wander in the hall and was down by an exit door but she didn't think the resident was going to leave and couldn't remember if she told anyone. During an interview on 7/30/21 at 10:23 AM, Resident Care Coordinator (RCC) RN #3 stated they didn't remember if Resident #5 exhibited signs of wandering when they were admitted to the facility. If a resident was identified at risk for elopement, they try to transfer the resident to the second floor. RCC RN #3 stated I am not really sure how Resident #5 got out of the building. During an interview on 7/30/21 at 10:39 AM, the facility receptionist stated they usually worked until 3:30 PM and was not on duty when Resident #5 eloped. The receptions stated there nobody worked the front desk after she left. The receptionist stated they were not sure how the resident would have gotten outside because the front door has always been coded. It required a code before it would open. The resident may have followed someone out the door or they somehow knew the code, but they change the door code frequently. During an interview on 7/30/21 at 12:34 PM, the Director of Nursing (DON) stated the expectation for wandering residents was to do the elopement assessment and if risk was determined try not to keep resident's downstairs on the first floor. It's easier to monitor residents upstairs and they can't get on the elevator because a code was needed. Resident #5 was wandering and looking out the door but that doesn't always mean they are trying to get out. During an interview on 7/30/21 at 12:37 PM, the facility Administrator stated they never determined how Resident #5 got out of the building. The expectation was residents should be supervised for the exact reason as what happened with Resident #5. They should be supervised, for safety, so they don't elope from the building. 415.12(h)(2)

Based on observation, record review, and interview conducted during a Standard survey completed on 7/30/21, the facility did not provide food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, two (Main Dining Room Servery and One West) of two test trays completed for food temperatures during meals had issues involving food and beverage items that were not at safe and appetizing temperatures. Residents (#13, 15, 89, and 312) were involved. The findings are: Review of the undated Policy and Procedure (P&P) entitled Food Temperatures dated 3/2021 documented to ensure safety and quality of food items, it is the policy of the facility to obtain and record temperatures of food items prior to serving to residents. Hot foods must reach an internal temperature of 145°F (degrees Fahrenheit) and allowed to rest for at least 3 minutes before consuming. Cold foods should be held below 40°F. During an interview on 7/26/21 at 11:38 AM Resident #312 stated the food usually comes up cold and could be warmer. Trays are late. During an interview on 7/27/21 at 8:52 AM Resident #13 stated the food is bad and it's cold when it comes up. I can't eat it. I make my own sandwich from my refrigerator. Every day the meals are cold, and the cold food is very warm, like room temperature including the milk and juices. During an interview on 7/27/21 at 9:53 AM Resident #15 stated the food is terrible. The food is cold, has no flavor and small portions. There are too many sandwiches on the menu for the supper meal. During an interview on 7/27/21 at 09:54 AM Resident #89 stated the food is terrible, cold, and no flavor. They have to many sandwiches at night. During the Resident Council Meeting on 7/27/21 at 10:06 Residents stated the meals are always late, sometimes two hours late and the food is always cold. During an observation on 07/28/21 at 1:44 PM after all the lunch trays were served to the residents on unit One West, the test tray temperatures were then taken by the facility Registered Dietitian using a facility thermometer. The temperatures obtained were as follows: -Green Beans- 121°F and tasted waxy and rubbery. -Milk- 51°F and tasted cool/ lukewarm, not palatable. -Prune Juice- 52.5°F and tasted cool not cold/ lukewarm, not palatable. During an observation on 7/28/21 at 1:44 PM the Dietary Aide #3 began serving the lunch meal in the Main Dining Room Servery and did not obtain the food temperatures prior to serving. During an observation on 7/28/21 at 01:54 PM after all the lunch trays were served to the residents in the Main Dining Room Servery, the test tray temperatures were then taken by Dietary Aid #3 using a facility thermometer. The temperatures obtained were as follows: -Meatballs- 142°F and tasted lukewarm, bland, and rubbery. -Green Beans- 115°F and tasted cold, bland and were mushy. -Spaghetti- 138°F and tasted lukewarm and the sauce tasted acidic. -Milk- 55°F and tasted lukewarm, not palatable. -Juice- 56° F and tasted lukewarm, not palatable. During an interview on 7/28/21 at 2:05 PM Dietary Aide #3 stated they did not take the food temperatures prior to serving the food to the residents. They thought the food temperatures were already taken in the kitchen but was unsure. During an interview on 7/28/21 at 2:42 PM the [NAME] stated the food was tempted prior to bringing to it to the Main Dining Room Servery and it was hot. The [NAME] stated they did not document the temperatures though. The [NAME] stated the temperatures should be over 140° F for hot items and below 40° F for cold items. They stated the server in the servery should temp the food and document on log prior to serving. During an interview on 7/28/21 at 3:23 PM the Dietary Technician and the Administrator revealed there were issues in the kitchen today at lunch due to the Food Service Director (FSD) being out of the facility. They were aware of the low food temperatures, all foods should be tempted and logged prior to serving. Hot foods should be served no lower than 130°F and cold foods below 40°F. 415.14(d)(1)(2)

Based on observation, interview and record review conducted during a Recertification survey completed on 7/30/21, the facility failed to ensure that infection control practices and procedures were maintained to provide a safe, sanitary, and comfortable environment to help prevent the development of COVID-19 and transmission of communicable diseases and infections. Specifically, staff member Registered Nurse (RN #2) did not wear an N95 mask, gloves, gown, and their surgical mask was below the nares during specimen collection for one Visitor (#1) of three visitors tested for COVID-19. The finding is: A CMS (Centers for Medicare and Medicaid Services) memorandum, revised 4/27/21 (Reference QSO-20-38-NH), documented: during COVID-19 specimen collection, facilities must maintain proper infection control and use recommended personal protective equipment (PPE), which includes an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection, gloves, and a gown when collecting specimens. CDC (Centers for Disease Control and Prevention) guidance, updated 2/26/21, titled Interim Guidelines for Collecting and Handling of Clinical Specimens for COVID-19 Testing documented: For healthcare providers collecting specimens or working within 6 feet of patients suspected to be infected with SARS-CoV-2, maintain proper infection control and use recommended personal protective equipment (PPE), which includes an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection, gloves, and a gown. Facility policy and procedure titled, COVID-19 Testing Requirements dated 3/22/21, documented: during specimen collection the facility would maintain proper infection control and use recommended personal protective equipment (PPE), which included an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection, gloves, and a gown when collecting specimens. During an observation on 7/26/21 at 4:09 PM, Registered Nurse (RN) #2 was in the parking lot at a car window performing a nares swab without donning gloves, gown, or an N95; RN #2 wore only a surgical mask positioned at the base of the nares, not covering their nose. During an interview on 7/26/21 at 4:12 PM, RN #2 stated a COVID-19 Rapid test swab was performed for a visitor who requested to have a test completed prior to visiting a resident. RN #2 stated the visitor was asymptomatic. RN #2 stated they forgot to put on the N95 mask and should have and the surgical mask should be worn over the nose to cover the nares. RN #2 stated they did not need to wear gloves because the swab was placed into the specimen test card and the specimen was not touched, therefore gloves were not required. RN #2 stated a gown was not worn because the testing was done outside the facility. During an interview on 7/30/21 at 12:09 PM, the Director of Nursing (DON) Infection Preventionist (IP), stated they were not aware RN #2 did not wear gloves and wore a surgical mask below the nares while RN #2 swabbed a visitor for COVID-19. The DON/IP stated staff were expected to wear appropriate PPE during COVID-19 swabbing, which included surgical mask in the correct position over the nose, gloves, gowns, N95, and eye protection when swabbing staff, residents, and visitors, including swabbing outside the facility. The DON/IP stated PPE was used to protect the staff from potential exposure and ultimately protect the residents from potential exposure to COVID-19. During an interview on 7/30/21 at 12:50 PM, the Administrator stated RN #2 didn't think full PPE was required since they were vaccinated for COVID-19 and that RN #2 should have worn full PPE (gown, gloves, N95, eye protection) during the swabbing process. 415.19(a)(1)

Based on observation, interview, and record review conducted during a Standard survey completed on 7/30/21, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, one of one Main Kitchen had issues with unacceptable dish washer temperatures when cleaning and sanitizing resident dinnerware and flatware, not properly cleaning and sanitizing the food processer equipment in between each food item that was being pureed, and staff not wearing beard guards while prepping and serving food. The findings are: Review of the facility Policy and Procedure (P&P) entitled Food and Nutrition Services dated 3/10/21 documented each resident is provided with a nourishing, palatable, well balanced diet that meets his or her nutritional and specialty dietary needs. All surfaces will be sanitized with approved sanitizing agent between food preparation efforts including sanitizing all small equipment. Review of the facility P&P entitled Dietary Dress Code dated 3/10/21 documented employees of the dietary department will wear professional appearing attire and will maintain appropriate hygiene while on duty. Staff with facial hair must keep the length less than half inch in length or a beard guard will be required. 1. During an observation on 07/28/21 at 10:20 AM in the dish machine room two dietary staff were in the process of cleaning the breakfast dishes for the day. Five racks of juice cups, plates, bowls, coffee cups, and flatware were rinsed and placed into the racks and sent through the conveyor of the high temperature dish machine. Observation of the wash cycle revealed the temperature not going above 141°F (degrees Fahrenheit) with the thermostat instructions revealed the water should be above 150°F. In addition, the rinse cycle instructions revealed the water should be above 180°F and it did not go over 153°F. The juice cups, plates, bowls, coffee cups and flatware were then stacked and stored to dry. These items were observed to be used during that day's lunch tray line. Review of the Dish Machine/Pot Washing Log dated July 2020 documented the wash and rinse cycle temperatures as follows: -7/28/21 at the breakfast meal wash cycle was 140°F and rinse cycle was 160°F. -7/28/21 at the dinner (lunch) meal wash cycle was 140°F and rinse cycle was 175°F. -7/29/21 at the breakfast meal wash cycle was 140°F and rinse cycle was 140°F. -7/29/21 at the dinner (lunch) meal wash cycle was 150°F and rinse cycle was 140°F. There were no documented temperatures for the supper meal for both days During an interview on 07/28/21 at 10:39 AM Dietary Aide #1 stated the dish machine temperatures are checked in the morning, wash cycle should be over 150°F and rinse cycle should be at 200°F but not be low 180°F. The dietary aide further revealed some days the temperatures are up and down, and it takes sometimes 4-5 passes of the dishes to go through to get to the required temperature. Dietary Aide #1 stated they do not rewash the dishes and did not notify anyone of the low temperatures this morning. Further interview at 10:58 AM Dietary Aide #2 informed the surveyor the rinse cycle was now up to 160°F and the dish machine temperatures should be between 160 -180°F for the rinse cycle. During an interview on 7/28/21 at 10:51 AM the Dietary Technician (DT) stated the dish machine temperatures are taken by the staff in the dish room before each meal and logged. Further interview at 11:28 AM the DT informed the surveyor maintenance checked the dish machine and the rinse cycle is now up to 190°F. The rinse cycle should be above 180°F if the temperature was not high enough the staff should have rewashed and sanitized the dishes. During a further observation on 7/28/21 at 2:43 PM two dietary staff were in the process of cleaning the lunch dishes for the day in the dish machine room. Five racks with juice cups, plates, bowls, coffee cups and flatware were rinsed and placed into racks and sent through the conveyor of the high temperature dish machine. Observation of the wash cycle thermostat revealed with instructions of the water should be above 150°F the wash cycle temperature did not go above 141°F and the last rinse cycle with instructions the water should be above 180°F, did not go 161°F. The juice cups, plates, bowels, coffee cups and flatware were then stacked and stored to dry. 2. During an observation on 07/28/21 at 10:41 AM the cook washed their hands donned gloves and added approximately 24 cooked meat balls, approximately eight green handled scoops of cooked macaroni and eight ladles of red sauce into the food processer for that day's lunch meal and pureed to a smooth texture. The cook then went to the manual dish sinks and removed their gloves. Observation of the wash sink revealed the sink was filled to the top with a large strainer and cooking pans soaking in the dirty, milky colored water with floating food debris and a greasy film on top. The cook put the food processer, spatula, and lid in the empty middle sink , turned on the hot water and rinsed each piece, wiping the inside of the processor with their bare hand. The cook then tapped all three pieces of equipment against the side of the sink and brought the equipment back to the processing station. The cook then put approximately ten gray handled scoops of cooked green beans in the un-sanitized food processer and a small amount of chicken broth and processed to a smooth texture. The cook then removed her gloves and took the food processor, spatula, and lid to the manual dish sinks, turned on the hot water, rinsed all three pieces of equipment up and down three times in the wash sink, that still contained the dirty, milky colored water, food debris and the greasy film, large strainer, and cooking pans. The cook then proceeded to rinse the three pieces of equipment under the tap water in the middle sink, tapped the equipment on the side of the sink and brought the three pieces of equipment back to the processing station. The [NAME] then went on to process the Italian bread in the un-sanitized food processor. During an interview on 7/28/21 at 11:31 AM the [NAME] stated they were not sure what the process was for cleaning the food processer in between each food item. During an interview on 7/28/21 at 12:20 PM with the DT, the surveyor asks if anything was wrong with the puree process this morning and the DT stated yes. The DT stated the cook did not clean and sanitize the equipment in between the spaghetti and green beans. I told the cook before you came in to watch the puree process and she needed to clean and sanitize the equipment in between each food item and that the pureed food should be thrown away, d/t unsanitized equipment. During an observation on 7/28/21 at 12:26 PM the DT told the [NAME] to remove all the pureed food from the tray line and warming oven. The observation further revealed the DT taking over the tray line and the [NAME] pureeing a new batch of spaghetti and meatballs, green beans and Italian bread. 