Every finding on record at Bridge View Nursing Home

Based on interview and record review conducted during an Abbreviated Survey (NY00348590), the facility failed to initiate an investigation of an alleged violation of abuse. This was evident for one (1) out of seven (7) residents (Resident #1) reviewed for abuse. Specifically, on 07/18/2024 at 4:06 PM the hospital Social Worker notified the facility's Director of Social Service that Resident #5 reported that they were physically and sexually abused while in the facility. Resident #5 also refused to be discharged back to the facility. The facility Director of Social Services did not immediately initiate an investigation to rule out abuse. The findings include: The facility policy and procedure titled Abuse, neglect, Exploitation or Misappropriation-Reporting and Investigating dated 01/2025 document that all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and to be thoroughly investigated by facility management. Findings of all investigations are documented and reported. The intake information dated 07/18/2024 at 4:06 PM documented Resident #1 was cleared to return to the facility, but the resident refused to return stating the nursing home had been physically and sexually abusive to them. The allegation was reported to the facility Social Work leadership (Director of Social Service) who stated that they are aware the resident was planning to report abuse to leave the facility. There have been no known incident and there was nothing for them to investigate. Review of the facility's grievance reports revealed there were no investigation related to the hospital report of alleged physical and sexual abuse. During an interview on 01/31/2025 at 10:10 AM, the Director of Social Service stated they received a call from the hospital social worker who stated that the nursing home staff had been physically and sexually abusive to Resident #5 and that they reported to the hospital social worker that they were aware Resident #5 was planning to report sexual abuse to leave the facility. They also stated that there have been no known incidents and there was nothing for them to investigate based on what the resident said. The Director of Social Service stated Resident #5 did not return to the facility and that they did not report the alleged allegation of abuse to the Administrator nor the Department of Health. The Director of Social Service also stated they did not investigate the alleged allegation of abuse. During an interview on 01/31/2025 at 1:11 PM, the Director of Nursing stated they were not aware of the allegation. During an interview on 01/31/2025 at 3:00 PM, the Administrator stated that they were not aware of any allegation of abuse. 10 NYCRR 483.12(c)(2)(4)

Based on interview and record review conducted during an abbreviated survey (NY00348590), the facility did not ensure that an alleged violation involving abuse, neglect, mistreatment, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involved abuse and do not result in serious bodily injury, to the administrator of the facility of the facility and to other officials including to the State Agency and adult protective services where state law provides for judications in long term care facilities) . This was evident for one (1) out of seven (7) residents (Resident #5) sampled for abuse. Specifically, on 07/18/2024 at 4:06 PM the hospital Social Worker reported to the Department of Health that Resident #5 reported that they were physically and sexually abused at the facility. Resident #5 also refused to be discharged back to the facility. The facility Director of Social Services was notified by the hospital Social Worker on 07/18/2024 at 4:06 PM, however, did not notify the Administrator, the Director of Nursing, nor New York State Department of Health. The findings include: The facility policy and procedure titled Abuse, neglect, Exploitation or Misappropriation-Reporting and Investigating dated 01/2025 document that all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. The policy further states that the administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: the state licensing/certification agency responsible for surveying/licensing the facility. Immediately is defined as within two hours of an allegation involving abuse or result in serious bodily injury. The intake information dated 07/18/2024 at 4:06 PM documented Resident #1 was cleared to return to the facility, but the resident refused to return stating the nursing home had been physically and sexually abusive to them. The allegation was reported to the facility Social Work leadership (Director of Social Service) who stated that they are aware the resident was planning to report abuse to leave the facility. There have been no known incident and there was nothing for them to investigate. During an interview on 01/31/2025 at 10:10 AM, the Director of Social Service stated they received a call from the hospital social worker who stated that the nursing home staff had been physically and sexually abusive to Resident #5 and that they reported to the hospital social worker that they were aware Resident #5 was planning to report sexual abuse as a means to leave the facility. They also stated that there have been no known incidents and there was nothing for them to investigate based on what the resident said. The Director of Social Service stated Resident #5 did not return to the facility and that they did not report the alleged allegation of abuse to the Administrator nor the Department of Health. The Director of Social Service also stated they did not investigate the alleged allegation of abuse. During an interview on 01/31/2025 at 1:11 PM, the Director of Nursing stated they were not aware of the allegation, therefore, it was not reported to the Department of Health. The Director of Nursing stated Resident #5 never made any report to them while they were employed at the facility. During an interview on 01/31/2025 at 3:00 PM, the Administrator stated that the facility was not aware of any allegation of abuse made to the Department of Health by the hospital. 10 NYCRR 482.12(c)

Based on observation and interview conducted during the recertification survey from 04/27/23 to 05/04/23, the facility did not ensure a safe, functional environment for residents, staff, and the public. This was evident during observations of the facility Elevators #1 and #2 and for 1 (Unit 3) of 5 Units. 1) Specifically, Elevators #1 and #2 were observed with loose metal handrails that were easily moved when touched and 2) the Unit 3 Nursing Station was observed with multiple loose cable wires, a broken desk, heavily faded and discolored chairs, and a loose staff sink. The findings are: 1) On 05/02 23 at 9:14 AM and 05/04/23 at 11:35 AM, Elevator #1 and #2 were observed with handrails that were not securely affixed to the elevator side wall. The handrails were loose and could be easily moved up and down when touched. The Director of Maintenance was interviewed on 05/04/23 at 10:44 AM and stated that Elevators #1 and #2 are inspected daily to ensure it is operating safely and appropriately. The handrails in the elevators are checked by maintenance once a week. 2) On 04/27/23 at 10:10 AM, the Unit 3 Nursing Station was observed with broken and missing cable wire covers leaving cable wires exposed, heavily soiled and discolored foam chairs, a missing desk drawer, and a staff sink not firmly affixed to the wall. On 05/04/23 at 09:52 AM, Unit 3 housekeeper, Housekeeper # 3, was interviewed and stated their morning routine includes collecting the garbage from all the rooms including the Nursing Station, cleaning the Nursing Station bathroom, and sweeping and mopping all of the rooms. If something is broken, there is a Maintenance Log Book on the unit. Someone checks the log book daily. 415.29

Based on observation, interviews, and record review conducted during the Recertification Survey from 4/27/23 to 5/04/23, the facility did not ensure the resident's right to a safe, clean, comfortable, and homelike environment. This was evident for 4 (Units 3, Unit 4, Unit 5, Unit 6) of 5 Units. Specifically, 1) Unit 3 was observed with walls with mismatching paint, plaster, broken tiles, and holes throughout multiple rooms, loose cable wires, a shower room in disrepair, and radiators that were dirty and in disrepair, 2) Unit 4 was observed with missing window blind blades, torn wallpaper, and holes in the wall, and 3) Unit 6 was observed with white spackled paint in multiple rooms and radiator covers in disrepair. The findings are: 1.) On 04/27/23 at 10:10 AM, Unit 3 was observed with the following: a) Shower room [ROOM NUMBER] had a sink not firmly affixed to the wall, broken wall tiles, missing borders inside the shower stall, and a Hoyer lifter wrapped with surgical tape stored in the room. b) Shower Room # 2 was observed with rusty radiator covers, missing radiator covers exposing the inner grills, was littered with an accumulation of dirt and debris, broken wall tiles, a shower chair with frayed mesh, and no grab bars in the toilet area. c) The 2 corridor bathroom accordion doors were observed with a black substance all along the bottom of the door. d) Both corridor bathrooms were missing the toilet paper holder and the metal faucet handles were loose and rusty. e) room [ROOM NUMBER]A had large white patches of paint along the walls, loose cable wires along the wall, and broken bathroom wall tiles. f) room [ROOM NUMBER]A/B had a broken cracked wall space below the mounted TV, spackled white paint patches on the walls, and peeling/torn wallpaper above the head of 305B. g) room [ROOM NUMBER]A had 6 holes and short cable wires along the wall. h) room [ROOM NUMBER] had dirt-streaked walls, an air conditioner cover with dust and debris and rusty radiator covers. i) room [ROOM NUMBER] had plaster on the wall above their bathroom mirror that had bubbled and was protruding, missing radiator covers exposing the inner coils littered with a thick accumulation of dirt and debris, multiple patches of white paint on the walls, multiple black scratches, and markings on room door. The Unit 3 Maintenance Book did not document staff reports of the observations listed above from 4/1/23 to 5/4/23. On 05/04/23 at 09:52 AM, Unit 3 housekeeper, Housekeeper # 3, was interviewed and stated they clean the shower room daily, sweep and mop all the rooms, wipe down the room furniture, and if something is broken, they use the Maintenance Logbook to write down the issue. Someone checks the book daily. On 05/04/23 at 10:13 AM the Certified Nurse Aide (CNA) # 3 was interviewed and stated that there is a Maintenance Logbook on the unit for the staff to write what needs repairing on the unit. CNA # 3 stated that only one of the two shower rooms are currently being used and the other is used for storage of resident equipment. 45988 2.) On 4/27/23 at 11:20 AM and 4/28/23 at , Unit 4 was observed with the following: a) room [ROOM NUMBER] had window blinds with 2 missing slats, blinds that did not slide to close all the way, several holes in the wall, patched up and peeling wallpaper, and mismatched floor tiles b) room [ROOM NUMBER] had window blinds with 1 missing slat and peeling wallpaper above bed A. On 04/27/23 at 11:20 AM, Resident #101 stated they were unhappy with the state of their room. The blinds didn't work well and they did not like having mismatched floor tiles and patches of different colored wallpaper. Resident #101 stated they complained to staff about the issues and was told the facility would take care of them, but nothing was done. On 05/03/23 at 9:58 AM, Housekeeper #2, assigned to Unit 4, was interviewed and stated they work on projects all over the building, such as buffing floors and changing blinds and curtains. The nurse calls them if there is a broken blind or dirty curtain, and they go to the floor and fix it. Housekeeper #2 stated that maintenance oversees replacing wallpaper and painting. There is a maintenance book where requests are put in for maintenance staff. On 05/04/23 at 10:51 AM, Registered Nurse (RN) #2 was interviewed and stated that the facility has an ongoing painting project that started months ago and is nearly completed. If a specific room needed attention or if they saw something not working, RN #2 calls maintenance to get it fixed. How long it takes to fix depends on maintenance's workload. Requests go in the maintenance book and RN #2 calls them for urgent matters. On 05/04/23 at 11:15 AM Maintenance Worker # 1 was interviewed and stated check daily for water and A/C temperature, call bell functioning, exit signs, Hoyer lifts. They also check the maintenance books for any problems or broken things. Sometimes they glue back the peeling wallpaper. Maintenance Worker # 1 stated there was a contractor who started a renovation project within in the facility, but they left. 37787 3) On 5/2/2023 at 3:24 PM and 5/3/2023 at 12:23 PM, the following was observed on unit 6: a) room [ROOM NUMBER] had a baseboard heater cover in disrepair. b) room [ROOM NUMBER] had window blinds that were broken. c) room [ROOM NUMBER] had multiple white painting spots on the wall. d) room [ROOM NUMBER] had a window seal in disrepair. On 05/04/2023 at 12:35 PM, the Registered Nurse (RN) # 3 was interviewed and stated that there was an ongoing painting project in the building and that's why there are white patches. On 05/04/23 at 10:44 AM, the Director of Maintenance/Director of Housekeeping (DOMH) was interviewed and stated they were hired by the facility 1 month ago. Housekeepers are assigned to every floor and are given monthly schedules. The DOMH is currently fixing many things in the building and makes routine rounds. Loose cable wires should be stapled to the wall to minimize accidents and for aesthetics reasons. The DOMH ordered support metal brackets which will be placed on the lower ends of the loose sink. There are no other sinks in the facility that are loose. The bubbled wall above the bathroom sink in room [ROOM NUMBER] is due to a possible leak. The cable wires should be placed in a cable molding or cable covers. Some televisions were removed from the walls and now there are loose cable wires. 415.5(h)(1) 415.29(j)(1)

