**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the abbreviated survey (NY00326875), the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 of 3 residents (Resident #1) reviewed. Specifically, Resident #1: - did not have physician's orders implemented on admission for the care of their urinary catheter (tube that drains urine from the bladder), colostomy (artificial opening in the abdomen draining stool into a bag), and peripherally inserted central catheter (PICC, for intravenous medication) line. - Did not have a comprehensive care plan (CCP) developed and implemented on admission to direct staff in caring for the urinary catheter, colostomy, and PICC line. - Did not have a follow-up appointment scheduled with infectious diseases (ID) timely after order. - Did not have a stool specimen sent for C Difficile (C-Diff, bacterial infection causing diarrhea and bowel inflammation) timely after order. Finding include: The facility's 8/2017 Catheter Care Policy documented all residents with indwelling catheters (tube that drains urine from the bladder) would be given catheter care one time per shift and as needed to prevent urinary tract infections, promote hygiene, and prevent odors. The facility's 2/2020 Central Venous Access Device (CVAD) Therapy Policy documented central venous therapy would be managed and discontinued in accordance with accepted standards by appropriately credentialed members of the facility. The physician provided the order, credentialed registered nurses (RN) changed the dressing every 7 days, labeled the dressing, and documented the exposed length of the catheter in centimeters weekly. End caps were to be changed every 4 days or in the event integrity was compromised or residual blood remained in the cap. Tubing was to be changed every 4 days. The facility's 7/2021 Consults Policy documented residents that required specialized outside services from consulting physicians were to receive those services. Medical Services provided orders, licensed nurses reviewed orders and notified the unit secretary to make the referral and the unit secretary made the appointment, notified resident/family, arranged transport and prepared packet for consult. The facility's 5/2022 Ordering and Reporting of Laboratory Tests Policy documented the facility was to assure laboratory tests were scheduled upon medical orders and results reported to Medical Services. The 9/2023 Colostomy Pouch (drainage bag) Evacuation and Cleaning Policy and Procedure documented colostomy pouches were to be emptied when one third full or when inflated with air to prevent leakage, usually this would be early morning, after meals and at bedtime. Residents were taught and encouraged to perform their own procedure for cleaning the pouch when physically able to. Resident #1 had diagnoses including urinary retention, colostomy status (artificial opening in the abdomen draining stool into a bag), and discitis (infection of the spaces between the spine). The 8/24/2023 Minimum Data Set (MDS) assessment documented the resident's cognition was intact, they required extensive 2-person assistance with bed mobility and was dependent on staff for transfers. The resident had an indwelling urinary catheter (tube that drained urine from the body), an ostomy, and received intravenous (IV) medications. Devices (Urinary Catheter, Colostomy, and PICC line) The 8/17/2023 hospital discharge summary documented the resident was admitted to the hospital with discitis and per infectious disease (ID), they needed 8 weeks of IV antibiotics via a PICC line (peripherally inserted central catheter, device for IV access). The PICC line was placed in the hospital and the resident was discharged on daily antibiotics via the PICC line through 10/6/2023. The 8/17/2023 at 10:43 PM registered nurse (RN) #1's admission Summary documented the resident was admitted after they were hospitalized with discitis. The resident had an indwelling urinary catheter that was intact and draining, a colostomy, and a PICC line in their right upper arm. The resident's admission 8/17/2023 physician's orders did not include orders for the care for the indwelling urinary catheter, the colostomy, or the PICC line. The resident's 8/18/23 physician's orders documented daily IV antibiotics were ordered via the PICC line until 10/6/2023. The 8/18/2023 comprehensive care plan (CCP) documented the resident required assistance with activities of daily living (ADL). There were no documented goals or interventions related to the resident's indwelling urinary catheter, colostomy, or PICC line. The undated [NAME] (care instructions) did not document the resident had a colostomy. The [NAME] documented to monitor/document pain/discomfort due to indwelling urinary catheter. The resident's progress notes included the following documentation: - on 8/22/2023 at 11:51 PM and 9/3/2023 at 11:17 PM by RN #4, PICC line dressing change completed. - On 9/12, 9/13 and 9/16/2023 by licensed practical nurse (LPN) #2, the colostomy was intact. - On 9/19/2012 at 1:49 AM by RN #1, the colostomy continued in left lower quadrant. The 8/2023, 9/2023, and 10/2023 Medication Administration Record (MAR) included: - on 9/12/2023, orders were implemented for urinary catheter care every shift including to change the urinary drainage bag weekly and change the catheter every 4 weeks with instructions on the size of the catheter and balloon to be used. - From 8/17/2023 to 10/5/2023, the resident received an IV antibiotic daily. There was no documented evidence the resident had their PICC line dressing changed or IV tubing changed during that time. - There was no documentation the resident received colostomy care and there was no documentation of instructions for changing the wafer (adhesive device applied to skin that holds the drainage bag) and changing the drainage bag. Outside Medical Consults The 10/12/2023 neurosurgeon consult documented the resident had worsening redness and swelling and significant constant pain to the left knee and the resident needed to be referred to ID. The 10/13/2023 attending physician #8's progress note documented neurosurgery was concerned about the resident's left knee and persistence of infection with a history of discitis. The plan included IV antibiotics