3. During an observation on 7/28/21 at 01:44 PM Dietary Aide #3 began serving lunch to the residents in the main dining room. They were wearing a surgical mask with facial hair protruding from the sides of the mask and below the chin approximately 1/2 to 1 inch of facial hair in length showing. During an interview on 7/28/21 at 2:05 PM Dietary Aide #3 stated they had just started working in the kitchen and was not wearing a beard guard and was unsure if the facility had any beard guards and was never told to wear one. During an interview on 7/28/21 at 3:23 PM the DT and Administrator revealed there were issues in the kitchen at lunch today as the Food Service Director (FSD) was not in the facility. Both the DT and Administrator agreed staff should be wearing beard guards if they have facial hair an inch or more. They were aware of the low temperatures on the dish machine and was working on getting the dish machine fixed and all equipment should be properly cleaned and sanitized. The hot foods should be served no lower than 130°F and cold foods below 40°F. 415.14 14-1.110(a)(c)(e) 14-1.72(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during the Standard survey completed 8/2/19, the facility did not not maintain a safe, clean, comfortable and home-like environment for three (1 West, 2 East and West) of three resident units. Specifically, resident rooms and hallways throughout the facility had soiled tile floors and carpets. Residents D, E, F, G, J, N, and O were involved. The findings are: Review of a policy and procedure titled Floor Care - Buffing, Carpet Cleaning, Machine Maintenance dated 10/2017 revealed the purpose of carpet care is to maintain the outward appearance of the facility and help control the spread of bacteria and infection. Hot water extraction is used to remove deep down dirt, soil and stains from various types of carpets within the facility. The amount of traffic to an area will determine the frequency of the cleaning. Interviews from 7/28/19 to 8/2/19 revealed the following: - 7/28/19 at 10:48 AM - Resident O stated the carpet in her room was very stained and looked dirty. She added it was this way when she arrived in June. The hallway carpets are also old and dirty. - 7/28/19 at 11:30 AM - Resident J stated the floors and carpets are dirty and staff don't generally vacuum unless we ask. - 7/28/19 at 11:35 AM - Resident E stated staff will not pick things up off the floor. If something gets spilled, we have to try and soak it up ourselves. - 7/29/19 at 11:30 AM - Resident N's family member said Look at the floor, it has been like this for two days. Shouldn't they be cleaning the floors daily? - 7/29/19 at 11:45 AM- a Certified Nurse Aide (CNA #2) stated the (tile) floor was very dirty and needed to be cleaned. (1 West) - 7/29/19 at 9:36 AM - Resident D stated the carpets in his room were stained and they were this way when he arrived. (7/19) During a resident group meeting on 7/29/19 at 10:15 AM, Residents E, F, and G stated the carpets in their individual rooms were dirty/stained and the hallway carpets are very stained. Resident G further stated, They tell us there will be changes coming but nothing ever happens Intermittent observations from 7/28/19 through 8/2/19, between the hours of 7:30 AM and 3:30 PM, revealed the following: a.) 1 [NAME] and resident rooms - 7/28/19 at 9:58 AM - Tan/brown hallway carpets were heavily soiled with varying sizes of dark brown stains from the Nurses' Station extending all the way down the hallway to the right (approximately 150 - 200 feet). The stains ranged from approximately three inches to 12 inches in size. - Multiple, daily, intermittent observations on 7/28/19 to 8/2/19 - The tan/brown carpets in resident rooms #1 through #8 were heavily stained. The stains varied in size from three to five inches to very large stains covering the majority of the carpet's surface within the room. The stains varied in colors and shades from light brown to dark brown. Some rooms also had rust stains on the surface of the carpet. - 7/28/19 and 7/29/19 - Resident room [ROOM NUMBER] - The white tile floor along the right side of the bed near the window, was covered with brown spills and splatters. b.) 2 West - The tan/brown hallway carpet was heavily soiled with brown stains extending from the Nurses' Station to the right, to the end of the hallway (approximately 150 to 200 feet). There was heavier soiling along the left side of the hallway in front of resident doorways. The stains varied in sizes from approximately three to eight inches. c.) 2 East - Intermittent observations from 8:05 AM on 7/29/19 through 12:40 PM on 8/1/19 - The tan/brown carpet in resident room [ROOM NUMBER] had multiple large overlapping ringed stains, approximate five feet by three feet in size, in the center of the carpet upon entering the room from the hallway. The room smelled of urine During an interview conducted in the hallway in front of resident room [ROOM NUMBER] (2 East) on 7/31/19 at 8:06 AM, the Maintenance Assistant stated the process for carpet cleaning is that maintenance staff are notified by nursing or resident families that a carpet needs to be cleaned and then they should be cleaned. The carpets would be done if we had a carpet cleaner, but we don't. The facility carpet cleaner is broken. The owner of the facility was aware, and he was going to get the carpet cleaner from a sister facility. This was about three weeks ago, but we still don't have it. During an interview on 8/2/19 at 12:02 PM, the Administrator stated the empty rooms on 1 [NAME] were ready and available for new admissions. She was aware of the poor condition of the carpets in the resident rooms and in the hallways. The DON and Administrator do environmental rounds regularly with the Environmental Director (currently unavailable) and the QA (Quality Assurance) team have audits that they do. They also have a program called Room of the Day, where one room gets deep cleaned every day. The carpet machine hasn't been working for a while, but they do try to get a sister facility's machine at times. Unfortunately, the carpet machine does not remove most of the stains. The facility had not attempted a professional cleaning. During an interview on 8/2/19 at 9:45 AM, Housekeeper #1 stated maintenance was responsible for cleaning the carpets. In the past, she had tried to spot clean the carpets but did not have much success. The machine has been broken for about the last month. The facility was aware the machine was broken and has not attempted a professional cleaning. During an interview on 8/2/19 at 11:09 AM, the Director of Nursing (DON) stated the maintenance department does the carpet cleaning. The carpets have been extracted but all the stains do not come out. The facility's carpet extractor was not working, but she cannot give an exact date when it broke. We have to borrow the carpet extractor from a sister facility. 415.5(h)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during a Complaint investigation (Complaint NY#00241179) during the Standard survey completed on 8/2/19 the facility did not ensure that all allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for one (Resident #94) of one resident reviewed for abuse. Specifically, there was a lack of a thorough investigation by the facility to rule out abuse, neglect or mistreatment when new information was identified through the collection of staff statements regarding bruises of unknown origin and when a T12 (twelfth thoracic vertebra in the spine) fracture was reported to the facility after the resident was hospitalized . The finding is: The facility policy and procedure titled Prevention of Resident Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property dated 3/2019 revealed all suspicious injuries of unknown origin will be investigated. The policy instructs to refer to the Incident/ Accident (A/I) reporting policy for complete investigation procedure. This was requested on 8/1/19 and not provided. 1. Resident #94 was admitted to the facility on [DATE] and had diagnoses which included chronic kidney disease (CKD), diabetes mellitus (DM), and adult failure to thrive. The Minimum Data Set (MDS-a resident assessment tool) dated 5/2/19 documented the resident was cognitively intact, understands and was understood. The current Comprehensive Care Plan dated 2/8/19 revealed the resident had a self-care deficit and required limited assist of one for upper body dressing and extensive assist for lower body dressing. The resident required limited assist of one to ambulate to all destinations with a gait belt and rolling walker. She was at high risk for falls and on anticoagulant therapy (medications used to prevent blood from clotting). Bleeding and bruising were to be reported to the nurse. The care plan which included a diagnosis list did not include a T12 compression fracture, osteoporosis (OP-condition where bone strength weakens and is susceptible to fracture) or osteopenia (when bones are weaker than normal). Review of untitled incident reports from 6/10/19 through 7/1/19 revealed the following: a.) Review of an incident report dated 6/10/19 revealed a (unidentified) Licensed Practical Nurse (LPN) reported to the Registered Nurse (RN) #1 Unit Manager (UM) Resident #94 had bruises to the front of both thighs noted during the resident's shower. The right thigh bruise measured 6 (centimeters) cm x 6 cm and the left thigh bruise measured 9 cm x 9 cm. The resident did not know what happened. Written statements included in the investigation revealed; Certified Nurse Aide (CNA) #1 documented, The bruises were reported to (LPN) #2 for almost four weeks. Unit Helper #1 and CNA #5 both documented, I reported the brown bruises on her thighs. CNA #5 documented, I noticed and reported the resident's leg bruises, but I don't know how it happened. In addition, documented on the report, After reviewing the statements and bruises, it is noted that the bruises align with the resident bedside table. Resident has been on Coumadin (anticoagulant) with (PT/ INR prothrombin time/ international normalized ratio) at all ranges. Reported by CNA #1 the bruises were previously noted. There was no statement from the (unidentified) LPN who reported the bruises to RN #1 or from LPN #2 who the bruises were reported to weeks prior. The statements from Unit Helper #1 and CNA #5 did not include when and to whom they reported the bruises. In addition, there was no further investigation into the newly identified information that the bruises had been present for almost four weeks. b.) Review of an untitled incident report dated 7/1/19 at 8:30 AM documented CNA #1 assisted the resident to stand. CNA #1 turned to reach for the oxygen tank while holding onto the gait belt. The resident leaned to the side and slid to the floor, the resident's fall was broken by the gait belt. She did not hit any object on the way down to the floor. It was a gentle slide to the floor. No injuries were observed at the time of the incident. The resident did not walk to the dining room. The plan was for the CNA to be educated on the importance of the positioning of the oxygen tank. Review of the nursing Progress Note dated 7/2/19 revealed the resident had difficulty ambulating and had a change in her mental status. The physician was notified, and the resident was transferred to the emergency room at a local hospital. At 8:35 PM it was documented the resident was admitted to the hospital with pneumonia, urinary tract infection (UTI), acute kidney injury (AKI) and a T12 compression fracture. Review of the radiology diagnostic reports available in the resident's electronic medical record (eMAR) dated 2/19/19 through 7/2/19 revealed there was no documented evidence that the resident had a T12 compression fracture. Review of the MD (medical doctor) Progress Notes dated 3/21/19 through 5/29/19 revealed no documented evidence of a T12 fracture, OP, or osteopenia. Review of the hospital History and Physical dated 7/2/19 documented the resident had a T12 acute fracture from fall. Review of a hospital CT Scan (computed tomography scan) dated 7/2/19 revealed the chest CT was completed because of trauma. The impression included there were mild degenerative changes of the thoracic spine. There was a T12 compression fracture of indeterminate age and clinical correlation was recommended. During an interview on 7/31/19 at 12:00 PM, the RN #1 UM stated she was responsible for completing the incident report. She could not recall who the LPN was that told her about the bruises, and she did not have the LPN write a statement. She did not start a new investigation when she learned the bruises were about four weeks old and she did not know if anyone else had. In addition, the RN #1 UM stated that she was aware of the resident's T12 fracture but was not sure if it was an old or new fracture. During an interview on 7/31/19 at 12:37 AM, the Director of Nurses (DON) stated that every A/I was reviewed by the Administrator and herself. She had no further investigation into the bruising on the resident's legs from 6/10/19 and did not further investigate the bruises once new information was identified. The DON stated, It was my impression the T12 fracture was an old fracture and I don't have an investigation regarding the T12 fracture. Had the resident returned I would've continued to investigate it. The physician didn't review or weigh in on the T12 fracture, because we hadn't yet had a QA (Quality Assurance) Meeting for the month. During an interview on 7/31/19 at 1:00 PM, the Corporate DON stated she would expect there to be an investigation and follow up if statements collected led to other dates of an injury. The expectation was this would be documented in the investigation and any additional follow up that was completed. Additionally, she would expect an investigation to be done if the facility learns that a resident had a fracture and document that investigation and findings. Review of a statement completed by the DON on 7/31/19 and provided to the surveyor on 8/1/19, the DON had the Medical Director review the resident's medical record available on the facilities computer system and on a diagnostic site. The Medical Director then spoke with the hospital radiology department who confirmed that a T12 compression fracture was present on CT scan dated 7/2/19 and on chest x-ray dated 2/15/19. The physician stated the resident had a long history of using steroids and had OP placing her a risk for a compression fracture. During an interview on 8/1/19 at 10:26 AM, the physician confirmed the DON's statement and stated he reviewed the resident's medial record on 7/31/19 and spoke with the radiology department on 7/31/19. He stated the T12 fracture was not new based on his review yesterday. 