Based on interviews and record review conducted during the Recertification and Complaint Survey (NY00311134) from 4/27/23 to 5/4/23, the facility did not ensure all alleged violations involving abuse were reported immediately to the NYSDOH, but not later than 2 hours after the alleged occurrence. This was evident for 2 (Resident #72 and #53) of 4 residents reviewed for Abuse out of 35 total sampled residents. Specifically, an altercation involving Resident #72 and #53 was not reported to the NYSDOH within a timely manner. The findings are: The facility policy titled Resident Abuse, Mistreatment and Neglect revised 5/2018 documented the Administrator or Director of Nursing (DON)/ Designee must report allegations of abuse immediately but no later than 2 hours after the alleged incident. Resident # 72 had diagnoses of Alzheimer's disease and depression. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident # 72 was severely cognitively impaired. Resident # 53 had diagnoses of schizophrenia and diabetes mellitus. The MDS dated [DATE] documented Resident # 53 was cognitively intact. The Accident/Incident (A/I) Report dated 2/17/2023 documented Resident #53 cursed at Resident #72 and Resident #72 hit Resident #53 on the left arm. Resident # 53 complained of pain on the left shoulder, an X-ray was ordered, and no fracture was documented. Nurse Practitioner Note dated 2/17/23 documented left shoulder x-ray was ordered for Resident #53. Nursing Notes dated 2/17/23 and 2/18/23 documented Resident #53 refused to have an x-ray of the left shoulder. The Aspen Complaint tracking System (ACTS) report dated 2/21/23 at 10:00 AM documented the facility reported the incident involving Resident #72 and #53 to the NYSDOH, more than 2 hours after the alleged occurrence. On 5/4/2023 at 12:59 PM the DON was interviewed and stated the resident-to-resident altercations involving Resident # 72 and Resident # 53 were investigated by the facility and it was determined no abuse occurred. The facility has 5 days to report the incident to the NYSDOH. On 5/4/2023 at 01:15 PM the Administrator was interviewed and stated they believed resident-to-resident altercations must be reported to the NYSDOH in the mandated timeframe. 415.4(b)(2)

Based on observation and interviews conducted during the recertification survey from 04/27/23 - 05/04/23, the facility did not ensure separately locked, permanently affixed compartments were provided for storage of controlled drugs and other drugs subject to abuse. This was evident for 1 (Unit 5) of 5 Medication Rooms reviewed for Medication Storage. Specifically, the Unit 5 Medication Room was observed with a broken narcotics box lock preventing the door from being locked with a key. The findings are: The facility policy titled Controlled Substance/Narcotic Management Protocol dated 01/2023 documented all controlled substance blister packs/medications will be stored in a double locked cabinet affixed to the wall in the medication rooms. On 04/28/23 at 11:15 AM, the narcotics box in the Unit 5 Medication Room was observed with an outer door that was closed and locked. Licensed Practical Nurse (LPN) #1 was present during the observation and used 1 key to open the outer lock of the narcotics box. The 2nd inner door of the narcotics box was observed with a broken lock and was opened without the use of a 2nd key. The narcotics box contained 2 blister packs of medication labeled Lorazepam and Clonazepam 0.5 mg. LPN # 1 was immediately interviewed at the time of the observation and stated they did not realize the lock was broken today. LPN # 1 counted the narcotics this morning during change of shift and removed medications earlier from the narcotics box to place them in the medication cart. The LPN #1 stated that it is important to keep narcotics double locked to mitigate easy access and possible theft. On 04/28/23 at 11:40 AM, the Registered Nurse Supervisor (RNS) #1 was interviewed and stated they became aware the narcotics box on Unit 5 had a broken lock on the inner door 2 to 3 weeks ago. RNS #1 inspected the Medication Room, noticed the narcotics box lock was broken, and reported it to a maintenance worker who is no longer employed by the facility. RNS #1 did not follow up and inform any other maintenance worker about the broken narcotics box lock. The Director of Nursing (DON) was interviewed on 05/04/23 at 8:31 AM and stated, they were never informed there was a narcotics box with a broken lock. Controlled substances must be safeguarded and stored under 2 locks and 2 keys. The nurse is to report any storage issues immediately to the DON and to the maintenance department. 415.18(e)(1-4)

Based on observation, interview, and record review conducted during the recertification survey from 4/27/23 to 5/4/23, the facility did not ensure full visual privacy for each resident. This was evident for 1 (Unit 5) of 5 Units. Specifically, there were multiple resident rooms without privacy curtains. The findings are: On 4/27/2023 at 11:00 AM, Certified Nursing Assistant (CNA) was observed changing Resident #47's incontinent brief on the far side of the room at the B bed. The A bed was empty. There were no privacy curtains in the room and the door to the room was left ajar. On 4/27/2023, 4/28/2023 and 5/1/2023 Unit 5 was observed with the following: 1. room [ROOM NUMBER], a 2-bedded room, with no privacy curtain or shade for 506A and 506B 2. room [ROOM NUMBER], a 3-bedded room, with no privacy curtain or shade for bed 506C 3. room [ROOM NUMBER], a 2-bedded room with no privacy curtain for bed 506A The Unit 5 Maintenance Logbook dated 4/1/23 to 5/4/23 documented no staff reports of missing privacy curtains. On 05/02/23 at 09:57 AM, Registered Nurse (RN) #1 stated they informed the Director of Housekeeping/Maintenance ([NAME]) verbally about installing curtains in resident rooms where they are missing curtains. RN #1 reported the missing curtains 1 week ago and forgot to follow-up to see if the curtains were installed. On 05/04/23 at 11:26 AM Housekeeper #1 was interviewed and stated Unit 5 is not their regular unit and if there is no curtain in the room, they do not know what to do. On 05/04/23 at 10:44 AM and 12:46 PM, the [NAME] was interviewed and stated they started working there a month ago and now ordered 20 curtains to go into the rooms that need them. It is important to have privacy curtains in the resident rooms for the resident's own personal privacy. 415.29

Based on record review and staff interview conducted during the Recertification survey from 4/27/23 to 5/4/23, the facility did not ensure that the Minimum Data Set (MDS) 3.0 Assessments were electronically transmitted to the Centers of Medicare/Medicaid Services (CMS) within 14 days of completion. This was evident for 31 of 31 residents reviewed for Resident Assessment (Resident #24, #25, #26, #162, #170, #3, #4, #6, #12, #19, #20, #32, #33, #39, #44, #67, #76, #85, #90, #107, #113, #118, #125, #130, #141, #142, #153, #164, #165, #171, and #178) Specifically, MDS submissions for Resident #24, #25, #26, and others were submitted to CMS more than 14 days after the completion date. The findings are: The facility policy titled MDS Completion and Submission Timeframes dated 01/2023 documented the Assessment Coordinator or designee is responsible for ensuring that resident assessments are submitted in accordance with current federal and state guidelines. 1) Resident #24: MDS completion dates were documented as 5/20/2022, 11/21/2022, 1/6/2023, and 4/24/2023. The submission dates were documented as 6/13/2022, 12/8/2022, 2/15/2023, and 4/30/2023. The MDS submission dates were more than 14 days after the completion dates. 2) Resident #25: MDS completion dates were documented as 6/03/2022, 10/06/2022, and 1/06/2023. The submission dates were documented as 6/22/2022, 11/2/2022, and 2/8/2023. The MDS submission dates were more than 14 days after the completion dates. 3) Resident #26: MDS completion dates were documented as 7/6/22, 11/13/2022, and 4/2/2023. The submission dates were documented as 7/28/2022, 12/7/2022, and 4/28/2023. The MDS submission dates were more than 14 days after the completion dates. On 05/04/23 at 09:39 AM, an interview was conducted with MDS Coordinator (MDSC) who stated there was a shortage of staff in the department that affected the submission of MDS assessments in 2022 and the transition of electronic medical record (EMR) system from the old to the new one in March 2023 also affected the MDS submission in early 2023. The MDSC stated they monitored the MDS completion and submission status every day for compliance. On 05/04/23 at 09:56 AM, the Assistant Director of Nursing (ADON) was interviewed and stated they oversaw the MDS department last year in 2022 because there was shortage of staff in the MDS Department. There were only 2 MDS assessors working last year in 2022 and they were not able to submit MDS assessments in a timely manner. The MDS staff had to assist with transitioning to the new EMR and did not have time to follow up the MDS submission in a timely manner in the first quarter of 2023. 415.11(a)(5)