to be restarted and the resident needed to go to ID. There was no documented evidence of a physician order for the consult to ID. The 10/16/2023 physician's order (3 days after recommended by neurosurgery) documented refer to ID clinic. On 10/25/23, the resident was discharged to the hospital. There was no documented evidence the resident was evaluated by ID. Diagnostic Testing The 10/22/2023 at 9:32 PM, licensed practical nurse (LPN) #4's progress note documented the resident had a temperature of 102.9 Fahrenheit (F) and cooling cloths were applied. The resident's temperature was rechecked at 8 PM and was 100.3 F. The RN Supervisor (unnamed) was updated and stated to monitor. The 10/23/2023 attending physician #8's progress note documented the resident had a recent fever and history of discitis. They had liquid stool in their colostomy bag and the resident reported feeling weak. The assessment/plan documented the resident had a fever which was now resolved and a history of C-Diff (bacterial infection that caused loose stools) 1 month ago. The plan was to recheck stool for C-Diff and hold off on antibiotics for now. There was no documented evidence of a physician's order for the stool specimen for C-Diff. The 10/26/2023 at 9:28 AM, RN #7's progress note (documented as a late entry) noted they were alerted the resident was not looking well. They were observed in their wheelchair, pale and not able to hold a conversation. Blood pressure was 102/56. Labs were drawn and a stool specimen collected from the colostomy. Their condition did not improve, and they were sent to the hospital. The 10/26/2023 hospital report documented the resident was admitted with hypotension (low blood pressure), a high white blood cell count (indicates infection), acute kidney failure and septic shock of undetermined source. The family reported the resident vomited yesterday and nursing reported a significant amount of stool through the ostomy bag. The plan included checking the stool for C-Diff and continue antibiotics. The report documented the resident tested positive for C-Diff on 10/26/2023. On 11/8/2023 at 12:42 PM, an email was sent to the Director of Nursing (DON) at the facility requesting the resident's C-Diff results and no results were received prior to survey exit. During a telephone interview on 11/13/2023 at 10:38 AM, RN #1 stated during the nursing admission assessment, RN #1 completed a head to toe assessment and obtained orders based on what was in the hospital discharge summary. The Nurse Manager was responsible to develop the CCP. RN #1 would enter orders for urinary catheter care every shift and for the drainage bag to be changed weekly, and to empty the colostomy bag every shift. If a resident's urinary catheter or colostomy was not noted on the care instructions, the nurse would be responsible to tell direct care staff a resident had those devices. RN #1 stated they were not sure why they did not obtain orders for the resident's indwelling urinary catheter or colostomy on admission and stated they should have. During a telephone interview on 11/13/2023 at 11:36 AM, LPN #2 stated physician's orders were typically in place for urinary catheter care, changing the urinary drainage bag weekly, and for colostomy care which included emptying the bag and replacing the wafer and bag as needed. Care for the urinary drainage catheter was done by the certified nurse aides (CNA) and CNAs documented the drainage but they were not sure if they documented care. They were not sure if the resident had a CCP plan in place for their urinary catheter or colostomy and they were not aware there were no orders in place for the resident's urinary catheter or colostomy when they were admitted . During a telephone interview on 11/13/2023, CNA #3 stated they knew how to care for a resident by reviewing information in the computer or a sheet taped on the back of a resident's closet door that had care instructions. They could also ask other staff how to care for a resident. The resident had a urinary drainage catheter and they were responsible to empty the bag every shift. Care of the catheter was documented in the computer. They did not recall what care they documented for the resident's catheter. CNAs and nurses were responsible to empty colostomy bags once per shift and they documented in the bowel movement section of the chart. There was no place for them to document if they changed the wafer/bag. During a telephone interview on 11/14/2023 at 12:55 PM and on 11/15/23 at 10:26 AM, RN Manager #6 stated: - physician orders were needed when a resident was admitted with a colostomy, urinary drainage catheter, and a PICC line. - A CCP and care instructions were also needed and an RN, themselves or their assistant or the Charge Nurse, were responsible to initiate/update the CCP. - Urinary catheter orders included the size/balloon of the catheter, frequency to change the bag and catheter, and catheter care. - PICC line orders included the frequency of changing the dressing. - When an outside consultant made recommendations, the medical provider reviewed the recommendations, informed nursing if they agreed, and nursing entered the order. Orders should be entered within 30-60 minutes after the physician agreed with the recommendations. - When the medical provider wanted a lab test done, it required an order. - They were not aware, and it was not timely, when there were no orders or care planned interventions for the resident's colostomy, no orders or interventions added for 3 weeks after admission for the resident's urinary catheter and no orders for PICC line dressing changes from 8/17/2023 through 10/6/2023. - There should have been an order to obtain a stool specimen for C-Diff on 10/23/2023 and they expected one. - When the nursing note documented the stool specimen was obtained on 10/25/2023, it was not obtained timely. - On 10/13/2023, the unit secretary faxed information to ID regarding the resident. On 10/16/2023, the unit secretary called ID and ID said they were still reviewing the faxed information. They were unsure if anyone called again to inquire about the referral. 