415.4(b)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during the Standard survey completed on 8/2/19, the facility did not develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care for one (Residents #16) of three residents reviewed for discharge planning. Specifically, the facility did not develop and implement a discharge plan for a resident admitted for short term rehabilitation. The resident expressed her wishes to return to the community. The finding is: The Social Work (SW) Job Description dated April 1, 1998 documented a role of the social worker was to develop discharge plans within 14 days of admission and to document that plan. Additionally, to assist the resident and family in the discharge process. 1. Resident #16 was admitted to the facility on [DATE] and had diagnoses that included colitis, chronic obstructive pulmonary disease (COPD), and a history of falls. The Minimum Data Set (MDS - a resident assessment tool) dated 4/28/19 documented the resident was cognitively intact, was understood and understands. Review of the Baseline Care Plan dated 4/12/19 documented the resident could easily communicate with staff. The initial admission and discharge goals documented the resident was at the facility for rehab (rehabilitation) and the plan was to return to the community. Review of an undated Comprehensive Care Plan (identified as current, by the SW) revealed there was no discharge care plan developed for this resident. A Physical Therapy (PT) Evaluation and Plan dated 4/13/19 documented the resident was admitted for short term rehab and demonstrated excellent rehab potential. The resident required skilled PT services to facilitate functional mobility, promote safety awareness minimizing falls. To facilitate discharge planning to enhance the patient's quality of life by improving ability to safely return to a private residence. An Occupational Therapy (OT) Evaluation & Plan of treatment dated 4/15/19 documented the resident anticipated d/c (discharge) plan was to live at home with support of others. The resident's rehab potential was very good, and she was started on skilled OT services in order to assess safety, independence with self- care tasks in order to enhance the resident's quality of life by improving ability to be able to return to prior level of living. A PT Discharge summary dated [DATE] documented the resident was discharged from program as the resident was able to transfer and ambulate within the facility independently with a rolling walker. An OT Discharge summary dated [DATE] documented the resident was discharged to LTC (long term care) and was independent with dressing and grooming. Mobility was independent with a rolling walker. Review of the interdisciplinary (IDT) Progress Notes dated 4/12/19 through 7/30/19 revealed the resident was alert and able to make her needs known. Independent with ADLs (activities of daily living). The resident displayed behaviors at times of non-compliance with care, had outbursts directed at staff and refused medications. Additional review of the IDT Progress Notes revealed the following: -4/12/19 at 9:14 PM Resident stated she was at the facility for short term rehab. -4/27/19 at 12:46 PM Resident was tearful about landlord taking her cat to a shelter. -6/27/19 at 4:09 PM Resident and physician discussed possible changes of living quarters, resident wants to get her own apartment. -6/4/19 at 11:38 AM Resident upset with her room being changed, resident thought she was going to be going home. -7/8/19 at 1:54 PM Resident displayed verbal and physical aggressive behavior towards staff, when resident was reminded that she lives at the facility. -7/11/19 at 2:15 PM Resident became upset and made inappropriate comments to a unit helper and staff member when they tried to assist her with making her bed. The resident stated, she was capable of making her own bed. -7/20/19 at 12:24 PM Resident can make her needs known, verbally aggressive with her care and makes it difficult to provide care and pass medications. The resident is independent with ADL's, provides her own care and is continent of bowel & bladder. -7/22/19 at 1:03 PM Resident had been washing clothes in her room, the soiled items were removed from her room. Resident became very angry, and staff explained the facility would be cleaning her clothing now. -7/24/19 at 7:11 PM The doctor spoke to the resident about refusing medications (antidepressants), and informed the physician that she was not depressed, but angry for being here and why not be depressed being here. The doctor asked her if she would take something else. At this point the resident became angry and kicked the doctor out. Continued review IDT Progress Notes between 4/12/19 and 7/30/19 revealed there was no documented evidence in the medical record that discharge planning was initiated or evaluated. There were no evidence referrals were made on behalf of the resident. Additionally, there was no evidence a determination was made that it was feasible or would not be feasible to return to the community, and who made that determination and include a rational. Review of a MD 60-day Review Note dated 6/7/19 revealed the resident was independent with most of her ADL's. At this point, I do not think the patient needs a high level of care like provided in a nursing home, however with issues with the placement she is in the nursing home. During an interview on 7/28/19 at 1:53 PM, the resident stated she was independent with everything and I don't even know why I'm here. The resident also stated no one had talked with her about discharge. During an interview on 7/31/19 at 8:37 AM, the SW stated Resident #16 was admitted for short term rehab. She was evicted from her apartment in April and had nowhere to go or support. He stated he had no evidence in the resident's medical record that he had made attempts to find alternate living arrangements or that rereferrals were made. He was not aware a discharge care plan had to be developed for a resident that was deemed to stay long term. He stated that during the MDS assessment he did ask her if she wanted to return to the community and she said no. He stated, We raise our hands a lot when no one else will take these people. We end up finding out the why, the hard way. During intermittent observations between 7/29/18 and 8/1/19 from 7:30 AM until 3:30 PM the resident was observed completing ADL's independently in her room, and on and off the unit. During observed interactions and interviews through survey the resident was well groomed, moved safely and independently and her actions and interactions were appropriate. During an interview on 8/2/19 at 9:02 AM, the Administrator stated that the SW should be proactive with discharge planning and the efforts should be reflected in the resident's medical record. 415.11(d)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 8/2/19, the facility did not ensure that a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good grooming and personal hygiene for one (Resident #18) of two residents reviewed for ADLs. Specifically, Resident #18 had long, ungroomed fingernails with chipped black nail polish. The finding is: The facility policy and procedure titled Nail Cutting Policy dated 4/2019 documented residents at the facility will receive the necessary services to maintain finger nails. Nurses may cut nails at any time needed and certified nurse aides can trim nails of non-diabetic residents. 1. Resident #18 was admitted to the facility on [DATE] and had diagnoses which include multiple sclerosis (MS), cerebral vascular accident (CVA - stroke) and altered mental status. The Minimum Data Set (MDS - a resident assessment tool) dated 5/3/19 documented the resident was severely cognitively impaired, sometimes understands and sometimes understood. The resident required the extensive assistance of one for personal hygiene. Review of the current Comprehensive Care Plan dated 5/23/19 revealed the resident had impaired cognition, self-care deficits, and a communication problem related to aphasia (absence or difficulty with speech). Interventions included staff anticipating the resident's needs and providing extensive assistance with personal hygiene. Review of the [NAME] (guide used by staff to provide care) dated 8/2/19 revealed the resident required extensive assist of one with personal hygiene and is to receive showers twice weekly. Observations on 7/28/19 at 11:08 AM and 7/29/19 at 9:40 AM revealed the resident had long finger nails, one quarter (1/4) of an inch above the tip of all 10 fingers. The edges were squared off and sharp and there was black chipped nail polish on the mid portion of the nails. During an interview and observation on 7/29/19 at 10:52 AM, the resident's daughter stated she had been asking for the resident's nails to be cut for about two months. She used to take care of her mom's nails, but one day her mom moved, and she nipped the tip of one of her pinky fingers and made it bleed. She was educated by a nurse to be careful while cutting her nails. She had been cutting and caring for her mom for years and that was the first time something like that had ever happened. She no longer cuts her mom's nails. I wish I could just visit, without having to complain about her care. During an observation of the resident and interview on 7/29/19 at 11:27 AM, CNA #2 stated the resident's nails were very long and needed to be cut and the polish removed. She had not taken care of this resident for a while and this am noticed her nails need care. She told the nurse, but there were no nail clippers available. During an interview on 8/2/19 at 8:01 AM, the Registered Nurse (RN #1) Unit Manager stated nail care is supposed be completed on shower days or whenever they to be cut. Resident #18 does not refuse care. Nail care concerns have been brought to her in the past by the family. She thought she had put it on the care plan for staff to cut the residents nails after the incident on 5/7/19, but she just educated the daughter. RN #1 further stated It was the responsibility of the staff to be doing nail care if it needed to be done. In addition, there were no nail clippers available on the unit, and she had to go and get some. 415.12(a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview conducted during a complaint investigation (Complaint NY#00241179) during the Standard survey completed on [DATE], the facility did not ensure that each resident received treatment and care based on the comprehensive assessment of the resident that is in accordance with professional standards of practice for one (Resident #94) nine residents reviewed for medications. Specifically, a medication transcription error resulted in a resident receiving the wrong dose of Lasix (diuretic-medication that promotes urine excretion) from [DATE]-[DATE]; there was no assessment or interventions related to the resident's insufficient fluid intake; and the physician did not monitor the resident's electrolytes after an increase in the resident's diuretic. The finding is: Review of a facility policy and procedure (P&P) titled Consults - Outside Facility dated 3/2019 revealed upon residents' return from an outside appointment, the Nurse Manager or designee will follow up with the physician to discuss any new consult recommendations. The nurse or designee will transcribe the order. Before filing the consult for the physician signature, two nurse initials are required to ensure the consult recommendations are noted and carried out. A facility P&P titled Transcription of Orders dated 4/2018 documented it is essential that the transcribing nurse exercise clarity and precision when transcribing a medication order. The nurse must ensure that orders specify the exact dose. A facility P&P titled Medication or Treatment Errors/ Discrepancies/ Occurrences/ Omissions dated 3/2019 documented a significant medication error is one which causes the resident discomfort or jeopardizes his or her health and safety. Significance may be subjective or relative depending on the individual situation and duration. The facility P&P titled Nutrition and Hydration dated 5/2018 documented it is the policy of the facility to monitor those residents who are identified at risk for dehydration and that interventions are established to address these potential issues. The purpose of the policy is to recognize, evaluate and address the needs of every resident and provide a therapeutic diet that considers the resident's clinical condition. Nursing will observe for signs of dehydration which include change in mental status, dry mucous membranes and will monitor fluid consumption and documentation. Medical will monitor lab values and provide medical management with efforts to reduce dehydration risk and occurrence. Residents with the following conditions (but not limited to) will be considered as at risk for dehydration: renal disease, diuretic therapy, use of bulk laxatives, history of dehydration, and severe cardiac compromise. 1. Resident #94 was admitted to the facility on [DATE] and had diagnoses which included chronic kidney disease (CKD), diabetes mellitus (DM), and adult failure to thrive. The Minimum Data Set (MDS - a resident assessment tool) dated [DATE] documented the resident was cognitively intact, understands and was understood. The Comprehensive Care Plan (CCP) dated [DATE] documented the resident had nutritional deficits related to a history of dehydration, congestive heart failure/ edema (swelling), diuretic therapy, CKD, and had a variable intake. CCP goals included a plan for the resident to maintain adequate hydration, moist mucous membranes and improved lab data. Interventions included a minimum of 2000 cc (cubic centimeter) of fluid per day; obtain and monitor lab data as ordered; and RD (Registered Dietician) to evaluate and make diet change recommendations as needed. Additionally, nursing interventions included to give medications as ordered and monitor and report signs and symptoms of acute kidney failure. Review of a Quarterly Nutritional Progress note dated [DATE] and signed by the Registered Dietitian (RD) on [DATE] revealed the resident's minimum fluid needs were 2000 cc/day and the resident was meeting the estimated needs. Labs (laboratory tests) were reviewed and pertinent medications included Furosemide (Lasix - diuretic) and Lactulose (laxative). The resident was having multiple bowel movements daily (formed/soft and loose), was on Senna (used to treat constipation) and recently started on Lactulose for hyperammonemia (elevated ammonia level in the blood). Additionally, the resident was to follow up with the nephrologist for CKD. There were no additional Nutritional Progress Notes or assessments after [DATE]. A physician progress note dated [DATE] documented an assessment and plan to monitor electrolytes carefully related to renal failure. Hepatic encephalopathy (altered level of consciousness as a result of liver failure) with a plan to monitor ammonia levels and continue with Lactulose. A Report of Consultation from the Nephrologist dated [DATE] documented increase Lasix to 40 milligrams (mg) in the morning and 20 mg in the PM (total 60 mg/day). There were no recommendations to routinely monitor blood work (labs). Additional review of the [DATE] Report of Consultation, revealed there was one nurse's signature written on the consult and not two as documented in the facility's P&P. Review of an Order Summary Report dated [DATE] revealed an order dated [DATE] for Furosemide 20 mg, administer 3 tablets (60 mg) (incorrect dose) one time daily in the morning