Based on interview and record review conducted during an abbreviated survey (Complaint # NY 255), the facility did not ensure that a resident was free from physical abuse. This was evident in 1 of 3 residents sampled for physical abuse (Resident #1). Specifically, on 1/2/2018 at 6:25 PM, a Licensed Practical Nurse (LPN) witnessed a Certified Nursing Assistant #1 (CNA #1) slapped Resident # 1 in his face and punched him in his head in the presence of other residents in the dining room. The findings are: The Facility's Policy and Procedure titled Resident Abuse, Mistreatment, and Neglect revised on 10/25/2017 documented that the facility has taken the steps within its control to prevent abuse, neglect or mistreatment of [REDACTED]. The policy defines the term abuse as inappropriate physical contact with nursing home patient/resident, while such patient or resident is under the supervision of the facility, which harms or is likely to harm the patient or the resident. The policy indicates that inappropriate physical contact includes, but is not limited to striking, pinching, kicking and shoving. Resident # 1 was initially admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Minimum Data Set, (MDS, a resident assessment tool) dated 11/19/2017 documented that Resident #1 had long/short-term memory impairments and was severely impaired, never/rarely made decisions. Review of the Abuse Prevention updated Care Plan dated 11/27/2017, revealed that Resident #1 was at risk for abuse. The interventions included ongoing assessment of specific behavior, staff to individualized approach to care, Staff to monitor behavior that may lead to conflict, staff to observe the resident whereabout and redirect as necessary, and staff to observe and monitor changes in behavior. The care plan did not include instructions on what staff should do if Resident #1 becomes agitated or combative. Review of the Nursing Assistant Accountability Record for 12/2017 to 1/2018 , revealed that there were no instructions on how CNAs to respond to the resident when the resident becomes agitated and combative. The Facility's Incident Report dated 1/2/2018 documented that on 1/2/2018 at around 7: 00 PM, a nurse informed the Nursing Supervisor that CNA #1 slapped Resident #1 on his face and punched him on his head. CNA #1 was immediately removed from duty. Resident #1 was assessed with [REDACTED]. The resident denied pain and discomfort. A nursing progress note, by Nursing Supervisor, dated 1/2/2018 documented that the body assessment revealed no injury, no swelling and no sign and symptoms of pain. The resident denied pain and discomfort. The doctor was notified and ordered neurological checks every 4 hours for 24 hours. CNA #1 was interviewed on 11/5/2018 at 9:55 AM and stated that Resident #1 was agitated and combative and that she was trying to prevent the resident from hitting her face. She said that she did not hit Resident #1. She pointed out that the LPN was in the day room but did not assist her with the combative resident. CNA # 2 was interviewed on 11/2/2018 at 3:44 PM and stated that she observed Resident #1 tried to hit CNA # 1. CNA # 1 attempted to hold the hands of Resident #1 to prevent him from hitting her. It appears that Resident #1 hit CNA # 1. CNA # 1 and Resident #1's hands were both in the air. The LPN was interviewed on 11/2/2018 at 12:13 PM and stated that Resident #1 was agitated; he stood up from the chair and was swinging his arms in the air. She said that Resident #1 did not hit CNA # 1. She pointed out that she observed CNA # 1 slapped Resident #1 in his face and punched him in the head. She told CNA #1 that she should not do that and she reported the incident to the Nursing Supervisor. During an additional interview with the LPN on 11/19/2018 at 4:04 PM, she said that Resident #1 had a history of [REDACTED]. The Director of Nursing (DON) was interviewed on 11/20/2017 at 3:14 PM and stated that the CNAs' accountability record does not specify what the staff should do when the resident becomes combative and aggressive. The interventions were in the care plan and not in the accountability record. The nurse's interventions for the agitated resident should be separating the resident from the staff to lessen the agitation and call the supervisor immediately. Anticipate the resident's needs and allow the resident to settle down. She stated that there was no instructions documented on the accountability record. 415.4(b)(1)(i)

Based on observation, record review and interviews conducted during a Recertification survey, the facility did not ensure that they had a policy regarding the use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. Specifically, the facility did not provide accommodations for heating and storage of food brought to residents from outside the facility. This was evident for all residents in the facility. The finding is: The facility Admission Packet contains a welcome document containing information about the services provided by the facility. The Welcome to Bridge View Nursing Home packet documented the following under the topic of Food: The facility is a Kosher facility. The facility recognizes that the involvement of a resident family member can be very beneficial to the resident's nutritional status. Therefore where appropriate and possible, staff will encourage family members to participate in the resident's dining experience. Family members are allowed within the confines of the facility policy to bring in foods that are compatible with the resident's diet and diet consistency. We respectfully ask, however, prior to doing this that you consult with nursing/social work/dietary so that their correct process is undertaken to ensure resident safety and adherence to the facility kosher laws/requirements. The facility policy for Feeding Family Participation (undated) documented that resident representatives are allowed to bring in outside foods that are compatible with the residents' therapeutic diet and diet consistency. The residents' representatives are also encourage to participate in meal oriented activities, such as holiday party and barbecues and by assisting with feeding the residents. Prior to bringing in outside food, the resident or representative must make a request to the Director of Recreation or the Dietician regarding the desire to bring in outside food. The family is then contacted and counseled regarding any therapeutic restrictions. The family is then instructed on the procedure to be followed. The procedure includes: (1) inform dietician before mealtime if an entire meal is to be brought in; (2) bring food in covered container to the nurse; (3) the nurse will oversee meal consumption; and (4) all leftover food is brought home by the family. The Policy further documented that all perishable food brought into the facility must be fully consumed within 1 sitting or brought back home by the family. The facility policy and procedure for Kosher Foods dated 5/2018 outlines the facility's Kosher food requirements. The policy documents the following: Bridge View Nursing Home is a Kosher Facility. This means all of it's operations must meet the requirements of Kosher Laws. The facility will ensure that all food preferences are honored within the confines of the Kosher policy and practice and make appropriate accommodations where possible. The facility's Kosher laws are overseen and managed by a full-time rabbi. Residents will be informed prior to admission and upon admission that the facility is Kosher. The facility does not have any separate non-Kosher designated eating areas. Should a resident have a non-kosher food preference, this will be discussed with the resident and resident representatives to ensure suitable and alternative choices/options are made available. This will include but not limited to restaurant choices, consumption of food in their rooms, and informed choice with regard to any potential health/safety concerns. The facility has 200 beds. The census at the time of the survey was 191 residents. The Facility Assessment, last reviewed (MONTH) (YEAR), included an attachment with a detailed breakdown of religious and ethnic group by resident. The attachment documented that the facility had 21 Jewish residents. The majority of the residents served by the facility do not require a Kosher diet based on their religious beliefs and/or personal convictions. On 9/24/18 at 10:35 AM and 9/27/18 at 12:30 PM, the Administrator was interviewed. He stated that the facility is licensed as a Kosher facility, the residents are made aware of the Kosher rules. Residents must speak to the Social Worker, Nursing, and Dietician prior to having outside food brought in to make sure it is safe and consistent with their diet. Any non-Kosher cooked items brought in must be consumed within one sitting. Any food left over or perishable items, such as dairy, that cannot be consumed are discarded. Residents cannot store any perishable items in the refrigerators on the unit. Residents are allowed to eat non-Kosher food in their rooms only, and there is no space in the facility outside of resident rooms where non-Kosher food can be eaten. Non-Kosher meals brought in from outside should be brought in ready to eat. He stated that the facility does not have any microwaves where residents can heat up food. He further stated that if the residents needed to heat something up, the food service can possibly set up sterno, but this has never been done or requested. The facility does not encourage residents to re-heat food. If a resident wants a non-Kosher item, we do accommodate them, but if they wanted non-Kosher items as a part of their regular diet, maybe this is not the place for them. The Administrator stated that if residents would like to have food brought in for something special, like a birthday party, it can be accommodated, but residents cannot constantly bring in food. The residents are provided with Kosher take-out menus if they want to order food from outside. Usually, it is about wanting a certain type of food, and there are Kosher options for different types of food in the community. The Administrator stated that the facility's rabbi is very strict. He stated that he is aware that other Kosher facilities have designated non-Kosher areas for residents to utilize, but the facility does not have one. On 09/25/2018 at 11:45 AM, an interview conducted with the Resident #184. The resident stated that she was aware of the facility policy regarding Kosher foods. She stated she was told that the facility is Kosher and they are not allowed to bring any other food to the facility. The resident further stated that she was offered a list of restaurants that sell Kosher foods when she was admitted to the facility in (MONTH) (YEAR). She stated that she plans to leave soon, that she is here for a short period of time. This resident also stated that she has never attempted to buy food outside because she doesn't have money to do so. Her money is not yet coming to the facility. On 09/25/2018 at 11:55 AM, an interview conducted with Resident #157. The resident stated that she was aware that the facility is Kosher. She stated that upon admission, she was told that she cannot bring any food in that is not Kosher. She has never tried to store any food in the facility. The resident stated that her son visits and brings her food every Wednesday, but she does not think the staff are aware. She eats the food in her room. A telephone interview was conducted with the son of Resident #113, on 9/25/18 at 4:28 PM. Resident's son stated that he does not recall the resident or himself being educated and informed regarding the facility's Kosher status prior to or upon admission. He does not believe that the facility ever explained to him or the resident what the Kosher restrictions are and how food options for the resident would be limited. The facility has never stated anything to him about bringing in outside food. He has brought in food for resident before (i.e. candy, cookies, pastries, and other small food items) and assumed there was no issue. The resident always ate any food items that were brought in for her in her room. The facility never explained any policies about food storage. Resident's son stated that he had brought in cookies a few months ago. He left the package of opened, partially eaten cookies in resident's bedside drawer. Presently, resident has been downgraded to a puree diet with thickened liquids; therefore, resident's son does not believe that resident would be able to order any outside food at this time. On 9/25/18 at 11 AM, the unit 5 pantry and unit were observed. There were no resident personal food items inside the pantry refrigerator. The refrigerator contained juices and milk provided by the facility kitchen. There was no microwave in the unit pantry or anywhere else on the unit. On 9/26/18 at 10:20AM, Unit 3 was observed. There was no microwave on the unit. The unit pantry had a refrigerator that contained food items from the kitchen. On 9/27/18 at 10:15 AM, Unit 6 was observed. There was no microwave on the unit. The refrigerator kept in the pantry was observed. It only contained food items from the kitchen. On 09/27/18 at 10:19 AM an observation of the food pantry on 2nd floor was completed. There were no personal food items (for residents or staff members) observed in pantry fridge. There is no microwave in the pantry or on the 2nd floor unit. On 9/26/18 at approximately 11AM, Registered Nurse (RN#1) was interviewed. She stated that food brought into the facility must be Kosher as per the Rabbi's order. The RN also stated that the staff inform family about the Kosher guidelines when they come in with food. The RN further stated that the pre-packaged foods will have a Kosher label also, and the staff will check all foods brought to the facility. She stated that, as per the refrigeration of food, we make sure only Kosher foods are kept and ensure they are properly labeled. Food can only be kept for 24 hours before it is discarded. There is no reheating or cooking of outside foods in the facility. On 09/27/18 at 02:18 PM the Licensed Practical Nurse (LPN #9) on the 3rd floor was interviewed. She stated she is aware of the kosher policy. There is no fridge and microwave on the units for resident use. Residents eating non-kosher foods must eat in their room. On 09/27/18 at 02:03 PM, an interview conducted with the Registered Nurse Supervisor (RN #8) on the 3rd floor. She stated she is aware of the policy that food brought in by the resident's family and visitors must be eaten in their room. Non- kosher foods cannot be stored on the unit or reheated because there is no refrigerator and microwave on the unit. This is the facility policy. The families are aware that when they bring in food, they should inform the staff and the resident will eat in their room. On admission, the families and residents are informed of the policy regarding the Kosher dietary restriction and that is enforced with family and staff. On 9/27/18 at 10:30 AM, the Registered Nurse (RN#5) on the 6th floor was interviewed. She confirmed that there is no microwave kept on the unit, and that no there is no refrigerator for non-kosher food on the unit. She stated that the refrigerator in the pantry is meant for only Kosher items. She stated she was not sure if residents are allowed to store food in the facility, but all food in the pantry refrigerator is from the kitchen. She further stated that so far, she has not heard of any issue with non-kosher food needing to be stored. On 9/27/18 at 10:38 AM, the Licensed Practical Nurse (LPN#3) on the 6th floor was interviewed. She reported that the refrigerator in the pantry is for resident's snacks and perishable items brought from the kitchen and from some family members that are Kosher. The LPN said that only the fruits brought by non-Kosher family members are also stored in the fridge after they are labeled and dated. She stated that if any food item brought in is not fruit and non-kosher, the family members are advised to see the Social worker and dietary for arrangements on how to store the food. She confirmed that there is no refrigerator on the floor for non-kosher food, and there are no microwaves. She stated that no family member is allowed into the fridge and that only Kosher food, fruit, and water are stored in the fridge. On 9/27/18 at 12:39 PM, the Food and Nutrition Director was interviewed. She stated that there are no microwaves in the facility. She said that they do not have microwaves because of safety factors and the Kosher policy. She stated if a resident brings food in, it is supposed to be for one-time consumption. The refrigerators in the pantry are just for kosher items. Residents are advised not to bring non-kosher food that needs to be refrigerated. Only nursing, dietary and housekeeping staff are allowed to go into the refrigerators. Residents are not supposed to go in the refrigerators. Nursing staff goes in to bring out stuff for the residents as needed, dietary replenishes them with items needed, and house-keeping goes in to clean them. Only Kosher foods are stored in the refrigerators as per the facility's Kosher policy. On 09/27/18 at 10:21 AM, an interview was conducted with CNA #11 on the 2nd floor. She has been employed with the facility for 7 months. The CNA#11 stated that the dayroom aide is responsible for securing all food items in the fridge. Residents are able to store their food in the fridge and the food is labeled with their names. Residents' food can only be kept for 24 hours and then the resident is informed that their food will need to be removed. First and foremost the nurse on duty is informed and that nurse ensures that only kosher food is placed in the fridge. The aide is aware that this is a kosher facility and only kosher food should be stored. CNA#11 always asks the charge nurse what to do first if a resident were to bring in non-kosher food items to be stored (especially meat items) in the pantry fridge. This is especially since dairy is kept in that same fridge. CNA#11 has not encountered an issue with heating up food at the facility. She has never been asked to heat up food. CNA#11 is unaware how food would be heated up if it was requested by resident. On 09/27/18 at 10:29 AM an interview was conducted with CNA#6 on the 2nd floor. CNA#6 has been an aide with the facility for approximately [AGE] years. She uses the pantry fridge to store juices, puddings, ice cream and sometimes residents' personal food items (dated and labeled). The food is not kept for more than one day. Some residents have asked to have non-kosher food stored in the fridge. She stated that she informs the charge nurse of the request, and the resident is informed that the facility is kosher. The CNA#6 will still store the personal food items for the residents in the pantry fridge with the permission of the nurse. The CNA#6 stated there is no way to heat up food in the facility, especially non-kosher food. On 09/27/18 at 10:35 AM an interview was conducted with LPN#2 on the 2nd floor. The LPN#2 has worked in the facility for approximately 5 years. He states that facility snacks, milkshakes, some sandwiches, and resident's supplements are stored in the pantry fridge. Residents are not allowed in the pantry and are not allowed to store food in the fridge. The LPN#2 states that the facility's Rabbi is very strict about the kosher designation. No outside food is allowed in the facility without the Rabbi's personal authorization. Residents/Family members have requested to store items and the LPN has had to tell them that it is not allowed. The LPN#2 is not aware of the Rabbi/Administration giving any special permission to any resident to store food. If a resident requests to have food from the kitchen re-heated, then a new tray is sent from the kitchen. The LPN#2 is not aware of a way to heat up food. Residents/Next of Kin are made aware of policy once they are admitted . On 09/27/18 at 10:42 AM, an interview was conducted with RN#4 on the 2nd floor. The RN#4 has worked for facility for approximately 1 month. Patients' supplements and juices are generally stored in the pantry. Residents may be able to use it depending on whether the food they are storing is in accordance with kosher guidelines. Resident's food, if approved, can be stored for a short amount of time and then disposed of. RN#4 has not had any family members or residents request to use the pantry. If she were asked to store non-kosher items, then the RN#4 would inform the resident/family member that non-kosher items cannot be stored, but they can request food from the kitchen. RN#4 is not aware of how or if the kitchen can actually heat up food for residents. On september 27, (YEAR) at 10:47 AM, Certified Nursing Assistant, (CNA) # 10 reported that no microwave has been provided since she has been working in the facility for over 2 years. She stated that the refrigerator in the pantry is for resident's perishable food that are Kosher, and that she has never really checked if there is mixture of kosher food or non-kosher in the fridge, but only know that they keep food from the kitchen and fruits brought for other residents that are labelled before stored in the fridge. She said that kitchen staff and the day room aids are allowed to use the fridge, and that she doesn't think they allow non- kosher food in the fridge. She stated that I have never seen any resident ordering food from outside since I have been here. The CNA stated that staff are not allowed to bring food from outside to the facility. An interview was conducted with the Risk Manager on 09/27/18 at 02:08 PM. She stated that she is knowledgeable that there is only Kosher food in the facility. On admission all families and residents are informed this is a Kosher facility. Food cannot be brought in the facility unless prior arrangements are made and the family is instructed by the dietician concerning appropriate foods for the resident based on the diet orders. Any of the clinical staff can reinforce the policy with families, residents and visitors. The policy states non-kosher foods cannot be warmed up or stored in the facility. There are no microwaves or refrigerators on the units that can be utilized for warming or storage of food. A resident who wishes to eat non-kosher foods is expected to eat in their room and the facility provides disposable utensils for the consumption of the food. Any food left over must be bagged and taken out of the facility. Staff are educated on the policy as needed and at least annually. 415.14(h)