10NYCRR415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the recertification and abbreviated surveys (NY00275797) conducted from 5/24/21-5/28/21 the facility did not implement corrective measures after an allegation of abuse was made for 1 of 2 residents (Resident #56) reviewed. Specifically, Resident #56 alleged rough treatment by certified nurse aide (CNA) #22. The facility's plan to prohibit CNA #22 from no longer caring for the resident was not documented and not implemented as planned as a corrective measure to prevent further allegations of abuse. Findings include: The facility policy Abuse Prevention and Training revised 2/2018 documents the facility will promote an environment free from all forms of abuse from all parties including residents/patients, R/P/Rs, employees, families, visitors and any other person who may come in contact with our residents/patients. Resident #56 was admitted to the facility with diagnoses including dementia, hypertension, and heart failure. The 4/5/21 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, required extensive assistance of two persons with bed mobility, and extensive assistance of one person for transfers, dressing, and personal hygiene. The comprehensive care plan (CCP) initiated 4/23/19 and updated on 5/3/19 documented the resident resident required assistance with ADLs (activities of daily living) and mobility. Interventions included assistance of one for bed mobility, assistance of 2 to pull up in bed and transfer and toileting assist of one with standing lift. A nurse practitioner (NP) progress notes dated 5/7/21 at 1:11 PM documented the resident was seen for new onset of right shoulder pain with radiation to the right upper arm. The resident stated their shoulder started hurting during routine care when their right upper extremity (RUE) was lifted over their head. A right shoulder and humeral X-ray was done. The radiologist stated there was an anterior right shoulder dislocation and with given history was acute. The dislocation was to be reduced (put back into place) in the emergency room. During an interview on 5/25/21 at 2:02 PM with Resident #56's family member, they reported someone was rough with their family member and the facility reported it to the state. They were notified the next day. The orthopedic physician told them the resident could not have dislocated their shoulder by themselves, but the facility told them that it was possible the resident dislocated it when trying to move around. The DON told the family member that CNA #22 would not care for the resident anymore and would not be on that unit. The family member received a letter in the mail saying staff was being rotated. The facility investigation dated 5/7/21 documented: - on 5/7/21 at 9:30 AM, the resident went to physical therapy and told PTA #26 (physical therapy assistant) their shoulder hurt and thought the person who took care of them yesterday was rough with their care. - PTA #26's statement documented on 5/7/21, the resident complained their right shoulder hurt. The resident gave a physical description of the staff member (CNA #22) and stated CNA #22 got them up the previous day, was too rough, and was often rough with the resident. - The resident was brought to the Nurse Manager who assessed the resident and notified the NP who ordered an x-ray which showed a suspect dislocation of the right shoulder and the resident was transferred to the emergency room for repair of the dislocation. - Staff caring for the resident during the previous 24-hour period were interviewed including CNA #22. - CNA #22's statement dated 5/7/21 at 2:50 PM, documented they cared for the resident 3 times on 5/6/21 and assisted with taking the resident to the bathroom. The resident complained of leg pain and needed help placing their hands on the stand lift. The resident was able to pull themselves up with help. - On 5/8/21, the resident was interviewed by the Director of Nursing (DON) in the presence of their family member. The resident denied any mistreatment by CNAs. - No findings of abuse or mistreatment were discovered during the investigation. There was no documented evidence of a plan to address CNA #22 who was the accused CNA. The staffing schedule documented CNA #22 worked on the resident's unit from 6 AM-2 PM on 5/10/21, 5/15/21 and 5/18/21. The ADL documentation documented CNA #22 provided Resident #56 assistance with dressing, bed mobility, personal hygiene, toileting, and transfer on 5/10/21, 5/15/21, and 5/18/21. There was no documentation in the resident's CCP or [NAME] (care instructions) specific staff were restricted from providing care to the resident. During an interview on 5/27/21 at 8:00 AM, with registered nurse (RN) Manager #24 they stated on 5/7/21, therapy was working with the resident and the resident reported pain. Therapy told the RN the resident reported during morning care their arm was lifted too high and they described the specific staff member and CNA #22 met the description and cared for the resident on that date. RN Manager #24 spoke with CNA #22 and told them they were not able to care for the resident anymore. CNA #22 still worked on the unit. The unit staff knew verbally CNA #22 was not allowed to provide care for Resident #22 but they did not think they could not put the CNA's name on the care plan, so it was not documented anywhere. RN Manager #24 stated CNA #22 knew they could not care for the resident. During an interview with CNA #25 on 5/27/21 at 8:30 AM they stated they were never told there was a CNA that was not allowed to care for Resident #56, and anyone could provide care to them. During an interview with CNA #22 on 5/27/21 at 10:22 AM, they stated the resident reported no pain prior to the incident and no one told them anything about the resident's arm until the next shift they worked on 5/10/21. They stated they did not work with the resident during the investigation which took one day and now they could care for any resident on the unit. 10NYCRR 415.4(b)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: [NAME], Shari Based on observation, interview, and record review during a recertification survey conducted from 5/24/21-5/28/21, the facility did not ensure each resident received adequate supervision to prevent accidents for 2 of 7 residents (Residents #12 and #95) reviewed. Specifically, Resident #12 rode the elevator to an unsupervised