for fluid retention and Lasix 20 mg in the evening for fluid retention. In addition, there was an order for Lactulose 45 ml (milliliters) three times daily (TID) dated [DATE] for increased ammonia levels and Senna 8.6 mg two tablets twice daily (BID) dated [DATE]. Review of the Medication Administration Records (MARs) dated [DATE] through [DATE] revealed the resident was erroneously administered Lasix 60 mg in the morning and 20 mg in the evening (80 mg daily). The resident also received Senna 8.6 mg BID, and Lactulose 45 ml TID. The resident refused the PM dose of Lactulose 17 times in June. An acute visit physician note dated [DATE] documented the resident was having confusion and mood swings, consultations were reviewed and a plan to monitor labs. There were no additional medical provider notes from [DATE] through [DATE]. Review of laboratory data dated [DATE] revealed the following results: - Blood Glucose - 41 (normal 74- 118 mg/dL (milligrams per deciliter) - BUN (blood urea nitrogen - blood test to determine kidney function) - 27.0 (normal 8 - 26) mg/dL - Creatinine (blood test to determine kidney function) -1.35 (normal 0.44-1.0) - Glomerular Filtration Rate (test to determine kidney function) - 38.9 (normal 60-999 ml/min (milliliters per minute) - Sodium - 147 (normal 136 -144) mmol/ L (millimoles/liter) - Potassium 3.2 (3.6-5.1) mmol/L There was no additional laboratory data available from [DATE] through [DATE] to monitor kidney function. Review of fluid intake sheets dated [DATE] through [DATE] revealed the resident did not meet her estimated fluid need of 2000 cc per day. Additional review of fluid intake sheets documented in the computerized documentation system revealed the resident consumed an average of 1500 cc of fluid daily. Review of the Monthly Bowel Movement List dated [DATE] revealed the resident had multiple bowel movements per day. Review of the weekly Nutritional/ Hydration Monitoring Committee Record dated [DATE] through [DATE] revealed the resident was on the list to be reviewed by the team. After [DATE] Resident #94 as no longer on the list to be reviewed. There was no documented evidence after [DATE], the resident's suboptimal fluid intake was addressed by dietary and there were no revisions to the meal plan. Review of nursing Progress Notes dated [DATE] through [DATE] revealed the resident had edema (swelling) of both upper and lower extremities, a significant increase in her diuretic, low and critically low blood sugars with altered mental status, a transfer to the emergency room ([DATE]), increased anxiety, elevated PT/INR's (prothrombin time/international normalized ratio used to determine the clotting tendency of blood), increased phlegm production with an occasional non -productive cough, a Mucinex order (treat coughs and congestion), increase need for staff assist and an incident involving being lowered to the floor. Urinary outputs were consistently monitored. There was no documented evidence a medical provider saw the resident from [DATE] through [DATE]. A nursing Progress Note dated [DATE] documented the resident had altered mental status and was sent to the hospital for evaluation. Review of a hospital emergency room note dated [DATE] revealed the nursing home reported the resident had an altered mental status since yesterday. The patient is somewhat difficult to understand given her significantly dry oral mucous. Lab data revealed a BUN of 100, a Creatine of 2.32, and a GFR of 20.8. Work up is consistent with AKI, pneumonia and urinary tract infection. While in the department the resident's blood pressure dropped into the 80's (normal 120) and was responsive to 1 liter of IV (intravenous) fluid wide open. A hospital History and Physical dated [DATE] documented an Assessment and Plan included metabolic encephalopathy secondary to UTI and pneumonia. IV antibiotics and fluids were started, and prognosis was poor. Diagnoses included Acute Kidney Failure secondary to Dehydration versus upper GI (gastro-intestinal) bleed. Review of a hospital Nephrology Consultation dated [DATE] revealed the patient was seen for acute kidney injury, had a 3-fold increase (3 times) of her serum creatine, and a decrease of her GFR greater than 70 % (percent) and decreased urinary output. During an interview on [DATE] at 8:49 AM, the Registered Diet Technician (DTR) stated she does not always attend morning report and relies on nursing staff to report to the nutritional staff (DTR, RD) important changes with the resident or their medications. She was not aware the resident had an increase in her Lasix. This information would have been important to know due to her history of dehydration and chronic kidney disease. The DTR would have expected labs to be monitored, especially electrolytes if the resident had an increase in her diuretic. The resident also had problems with her ammonia levels and was given Lactulose to increase stooling. Absolutely decreased intake and increased diuretic could cause AKI. The DTR only reviews the intake sheets when a quarterly assessment is to be completed, or if the resident had a significant change. During the interview, the DTR reviewed the fluid intake sheets from [DATE] through [DATE] and stated the resident was not meeting her estimated fluid needs of 2000 cc. Had she been made aware of the changes in her medication, she would have adjusted the resident's meal plan. Not monitoring electrolytes can lead to potential complications like confusion, falling, urinary tract infections (UTI) and dehydration. The facility has a weekly high-risk meeting (nutrition/hydration) where this information could have been passed along; unfortunately, the meetings were often canceled. Resident #94 was not reviewed at the weekly high-risk meetings after the first four weeks of her admission. The DTR stated there were no additional nutritional notes or assessments available. During a telephone interview on [DATE] at 9:26 AM, the RD stated the nursing department should be notifying them (RD, DTR) of changes with the residents and/or medications. She was not aware the resident had an increase in her diuretic dosage. Fluid intakes and labs should have been monitored to ensure the resident was maintaining her hydration status. Meal plans and nutritional interventions could have and should have been implemented. This was potentially avoidable, if her electrolytes had been monitored During an interview on [DATE] at 9:45 AM, the Registered Nurse (RN #1) Unit Manager reviewed the eMAR (electronic medical record) and stated the last time a medical provider saw the resident was on [DATE] and that visit note was not available. The resident was seen on [DATE] by the Nephrologist but that note was also not available in the eMAR. The in house Physician just signed off on the Nephrologist's consult dated [DATE] and the labs dated [DATE], this week. All new orders get reported in morning report and other than in morning report, she did not notify or speak with the nutritional staff about the Lasix increase. RN #1 did not recall if anyone from the nutritional staff was present. Additionally, it was up to the nutritional staff to monitor the resident's fluid intake and the MD (medical doctor) would make the decisions about ordering lab work. During an interview on [DATE] at 10:26 AM, Physician #1 stated it was the Nephrologist's responsibility to make their recommendations clear regarding monitoring lab work. If there were no recommendations, he should have followed up. The physician looked at the eMAR and stated the most recent labs uploaded were from [DATE]. The resident's condition at the time of arrival to the hospital, laboratory data, and decreased fluid intake was discussed with the physician. The physician stated the resident's electrolytes should have been monitored, and it was his responsibility to do this. I should have been more cautious. I knew this resident for a long time. I don't know what the h--- happened. This situation could have been avoided if I would have seen her. During an interview on [DATE] at 11:08 AM, Certified Nurse Aide #1 stated on [DATE] the resident complained of generally not feeling well. When she assisted the resident to a standing position the resident complained of being dizzy, that's when she had to lower the resident to the floor. During an interview on [DATE] at 11:29 AM, the Director of Nursing (DON) stated the nutritional staff should have been made aware of the resident's increase in Lasix. All new orders do get reviewed in morning report, but verbal communication should be occurring. They do not keep attendance at the morning meetings. There are weekly high-risk nutritional meetings, but they do get changed or canceled at times. The Unit Managers are responsible for overseeing the unit and the residents' care. Intakes are recorded by multiple staff assigned to the dining room. Both nursing and nutritional staff should be monitoring the fluid intake records. She would expect nursing staff to be monitoring the resident, evaluating and relaying all the pieces of information to the physician accurately, including fluid intakes and the need for labs. During an interview on [DATE] at 2:35 PM, the Director of Nursing (DON) read the Nephrology consult and stated the recommendation was for Lasix 40 mg in the AM and 20 mg in the PM. The nurse should have clarified the order with the Nephrologist's office, and she would consider this a significant medication error. At 2:45 PM, the DON approached the surveyor and stated the order was signed by the Nurse Practitioner (NP) so she would consider this a transcription error, not a medication error. During a telephone interview on [DATE] at 2:25 PM, a representative from the Nephrologist's office, stated the recommendation made on [DATE] was for Lasix 40 mg in the morning and 20 mg in the evening. During an interview on [DATE] at 2:28 PM, the Registered Nurse (RN #1) Unit Manager stated she reviewed the Nephrology consult dated [DATE]; she contacted the on-call provider and transcribed the order. RN #1 reviewed the Nephrology consult and stated the recommendation was for Lasix 60 mg in the morning and 20 mg in the evening. The RN Unit Manager did not contact the Nephrologist's office for clarification regarding the dose. During a telephone interview on [DATE] at 8:24 AM, the Nurse Practitioner (NP) stated she had not been in the facility for the past month and a half. However, she was on the on-call list and would get calls if something needed to be addressed. There had been some changes with the providers' schedules. The NP was not that the orders for Lasix that she signed were transcribed incorrectly. Orders are usually validated when a consult is reviewed and signed off, but she had not reviewed the Nephrologist's consult. It was the responsibility of the nurse to relay the information to the provider accurately and to put the orders into the computer accurately. It was not her intention to change the recommendations made by the Nephrologist on [DATE]. Orders were given based on the information provided to her by the nurse. The NP stated, monitoring laboratory data was important for this resident. This is very unfortunate; this resident was known to us and we should have made sure her levels were being monitored, especially with her CKD. We have to make some changes and make sure things are being double checked. During an interview on [DATE] at 10:50 AM, Physician #1 stated he reviewed and signed the Nephrologist's consult this week. The Physician was unaware the order for Lasix was transcribed incorrectly and the resident received an additional 20 mg of Lasix daily from [DATE] through her transfer to the hospital on [DATE]. He stated this would be a significant error, particularly for this resident. Additionally, he stated that he went to the hospital last night to further review the hospital record in detail. He stated after IV fluids her kidney function did improve and this was an avoidable situation. The resident expired on [DATE]. 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a complaint investigation (Complaint NY#00241179) during the Standard survey completed on 8/2/19, the facility did not ensure that during physician visits the physician must review the resident's total program of care, including medications and treatments and sign and date all orders with the exception of influenza and pneumococcal vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications for four (Residents #63, 68, 85, 94) of 24 residents reviewed for physician services. Specifically, the issue involved the physician not signing and dating orders at each visit. The findings are but not limited to: 1. Resident #68 was admitted to the facility 8/21/18 with diagnoses which include depression, hyperlipidemia (elevated fat levels in the blood), and diabetes mellitus (DM). The Minimum Data Set (MDS - a resident assessment tool) dated 6/21/19 documented the resident was cognitively intact. Review of the electronic Physician Order Details dated 5/31/19 through 7/23/19 revealed the following orders were written and signed by MD (medical doctor) #2 on 8/1/19 at 12:27 PM: Order date: 5/31/19. CBC (complete blood count) one time only for 5 days. Abilify (antipsychotic medication) 10 mg (milligrams) give 10 mg by mouth at bedtime for depression. Isosorbide Mononitrate (medication used to prevent chest pain) ER (extended release) Tablet 30mg. Give 0.5 tablet by mouth one time a day for angina (chest pain caused by reduced blood flow to the heart). 2. Resident #63 was admitted to the facility on [DATE] with diagnoses which include chronic obstructive pulmonary disease (COPD), heart failure, and anemia. The MDS dated [DATE] documented the resident was cognitively intact. Review of the electronic Physician Order Details dated 5/17/19 revealed the following order was written and signed by MD #2 on 8/1/19 at 12:23 PM: -Order date: 5/17/19. Clarithromycin (antibiotic) tablet 500 mg. Give 1 tablet by mouth two times a day for infection for 7 days. Discontinue: 5/17/19. Discontinue date/ Reason: Sputum culture negative. 3. Resident #85 was admitted to the facility on [DATE] with diagnoses which include dementia, chronic pain syndrome and chronic kidney disease stage 3. The MDS dated [DATE] documented the resident was severely cognitively impaired. Review of the electronic Physician Order Details dated 7/19/19 revealed the following orders were written and signed by MD #2 on 8/1/19 at 12:19 PM. -Order date: 7/191/9. Doxycycline Monohydrate Capsule (antibiotic) 100 mg give two times a day by mouth for a boil for 10 days. During an interview on 8/1/19 at 8:38 AM MD #2 stated, I've only been here 5 or 6 times since I started working here in April or May. I haven't signed any of the electronic orders since I've been here. I lost my username and password for the computer system. During an interview on 8/2/19 at 10:35 AM, the Administrator stated, I've personally given MD #2 re-access to the medical record at least 2 times since he was originally given access to the system. In addition, the Administrator stated she was not aware MD #2 had not been signing the physician orders in the electronic medical record. 