Based on observation, and staff interviews during the recertification survey, the facility did not ensure that personnel transported linens so as to prevent the spread of infection. Specifically, housekeeping staff was observed transporting linens in uncovered carts throughout the basement and in elevators used by the public. This deficient practice had the potential to affect the entire facility. The Policy and Procedures on Laundry and linens dated on (MONTH) (YEAR) documents, Policy: An adequate supply of clean linen shall be maintained for the facility through safe and sanitary laundry procedures. The laundry service processes soiled linen so that the risk of disease to residents and to employees who handle these linens is minimal. Procedures: The Director of laundry services will work closely with the infection control committee to establish and maintain consistently high standards. All laundry employees will be expected to attend inservice programs pertaining to infection control. All clean linen will be covered during transportation to mitigate the risk of contamination. The findings are: On 9/26/18 around 3:30 PM the State Agency surveyor (SA) observed Housekeeper pulling two large carts of clean linens, towels, hospital gowns to the elevator. Both carts were opened and uncovered. The blue covering was rolled up on top of cart with additional linens. The housekeeper entered the elevator from the basement to go the the unit to supply the units with clean linen supplies. Immediately after observation the SA (state agency surveyor) interviewed the Housekeeper. The SA asked the housekeeper what was he instructed or trained on how to deliver clean linens on the floor. The housekeeper stated he was not instructed or trained on how to deliver these items on the unit. Stated he would not allow residents to be on the elevator when bringing up the clean linen carts. He would drop off the linens on the unit and if there are residents in the hallway he would cover the carts. On 09/27/18 at approximately 12:56 an interview was conducted with the Director of Housekeeping. The director stated that the housekeeper who the SA observed, fills in two days a week when the other housekeeper is off in the evening. The housekeeper covers the 8-4 PM and 3-11 PM shifts. He works 4 days a week. He is normally the person that brings the 3-11 supplies such as linens, towel, gowns on all units for the 3-11 shift. He trains the staff and inservice them three to four times a year. The last time the staff was inserviced was (MONTH) 28,2018. The SA asked what is the policy and procedure in transporting linens, hospital gowns and towels? The Housekeeping Director stated that when they transport linens and gowns to all units the carts are suppose to be covered. They transport the two carts and go from unit to unit to fill the carts on each unit. 415.19