area of the facility where they fell out of their wheelchair. The resident was not re-assessed for wandering or elopement and the incident was not reported to the New York State Department of Health (NYS DOH) as required. Additionally, a plan was not implemented to prevent residents without wanderguards from going to the basement (a non-resident area). Resident #95 was observed ambulating in an unsupervised closed unit ([NAME] North) while maintenance was making repairs in rooms and the plan of care was not updated to ensure adequate supervision to prevent further wandering. Findings include: The facility Elopement Management policy, revised 11/2018, documents: - Residents are evaluated for wandering/elopement risk on admission, readmission, quarterly, with significant change and as needed utilizing the Wandering Risk Assessment 2 tool. - The Wandering Risk Assessment 2 tool determines if a resident needs a Wanderguard (electronic monitoring device). - Nursing checks the Wanderguard placement every shift and documents on the electronic treatment administration record (ETAR). - The Wanderguard device is documented on the comprehensive care plan (CCP) and [NAME] (care instructions). The facility Resident Safety Report policy, revised 4/2019, documents: - An unusual occurrence will be documented in the record and a safety report completed. This includes a resident fall or resident found on the floor/ground. - The registered nurse (RN) Unit Manager and Director of Nursing (DON) are to complete an investigation and determine with the interdisciplinary team (IDT) a root cause analysis of the incident. 1) Resident #12 was admitted to the facility with diagnoses including arthritis and hip fracture. The 3/4/21 Minimum Data Set (MDS) Assessment documented the resident had severe cognitive impairment, required extensive assistance of one person for locomotion off the unit, had a history of falls and had no wandering behaviors. The comprehensive care plan (CCP) initiated 1/14/21 documented the resident required supervision with wheelchair mobility and was at high risk for falls. Interventions included to keep the resident close to nursing station when able and the resident was to be on the early morning get-up list as they had the most falls in the early morning. The CCP documented the resident had falls on 1/20/21, 3/16/21, 3/18/21 from wheelchair, 3/20/21, 3/21/21 from wheelchair, and 3/23/21, 3/29/21 and 5/25/21. The Wandering Risk Assessment tool documented the resident was assessed on 1/13/21. The resident was deemed not at risk for wandering or elopement. There was no Wandering Risk Assessment tool completed when the resident moved from [NAME] North (the rehab unit) to [NAME] East on 3/17/21. The Facility Safety (incident) Report dated 3/21/21 at 8:15 AM and completed by registered nurse Supervisor (RNS) #8 documented the resident was found in the basement on the floor in front of their wheelchair. The resident stated they fell out of the chair and denied pain. An assessment was done and there were no injuries. The resident was assisted to their wheelchair by 2 staff members and was taken back to [NAME] East (second floor). Analysis of the incident included analysis of the incident and documented the root cause was resident was wandering, staff were not educated and the care plan was followed. The follow-up action included a wanderguard was applied and the resident would be on hourly rounds. There was no documentation the resident was reassed for elopement risk or a determination of how the resident was able to enter the elevator and exit in the basement unnoticed. The CCP revised 3/22/21 documented the resident had a fall in the basement on 3/21/21. The resident fell from their wheelchair and there no injuries. The CCP did not document elopement risk or use of a Wanderguard. During an interview on 5/27/21 at 9:14 AM, RNS #8 stated they received a phone call from the housekeeping supervisor on the morning of 3/21/21 notifying them Resident #12 was found on the floor in the basement. They were not sure how the resident got there as they were not a known wanderer. The resident had been seen eating breakfast on [NAME] North not too long before they received the phone call the resident was in the basement. The resident was assessed and had no injuries. They were taken back to the unit and a Wanderguard was applied to the resident's ankle. During an interview 5/27/21 at 9:26 AM, laundry staff #16 stated on 3/21/21, they saw Resident #12 in the basement on the floor just outside the elevator, trying to pull themselves up by the linen cart. The resident was stuck in between the elevator doors. Their wheelchair was still in the elevator. They called RNS #8 and RNS #8 arrived with a certified nurse aide (CNA). The resident was assessed and taken back to the unit. During an interview 5/27/21 at 9:39 AM the Director of Nursing (DON) stated they did not think the 3/21/21 incident was reportable to NYS DOH because the resident was alert and oriented and was not a wander risk. If the resident had been a known wanderer and ended up in the basement, they would have reported it to NYS DOH. The facility team typically discussed residents who were trying to get out of the building in morning report. Resident #12 was not trying to get out of the building. On 5/27/21 at 1:23 PM, the DON stated in a second interview, this resident's incient was an isolated incident. It was rare for residents to get on the elevator and make it to another floor. Nothing was put into place to prevent other residents from doing this. The incident should have been reported to NYS DOH. 2) Resident #95 was admitted to the facility with diagnoses including dementia and atrial-fibrillation (irregular heartbeat). The 4/22/21 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, had difficulty focusing attention, wandered 1 to 3 of 7 days, ambulated in room and corridor with supervision, did not use mobility devices and used a wander/elopement alarm daily. Resident #95's Wandering risk assessment, effective 4/15/21, documented the resident was at high risk for wandering and a Wanderguard was placed on the resident's left ankle. The comprehensive care plan (CCP), revised 4/19/21, documented the resident was at risk for