415.15(b)(2)(iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Standard survey completed on 8/2/19, the facility did not ensure that each resident's drug regime is free from unnecessary drugs for one (Resident #64) of six residents reviewed for unnecessary medications. Specifically, a resident remained on antibiotics without adequate indications for its use. The finding is: Review of the facility's policy titled Antibiotic Stewardship Program dated 9/2017 revealed the main goal is to optimize the treatment of infections while reducing potential adverse effects. The Infection Preventionist (IP) will utilize several strategies such as tracking antibiotic use, monitoring adherence to standards and will gather and organize data regarding antibiotic use in the facility, including resistance, and monitor the number of residents on antibiotics that do not meet the criteria for active infection. In addition, the IP will collect and review data whether the appropriate tests were obtained prior to ordering antibiotics, and whether the antibiotic was changed during treatment. In addition, the IP will report findings to facility staff assuring appropriate antibiotic therapy is utilized, and unnecessary antibiotic use is decreased. 1. Resident #64 was admitted to the facility on [DATE] after an acute hospital stay and had diagnoses of non-displaced neck fracture (status post-surgery), hypertension (HTN - high blood pressure) and chronic kidney disease (CKD). The Minimum Data Set (MDS - a resident assessment tool) dated 6/22/19 documented the resident was cognitively intact and was understood and understands. Review of the current Comprehensive Care Plan dated 7/2/19 documented the resident was incontinent of urine and had a history of urinary tract infections (UTI). Interventions included to report any changes in urine such as increased frequency, odor, and color. The plan did not reflect a current UTI or antibiotic use. Review of the interdisciplinary (IDT) Progress Notes dated 6/15/19 to 6/26/19 revealed the following; - 6/27/19 at 11:19 AM the resident complained of being weak and not feeling well. Also complained of some burning with urination, when asked. The resident's temperature was 99.3 (normal 97.7-99.5 °F). The physician was made aware, new orders were obtained for a U/A (urinalysis), C&S (culture and sensitivity) and to start Bactrim DS (double strength antibiotic). - 6/28/19 at 1:21 PM and 6/29/19 at 3:14 PM the resident denied any pain with urination. - 6/30/19 at 2:47 PM antibiotic continues for UTI, however per lab results the resident does not have a UTI. Urine is yellow and without odor and resident continues to deny pain or discomfort when voiding. Return call from physician is pending. Review of the Order Summary Report (Physician's Orders) revealed an order dated 6/27/19 for Bactrim DS BID (twice daily) for a possible UTI for 10 days. Review of the Medication Administration Record (MAR) revealed the resident received Bactrim DS from 6/27/19 through 7/1/19. Continued review of IDT Progress Notes from 7/1/19 to 7/15/19 revealed the following; - 7/16/19 at 5:45 PM the resident's temperature was 101.6. Resident with urinary issues such as some burning. The resident just got over a UTI. The MD (medical doctor) was made aware and recommenced a U/A and C&S. New orders were given for Ceftin (antibiotic) BID for 10 days. - 7/20 /19 at 1:21 PM Ceftin continues despite results of U/A and C&S still pending. - 7/21/19 at 12:13 PM Resident denies any discomfort with voiding results of U/A and C&S pending. Review of the Order Summary Report revealed on 7/18/19 Ceftin (antibiotic) 500 milligrams (mg) was ordered for a possible UTI for 10 days Review of the Medication Administration Record (MAR) revealed the resident received the Ceftin from 7/18/19 to 7/24/19. An IDT Progress Notes dated 7/24/19 at 1:06 PM revealed the U/A and C&S results were obtained and noted positive for Gram-Bacilli (bacteria). At 4:47 PM the physician was advised, with a new order to d/c (discontinue) Ceftin and start Cipro (antibiotic) 500 mg BID for 10 days. Review of the specimen inquire report (urine culture results) dated 7/19/19 revealed Ceftin was resistant to the organism (Gram negative Bacilli). Review of a Physician's Orders revealed an order dated 7/24/19 to stop Ceftin and start Cipro 500 mg BID for 10 days. Review of the MAR dated 7/27/19 through 7/30/19 revealed the resident was administered Cipro as ordered. During an interview on 7/30/19 at 1:14 PM, Registered Nurse (RN) #1 Unit Manager (UM) stated urine cultures generally get reported to the facility within 3 days via fax. She contacted the lab on 7/23/19 to obtain the urine test results as they had not received the results, because the fax machine was out of toner. An alternate number was provided to the lab on 7/23/19 but the results never came through. She followed up again on 7/24/19 and notified the doctor. During a telephone interview on 7/30/19 at 1:50 PM, Representative #1 from the lab stated the facility was made aware of the culture results on 7/22/19 via fax. During an interview on 8/1/19 at 8:00 AM, the Assistant Director of Nursing (ADON)/IP stated, a single episode of burning upon urination was not a sufficient reason to start a resident on an antibiotic and that an increase in temperature may have been a result of something else. The resident should have been monitored pending the culture results prior to starting the resident on an antibiotic. The resident did not meet the facilities criteria for antibiotic use. 415.12(l)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 8/2/19, the facility did not ensure each resident's drug regimen is free from unnecessary drugs, and residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. An unnecessary drug includes drugs used without adequate indications for its use and without adequate monitoring for three (Residents #55, 60, 68) of five residents reviewed for unnecessary antipsychotic medications. Specifically, there was a lack of adequate indication for use (#68), lack of the implementation of non-pharmacological interventions (#55, 60), and lack of behavioral documentation to support the use prior to the initiation of antipsychotic medication (#55, 68). The findings are: The facility policy and procedure titled Psychotropic Medication Use/ Non-Pharmacological Interventions dated 10/2017 revealed residents who have not used psychotropic drugs previously will not be given these medications unless there is a documented diagnosis of a specific condition in the clinical record, and that the ordered psychotropic medication is necessary to treat the specific condition. Psychotropic medication will only be used in conjunction with behavior management interventions (non-pharmacological interventions) and will be directed specifically toward the reduction of and eventual elimination of the behaviors for which the medications is used. 1. Resident #68 was admitted to the facility 8/21/18 with diagnoses which include depression, hyperlipidemia (elevated fat levels in the blood), and diabetes mellitus (DM). The Minimum Data Set (MDS - a resident assessment tool) dated 6/21/19 documented the resident was cognitively intact, received antidepressant medication for seven days, and received antipsychotic medication for seven days. In addition, the MDS documented the resident had no mood and/or behaviors. Review of a Physician Note dated 5/31/19 included the following: -Subjective (refers to observations that are verbally expressed by the patient, such as information about symptoms) - Psych (psychiatric): Denies psychiatric symptoms. -Objective (refers to the information the healthcare provider observes or measures from the patient's current presentation) - Psych: Mood/Affect (observable expression of emotion): Patient's attitude is cooperative and appropriate. Mood is normal. Patient's affect is appropriate to mood. -Cognition: Judgement and insight are grossly intact. Review of an interdisciplinary (IDT) Progress Note written by Registered Nurse (RN) #4 Unit Manager (UM) dated 5/31/19 at 3:58 PM revealed the Physician saw the resident today for 60-day review. Resident c/o (complained of) some depression. New order received for Abilify (aripiprazole - antipsychotic medication) 10 mg (milligrams) at HS (hour of sleep). Review of electronic Physician Order Details included the following orders: -Abilify tablet 10 mg. Give 10 mg by mouth at HS for depression. Start Date 6/1/19. End date 7/19/19. -Abilify tablet 10 mg. Give 1 tablet by mouth one time a day for antipsychotic. Review of the June 2019 Medication Administration Record (MARs) revealed Abilify 10 mg was administered every day in June with the exception of 6/8/19, 6/9/19, and 6/23/19. Review of the July 2019 MARs revealed Abilify 10 mg was administered 7/1/19 through 7/18/19, and 7/24/19 through 7/30/19. The resident was hospitalized [DATE] through 7/23/19. Review of IDT Progress Notes dated 5/1/19 through 5/30/19 revealed no documented behaviors. Intermittent observations of the resident on 7/28/19, 7/29/19, and 7/30/19 between 9:00 AM and 3:00 PM revealed the resident was pleasant and cooperative with staff and residents and participated in various activities. In addition, no aggressive behaviors were witnessed. During an interview on 7/31/19 at 9:09 AM, RN #4 UM stated the resident complained of some depression to the Physician on 5/31/19 and the Physician ordered the antipsychotic medication. During an interview on 8/1/19 at 8:38 AM, the Attending Physician stated the resident had depression that was not controlled and added an antipsychotic medication as an adjunct treatment for depression. During an interview on 8/1/19 at 11:49 AM, the Medical Director stated an antipsychotic medication was not appropriate for the resident as there was neither psychosis or bipolar issues. 2. Resident #60 was admitted to the facility 11/23/16 with diagnoses which include dementia, diabetes mellitus (DM), and hypertension (HTN - high blood pressure). The MDS dated [DATE] documented the resident was moderately cognitively impaired, was understood, understands, and received antipsychotic medication for seven days. Review of electronic Physician Order Details of current, discontinued, and completed antipsychotic medication included an order for Risperdal tablet 1 mg (Risperidone). Give 1 mg by mouth one time a day for mood. Start date 10/1/2018. End date 1/2/2019. Review of IDT Progress Notes dated 9/25/18 through 10/1/18 included the following: -9/26/18 at 5:54 PM. Resident stole other resident's candy from room. [NAME] was removed from dish that Resident #1 was taking to her room. Resident swore, threatened to punch staff. Resident #1 was taken outside for cigarette by supervisor and then went to Bingo. Resident has kept behavior up even at dinner - taking other resident's fluid and food. Before 8:00 PM resident was caught in Resident #2's room - Resident #2 was screaming at Resident #1 and Resident #1 had her fist clenched stating she was going to punch her. When the residents were separated, she said she could go anywhere she wants. -9/30/18 at 11:48 AM. Resident observed coming out of other resident's room with a handful of hard candy. Eventually surrendered candy to CNA (Certified Nurse Aide). Denied taking it. Attempted to reach into male resident shirt pocket for candy and resident placed hand over pocket and asked her not to do that. Resident then started cursing and calling male resident names. Resident redirected verbally from male resident area and went to room. -9/30/18 at 5:38 PM. Resident continues to go in other resident's rooms and taking things out of there, denies it and then starts yelling. -9/30/18 at 9:38 PM. Resident attempted to hit another resident but missed. She then turned around and hit the LPN (Licensed Practical Nurse) in the back multiple times. Resident states she did not hit anybody, there were multiple witnesses. Resident then went to watch TV in the hall. Resident states she will not hit anybody again. She did apologize to the nurse. No further incident reported. No further behaviors. -10/1/18 at 3:29PM. Spoke with Medical Director and NO (new order) for Risperdal 1 mg daily. Review of the Comprehensive Care Plan (CCP) included the following: Focus: The resident has a behavior problem r/t (related to) repetitive behavior, can antagonize other residents, displays manipulative behavior, can be verbally/ physically aggressive, and tends not to provide factual information. The resident can also be resistive to care at times. Date initiated: 6/20/17. Revision on: 11/7/18. Goal: The resident will have fewer episodes of repetitive behavior, antagonizing others by review date. Date initiated: 6/20/17. Revision on: 7/29/19. Interventions/Tasks: Anticipate and meet the resident's needs. Date initiated: 6/20/17; Attempt to determine triggers that caused behavior. Date initiated: 6/20/17; Engage in activities PRN (as needed). Date initiated: 6/20/17; Explain all procedures to the resident before starting and allow time for the resident to adjust to changes. Date initiated: 6/20/17; Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Date initiated: 9/4/17; Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Date initiated: 6/20/17; Psychological consult and follow up as indicated. Date initiated: 9/4/17. Revision on: 5/14/19. During an interview on 7/31/19 at 8:40 AM, RN) #4 UM stated, I don't see it (non-pharmacological interventions) on the care plan, it's mostly just redirection that we use, nothing specific. During an interview on 8/2/19 at 8:19 AM, the RN Director of Nursing (DON) stated, I expect nursing staff to provide non-pharmacological interventions such as distraction or one on one. I would expect the interventions to be individualized to that resident. Interventions should be revised prior to the initiation of an antipsychotic medication. 3. Resident #55 was admitted to the facility on [DATE] with diagnoses which include depression, anxiety, and mood disorder. The MDS dated [DATE] documented the resident was cognitively intact, understood, understands, and received antipsychotic medication for seven days. Review of electronic Physician Order Details revealed an order for Zyprexa (Olanzapine - antipsychotic medication) 5 mg by mouth at bedtime. Start date: 2/8/19. End date: 2/20/19. Review of IDT Progress Notes dated 1/24/19 through 2/8/19 included the following: -2/1/19 at 2:58 PM. Resident was downstairs attempting to go out the side door. Resident did not get out of facility. She was very upset and talking about things that did make sense. She was downstairs one on one for approximately 30 minutes with staff attempting to get resident upstairs, eventually were successful in getting resident back to the unit. MD (medical doctor) was notified and new order received for U/A (urinalysis), C&S (culture and sensitivity). -2/1/19 at 5:17 PM. Resident refusing to eat, sitting on the 2 East nurse's unit by the elevator, until 7:00 PM. Angry and yelling thinking her daughter die (sic) but it was her sister that had actually passed away. Called daughter but resident refused to get on the phone. Yelling you're a liar. My daughter is gone. Stop lying. At 7:00 PM packed her bag and waited to be picked up, reassurance and 1:1 without effect. Resident continues to sit on 2 East unit. -2/3/19 at 3:16 PM. Patient refusing meds (medications) despite much encouragement. States we are filling her with poison, and she is not taking it anymore. Continue to walk to elevators asking people to help her leave by letting her on. At this time in activity watching puppy bowl. -2/3/19 at 5:29 PM. Patient wandering hallway asking people to let her on elevator sitting in middle hallway. Urine results with no abnormal bacteria. -2/6/19 at 5:20 PM. Patient refusing to have BP (blood pressure) checked. Laying naked in room. Refused 4:00 PM meds, stated it was poison. -2/7/19 at 1:45 PM. Resident has had periods of paranoia this shift. Review of the CCP included the following: Focus: The resident has depression, anxiety, and exhibits symptoms of paranoia, delusions, and hallucinations. Date initiated: 8/13/18. Revision on: 7/4/19. Goal: The resident will exhibit indicators of depression, anxiety or sad mood less than daily by review date. Date initiated: 8/13/18. Revision on: 4/3/19. Interventions/ Tasks: Administer medications as ordered. Monitor/ document for side effects and effectiveness. Date initiated 8/13/18. Revision on 5/28/19; Monitor/ document/ report PRN any s/sx of depression, including hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing negative statements, repetitive anxious or health related complaints, tearfulness. Date initiated: 8/13/18; Pharmacy review monthly or per protocol. Date initiated: 8/13/18. During an interview on 8/1/19 at 11:14 AM, the Social Worker (SW) stated, Her (Resident # 55) sister passed away and she went off the deep end. She was exit seeking and thought her daughter had died. Further review of the CCP revealed no focus, goal, or intervention/ tasks related to the resident's reaction to the death of her sister. During an interview on 8/2/19 at 8:19 AM, the DON stated, I expect nursing staff to provide non-pharmacological interventions such as distraction or one on one. I would expect the interventions to be individualized to that resident. Interventions should be revised prior to the initiation of an antipsychotic medication. 415.12 (1)(2)(i)