Based on observation, record review, and staff interviews conducted during the Recertification survey, the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice. Specifically, a resident with skin tears to bilateral lower legs did not receive proper assessment and treatment. This was evident for 1 out of 3 residents reviewed for Skin Conditions (non-pressure). (Resident #137) The findings are: Resident #137 is a resident admitted [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 dated 8/21/18 documented that resident had severely impaired cognition. The MDS further documented the resident did not have any skin tears or open [MEDICAL CONDITION]. The resident required the extensive assist of one person for dressing, personal hygiene, and toileting. The resident required physical help in part of bathing activity. The resident was observed on 09/19/18 at 9:24 AM with redness, dry looking scaly skin, and maroon colored scabs on bilateral lower shins. The resident also had fresh blood oozing from open areas next to the scabs on his shins and trickling down both legs. Resident indicated that he gets itchy and scratches himself causing the skin openings. A wanderguard was present on resident's left lower leg and was constricting and coming into contact with the exposed open areas. The resident was able to maneuver the strap of wanderguard down to his ankle and a red impression was left around resident's shin. There were slight streaks of blood from resident's shin left on the strap of the wanderguard. During the observation, the State Agent (SA) asked the resident what happened to his legs. The resident was unable to respond verbally, but he gestured using a scratching motion with his hands to show that he scratched his legs. Resident was again observed on 09/20/18 at 09:13 AM with fresh and dried blood on bilateral shins in the same area as the previous day. Oozing from the open areas and scaly skin were observed. Resident was out of bed and dressed in same clothing as previous day. The Comprehensive Care Plan (CCP) for Pressure Ulcer/Skin Break, updated on 8/22/18, was triggered as a result of dry skin to bilateral lower legs related to pressure ulcer. The expected outcome is for resident to be free of infection, be free of pain, adhere to infection control precautions and to avoid prolonged pressure to skin. The interventions documented staff are responsible for providing ongoing assessment of pressure ulcer/ skin break, providing treatment as per Medical Doctor (MD) order (Ammonium [MEDICATION NAME]/[MEDICATION NAME] as ordered), notifying MD of any changes, and providing lotion for dry/fragile skin. The Physician's (MD) Orders dated 9/18/18 documented treatment orders for [MEDICATION NAME] twice daily for dry skin and Ammonium [MEDICATION NAME] external lotion 12% once daily for dry skin. There were orders for wanderguard to left ankle. The Medication Administration Record [REDACTED]. The Ammonium [MEDICATION NAME] Lotion was provided from 9/19/18 to 9/23/18. The Ammonium [MEDICATION NAME] Lotion was not provided on 9/24/18. The resident was given [MEDICATION NAME] BID on 9/19/18. The resident was only provided with [MEDICATION NAME] once daily on 9/20, 9/21, 9/22, and 9/23/18. The resident was not provided with [MEDICATION NAME] on 9/24 and 9/25/18 at all. The Nursing Notes, Physician's Notes, Care Plan, and physician's orders [REDACTED]. There was no documented evidence in the medical record that the resident was assessed or treated for [REDACTED]. On 09/25/18 at 09:43 AM, an interview was conducted with the resident's regularly assigned Certified Nursing Assistant (CNA), CNA#2. CNA#2 has been employed with the facility since 2014 and has cared for the resident since his admission to the facility in 5/2018. CNA#2 stated she provides assistance with dressing, grooming, and tray setup for meals. CNA#2 also assists with showers upon the resident's request. CNA#2 further stated she is aware that resident has a condition where his lower shins are irritated and that he scratches at times until there is bleeding/scabs. CNA#2 had previously made the Registered Nurse/Charge Nurse (RN#4) of the unit, aware of this condition at the beginning of (MONTH) (YEAR). The resident's treatment orders were then changed from [MEDICATION NAME] to the current lotion/treatment that the resident receives. CNA#2 stated that she has not recently reported anything within the past few weeks to the nursing staff regarding resident's condition. On 9/25/18, an interview was conducted with RN/Charge Nurse, RN#4. RN#4 confirmed that at one time, she had been informed by the resident's CNA#2 that the [MEDICATION NAME] ordered for resident was not effective and that he continued to scratch at his bilateral lower legs. RN#4 contacted the Nurse Practitioner (NP) and resident's treatment order was changed to Ammonium [MEDICATION NAME] in order to address the dry skin/itching. There was no treatment ordered for any excoriation. RN#4 stated that any and all open areas and scabs observed on residents are reported immediately to the MD/NP. If deemed necessary, an incident report is completed. RN#4 stated that in order to cleanse the area the staff generally use normal saline solution, but any further treatment is determined by the NP/MD. RN#4 stated she has not been doing treatments for residents within the past few weeks because a new treatment nurse had been doing the treatments. She stated that she was not aware of any new concerns or issues with the resident's skin. Once the SA made RN#4 aware of the skin openings observed, she stated that the NP would be informed of the scabs on the resident's lower extremities. An interview was also conducted with the regular Licensed Practical Nurse (LPN), LPN#2, on 09/25/18 at 10:05 AM. LPN#2 stated that he was the nurse that completed the treatment with Ammonium [MEDICATION NAME] and [MEDICATION NAME] to resident's bilateral lower shins today. LPN#2 only noticed some scratch marks and redness without the presence of open skin areas. LPN#2 stated that he did notice a few small dried scabs. LPN#2 stated that once open areas are noticed, then normal saline is used to clean the area and possibly [MEDICATION NAME]. LPN#2 also stated that the RN would be made aware in order to determine if further intervention for open area is needed and to ensure that the NP/MD was made aware. On 09/25/18 at 10:38 AM, LPN#2 was brought to resident's room to observe the condition of resident's bilateral lower legs. LPN#2 observed that the resident had multiple dried scabs and redness covering the shins of resident. LPN#2 denied observing any open areas to resident's shins within the past few weeks. LPN#2 denied signing off on MAR indicated [REDACTED]. Upon returning to the nursing station on the 2nd Floor Unit, LPN#2 proceeded to speak with the NP in order to inform him of resident's condition. On 9/25/18 at 10:48 AM, the NP was interviewed after he assessed the resident. The NP stated that he was unaware of any open areas or concerns with the resident's lower extremities within the last week, including 9/19 and 9/20/18. The NP stated that currently there is an open area to the right lateral side of resident's calf. He has ordered for resident's leg to be cleansed with normal saline, pat dry, and apply [MEDICATION NAME] daily and as needed. He also stated that the Ammonium [MEDICATION NAME] orders will be changed from once daily to twice daily. On 09/27/18 at 11:49 AM an interview was conducted with the DON. The DON stated that when CNAs take care of residents, they are supposed to tell the nurse if there are any skin conditions. The LPN will assess and will inform the supervisor. The MD/NP will be contacted to evaluate whether there will be any orders for treatment. Upon admission, the RN is responsible for reporting any skin conditions and/or open skin areas. The CNA should inform the LPN immediately if they note any open areas and/or scratches. Each discipline should immediately inform the next person to address resident care (CNA to the LPN, LPN to the RN, RN to the MD/NP). The concern should be reported no later than the end of the shift. The the nurse will then document any changes to a resident's condition in their Nursing Notes and will endorse to the next shift using the 24 Hour Report. The LPN who works the next shift, will validate the orders and ensure it is on the Medication/Treatment Record. The RN supervisor follows up to ensure treatment is provided. The LPN is responsible for simple applications of any simple treatments such as lotion. The RN is responsible for the larger more complicated wounds (i.e. pressure ulcers). However, LPNs are trained and can do all types of wound care if necessary. On 9/26/16, all nursing staff that had been scheduled to work on resident's unit on 9/18 and 9/19/18 (LPN#2, LPN#3, LPN#4, and RN#4) denied signing for or providing [MEDICATION NAME] and Ammonium [MEDICATION NAME] treatments to resident's shins on 9/18 and 9/19/18. This matter was brought to the Director of Nursing's(DON) attention in an effort to locate the LPN or RN that provided treatment to the resident for 9/18 and 9/19/18. The DON was unable to identify the nurse that signed the treatment record for resident on 9/18 and 9/19/18. 415.12

Based on record review and staff interviews conducted during the Recertification survey, the facility did not ensure the pneumococcal immunization was offered to a resident. Specifically, the facility did not ensure that the [MEDICATION NAME] vaccine was offered to a resident. This was evident for 1 out of 5 residents reviewed for Influenza and Pneumococcal Immunizations. (Resident # 137) The finding is: The facility's undated Policy and Procedure for Resident [MEDICATION NAME] Vaccination Program documented that The [MEDICATION NAME] vaccine is to be given to all residents who have no prior documented evidence of receiving it. All new admissions are to be assessed for the need for this vaccine as part of the admission medical work-up. Resident #137 is a resident admitted [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 dated 8/21/18 documented the resident had severely impaired cognition. The resident's medical record contained blank flu and [MEDICATION NAME] forms. There was no Flu Vaccine/Pneumococcal Vaccine Comprehensive Care Plan (CCP) in the medical record. The Immunization Record documented that on 6/8 and 6/10/18, the resident was given a PPD test. The Influenza/Pneumococcal Vaccine Information Education form present on resident's chart contained only one printed side of a double sided form. It was also lacking a signature of RN/LPN and/or signature of resident. The [MEDICATION NAME] Screening Checklist was present and blank. There was no Vaccination Declination Form present on resident's chart. There was no documented evidence in the medical record that the facility educated the resident or the resident's representative about the [MEDICATION NAME] Vaccine and offered the vaccine. On 09/25/18 at 04:00 PM, Registered Nurse (RN #3) was interviewed. RN#3 stated that resident declined [MEDICATION NAME] upon admission; however, provided no documentation of a refusal and could not verify when/by whom the vaccination was offered. RN#3 stated that there should be a declination form in the chart. In the event that a resident refuses flu and/or pneumococcal immunization, a form is to be initiated by the Social Work Department (SWD) that indicates that the resident and/or next of kin (NOK) was educated and provided with risks and benefits of refusal. A CCP should also be initiated. She confirmed that there was no CCP on the chart. On 09/27/18 at 11:22 AM, an interview with resident's friend/Designated Representative (Des Rep) was conducted. The Des Rep has known the resident for approximately [AGE] years. The Des Rep is the director of the resident's former residence/adult home. The Des Rep has been contacted by facility for the initial Interdisciplinary CCP meeting. The De Rep stated that she has no idea about any vaccination/immunization offerings. The facility never discussed this with her. An interview was then conducted with the Director of Social Service (DSS) on 09/27/18 at 12:28 PM. The DSS has been employed with facility for approx 7 months. She stated the social worker is responsible for being part of the process to educate residents and Des Reps regarding the risks and benefits of the flu vaccine if they refuse. The Social Work Department does not provide education or counseling to residents who decline [MEDICATION NAME] vaccines. The Social Work Department is not made aware of any pneumococcal immunization refusals. On 09/27/18 at 12:00 PM and 12:35 PM, the Director of Nursing (DON) was interviewed. According to the DON, upon admission, a resident's pre-admission package is checked to evaluate whether the resident has had vaccinations prior to admission. The admitting nurse checks specifically for Flu/Pneumococcal/[MEDICAL CONDITION] vaccinations. If none are located, the RN/LPN for the unit is responsible for contacting the Des Rep to find out whether the resident has had any vaccinations. This information should be obtained within the 1st week of admission or at least prior to the initial Interdisciplinary CCP meeting. Letters are sent to the family for residents with cognitive impairment re: flu season and the flu vaccine. Pneumococcal vaccinations for long-term residents will be documented on the immunization record to ensure that each eligible resident receives the vaccine every 5 years. If the resident/Des Rep is unable to say whether resident has had a vaccine, the Physician (MD) will be made aware. The MD will then determine whether it is safe to provide vaccination to the resident. Nursing should document in the nursing notes whether they are able to find the vaccination information and whether the MD was contacted. The DON stated that in the event that a resident refuses a vaccination offering, the resident or Des Rep will fill out and sign a declination form. The RN and/or LPN and/or MDs are responsible for providing education regarding the risks and/or benefits of refusing vaccination once the resident and/or Des Rep refuses. This procedure is the same for any of the vaccines offered by the facility, including flu or [MEDICATION NAME]. A notation is then made in the Nurses' Notes documenting the refusal. 415.19(a)(1)