wandering as they had a history of wandering throughout the neighborhood at home, had a diagnosis of dementia, and was asking daily to go home and tried to find a ride to get there. The intervention was to apply a Wanderguard to the resident's left ankle. The certified nurse aide (CNA) Care Sign-Off Form dated 4/19/21 documented the resident was on one-hour safety checks. The resident's [NAME] (care instructions) active on 5/24/21 did not document the resident wore a Wanderguard or was a wandering risk. An elopement book on [NAME] documented 5 residents were at risk for elopement, including Resident #95. Nursing Progress notes documented the resident had wandering and exit-seeking behaviors and was asking to go home on 4/15/21, 4/16/21, 4/17/21, 4/19/21, 4/20/21, 4/21/21, 4/25/21 and 5/8/21. During the entrance conference interview with the Administrator on 5/24/21 at 10:18 AM, they stated four of the five units of the facility were open. [NAME] North, on the second floor, was closed and had no residents residing on it for the past few months. During an observation on 5/24/21, at 10:50 AM the [NAME] North unit was dark and only the 24-hour emergency hall lights were on. During an observation on 5/24/2021 at 11:41 AM, [NAME] North unit resident room [ROOM NUMBER] had water damage with buckets collecting dripping water, there was a dismantled air conditioner/heater unit on the floor, and there was exposed wiring. The door to the room was not secured or locked. On 5/24/21 at 1:15 PM, the resident was observed ambulating in the hall on [NAME] West, asking how they could get to Utica and on 5/24/21 at 3:00 PM, the resident was observed being escorted out of [NAME] North (a closed unit) by two maintenance staff. There was no documentation in the medical record the resident wandered onto the closed unit, [NAME] North, on 5/24/21. During an interview 5/24/21 at 4:30 PM CNA #9 stated if a resident with a Wanderguard went near the elevator the alarm sounded and the elevator would not move. The buzzing noise heard on the unit was for [NAME] North which was a closed unit and the buzzing indicated when someone entered the first set of doors. The door alarmed when it was opened. Residents with Wanderguards could enter the closed unit. During an interview 5/24/21 at 4:36 PM, CNA #12 stated when a resident with a Wanderguard went near the elevator an alarm went off. If a resident walked from unit to unit, staff had to let the other unit know as most residents did not have 1:1 supervision. During a review of the video footage of [NAME] North with the Maintenance Director on 5/24/21 at 5:40 PM, Resident #95 was observed exiting [NAME] North on 5/24/21 at 3:00 PM with the two maintenance staff. There was no camera located at the other end of the hall to [NAME] North where the resident possibly entered. During an interview 5/24/21 at 5:53PM, CNA #13 stated hourly checks meant to check every hour to see if a resident was in their bed or if they needed something. They check the residents' care plans to see if the resident wears a Wanderguard. During an interview 5/24/21 at 6:00 PM, maintenance staff person #4 stated they were with another staff member working on a heating pump in room [ROOM NUMBER] on [NAME] North when they heard the door alarm. They responded and observed Resident #95 ambulating in the hall. They had never seen this resident on [NAME] North before. The Director of Nursing (DON) happened to be in the area and heard the alarm and helped guide the resident off the unit and back to their room on [NAME] West. During an interview 5/24/21 at 6:45 PM maintenance staff #5 stated they had never seen any residents on the closed unit, [NAME] North. When they have heard a door alarm in the past, they would stop what they were doing and check the hallway. They would escort a resident back to their room and then report it to the supervisor immediately. During a phone interview 5/24/21 at 6:49 PM, CNA #7 stated they cared for Resident #95 on 5/24/21. They saw the resident just before they left at the end of their shift at 3:00 PM. The resident would wander on [NAME] and East all shift. They stated Resident #95 was not on any set checks, but they would usually check on the resident every 15 to 30 minutes. The staff would try to bring back Resident #95 when went onto [NAME] North and it was not very often. CNA #7 would hear the door alarm on [NAME] North when the resident entered. The recreation department used a room for activities on [NAME] North because there was not enough room on [NAME] East and West. They were not aware that Resident #95 attempted to enter [NAME] North today. The resident wore a Wanderguard which alarmed when the resident went near the elevator. During an interview 5/24/21 at 7:00 PM maintenance staff #6 stated they were working on [NAME] North on 5/24/21, the far end near the fire doors and room [ROOM NUMBER]. They placed a cart on wheels in front of the doors at the far end of the unit to prevent any residents from entering while they were working there. They stated residents attempt to enter [NAME] North 1 - 2 times a day and it was usually Resident #95. They have not reported this because other staff members would enter to try to find Resident #95 and would redirect them out of the closed unit. At 4:30 PM today, Resident #95 attempted to enter the far end of [NAME] North (near room [ROOM NUMBER]) but the cart kept them from pushing through the doors and they left. During an interview 5/24/21 at 7:23 PM on [NAME] West, RN Manager #11 stated Resident #95 received a Wanderguard the day they arrived on the unit. The resident wandered to [NAME] East and was never found in an unsupervised area. [NAME] North was a closed unit and had a door alarm when opened. At 7:28 PM RN Manager #11 stated Resident #95 did enter [NAME] North the other day but not since then. Residents were not supposed to go on [NAME] North but some residents can be sneaky and get through the door. Residents with Wanderguards can go through the doors on [NAME] North as there is no Wanderguard alarm like the elevator has. Staff should be checking to see why the door is alarming. During an interview 5/24/21 at 8:30 PM, the DON stated they have not been documenting in a progress note when a resident wandered