Based on observation, record review and interview during the Standard survey completed on 8/2/19, the facility did not maintain all essential mechanical, electrical and patient care equipment in safe operating condition. Specifically, the oven and stove top were not functioning properly and the palate and plate warmer was not working. The finding is: During an observation of the lunch meal preparation on 7/31/19 at 11:48 AM the tuna casserole was placed back into the oven two additional times to reach an appropriate temperature. During an interview on 7/31/19 at 12:02 PM, the Food Service Director (FSD) stated the oven and the stove top were only half working and had reported the concerns. Review of the Food Committee Meeting minutes dated 2/20/19 revealed residents were informed new equipment was coming to improve the accuracy and the quality of the food such as a new steamer and currently all food was being cooked in a single oven which was not big enough. The 4/24/19 meeting minutes documented the residents voiced concerns regarding dietary needing more staff. During the 5/22/19 meeting the residents were informed the new equipment was coming soon and at the 6/19/19 the residents voiced concerns that breakfast was cold, and documented the facility was still waiting on new equipment. During an interview on 8/1/19 at 8:19 AM, the FSD stated he informed the Administrator the oven was only half working in March, the palate and plate warmer was not working at all and the flat top stove was only half working in April. Maintenance looked at the oven and stove top sometime in March, but he was informed it was too old and they could not fix them. A kitchen company came into repair the oven and stove top, the facility was informed they were not able to repair them. A new oven and stove top would need to be purchased. The FSD provided three estimates for an oven and stove top to the administrator, and believed the estimates were given to corporate. The FSD also stated a corporate purchaser was out twice sometime in March and April to assess the kitchen equipment but doesn't know if the equipment was ordered. During an interview on 8/2/19 at 9:28 AM, the Administrator stated she was not aware a plate warmer was needed. She did not recall when she was informed the oven was not working properly and she was informed the stove top was not working properly in the beginning of July. During a telephone interview on 8/2/19 at 10:04 AM, a gentleman (who described his position to over-see contracts/ venders for the facility) stated he had been out to the facility to assess the kitchen needs and was working with the vendors and construction company for the kitchen equipment. A new oven and stove top are ordered and are to be installed in August 2019. Additionally, at this time a plate warmer had not been ordered. 415.29(b)

Based on observation, interview and record review conducted during the Standard survey completed on 8/2/19, the facility did not ensure sufficient staff with the appropriate competencies and skill sets to carry out the necessary functions to safely and effectively carry out the functions of the food and nutrition service. Specifically, a dietary aide was acting as a cook without sufficient training, and the facility did not ensure sufficient support personnel resulting in extended meal wait times, use of disposable products. In addition, menus not being followed, food not palatable and temperatures not within appetizing temperatures. The findings are: Refer to: F 803 Menus Meet Resident Needs/ Prep in Advanced and Followed - Scope and Severity (S/S) = E Refer to: F 804 Nutritive Value/Appearance, Palatable/ Preferred Temperature - S/S = E Review of a facility policy entitled Staffing - Dietary dated 9/2017 documented it is the facility's policy to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service taking into consideration resident assessments, individual plans and care and the number, acuity and diagnosis of the facility's resident population. Sufficient support personnel means having enough dietary and food and nutrition staff to safely carry out all of the functions of the food and nutrition services. The Food Serviced Director (FSD) must ensure the following: Determine if there are sufficient support personnel to safely and effectively carry out the meal preparation and other food and nutrition services; ensure that the residents needs and preferences are met and food is palatable, attractive, served at the proper temperatures and at appropriate times; and sufficient staff to prepare and serve meals in a timely manner. Review of the Job Description for Dietary [NAME] dated April 1,1998 documented, responsible for preparation of foods for residents and staff. Responsible for appropriate quantities of food prepared to meet menu and special diet specifications with consideration for portion control. The essential position functions demonstrates knowledge, skills, and techniques necessary to prepare meals for residents with the following needs: regular and therapeutic diets along with consistency modifications; monitors tray line at meal time to ensure that proper portion control standards, dietary restrictions and dietary supplementation are being adhered to; prepares food to coincide with meal serving hours so that excellence, quantity, temperature and appearance of food is preserved; accounts for proper portion control to ensure adequate nutritional intake; and qualifications include - must have some formal education or on-the-job training in food preparation. Review of the facility's Emergency/ Disaster Plan undated and signed by the Administrator revealed there was no documented information of emergency staffing plans for the kitchen. a.) During an interview on 7/28/19 at 9:45 AM Dietary Aide #2 stated she was a dietary aide but was filling in as a cook today. The cook called in and the other cooks and the Food Service Director (FSD) were not available. She stated yesterday (7/27/19) at breakfast was the first time she cooked a meal in the facility and the FSD (Food Service Director) had come in to teach her how to cook lunch. She stated she did not have any training or experience to be a cook. She was cooking again today because the residents need to eat and there was no one else available. During an observations and interviews in the kitchen on 7/28/19 at 11:15 AM revealed soup and mashed potatoes were on the stove top boiling. Dietary Aide #2 (acting cook) was stirring boiling mashed potatoes without safety gloves on and burned her finger from boiling/ spurting mashed potatoes. At 11:46 AM, Dietary Aid #2 was attempting to puree chicken then stopped and left the kitchen at 11:48 AM to have her burned finger assessed. While Dietary Aid #2 was out of the kitchen a hazy cloud of smoke and a burning odor filled the kitchen. Dietary Aid #1 was standing in the kitchen and stated she recently started working at the facility about two weeks ago; and did not know what to do or who to call. Dietary Aide #1 also stated the tray line should have started at 11:45 AM. At 11:51 AM, Dietary Aid #2 returned to kitchen, took the cooked chicken breasts out of the oven and stated the chicken was burnt. She further stated she did not know what to do or what to prepare for the resident's meals, as the chicken was not edible. Surveyor intervened and requested the dietary staff to find the Administrator for guidance. During continued observation of the kitchen at 11:58 AM, the Administrator, DON (Director of Nursing), Assistant DON (ADON), and Registered Nurse (RN) #4 put on hair nets, gloves and started preparing sandwiches for lunch in place of the chicken breast. During an interview on 7/28/19 at 12:23 PM, Dietary Aide #3 stated he had only been employed at the facility for there for a couple of weeks and was still learning. Normally there were four employees in the kitchen, but the cook had called off. He was not sure who the supervisor was, since there were only dietary aides here today. During further observation on 7/28/19 at 12:26 PM, Dietary Aide #2 directed the ADON to start tray line and took ladles out of the drawer and informed ADON which ladle goes into which food product on the tray line and ADON placed the ladles in the food products. b.) During a dining observation of the lunch meal on 7/28/19 at 12:09 PM there were 56 residents in the main dining room waiting to be served. During an interview on 7/28/19 at 12:50 PM, Resident H stated, the facility has had a lot of issues on the weekends and the meals are served late. During a group meeting on 7/29/10 at 10:04 AM, Resident G stated she stopped coming to the dining room because the wait times were so long. Continued dining observations and interviews on 7/28/19 at 12:50 PM revealed the meal carts were being prepared, loaded and delivered to the units. At approximately 12:53 PM the lunch meals began to be served to the residents in the main dining room. At 1:04 PM, certified nurse aide (CNA) #3 stated, we are usually all done with lunch by this time and people are being laid back down. The last lunch meal was served in the main dining room at 1:20 PM. c.) During continued dining an observation of the lunch meal on 7/28/19 at 12:23 PM drinks were poured and served plastic disposable glasses; and salads were served in Styrofoam bowls. During a group meeting on 7/29/10 at 10:04 AM, Resident G stated she doesn't mind eating on picnic wear now and then but it's not a picnic every day. During interviews on 7/31/19 at 12:52 PM, Resident E and F complained they are served salad in Styrofoam bowls often and they don't like it. d.) During a dinner meal dining observation on 7/28/19 revealed the dinner meal carts were delivered to the 2 East and 2 [NAME] units at 6:20 PM. At 6:45 PM the last meal was served in the main dining room. During an interview on 7/28/19 at 7:18 PM, [NAME] #2 stated there are supposed to have four employees in the kitchen but were frequently short staff. One person is the cook, one dietary aide pouring coffee, preparing bread and desserts; a second dietary aide preparing nourishments and a third dietary aid pouring drinks, but we are short a lot. During an interview on 7/28/19 at 5:58 PM, the FSD stated he was aware the cook called in yesterday (7/27/19) and this morning. Dietary Aid #2 cooked yesterday's lunch meal with his oversight. He was aware Dietary Aide #2 cooked yesterday and this morning's breakfast without any oversight. He stated he was not able to get to the facility until mid-afternoon today and was aware the other cooks were not able to come in. He stated, if a cook calls in then the other two cooks are called as well as he and there is not usually a problem getting a cook, but no one was able to come in today. He stated Dietary Aid #2 wants to become a cook and was willing to cook today. He stated his job is to make sure the staff are knowledgeable. During an additional interview on 7/31/19 at 10:44 AM stated a cook usually receives 7 days of training, one day is not enough. During an interview on 7/31/19 at 10:58 AM, the Diet Technician stated there used to be one cook and three to four dietary aids to prepare meals, but the staffing has been cut to one cook and two dietary aids and it makes it difficult to get everything done especially when the food delivery truck arrives on Tuesdays and Fridays. During an interview on 7/31/19 at 11:36 AM, the Registered Dietician stated the kitchen should be staffed with a cook and minimum of three dietary aids, but staffing has been decreased since she started and now fully staff is considered a cook and two dietary aides, and it is difficult to get everything done timely. Additionally, one meal of oversight training was not enough training to be a cook. During an interview on 7/31/19 at 1:15 PM, [NAME] #1 stated a cook generally gets seven days of orientation/ training in the kitchen. At 1:16 PM, [NAME] #3 stated Dietary Aid #2 should have had more than one day of oversight before trying to cook alone. During an interview on 8/1/19 at 8:19 AM, the FSD stated they are frequently short staffed, because they are only allowed to staff one cook and two dietary aids for day shift and evening shift. If one person calls off there isn't enough staff to serve the residents timely and we need to use disposable dish products. Disposable products were to be used only in an emergency because it was a dignity issue for the residents. There isn't enough dietary staff, so disposable products are used when needed; which was more often than should be. During an interview on 8/2/19 at 9:13 AM, the Director of Nursing (DON) stated she believed the new owners decreased the number of employees in the kitchen. There was a high turn-over rate of staffing in the dietary department. The FSD works more as a line worker than a director because of short staffing, which all contribute to the issues in the kitchen. Dietary #2 should not have been cooking, she wasn't ready or capable. In addition, she stated she believed the facility had an Emergency Meal Plan, but they didn't use it and just started making sandwiches. During an interview on 8/2/19 at 9:28 AM, the Administrator stated she would expect to have been notified on Saturday 7/27/19 that the cook called off and earlier then 9:30 AM on 7/28/19 that the cook called off. She was aware the other cooks and the FSD were not able to come in. She (herself) should have called a sister facility for a cook. The expectation was for the kitchen to have a cook and the FSD overseeing and filling in as needed. Kitchen staffing includes was one cook and two dietary aides on days and evenings with the FSD overseeing. If the staffing was decreased in the past this may be a contributing factor to the issues, as well as staff call offs would cause production issues and untimely meals. Typically they were to only use disposable products for meals in an emergency, such as power outages, natural disaster and was aware disposable products were being used on an as needed basis related to dietary staff shortages. She would expect a cook to receive at least a week of training, not just one shift. Dietary Aid #2 should not have been left alone to cook the meals; she doesn't have any qualifications to cook at this time and had not had the proper training. In addition, she stated they should have followed the Emergency Plan for Meals and doesn't know if there is an Emergency Staffing Plan for the kitchen. 415.14 (b)(1)(2)