Based on observation and interview, during the Recertification survey, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety to prevent foodborne illness. Specifically, 1) employees were observed touching resident food with bare hands during meal service; 2)Beard nets were not used by kitchen staff; 3) food boxes were observed stored on the floor and close to the ceiling; 4)staff were observed touching raw chicken meat in the kitchen and then touching other items without removing gloves and properly sanitizing hands; 5) dented cans were observed being stored among cans stored for use; 6) staff were observed preparing foods to be served from dented cans; and 7) potentially hazardous cold foods were not held at the proper temperatures during tray line. This was evident for 1 of 6 dining rooms observed in the Dining Observation (3rd floor) and the Kitchen Observation. The findings are: The Kitchen Policy and Procedure dated (MONTH) (YEAR) documented: 1)General Food Preparation and Handling - Food Storage - Foods will be received, checked and stored properly as soon as they are delivered. Food in broken packages or swollen or dented cans will not be served. Food will be prepared and served with clean tongs, scoops, forks, spoons, spatulas, or other suitable implements to avoid manual contact of prepared foods. 2)Food and Safety Sanitation - Employees are required to have their hair styled so that it does not touch equipment or food, and to wear clean aprons and shoes:(NAME)nets are required. Food stored in dry storage is placed on clean racks at least 6 inches above the floor, 18 from the ceiling. Dented cans are to be placed in the dented can shelves in the storeroom. 1) On 09/18/18 at 09:38 AM, the brief initial tour of the Kitchen was conducted with the Food Service Director (FSD). The following was observed: Two kitchen staff members were observed with facial hair and beards without beard nets. A Dietary Aide, with a beard approximately 1.5 inches in length, was observed tending to garbage and not wearing a beard net. The rabbi, with a beard approximately 6 inches in length, was speaking to a member of the kitchen staff who was grinding meat in the meat grinder. During the same tour, a kitchen staff member was observed washing and touching raw chicken with gloved hands. He then used the same gloved hands to touch other utensils and to grab plastic spice bottles to season chicken. The staff member grabbed the spice bottles by the lid and was observed with fingers protruding into the cap of the spices. No hand washing or glove change was observed. The basement dry food storage room was also observed during the brief kitchen tour. Five boxes of rice were observed on a hand truck on the floor of pantry. The boxes were directly touching the floor even though the hand truck was partially underneath them. Several food boxes in the pantry were approximately 1/2 inch from a drop ceiling partition. The drop ceiling provided a partition between the food boxes and the pipes that were protruding from the ceiling. On 09/21/18 at 09:17 AM the Kitchen and storage areas were observed again. The following was observed: A kitchen staff member was observed scraping food from dishes into a garbage can. The staff member had a beard and no beard net was being utilized. A 2nd kitchen staff member placing empty metal bins in the hot food station to set up for lunch service was also observed with a beard and no beard net in use. The dry food storage area in the basement was observed. There were 3 dented cans of(NAME)Harvest diced potatoes 100 oz and 3 dented cans of Pudin De Vanilla 100 oz on a regular stock shelf to be used for resident consumption. They were not on the dented can shelf. The FSD noticed 2 out of the 3 dented cans of potatoes and 2 out of the 3 dented cans of vanilla pudding that the State Agent (SA) observed and moved them to the dented can section. There were also 2 boxes of pepper packets piled all the way up to drop ceiling and touching the base of the drop ceiling. A box of zesta saltine crackers and a box of butter, oatmeal, chocolate chip cookies were observed approximately 1 inch from drop ceiling. Upon return to the Kitchen, one can of dented Beets 100 oz was observed on a salad prep table near the back of kitchen. Dietary Aide #1 was observed opening the dented can for use in preparation of the salad for the lunch to be served that day. The FSD confirmed beet salad was on the menu. An interview was conducted with Dietary Aide #1 (DA #1) on 09/21/18 at 10:23 AM. DA#1 stated the kitchen staff do not use dented cans. If dented cans are observed, it is reported to the supervisor and they are taken out of use. He believes that they are then sent back to the manufacturing company. DA#1 stated that dented cans are not used because something in the metal causes the food to go bad. An interview was conducted with Dietary Aide #2, on 09/25/18 at 11:21 AM. DA #2 was observed in the kitchen with a beard and no beard net in use. He has worked in facility for approximately [AGE] years. He stated that beard protectors are used to prevent any contamination of food. DA #2 uses the beard protector when in the kitchen but takes it off when exiting kitchen. DA #2 stated that he did not currently have a beard net on because his co-worker asked for assistance with placing lids on soup for lunch today. He further stated had just come in from outside and did not have a chance to put it on. The policy is to have it on at all times when in the kitchen, but most importantly, when working with the food. An interview was conducted with Dietary Aide #3, on 09/27/18 at 09:15 AM. DA #3 is currently responsible for the store room/pantry in the basement. When he receives shipments of cans, he tells the FSD if there are any dented ones so they can be sent back to manufacturer. He stated the boxes should not be piled higher than a certain level that is designated by a line on the wall in the basement. He uses this line as his guide to ensure that boxes are not piled too high. DA #3 stated the drop ceiling is a part of the ceiling, and boxes should not be touching or piled too close to these portions of the ceiling. Once shipments are received, the food items are immediately placed on a crate to prevent them from touching the floor. Items should not be stored on or touching the floor due to the floor being dirty. There are general inservices that cover some information regarding policies of the kitchen, and there is ongoing education and training to ensure that staff are aware of policies. An interview was conducted with the FSD following the observations on 09/18/18 at 09:38 AM and 09/21/18 at 09:17 AM. The FSD was also interviewed on 09/26/18 at 08:59 AM. The FSD stated that spices are used for the entire meat section and not just for chicken. She also stated that the work station will be sanitized once the raw chicken has been prepared, although she offered no explanation as to how the individual spices would be sanitized. The FSD stated that she was not sure when the boxes of rice on the hand truck were going to be used, how long they had been on the floor, or when they would be moved. The FSD stated that the boxes should not have been left on the floor. The FSD stated that the facility does not consider the drop ceiling to be part of the ceiling, so boxes do not need to be 18 inches away from it. The FSD stated that there is a dented cans section where dented cans are stored until they are returned to the corresponding manufacturing company. The FSD stated that the stock person receives the delivery and should be checking the cans, but it is everyone's responsibility in the kitchen to ensure that dented cans are not used for resident consumption. She stated that dented cans can cause a toxicity and compromise the integrity of the food and should not be used. The FSD stated that all kitchen staff are expected to wear beard nets if they have facial hair.(NAME)nets should be put on as soon as staff enter the kitchen, regardless of what task they may be completing. If there is any hair that is hanging below the chin (no matter the length) then the staff needs a beard net. If staff are seen without a beard net, they are instructed to put it on. There are inservices and staff education done to ensure that all staff are aware of this policy, but the FSD was unsure when the last inservice was done. 2) A tray line observation was conducted on 09/25/18 at 11:37 AM. The Food Service Director (FSD) presented a digital thermometer and proceeded to calibrate the thermometer prior to testing. The FSD proceeded to retrieve a cold tuna salad sandwich from a tray prepared on the tray line. The initial temperature of the tuna sandwich was 68 degrees Fahrenheit (F). The FSD then proceeded to remove all tuna salad sandwiches from the service carts and replaced them with fresh tuna sandwiches from the kitchen refrigerator. The DFS brought a new tuna sandwich from the refrigerator to be tested . The temperature of the replacement tuna sandwich was 57.2 F. On 09/26/18 at 08:59 AM, the FSD was interviewed. The FSD stated that staff has been educated that sandwiches (including the tuna sandwiches) should be kept on ice in order to maintain proper internal temperatures. The FSD stated that cold items should be kept at below 40F degrees. Temperature checks are conducted by the kitchen manager 2 to 3 times weekly. Spot checking is also done in order to ensure temperatures are within acceptable range. The last temperature check was done the prior week. There is a log that is kept for the hot food temperature checks, but there is no log currently kept for the cold food. She stated that they will be implementing a log for the cold food in the future. 3) On 09/18/18 a lunch observation was conducted in the 3rd floor dining room. The following was observed: At 12:18 PM, a Certified Nursing Assistant (CNA) # 4 was observed peeling a banana for a resident. She took the banana out of the peel with her bare hands and placed it on the resident's plate. CNA #1 previously attended to another resident and did not wash her hands. She was observed pushing another resident's chair closer to the table after setting up the tray for the resident and did not wash her hands before touching the banana. At 12:37 PM, CNA # 3 picked up a slice of buttered bread from the tray of resident with her bare hands, folded the bread, and gave it to the resident. On 09/19/18 at 12:00 PM, a second lunch observation was conducted on the 3rd floor. At 12:30 PM, CNA # 5 was observed removing a tea bag from the wrapper. She picked up the tea bag and touched the part that holds the tea with her bare hands, then placed it in the cup of hot water on a resident's tray. On 09/25/18 at 11:18 AM an interview was conducted with CNA # 4. She stated she is aware that she should not touch the resident's food with her hands, and she must adhere with washing her hands before and after attending to a resident in the dining room. She further stated she attended an in-service on maintaining infection control precautions about two weeks ago. On 09/25/18 at 11:43 AM an interviewed was conducted with CNA # 3. She stated she was instructed on infection control precaution in the dining room setting, and she must wash her hands before and after she attends to a resident. She was last in-serviced about two weeks ago on maintaining infection control precautions. On 09/26/18 at 02:27 PM an interview was conducted with CNA # 5. She stated that she is aware she must wash her hands before and after attending to a resident in the dining room, and she must not touch the resident's food with her hands. She was in-serviced about two to three weeks ago on food safety and maintaining infection control precautions. On 09/27/18 at 09:10 AM an interview was conducted with the Registered Nurse (RN) Supervisor # 8 on the third-floor unit concerning the policy and procedure in the serving of food in the dining room. All staff must wash their hands before serving the trays. The staff are instructed on food handling precautions and infection control precautions. Additionally, the staff are instructed to wash their hands if they touch any part of their body when serving meals. 483.60 (i) (2)

Based on observation, record review and interviews conducted during the Recertification survey, the facility did not ensure that dental services were provided for a resident. Specifically, a resident who needed dental follow-up for cleaning and three crowns did not receive the necessary follow-up appointments. The two appointments that were scheduled were cancelled by the facility, and the resident was not provided information regarding when the services would be provided. This was evident for 1 out of 9 residents reviewed for Dental (Resident #43). The Finding is: The facility policy on Dental Consultation dated (MONTH) 15, (YEAR) documented that all residents requiring specialty medical care, including dental, must be evaluated by a specialty physician in or outside the facility. Routine, emergency, and denture (lost or damaged) referrals will be ordered by the primary physician. The Licensed Nurse will ensure that the dental consultation follow-up is ordered by the Primary Physician and schedule for follow-up is made. The Licensed Nurse will also ensure that the resident and/or representative are notified of any changes. Resident #43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimal Data Set ((MDS) dated [DATE] documented the resident had intact cognition and no behavior problems. The MDS further documented the resident had no dental concerns. On 09/19/18 at 09:54 AM the resident was interviewed. The resident stated she had not seen a dentist for follow-up, and two appointments were cancelled. She further stated she has gum disease,e and she is having problems with her teeth. The physician's orders [REDACTED]. The Dental Consult Report dated 6/13/18 documented the resident was seen for broken teeth and X-rays. The treatment plan section documented three crowns were needed, and the resident had to return for dental cleaning and crown preparation for teeth # 7, 8, and 29. The nurses progress note dated 6/13/18 at 12:00 PM documented the resident returned from the dental appointment at 3:25 PM. The note further documented the next dental appointment was scheduled for (MONTH) 27th at 10:00 AM. There was no documented evidence in the medical record that the resident saw the dentist after 6/13/18. There was no documented evidence in the medical record that the resident had any cancelled or refused dental appointments. On 9/21/18 at 10:30 AM, the Risk Manager (RM) was interviewed. She stated that she could not provide any information regarding the dental follow-up because there was no documentation in the medical record. On 9/24/18 at 09:29 AM and 09/25/18 at 12:12 PM an interview was conducted with the Risk Manager. She stated that on 8/27/18 the dental clinic called the facility and cancelled the appointment. The AA received the call on 8/27/18. The RM stated that on 9/21/18 she asked the AA to follow-up with the dental clinic to find out about the resident's dental appointments. It was confirmed that the resident had a dental appointment at the clinic on 11/12/18. There was no documentation in the record that the resident was informed of the scheduled dental appointment on 11/12/18. On 9/24/18 at 11:09 AM, the Administrative Assistant (AA) was interviewed. She stated that she was not aware of the status of the resident's dental follow-up appointments as of 9/21/18. She further stated the Risk Manager requested she contact the dental clinic on 9/21/18 to find out information about the resident's dental appointments and cancellations. The AA stated that the dental clinic informed her that the called the facility on 8/27/18 to cancel the dental appointment due to the absence of the hygienist. The resident's appointment was rescheduled for 9/4/18, but that appointment was later cancelled by the dental clinic and rescheduled for 11/12/18. She stated she was not aware of the staff person who received the verbal cancellation notice from the dental clinic. Information regarding dental appointments may be called directly to a nurse on the unit or the administrative receptionist by the dental clinic. Different clinics contact the facility in different ways. Transportation arrangements must be facilitated by her department. On 9/26/18 at 09:44 AM an interview was conducted with the Registered Nurse Unit Supervisor (RN #8) related to the policy and procedure for scheduling a dental appointment. She stated that after the resident returns from a dental appointment, the consultation note is reviewed by the licensed nurse who reports the recommendations documented on the note to the Primary Care Physician (PCP). If necessary, he/she will obtain a verbal order from the physician to proceed with scheduling an appointment with the dental clinic for further treatment. The licensed nurse will enter the telephone order in the electronic medical record, inform the family of the plan of care, and complete the nurses progress note concerning the event and the plan. The information is put on the twenty-four-hour report by the licensed nurse. The licensed nurse is also responsible for providing the administrative office with the necessary information concerning the scheduled dental appointment. The administrative office is responsible for arranging the transportation. 415.17(a-d)