onto [NAME] North. They would call the incident with Resident #95 today a near miss. If it was something consistent, they might document a progress note. If it is just a breach it was not anything they would discuss in morning report. They heard the door alarm around 3:00 PM and that is when they caught up with the two maintenance staff escorting Resident #95 off [NAME] North. The resident did not get very far. All staff was expected to respond to the door alarm. Most residents wander unsupervised on this floor. The residents did not understand [NAME] North is closed as they used to be able to wander onto it like they do [NAME] East and West. The doors to [NAME] North do not have a Wanderguard alarm. On 5/25/21 at 10:19 AM, the resident was observed ambulating on [NAME] East stating they were looking for a way out. On 5/27/21 at 3:28 PM, the resident was observed ambulating on [NAME] East and stated they were looking for their car. During an interview 5/28/21 at 2:58 PM the DON stated they do not have any protections in place to prevent residents from wandering onto [NAME] North, the closed unit. They did not want any residents wandering onto the closed unit with the potential for getting into an accident. 10 NYCRR 415.12(h)(2) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification survey conducted 5/24/21-5/28/21, the facility did not ensure food and drinks were palatable, attractive, and at a safe and appetizing temperature for 3 of 3 meals (5/26/21 lunch, 5/27/21 lunch, and 5/28/21 lunch) reviewed. Specifically, food and drinks were not served at palatable temperatures including chef salad, lemon mousse, yogurt, turkey and cheese sandwich, tossed salad, fries, coleslaw and milk). Findings include: The April 2021 Food Committee Meeting minutes documented that vegetables were mushy, and juices/milks were not as cold as residents would prefer. The May 2021 Food Committee Meetings documented that mushy vegetables were getting better and hot food items were losing temperature somewhere between the serving and delivery process. During a resident council meeting on 5/24/21 at 2:02 PM, two residents stated food was not being served at proper temperatures. On 5/26/21 at 12:28 PM, a lunch meal tray was delivered to Resident #47. Temperatures and taste tests were conducted on the tray and the resident received a replacement. The chef salad, which contained eggs and cheese, had a temperature of 65 Fahrenheit (F), and the provolone cheese within the chef salad had a temperature of 68 F. The lemon mousse had a temperature of 63 F. During an interview on 5/26/21 at 12:28 PM, Food Service Supervisor #17 stated that the chef salad and lemon mousse were too warm and within the temperature danger zone. All cold foods should be served at a temperature of 40 F or lower, below the temperature danger zone. On 5/27/21 at 12:29 PM, a lunch meal tray was delivered to Resident #52. Temperatures and taste tests were conducted on the tray and the resident received a replacement. At 12:34 PM, the yogurt had a temperature of 53 F, the turkey and cheese sandwich had a temperature of 59 F, the French fries had a temperature of 99 F and the tossed salad had a temperature of 55 F. The cheese in the sandwich was not appealing and the sandwich was not palatable. During an interview on 5/27/21 at 1:00 PM, the Operations Manager 2 stated that yogurt was placed in the walk-in cooler of the main kitchen and then placed into the unit nourishment preparation room refrigerator. Yogurt at 53 F was not acceptable and should be maintained at 40 F. Cold cuts were kept in the walk-in cooler at 40 F or lower. Sandwiches should be served at 50 F or lower to be palatable, and a 59 F sandwich was not palatable. Fried food was not great at holding hot temperatures well, and fries should be over 120 F to be palatable. During an interview on 5/27/21 at 1:35 PM, the Operations Manager 2 stated they had not heard of any resident complaints that cold food items were too warm. During an interview on 5/28/21 at 10:47 AM, the Dining Room Manager stated the first week of every month there was a meal committee for food issues. This committee indicated that there were hot food items on resident room trays that were cold (below 140 F). Once the facility went to plexiglass divided tables, and 10 more residents were served in the dining rooms, there had been no food complaints. The Dining Room Manager had never been told about cold items being hot. They stated air temperatures of the nourishment preparation rooms have felt to be over 90 F and have been warm/hot for a year. A hot nourishment preparation room cause a quicker rise in temperature of a cold item outside of the temperature range. During a joint interview on 5/28/21 at 10:50 AM, the Dining Room Manager and Operations Manager 2 both stated that the overhead exhaust in all six nourishment preparation rooms have been out of service for over a year. During an observation on 5/28/21 at 12:09 PM, there were 1/2 gallons of milk in ice bins in the [NAME] East unit nourishment preparation room. The milk was being poured into glasses for resident hall trays and then being placed into two rolling carts. The milk was not placed into the refrigerator within the nourishment preparation room. The doors to both rolling carts were kept open and remained open at 12:34 PM. During observation on 5/28/21 at 12:21 PM, the [NAME] East unit nourishment preparation room counter had an ice bath with a bin of coleslaw inside it. The coleslaw was still on the counter at 12:45 PM. During an interview on 5/28/21 at 12:27 PM, food service worker #21 stated an extra person was heating plate bottoms in [NAME] North unit nourishment preparation room. If both doors are closed to this room, the air temperature in this room can reach over 90 F. During observation on 5/28/21 at 12:31 PM, the heating plate bottoms for the [NAME] East unit nourishment preparation room were brought back from [NAME] North unit nourishment preparation room. During an observation on 5/28/21 at 12:49 PM the [NAME] East unit meal cart was sent out to residents and the trays started being delivered immediately. On 5/28/21 at 12:56 PM, the second hall cart was delivered and a temperature and a taste test was conducted on a resident meal