Based on observation, interview and record review conducted during the Standard survey completed on 8/2/19, the facility did not follow the prepared menus on 7/28/19 and did meet the nutritional needs of each resident in accordance with established national guide lines for two (lunch and supper) of two meals observed. Specifically, Residents A, B, C, D were not served vegetables, there were no dinner rolls provided, and the chicken with cranberry onions was not served to residents on a regular house diet that requested the chicken. In addition, on 7/28/19 at the supper meal all residents who received goulash did not receive Italian bread as planned received half of the planned portion. The findings are: Review of a Dining Manager- Menu Diets document dated fall/winter 2018 - 19 revealed the following menu item with the recommended portion size: Day 1 - Sunday: Lunch: - cranberry onion chicken - mechanical and pureed #8 dip (4 ounce (oz) serving) - dinner roll/ margarine - mechanical soft, dinner roll - pureed - #20 (2 oz) - broccoli pureed - #12 dip (3 oz serving) - party potatoes - alternate of BBQ brisket. Supper: - Goulash - regular (8 oz spoodle), mechanical soft (8 oz spoodle (a spoon that is a strainer as well), pureed - 2 #8 dip ((2) - 4 oz serving) - Italian bread / margarine - mechanical soft - 1 slice, pureed - #20 (2 oz) Review of the facility Dishers identification book identified the following: - #20 Yellow scoop = 1 5/8 once (oz) serving - #12 [NAME] scoop = 2 2/3 oz serving - #8 Gray scoop = 4 oz serving During an interview on 7/28/19 at 9:45 AM, Dietary Aide #2 stated she was a dietary aide but was filling in as a cook today (7/28/19), because the cook had called in. Yesterday was the first time she cooked a meal in the facility. Additionally, she stated that she did not have any training or experience to be a cook. During an interview on 7/28/19 at 11:31 AM, Resident J stated they often run out of food so you can't get what you want. During an interview on 7/28/19 at 11:35 AM, Resident E stated, sometimes all there is to eat is peanut butter and jelly sandwiches, because they run out of food. During an observation on 7/28/19 at 11:51 AM, Dietary Aide #2 (acting as the cook) was observed to pull a large tray of chicken breasts out of the oven, and stated the chicken was burnt, dried out and could not be served as it was inedible. During an observation on 7/28/19 at 12:09 PM the RN and the nursing staff were observed in the main dining room going from table to table, taking meal requests from the residents and offering the choice cranberry chicken or a pork riblet. During an interview on 7/28/19 at 12:54 PM, Registered Nurse (RN) #2 and Certified Nursing Assistant (CNA) #3 stated they did not know that the menu had changed, and they had asked the residents their preferences based on the items listed on the menu; chicken or pork riblet. Continued observation on 7/28/19 at 1:17 PM residents A, B, C & D received a yellow scoop of pureed chicken; identified as a 1 5/8 once (oz) scoop and no pureed vegetable was offered. Additionally, all residents were not severed a dinner roll as planned. During an interview on 7/28/19 at 1:28 PM, Dietary Aide #2 stated she did not know how much food to cook; how much food to put into the blender to make ground or pureed foods; had no idea of the serving sizes for each ladle/ scoop and did not know what the serving size should be for each meal product. During an interview on 7/28/19 at 1:45 PM, [NAME] #1 stated the last tray served with ground chicken was not the correct portion because they ran out of ground meat. The last few puree meals did not receive vegetables because they ran out of vegetables and the scoop size for the pureed chicken was only a 2 oz scoop and should have been a 4 oz scoop. [NAME] #1 also stated they ran out of soup and she was unable to provide to the last few residents soup who had requested soup and was afraid to provide additional mashed potatoes to some because the mashed potatoes were burnt. During another interview on 7/28/19 at 5:45 PM, [NAME] #1 stated the steam table was already set up when she arrived and didn't realize the wrong scoop size was in the pureed chicken until the end of the meal. During an observation on 7/28/19 of the supper meal from 5:45 PM until 6:45 PM on 7/28/19 revealed all resident's that received goulash for dinner received one grey handled scoop (4 oz) and there was no Italian bread served. During an interview on 7/28/19 at 5:58 PM, the Food Service Director (FSD) stated he was not aware the dietary staff used a yellow scoop to serve pureed chicken, and this is too small of a portion size and was not aware they ran out of ground chicken, pureed chicken, pureed vegetables and soup at the lunch meal on 7/28/19 and should have been informed. He stated the residents who received the pureed chicken should have received 4 oz, but the yellow scoop is only 2 oz therefore they were served half of what was recommended. In addition, he was not notified the staff used the wrong scoop size and/ or ran out of food at lunch. He should have been notified so he could have adjusted the meal at supper for the residents to ensure they were offered the recommended protein and caloric values. During an interview on 7/28/19 at 6:45 PM, the FSD stated the gray scoop was a 4 oz scoop. He stated the appropriate serving size for goulash was 8 ounces. Therefore, two serving of the gray scoop to equal an 8 oz serving size should have been provided to the residents who received goulash. In addition, the FSD stated rolls were not served at the lunch meal because they didn't have any rolls and Italian bread was not served at the dinner meal because they didn't have any Italian bread, but an alternate bread such as white or wheat bread should have been offered if their diet plan recommended a bread. He stated he orders food for the facility and must have forgotten to order the dinner rolls and Italian bread. He further stated he doesn't know why [NAME] #2 didn't know she needed to serve 2 scoops of goulash, she has been here for years. He stated it was his job to make sure the staff are giving the correct potion sizes of food and know what color ladle is to be used. All dietary staff should be following the menu which indicates the portion size. During an interview on 7/28/19 at 7:18 PM, [NAME] #2 stated at the lunch meal today she used the yellow scoop for the pureed chicken because it was already on the steam table, but it was too small of a portion. and knew they ran out of pureed chicken, ground chicken, pureed vegetables and soup and didn't tell the FSD. In addition; she stated she gave one scoop of goulash to all residents who were served goulash; because she didn't know the menu required 2 scoops to equal the 8 oz serving as recommended and she didn't serve Italian bread because they didn't have any and she didn't think she had time to prepare regular bread for the meal. During a resident group meeting on 7/29/19 at 10:04 AM, several residents stated they were not made aware of the menu changes on 7/28/19 during the lunch meal. During a resident group meeting on 7/29/10 at 10:04 AM, Resident L stated they are not consistent with the portion sizes. Some people get a lot and others hardly get anything. During an interview on 7/31/19 at 8:50 AM, Dietary Aide #2 stated there were no dinner rolls to serve to the residents at the lunch meal on 7/28/19 and did not serve any bread products as planned. During an interview on 7/31/19 at 10:44 AM, the FSD stated he was concerned the residents didn't receive the recommended servings of food at the lunch and supper meal. This affects their recommended protein and caloric intake. During an interview on 7/31/19 at 10:58 AM, the Diet Technician stated the facility runs out of food at times and the Administrator had been notified in the past. Usually they run out of soup, salad and sometimes the alternate if many residents choose the alternate meal. When the FSD places a food order he is called and questioned why and if he really needs the entire order, because it's over the budget. She has been concerned about the food shortage and has had discussions with the FSD in the past and discussed following the recipes and portion sizes to make sure the residents have adequate food prepared. The DTR was not aware at the lunch meal on 7/28/19 they ran out of food (ground and pureed chicken, pureed vegetables and soup). She was not aware residents did not receive the correct portion of chicken, that some residents did not receive pureed vegetables, and dinner rolls were not served. She stated residents who received BBQ riblet and pureed chicken should have received a dinner roll. She was not aware the residents did not receive the correct portion of goulash or Italian bread at the dinner meal on 7/28/19 as planned. The DTR stated she did not know the dietary staff were using the wrong scoop sizes on 7/28/19 and was concerned the staff were not aware of what size scoops they should have used. In addition, she stated she was concerned some of the residents did not receive the recommended protein, minerals, vitamin and caloric needs during 7/28/19 lunch and dinner meals. During an interview on 7/31/19 at 11:36 AM, the Registered Dietician (RD) stated she was not aware the dietary staff used the incorrect scoop size for the pureed food. She was unaware they ran out of ground chicken, pureed chicken, pureed vegetable, soup, had no dinner rolls available and didn't offer an alternative during the lunch meal on 7/28/19. She was not aware the facility offered sandwiches as the alternative at the lunch meal on 7/28/19 because the chicken had burned. She stated that she should have been called to determine an alternative meal plan to ensure adequate protein and caloric exchange. Additionally, she wasn't aware they did not have any Italian bread for the supper meal and residents were not offer an alternate bread. She stated she was concerned some of the residents did not receive the recommended protein, vitamins, minerals and caloric needs during lunch and dinner meals on 7/28/19. During an interview on 8/2/19 at 9:28 AM, the Administrator stated she was not aware until evening hours on 7/28/19 that some residents did not have receive the recommended food portions related to running out of food and using the incorrect scoop sizes. She stated that she immediately educated the dietary staff on scoop sizes and was concerned they ran out of food. In addition, she would be looking into why they ran out of food at the lunch meal on 7/28/19 and will be looking into why they did not have dinner rolls or Italian bread for the meals on 7/28/19. 415.14 (c) (1-3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 8/2/19, the facility did not provide food for resident consumption that was palatable and served at appetizing temperatures. Specifically, four (Main Dining Room, Units 1 West, 2 East and 2 West) of 4 dining areas observed for meal service had issues involving cold food temperatures. Residents E, F, G, I, J and M are involved. The findings are: Review of a facility policy and procedure titled Food Temperatures - Test Trays dated 3/2019 revealed food items will be taken and properly recorded after all residents have been served. All hot food items must be served to the resident at the temperature of at least 140 degrees Fahrenheit (F) at the time the resident received the food and all cold food items must be served to resident at a temperature of 40 degree F or below at the time the resident receives the food. Review of the Food Committee Meeting minutes dated 2/20/19 revealed residents were informed new equipment was coming to improve the accuracy and the quality of the food such as a new steamer and currently all food was being cooked in a single oven which was not big enough. The 4/24/19 meeting minutes documented the residents voiced concerns regarding dietary needing more staff. During the 5/22/19 meeting the residents were informed the new equipment was coming soon and at the 6/19/19 the residents voiced concerns that breakfast was cold, and documented the facility was still waiting on new equipment. 1.During an interview on 7/28/19 at 11:31 AM, Resident J stated the food was terrible, it does not have any flavor, it is often hard, overcooked or burnt. The meals were served late and were often cold by the time gets to them. During an interview on 7/28/19 at 11:35 AM, Resident E stated, we wait a long time to be served and often items are burnt and inedible. During an interview on 7/28/19 at 12:45 PM, Resident M stated, the food isn't very good here, and they burned the food today, and stated, I'm hungry. During an interview on 7/28/19 at 1:01 PM, Resident I stated, somehow the mashed potatoes were burned, so she didn't eat them. During a group meeting on 7/29/19 at 10:04 AM the following was stated: Resident F stated the vegetables are very watery, which mixes with other items on the plate, so it's like you're eating soup. Resident G stated the mashed potatoes at yesterday's lunch (7/28/19) had black flecks in them, they tasted burnt, and the meat was overcooked. During an interview on 7/29/19 at 3:20 PM, the Activity Department Director stated she was aware residents who attended the Food Committee Meetings expressed the hot meals were cold, and meals are served late both on the units and in the main dining room. The Food Service Director (FSD) was addressing those concerns and working on getting a plate warmer to keep the food warmer. During an interview on 7/31/19 at 10:44 AM, the FSD stated he was aware residents have complained about the temperatures of the food, but the plate warmer are broken and they are doing the best they can. He stated corporate was informed and someone came in to walk thru the kitchen to assess what is needed sometime in April 2019; and was told a plate warmer was ordered. In addition, he stated if he had plate warmers and palate warmers this would keep the food warm. During an interview on 7/31/19 at 11:36 AM, the Registered Dietician (RD) stated she was aware the residents have complained about food being cold on the units and they are waiting for a plate warmer to keep the food warm. Review of the Week One Menu- Day 4 revealed the lunch meal included marinated pork loin, yams, cauliflower with cheese sauce, apple brown [NAME], and bread. Test trays were completed on each unit on 7/31/19 with the following results: Unit 1 West: The test tray was prepared in the Main Dining Room on 7/31/19 at 12:03 PM and placed on a transport cart, Unit 1 [NAME] cart left the Main Dining Room at 12:11 PM, the trays were passed on the unit by 12:18 PM. The test tray temperatures were obtained at 12:18 PM after all residents were served their meal by the FSD with the facilities thermometer. The temperatures obtained were as follows: - pork loin measured at 115 degrees F, tasted cool and was not palatable - yams measured at 121.2 degrees F, tasted cool and was not palatable - cauliflower measured at 124.8 F, tasted cool and was not palatable - coffee measured at 130 degrees F, tasted lukewarm and was not palatable - milk measured at 50 degrees F, tasted lukewarm and was not palatable - juice measured at 50.5 degrees F, tasted lukewarm and was not palatable. During an interview at the time the