Based on observations and staff interviews during the recertification survey, the facility did not ensure that medications were stored at proper temperatures. Specifically, [MEDICATION NAME] flex pens for two residents were kept on the medication cart unopened and not stored in the refrigerator until ready to use. This was evident for one of five medication carts inspected. The finding is: On 09/21/18 at approximately 12:01 PM the 4th floor medication cart was checked with LPN #6. The following Insulin pens were stored in the medication cart and not stored in refrigerator: 1. One (1) [MEDICATION NAME] pen (RX: 276) for Resident #198 which was dispensed on 9/17/18 containing 100 units of insulin. 2. One (1) [MEDICATION NAME] pen (RX: 519) for Resident #25 which was dispensed on 9/17/18 containing 100 units of insulin. The LPN#6 was immediately interviewed and stated that unopened insulin pens should be stored in the refrigerator until they are to be used. Otherwise, the Insulin may not be effective in controlling blood sugar. She further stated that the nurse who receives medications from the Pharmacy will check that all of the meds sent from the Pharmacy are received and will sign the Pharmacy paper. The nurse will receive a receipt from the Pharmacy which is retained on the unit but the nurse does not sign that paperwork. On 09/27/18 at approximately 11:43 AM, RN#2 was interviewed and stated that the nurse who receives the medications will sign a tablet from pharmacy delivery person. No record is kept here regarding who would have signed for medications. Medication delivery is at various times during day, evening and night. On 09/27/18 at approximately 11:45 AM, LPN#7 was interviewed and stated that all of the new Insulins are placed in refrigerator until they are needed for the resident. He also stated that his routine in the morning is he checks that flex pens are not out of date when he checks the Medication Cart and the refrigerator . He stated that he was not the Medication Nurse on 9/17/18. 415.18(e)(1-4)

Based on record review and interview conducted during the Recertification Survey, the facility did not ensure that the resident's drug regimen was free of unnecessary medications. Specifically, the psychiatrist ordered a dosage reduction in [MEDICATION NAME] and the initiation of [MEDICATION NAME] for a resident. The medication changes were not given as ordered resulting in the resident receiving extra doses of [MEDICATION NAME] and no [MEDICATION NAME]. This was evident for 1 of 5 residents reviewed for Unnecessary Medications (Resident #177). The finding is: Resident #177 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment ((MDS) dated [DATE] documented the resident had severely impaired cognition. The MDS further documented the resident received antipsychotic medication. The physician's orders [REDACTED]. The Drug Regimen Review (DRR) dated 9/11/18 documented the following recommendation regarding the resident's [MEDICATION NAME]: The resident was receiving [MEDICATION NAME] as a monotherapy (using a single drug to treat a condition) with the [DIAGNOSES REDACTED]. Please evaluate and consider trial taper to discontinue and, if necessary, add antidepressant. The Physician (MD) signed the DRR and documented that he agreed with the recommendation and would follow-up with Psychiatry. The Psychiatry Consult dated 9/22/18 documented the resident had [DIAGNOSES REDACTED]. The consult further documented that the resident has behavior and dysphoric mood secondary to Dementia, and [MEDICAL CONDITION] medication is not the first line of treatment and not clinically justified. The plan recommended was a [MEDICATION NAME] taper to discontinue the medication as follows: change the [MEDICATION NAME] to 25 milligrams (Mg) BID (twice per day) for 7 days, then reduce to 25 mg HS (at bedtime) for 3 days, then discontinue. The consult also documented recommendations to start the resident on [MEDICATION NAME] ([MEDICATION NAME]) 100 mg q (every) HS for 7 days and then 100 mg BID. The MD signed the consult The physician's orders [REDACTED]. [MEDICATION NAME] 25 mg tablet- 2 tablets by mouth twice daily for 7 days starting 9/22/18 and ending 9/28/18; [MEDICATION NAME] 25 mg tablet- 1 tablet by mouth at bedtime for 3 days starting 9/29/18 and ending 10/1/18; [MEDICATION NAME] 100 mg capsule- 1 capsule by mouth at bedtime for 7 days starting 9/22/18 and ending 9/28/18; [MEDICATION NAME] 100 mg capsule- 1 capsule by mouth twice daily starting 9/29/18 and ending 10/28/18. The Medication Administration Record (MAR) covering 9/6/18 to 10/6/18 documented the resident continued to receive [MEDICATION NAME] 25 mg 3 times daily from 9/22/18 to 9/26/18 at 10:00 AM, 2:00 PM, and 5:00 PM. The MAR did not contain any administrations of [MEDICATION NAME] 100 mg capsule at bedtime. The resident received 5 extra doses of [MEDICATION NAME] and missed 5 doses of [MEDICATION NAME]. The new medication orders were never transcribed to the MAR by the nurse. The 24 Hour Patient Care Record reports dated 9/22/18 to 9/26/18 did not contain any information regarding Resident #177 and the medication changes. On 9/27/18 at 02:00 PM, the MDS Registered Nurse (RN #5) was interviewed. RN #5 stated that Resident #177 was seen by psychiatrist on 9/22/2018 and recommendations were given to decrease the [MEDICATION NAME] and start [MEDICATION NAME]. The RN Supervisor, RN #7, entered the new orders in the system and the blister packs never came. She further stated the error was discovered today and she called the MD to inform him of the situation. The MD agrees to start with the orders today. The orders from 9/22/18 will be discontinued. The pharmacy delivered the [MEDICATION NAME] to the facility on the night of 9/22/18. The resident never received the [MEDICATION NAME] or the [MEDICATION NAME] reduction as ordered from 9/22/18 to 9/26/18. On 9/27/18 at 02:20 PM, the Pharmacist was interviewed. The Pharmacist stated that the pharmacy received an order on 9/22/18 at 2:08 PM for [MEDICATION NAME] 25 mg BID and [MEDICATION NAME] 100 mg HS (at bedtime). On 9/9/18, the facility received 90 tablets of [MEDICATION NAME] 25 mg due to the previous orders for [MEDICATION NAME] TID, so the facility should use the [MEDICATION NAME] on hand. [MEDICATION NAME] will be sent to the facility again on 10/7/18. The [MEDICATION NAME] was requested on 9/22/18 at 2:26 PM and delivered to the facility on [DATE] at 10:30 PM. On 09/27/18 at 03:58 PM, the evening Licensed Practical Nurse (LPN #5) was interviewed. LPN #5 stated that she worked on 9/22/18 during the evening. She stated that it was endorsed to her that the psychiatrist saw the resident, but she was not informed of any new orders. Resident #177 was not on the 24 hour report. She also stated she does not remember receiving any medication for the resident. LPN #5 stated that if the psychiatrist sees a resident during her shift, she should document it on the 24 hour report, enter follow-up in the computer, and pick up any new orders which go straight to the pharmacy via the computer. The MAR should be printed and put in the book. The 3-11 shift is responsible for entering the order on the MAR, and the day shift would also verify the order. On 9/27/18 at 05:04 PM, the RN Supervisor (RN #7) was interviewed via phone. She stated that she has worked in the facility for 3 years. She confirmed that she worked the day and evening shift on 9/22/18. On 9/22/2018, the psych doctor came to the facility and saw resident #177 on the 6th floor around 10 am. He told her that he was going to change the order for the [MEDICATION NAME]. She reviewed the consults, picked up the orders, and printed the MAR. She further stated she gave the MAR to LPN #5 on the floor. While she was picking up the orders, she entered her name, but she did not pay attention to log-in user on the computer. She looked at the screen and noticed RN #6, the night shift supervisor, was logged into the system instead of herself. RN #7 stated that she signed out and signed-in again and thought everything was going to be okay. She then noticed the supervisors's name again so she cancelled, turned of the computer, and re-started the computer. Her name came up after closing the computer and turning it back on. The policy is that all nurses on the shift when the order is written are responsible for picking up the order. Sometimes the nurse on the floor does it and sometimes the supervisor would put them in depending on how the day is going. Normally once you pick up the orders, they are transferred automatically to the pharmacy because they are link with our system. Pharmacy normally delivers medications to the floor except for narcotic, only supervisors are responsible to receive and sign for them. I remembered printing out the MAR and delivering it to the nurse (LPN #5) after dinner that Saturday. On 09/27/18 at 04:49 PM, the surveyor attempted to reach RN #6 (Supervisor), but there was no answer. 415.12(l)(1)