tray. The resident received a replacement. At 12:57 PM, the milk had a temperature of 55 F, and the coleslaw had a temperature of 49 F. The milk was not palatable, and the coleslaw was not cold. During an observation on 5/28/21 at 1:04 PM, with the Dining Room Manager present, the following temperatures were made from the meal tray for verification: - the milk had a temperature of 56 F using the surveyor thermometer, and a temperature of 56 F using the facility thermometer; and - the coleslaw had a temperature of 52 F using the surveyor thermometer, and a temperature of 53 F using the facility thermometer. During an interview on 5/28/21 at 1:04 PM, the Dining Room Manager stated the coleslaw bin in the container of ice bath should have been out while filling the first resident hall cart and then should be placed back in refrigerator until next cart is ready. The milk should have been poured just before hot items were placed on the food tray. It was not acceptable for cold milk to be held in a hot room for 22 minutes or longer before it was to be sent out to the floor. Although the nourishment preparation rooms were always warm/hot, he had never checked the air temperature of these rooms during meal service. During an interview on 5/28/21 at 1:49 PM, the Director of Environment Services stated there were no overhead pumps just exhaust fans in the nourishment rooms. Both doors to the nourishment preparation rooms have magnetic hold open devices on them. This would allow cooler air to flow into the room from both the hallway on the outside and the dining room on the inside. 10NYCRR 415.14(d)(1)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during the recertification survey conducted from 5/24/21-5/28/21, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety in three isolated rooms (the main kitchen, the [NAME] nourishment room, the [NAME] North staff lounge, and the [NAME] North nourishment room). Specifically, in the main kitchen there were 4 whole pork roasts not cooled safely after being cooked, miscellaneous debris on the floors of the walk-in freezer and dairy cooler, outdated food in the cooler, an unclean slicer, and a section of the hood vent was missing; in the [NAME] unit nourishment room there was a broken refrigerator; and in the [NAME] North nourishment room there were loose miscellaneous sized cup lids and cups not protected from dust/debris. Findings included: The facility Cooling and Chilling Guidelines revised 8/1/2020 documents cooked TCS (temperature control for safety)/PHF (potentially hazardous foods) food shall be cooled from 140 Fahrenheit (F) to 70 F within two hours or less and then to 40 F or below within an additional 4 hours (total maximum cooling time is 6 hours). Cooling and chilling of temperatures must be taken with a calibrated thermometer and recorded on the HACCP (a system which addresses food safety) cooling and chilling log. The undated facility policy Food Storage documents food shall be protected from contamination by storing food in a clean, dry location, in an area where it is not exposed to splash, dust, or other contamination. The facility policy Nutrition Floor Supplies revised 3/16/21 documents nutrition ambassadors shall remove any expired items from refrigerator/freezer daily and shall clean/sanitize unit refrigerators/freezers and kitchenette daily. MAIN KITCHEN 1. Food Cooling During an observation on 5/25/21 at 10:50 AM, there were four whole pork roasts (approximately 5-10 pounds each) in the main kitchen walk-in cooler covered with plastic. The pork was hot to touch. The cook #12 measured the temperature of the meat at 138-145 F using a probe thermometer. The cook uncovered and moved the pork to the walk in freezer. During an interview on 5/25/21 at 10:50 AM, cook #12 stated that the four whole pork roasts were cooked and cooled that morning. Staff normally would record the cooling process in a logbook but they forgot to enter today's pork roast into this log. The pork was cooked to 172 F and placed in the walk in cooler between 8:30 AM-9:00 AM. The meat was left with a thermometer in it to check the temp as it cooled. After one hour the pan was changed. After two hours the meat was at 138 F, covered and returned to the cooler. [NAME] #12 stated they were unsure of the cooling curve. During an observation on 5/25/21 at 11:40 AM, the pork roast temperatures were measured at 104 F. During an observation on 5/25/21 at 12:45 PM the pork roast temperatures were measured at 69 F. 2. Debris on Ground During an observation on 5/24/21 at 10:20 AM, the main kitchen walk-in freezer had miscellaneous debris on the floor under the storage racks, and there was a puddle of an unknown brown substance present on the floor in the milk walk-in cooler. During an observation on 5/25/21 at 11:10 AM, the brown puddle of unknown substance was still present on the milk walk-in cooler floor. During an interview on 5/25/21 at 11:10 AM, the Operations Manager 2 stated that the coolers racks and floors of the main kitchen were cleaned daily. During an observation on 5/25/21 at 11:15 AM, the main kitchen walk-in freezer had miscellaneous debris on the ground under the racks. There was no documented evidence the log for the cleaning of the racks and floors in the main kitchen had been completed on 5/24/21. During an observation with the Operations Manager 2 on 5/27/21 at 2:30 PM, there was water seeping along the wall in the milk walk-in cooler. During an interview on 5/27/21 at 2:30 PM, the Operations Manager 2 stated the floor in the milk walk-in cooler had been mopped the night before and the puddle was back when they came in the next day and a work order was placed that morning. 3. Broken Refrigerator During an observation on 5/24/21 at 2:18 PM, the thermometer inside the [NAME] nourishment room refrigerator measured 52 F. During an observation on 5/24/21 at 2:50 PM, the temperature inside the [NAME] nourishment preparation room refrigerator was 60 F using a state DOH thermometer and 58 F using a facility thermometer. During an interview on 5/27/21 at 1:35 PM, the Operations Manager 2 stated the temperatures of the main kitchen and the nourishment preparation room refrigerators were checked daily between 6:15 to 6:30 AM every morning by a morning supervisor. 