test tray was completed, the FSD stated the pork and yams should be at least 140 degrees F, the milk and juice should not be above 40 degrees F. The taste tray was not palatable according to the temperatures taken. Unit 2 East: The test tray was prepared in the Main Dining Room on 7/31/19 at 12:21 PM placed on the transport cart and left the Main Dining Room to the elevator. The trays arrived on the 2 East Unit at 12:22 PM, the trays were past by 12:32 PM. The test tray temperatures were obtained by the Diet Technician (DTR) at 12:32 PM using a facility thermometer. The temperatures obtained were as follows: - pork loin measured at 109.5 degrees F, tasted cool, bland and was not palatable - yams measured at 112.8 degrees F, tasted cool and was not palatable - cauliflower measured at 108.1 degrees F and tasted lukewarm - milk measured at 56.6 degrees F, tasted warm and was not palatable - juice measured at 51.5 degrees F and tasted lukewarm and was not palatable - coffee measured at 116.7 degrees F and tasted lukewarm and was not palatable. During an interview at the time of the test tray was completed, the DTR, she stated the expected temperature for meat should be between 120 and 130 degrees F because the meat is thin. The yams and vegetables should be around 150 to 160 degrees F, the milk and juice was expected to be lower than 40 degrees F. In addition, on 7/31/19 at 12:39 PM the DTR stated, the facility did not have a palate or plate warmers. If they did that would make a difference in maintaining the food temperatures. Unit 2 West: The test tray was prepared in the Main Dining Room on 7/31/19 at 12:38 PM placed on the transport cart and left the Main Dining Room to the elevator. The trays arrived on the 2 [NAME] Unit at 12:39 PM. After all trays were served at 12:49 PM. The test tray temperatures were obtained by the Registered Dietician (RD), using a facility digital thermometer. The temperatures obtained were as follows: - marinated pork loin measured at 118 degrees F and tasted cool and was not palatable - yams measured 126 degrees F and tasted lukewarm - cauliflower with cheese sauce measured at 121 degrees F and tasted cool - chocolate milk measured at 57 degrees F, tasted lukewarm and was not palatable - coffee measured at 115 degrees and tasted lukewarm. During an interview on 7/31/19 at 1:17 PM Resident G stated, the meat was on the cool side, the cauliflower with cheese was good, but it tasted cold, and the sweet potatoes were so cold it wouldn't even melt my butter. Main Dining Room: The test tray was prepared in the Main Dining Room servery on 7/31/19 at 1:07 PM after all trays were passed to the residents. The test tray temperature was then taken by the FSD using a facility thermometer at 1:07 PM. The test tray main meal of marinated pork loin was replaced with tuna casserole because there was no pork remaining. The temperatures obtained were as follows: - tuna casserole measured at 132.8 degrees F, tasted bland, lukewarm and was not palatable - peas measured at 126.6 degrees F, tasted bland and cool - milk measured at 63 degrees F, tasted warm and was not palatable - juice was 52.3 degrees F, and tasted lukewarm. During an interview at the time of the test tray, the FSD stated the hot food- tuna casserole and peas should be at least 140 degrees F, the milk and juice should not be above 40 degrees F. During an interview on 8/1/19 with the FSD stated the plate warmer and palate warmer have not been working since April 2019 and they need them to keep the food warm. During an interview on 8/2/19 at 9:13 AM, the Director of Nursing (DON) stated she was aware the residents had complained about cold food and determined it was taking too long to serve the residents. So, additional assistance to pass the trays from the nursing department was initiated. She was not aware residents continued to complain about food temperatures. 415.(d)(1)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a complaint investigation (Complaint NY#00241179) during the Standard survey completed on 8/2/19, the facility did not maintain clinical records on each resident in accordance with accepted professional standards and practices, that were complete, accurately documented, and readily accessible for nine (Resident #l8, #20, #55, #63, #67, #68, #78, #84, #94) of 22 residents reviewed for medical records. Issues involved medical provider visit notes that were not available in the Electronic Medical Record (EMR) (#20, # 55, #63, #67, #68, #84, #94), lack of laboratory results in the EMR (#18), and lack of documentation of PICC (peripherally inserted central catheter-a catheter that is inserted through a vein and advanced until the tip enters the central venous system) line catheter external length and/or arm circumference measurements (#78). The findings include but are not limited to: Review of a facility policy and procedure titled Medical Records-Guidelines for Maintenance, Organization, Retention & Resident/Other Access dated 3/2019 revealed a medical record must be maintained for every resident in a long-term care facility. It is critical that every facility have formalized systems in place for the maintenance of their records. Records should be systematically organized and readily accessible. The medical record includes, but is not limited to, the following types of information: history and physical exams and other related hospital records, assessments, physician's orders, physician and professional consult progress notes, nursing documentation/progress notes, medication and treatment records, reports from lab, x-rays and other diagnostic tests. 1. Resident #18 was admitted to the facility on [DATE] and had diagnoses which include multiple sclerosis (MS), cerebral vascular accident (CVA - stroke), and altered mental status. The Minimum Data Set (MDS - a resident assessment tool) dated 5/3/19 documented the resident was severely cognitively impaired, sometimes understands and sometimes understood. The resident required the extensive assistance of one for personal hygiene. The current Comprehensive Care Plan dated 1/14/18 documented the resident had a seizure disorder. Interventions included administering medications as ordered, monitoring labs, reporting results to the MD (medical doctor) and following up as indicted. Review of an Order Summary Report revealed a physician order dated 3/15/19 to increase Valproic Acid (seizure medication) to 250 milligrams (mg) three times (TID) a day for seizures. Additional review revealed an order dated 6/5/19 for bloodwork to be drawn on 6/6/19 which included a CBC (complete blood count, CMP (complete metabolic profile), TSH (thyroid stimulating hormone), lipid panel, and a Valproic Acid level. Review of the entire electronic medical record (eMAR) including the results tab on 7/31/19 revealed there was no laboratory results available for the bloodwork order to be obtained on 6/6/19. During an interview on 7/31/19 at 11:00 AM, the Registered Nurse (RN #1) Unit Manager reviewed the eMAR and MD folders and stated she would have to continue to look for the results. During an interview on 7/31/19 at 11:36 AM, RN #1 stated she was unable to locate the Valproic Acid level results and had to contact the lab today (7/31/19) to have the results faxed over. They should have been scanned into the computer and available. 2. Resident # 68 was admitted to the facility 8/21/18 with diagnoses which include depression, hyperlipidemia (high levels of fat particles in the blood), and diabetes mellitus (DM). The MDS dated [DATE] documented the resident was cognitively intact. Review of the electronic medical record (EMR) on 7/30/19 revealed the most recent attending physician Progress Note available was dated 9/24/18. During an interview on 7/30/19 at 1:06 PM, the Administrator stated the facility had identified an issue with the timely availability of physician documentation in December 2018. The Administrator stated the provider, Physician and/or Nurse Practitioner (NP) Progress Notes should be uploaded (stored copy) into the EMR within 10 days of the visit. Review of uploaded documents in the EMR revealed the following Physician Visit Note and/or NP Visit note were not uploaded into the EMR and available in the facility until 7/31/19: - Effective date: 10/9/18. NP Acute Visit Progress Note. - Effective date: 11/19/18. Physician Acute Visit Progress Note. - Effective date: 4/4/19. Physician Progress Note. - Effective date: 4/29/19. NP Acute Visit Progress Note. - Effective date: 7/5/19. Physician Acute Visit Progress Note. 3. Resident #78 was admitted to the facility on [DATE] with diagnoses which include peripheral vascular disease, major depressive disorder and DM. The MDS dated [DATE] documented the resident was cognitively intact. Review of the Medication Administration Record (MAR) dated July 2019 revealed an order entry to measure the external PICC line (peripherally inserted central catheter - a thin, soft long catheter that is inserted into a vein and the tip of the catheter is positioned in a large vein into the heart) from the insertion site to the hub of the access cap and measure arm circumference at the PICC insertion site every Wednesday. Additional review of the MAR revealed no documented evidence that the PICC line or arm circumference was measured on 7/3/19, 7/10/19, and/or 7/24/19. Review of Progress Notes dated 7/1/19 through 7/31/19 revealed there was no documented evidence that the PICC line measurements or arm circumference measurements were obtained. During an interview on 8/1/19 at 10:25 AM, the Assistant Director of Nursing (ADON) stated she measured the PICC line and arm circumference on 7/3/19 and 7/10/19 but forgot to document the measurements. The purpose of measuring the PICC line is to ensure the line is in proper placement, and the circumference measurement of the arm is to ensure there is not any inflammation or swelling in the arm related to the PICC line. The ADON stated the measurements are important and it should have been documented. The measurements should be compared week to week to ensure the PICC maintains proper placement. During an interview on 8/1/19 at 10:45 AM, the Registered Nurse (RN #1) Resident Care Coordinator (RCC) stated she measured the PICC line and arm circumference on 7/24/19 but forgot to document the measurements. During an interview on 8/2/19 at 9:04 AM, the Director of Nursing (DON) stated the staff should be measuring, documenting and comparing the measurements of the PICC line length and arm circumference from week to week to ensure proper placement and ensure there is not any signs of infection and/or swelling. The DON stated there should not be any blanks on the MARs. 415.22(a)(1-3)

Based on interview and record review conducted during the Standard survey completed on 8/2/19, the facility did not ensure that the Quality Assessment and Assurance (QAA) Committee developed and implemented appropriate plans of action to correct identified quality deficiencies and regularly reviewed, analyzed and acted on available data to make improvements. Specifically, the QAA Committee identified an issue involving the lack of availability of medical provider visit notes in the Electronic Health Record (EHR). The facility identified corrective actions which were not effective and the plan was not revised. The findings are: Refer to F 842 - Resident Records - Scope and Severity E. 1. Review of a facility policy and procedure (P&P) entitled Quality Assurance and Performance Improvement Program (QAPI) dated 10/2017 revealed the QAPI team at each facility will review sources of information to determine if gaps or patterns exist in the systems of care that could result in quality programs; or if there are opportunities to make improvements. Based on the result of the review of information, the QAPI team will prioritize opportunities for improvement, taking into consideration the importance of the issues (high risk, high frequency, and/or problem prone). The QAPI team will determine which problems will become the focus for a performance improvement project (PIP). Depending on the PIP to be started, the QAPI team will charter a PIP team who is entrusted with a mission to look into a problem area and come up with plans for correction and/or improvement to be implemented. During an interview on 7/28/19 at 11:01 AM, the Administrator stated the QAA Committee meets monthly and the full QAA committee meets quarterly. She stated the Medical Director phones into the monthly meeting and attends the quarterly. Corporate QA calls into the quarterly meetings. During an interview on 7/31/19 at 11:04 AM, the Director of Nursing (DON) was asked why medical provider notes were not available on paper or in the EHR. The DON stated the facility has identified the issue regarding the lack of provider notes and have done a QAPI on it. It has been addressed. There have been meetings with the Doctors and their Office Managers. The facility's Medical Records department sends the Doctors a list of what is missing every week. The DON stated the Administrator and Corporate Administrator are looking into the issue. She stated it is a problem with continuity of care with the residents in the facility. One practice they have implemented is to have the Nurse on duty, round with the Doctor when they are in seeing residents, so they can note the visit date, any new orders, what they are seeing the resident for, etc. The DON stated she would expect the Nurse on duty to write a progress note in the resident's EHR and the facility 24 Hour Report. The interdisciplinary team (IDT) reviews the 24 Hour Report every morning. During further interview on 7/31/19 at 11:08 AM, the DON stated the lack of timely provider notes has been an issue in the facility since December 2018 and it continues to be an issue still. During an interview on 8/2/19 at 10:35 AM, with the DON present, the Administrator stated the Provider Notes QAPI was identified in December 2018 and the following concerns were reviewed at the monthly QAA meetings: - January 2019 - The QAA team met with the facility Doctors. - February 2019 - The QAA team established a list of documentation that was missing from the EHR that was sent to the Provider's respective Office Managers. - March 2019 - The QAA team updated the list of missing documentation, re-emailed to the Doctor's offices and re-addressed the missing provider notes with the facility Medical Director. The QAA committee noted that the timeliness of recent Provider Visit Notes were improved, but they were not catching up on prior visit notes that had not been submitted to the facility for the EHR. - April 2019 - Letters were sent out the Providers in addition to the list of missing dictations. - May 2019 - All dictations were sent to the providers requesting updates on long outstanding notes that were missing. - June 2019 - Started receiving some of the older outstanding notes. - July 2019 - Resent missing documentation list. Emailed and called the offices for missing documentation. During further interview on 8/2/19 at 11:05 AM, the Administrator stated the DON and I kept emailing, calling different people, supervisors of practices, and the next up the chain of the command. The Administrator stated she would speak with the Medical Director each time he was in the facility to update, and Corporate was aware of the identified issue of missing documentation. When asked what happened this week that a lot of provider notes were submitted to the facility, the DON stated the Department of Health happened. You arrived at the facility for survey. 415.27(a,c)(3)(v)