4. Unclean Equipment/Areas During an observation on 5/25/21 at 12:55 PM, a slicer in the main kitchen was soiled with dried on food debris around the handles and control knob. The back of the blade was also soiled with food debris. During a joint interview on 5/25/21 at 12:55 PM, the Operations Manager 2 and cook #12 both stated the slicer in the main kitchen was cleaned after each use, about 4-5 times per week. The Operations Manager 2 stated that it was not clean now. During an observation on 5/25/21 at 2:17 PM, the [NAME] North nourishment room had loose miscellaneous sized cup lids and cups that were not protected from dust/debris. The uncovered cups and cup lids were located inside a cabinet. During an interview on 5/25/21 at 2:30 PM, food service worker #18 stated they could not reach or see the top shelf in the [NAME] North nourishment. They had tried to keep all shelves organized and clean and did not like clutter. There should be no loose cups/lids on the counter or on shelves. During an interview on 5/25/21 at 2:40 PM, the Operations Manager 2 stated that the cups and cup lids in the [NAME] North nourishment room should have been stored inside a container or kept inside the plastic sleeve they arrived in to avoid contamination. 5. Outdated Food During an observation on 5/24/21 at 10:20 AM, in a main kitchen walk-in cooler there was a container of pizza sauce with a discard date of 5/16/21 and a container of mushrooms with a discard date of 5/22/21. During an interview on 5/25/21 at 11:10 AM, the Operations Manager 2 stated that there was no outdated food in main kitchen coolers when they came in that morning. Managers were responsible for inspecting the walk-in coolers to check dates and remove expired items. They had not worked the previous day, and a log they had for daily checks had not been completed. If there was no discard date, the date on the label was the open date. 6. Kitchen Hood During an observation on 5/24/21 at 10:20 AM, there was one section of the kitchen hood vent that was out of place/open. During an observation on 5/25/21 at 11:26 AM, the same section of the kitchen hood vent was out of place/open. The kitchen hood label on the side of the hood documented the last time the hood was inspected was 3/29/21. During an interview on 5/25/21 at 11:26 AM, the Operations Manager 2 stated they were not aware how long the hood vent had been open and thought this had been out of place since it was done by the company that cleans the hoods on 3/29/21. 10NYCRR 415.14(h)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification survey conducted from 5/24/21-5/28/21, the facility did not maintain all mechanical, electrical, and patient care equipment in safe operating condition for 3 of 5 unit nourishment preparation rooms ([NAME] West, [NAME] East and [NAME] North) reviewed. Specifically, the [NAME] and the [NAME] North unit nourishment preparation room had electric steam tables turned on and the room was unlocked and accessible to residents. The [NAME] East unit nourishment preparation room had a steam table with a missing knob and staff were not aware if it was turned off or on. Findings include: During an observation on 5/24/21 at 2:10 PM, the small soup warmer in the [NAME] unit nourishment preparation room was turned on, in the high position, after meal service had been completed. The door to the room was unlocked and accessible for entrance. During an interview on 5/24/21 at 2:10 PM, food service worker #19 stated that all equipment in the [NAME] unit nourishment preparation room was off. When made aware that the small soup warmer was still on, they stated the food service had been running late and they had forgotten to turn off all equipment when food service was completed. During an observation on 5/24/21 at 2:50 PM, the left knob of the four bay steam table in the [NAME] East unit nourishment preparation room was missing and the table was still on. During an interview on 5/24/21 at 2:50 PM, food service worker #20 stated that all equipment was off. The [NAME] East unit nourishment preparation room four bay steam table knob had been missing since at least Sunday. During an interview on 5/24/21 at 2:50 PM, the Maintenance Director stated that a work order had been put in on the previous Friday (5/21/21) for the [NAME] East unit nourishment preparation room four bay steam table knob. During an observation at 5/24/21 at 6:00 PM, there was a four bay steam table in the [NAME] East unit nourishment preparation room turned on after the completion of the evening meal. The door to the room was unlocked and accessible for entrance. During an interview on 5/25/21 at 10:50 AM, food service worker #20 stated they had been instructed by Food Service Supervisor #17 to turn off the broken [NAME] East unit nourishment preparation room four bay steam table by unplugging it from the wall. During an interview on 5/25/21 at 12:00 PM, Food Service Supervisor #15 stated that the facility food service managers turned the equipment on in the morning, it was to be left on the entire day, and they would turn it off at the end of the day. The food service workers in that area could turn off the equipment after each meal but were then responsible for turning it back on in time for the next meal service. When the equipment was left on the doors to the room were required to be closed and locked between meal services. These small rooms tend to get hot, so staff usually preferred to turn off the equipment. During an observation on 5/25/21 at 2:20 PM, the [NAME] North nourishment preparation room was open, the dining room dark and there were no staff present. One of four bays on the steam table and plate warming units was on was hot to the touch. During an interview on 5/25/21 at 2:25 PM, food service worker #18 stated that it was the food service workers duty to turn off all equipment after each service, but the manager's responsibility to turn it on. During an interview on 5/25/21 at 2:30 PM Operations Manager 2 stated that the unit nourishment preparation rooms should be closed and locked when not in use. The Operations manager 2 and supervisors were responsible for turning on the equipment in the morning and off at the end of dinner service. 10 NYCRR 415.29