Based on record review and staff interviews conducted during the Recertification survey, the facility did not ensure care plans were reviewed and revised after each assessment. Specifically, the facility did not ensure that a resident's care plan was updated on the resident's readmission to include a new [DIAGNOSES REDACTED]. (Resident #113) The finding is: Resident #113 is a resident, readmitted [DATE], with a [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 dated 7/03/18 documented the resident had moderately impaired cognition. The MDS further documented that resident is able to express wants and needs and has the ability to understand others. The Readmission record dated 9/10/2018 documented the resident was readmitted from the hospital with a new [DIAGNOSES REDACTED]. The physician's orders [REDACTED].@ 4L/MIN via nasal canula continuous and a [DIAGNOSES REDACTED]. The Comprehensive Care Plans (CCP) included in the resident's active chart included no care plan for Respiratory Oxygenation/Ineffective Breathing. The Care Plans contained no documentation regarding the resident's new oxygen orders or [DIAGNOSES REDACTED]. A Comprehensive Care Plan Respiratory Oxygenation/Ineffective Breathing Care Plan dated 4/30/2018 was found in the resident's debrided chart. The CCP documented that the resident has a history of pleural effusion. The CCP was last updated on 7/10/2018 and documented the resident was receiving O2 2L/MIN via nasal canula PRN. There was no documented evidence in the medical record that the Respiratory Oxygenation/Ineffective Breathing CCP found in the debrided chart was updated with the resident's new [DIAGNOSES REDACTED]. [REDACTED]. In addition, the Respiratory Oxygenation/ Ineffective Breathing CCP was not kept in the resident's active chart that was being used by staff to determine resident's current plan of care. An interview with the Registered Nurse (RN#3) was conducted on 9/26/2018 at 2:37 pm. The RN#3 stated that the resident was readmitted to the facility and placed on a different unit. The old CCP book could not be located, therefore a new CCP book was initiated. The RN#3 acknowledged that there was no Respiratory Oxygenation/Ineffective Breathing CCP included in the new CCP book and that the old CCP had not been updated. The RN#3 stated that a part-time staff member from MDS is responsible for filling out all Nursing related CCPs including the Respiratory CCP. An interview was conducted with the Director of Nursing (DON) on 9/27/18 at 11:46 AM. The DON stated that the nurse manager for the unit would be responsible for filling out and ensuring that a Respiratory CCP is in place. The MDS Coordinator and RN collaborate and are responsible for ensuring that CCPs are present in the chart and that they are reviewed and updated as needed. 415.11(c)(2)(i-iii)

Based on observations, record review and interviews during the recertification survey, the facility did not ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain, grooming, and personal hygiene. Specifically, Resident #25 was not provided assistance with cleaning and maintenance of prosthetic eye as recommended by consultant Optometrist. This was evident for one resident reviewed for Activities of Daily Living out of a sample of 35 residents. The facility's Policy, Procedures and Information entitled: Medical Consultation was reviewed. It documented: Purpose: To ensure continuity of medical needs. Procedure: 9. The Primary Physician will review and document findings and recommendations by the Consulting Physician including follow-up visit. 10. The Primary Physician will give a telephone order or write an order of the findings and recommendations by the consulting physician. The finding is: Resident #25 is [AGE] years old with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] documented that the resident has a BIMS score of 14/15, indicating intact cognition. He requires extensive assist of one person for transfers, toileting, and personal hygiene. On 9/21/18 at approximately 9:33 AM resident #25 was observed not wearing eyeglasses and his left eye was closed. Thorough out the survey from 9/19 to 9/27/18, the resident did not wear eyeglasses and his left eye was closed. No discharge or drainage was observed from either eye during the entire survey from 9/18/18 to 9/27/18. The Optometry consult (Facility's green sheet) dated 7/11/18 was reviewed. It was ordered on [DATE] for: complaint of left eye weakness. The bottom of green sheet documented: DX(diagnosis): Prosthetic OS (left eye) Rec: (recommend): clean with saline PRN (as necessary). Use [MEDICATION NAME] lid wipes q (every) AM/PM, glasses ordered. F/U (follow-up) 6 months/PRN. This form was co-signed by the Nurse Practitioner (NP). Optometry (white form): seen 7/11/18. A/P (assessment/plan): h/o (history of ) ocular trauma OS (left eye) and complete [DIAGNOSES REDACTED] (drooping upper eyelid). Daily lid hygiene, clean prosthesis w/saline PRN. Co-signed by MD #2. The Physician order [REDACTED]. There were no orders instructing nursing staff to clean the Prosthetic left eye with saline PRN (as needed) and to use [MEDICATION NAME] lid wipes every AM/PM. On 09/19/18 at approximately 1:22 PM the resident was interviewed. The resident told the State Surveyor, that he told a nurse a month ago, that his glasses were no good and no action was taken. On 9/21/18 at approximately 9:33 AM resident #25 was observed not wearing eyeglasses and his left eye was partially closed. Thorough out the survey from 9/19 to 9/27/18, the resident did not wear eyeglasses. The State Surveyor did not observe nursing staff cleansing prosthetic eye. On 9/26/18 at approximately 12:00PM: resident stated to State Surveyor that he has had a left eye prosthesis since 1992. On 9/21/18 at approximately 10:07 AM CNA #1 was interviewed. She stated that she knows the resident over one year and he is steady on her assignment. She gets report in the morning from the charge nurse if there are any changes for the resident. He is able to make his needs known and gets around the facility in a wheelchair. She stated that he has one natural eye and he has one prosthetic eye, it is the left eye. She stated that she cleans his left eyelid and lower inner/outer eye area for him daily. She uses cold water and a soft wash cloth to clean around his left eye, and dries it. He has no c/o pain or discomfort. The resident does not have any manufactured cloth that is provided to her to clean his left eye. She does not take out the prosthesis and she never saw the resident remove his prosthetic eye. She continued to state that she never had any specialized cleaning cloth for his eye lid care. She stated that she never received any instructions from RN#1 or RN#2 regarding left eye lid care. On 09/24/18 at approximately 12:43 PM an interview was conducted with Nurse Practitioner. He stated that he co-signed the facility's green consult sheet and dated it. He stated that he looked at it and gave it back to MD #2. He stated that when he signs the form it means he (NP) agrees to the recommendations but the Medical Doctor makes the final decision. He does not follow up with the Medical Doctor regarding the recommendations. The green sheet goes into the alert book also known as the Physician Communication Book. This is a black binder which is kept on top of the nurse's desk. MD#2 has his own section for his patient's consults in this book. The Interim Progress Notes were reviewed with NP. He could not find any documentation where the Physician wrote that he reviewed the consultant's paperwork. The nurse's notes were reviewed with NP. There is no documentation that the nurse reviewed the consultation report, or gave it to MD#2 on 7/11/18 or afterwards. On 09/25/18 at approximately 12:33 PM a telephone interview was conducted with MD#2. He stated that the resident was followed by another doctor at that time. The consultant's recommendations are supposed to be picked up by Nursing. The process is that the Consult comes to the doctor, then it is referred to the Nursing Supervisor. The Nursing Supervisor will pick up orders from consult sheet. The Nursing Supervisor will always discuss the consult with him. He tells them to follow the recommendations, he sees the consult and signs the report. Any consult is supposed to be picked up by Nursing when reviewed by the doctor. He stated that he was not the attending physician at the time of the consult, however, he did sign the report. The patient was switched to another doctor and he did not follow-up with the patient's care. If the accepting physician has questions, he will call him. The resident was changed to another MD and he did not follow. On 9/26/18 at approximately 12:10 PM, the Optometrist, MD #1 was interviewed. She stated that on 7/11/18 she saw mucous covering the prosthetic eye and that is why she recommended to take out the prosthetic eye and clean as needed. She continued to state the resident cannot do this for himself, the staff must do it. Regarding the consult, she stated that she expects her recommendations to be followed and believes if the Physician has questions he will contact her. At approximately 12:52 PM the Optometrist was re-interviewed and was asked why she ordered [MEDICATION NAME] lid wipes. She stated that on her last visit she found Resident #25 had Blepharitis (inflammation of the eyelid that affects the eyelashes or tear production) and Blepharitis responds quicker to [MEDICATION NAME] lid wipes. On 09/26/18 at approximately 4:14 PM via telephone an interview was conducted with MD #3. Regarding the Optometry consult dated 7/11/18 he stated that MD#2 signed it. He stated that MD #2 had the resident first. He does not recall when he took over the patient's care. He discusses things with the NP#1 but cannot recall if he was told about this consult. He further stated that when the Physician signs a consult it is an acknowledgement of the consult. The Physician is required to sign the consults. And, it is his choice to follow or not to follow the recommendations. The Physician will directly communicate with the nurse. The nurse carries out the doctor's orders and enters them in the computer. If the doctor is not in the building, the consult paper goes back in the MD Communication book to be signed off by the Physician. The nurses are expected to write in the Nurse's notes that the doctor gave orders for the recommendations. The Physician follows up that his orders are followed by looking in the chart and signing-off in the computer: either in-house or remotely. On 09/27/18 02:21 PM RN#2 was interviewed and stated that the nurse manager or the medication nurses should have followed up with MD re: care of prosthetic eye. She is covering this floor temporarily-not her permanent floor. She writes in Nursing communication book care issues to discuss for residents in Morning Report with all disciplines. She continued to state that RN#1 is a new Nurse Manager who was not here in July, (YEAR). The Nurse Manager who was working on the unit is out on disability and one Nurse Manager no longer works here. She lastly stated we are all responsible to care for the resident. On 09/27/18 at approximately 3:14 PM RN#1 was interviewed and stated she did not know that the resident had a prosthetic eye. She stated that she learned about it (presence of prosthetic Left eye) on 9/26/18 from the resident during a conversation about wearing eye glasses. He told her that the left eye is not his real eye. Lastly, she stated that there are no changes in his Activities of Daily Living. 415.12(a)(3)

Based on staff interviews and record reviews conducted during an abbreviated survey (NY 731), the facility did not have evidence that all alleged violations involving resident to resident abuse reported to New York State Department of Health (NYS DOH) in a timely manner. This was evidenced in 1 out of 4 sampled incidents (Resident #1). Specifically, on 4/1/2018, a Certified Nursing Assistant (CNA) observed Resident #1 holding a pillow over the face of Resident #2. Resident #1 was transferred out to the emergency room (ER) on 4/1/2018 at 11:45 PM for psychiatric evaluation. The facility reported the incident on 4/4/2018 at to NYS DOH. Th findings include: The facility Policy and Procedure on Abuse Investigation states that should the investigation reveal that abuse occurred, the administrator will report such findings to the local police department, the ombudsman, the state licensing agency and others as may be required by state or local laws within 24 hours of the results of the completion of the investigation. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS, an assessment tool) dated 10/17/2017, Resident #1 had a BIMS (Brief Interview for Mental Status used to determine attention, orientation and ability to recall information) score of 14/5, associated with intact cognition (00-7 Severe Impairment, 08-12 Moderate Impairment & 12-15 Cognitively Intact). Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS, an assessment tool) dated 2/28/2018, Resident #1 had a BIMS (Brief Interview for Mental Status used to determine attention, orientation and ability to recall information) score of 7/15, associated with intact cognition (00-7 Severe Impairment, 08-12 Moderate Impairment & 12-15 Cognitively Intact). A facility Accident/Incident Report dated 4/1/2018 documented that a CNA witnessed Resident #1 with a pillow over the face of Resident #2. The CNA reported her observation to the nurse and Resident #1 was placed on 1:1 monitoring prior to being transferred to the ER for evaluation on 4/1/2018. Resident #2 was assessed with [REDACTED]. A Nursing Progress Note dated 4/1/2018 at 10:50 PM documented that a CNA observed Resident #1 holding a pillow over his roommate's face. The residents were immediately separated. The roommate was not injured. The Medical Doctor was notified and an order was given to transfer Resident #1 to the Psych hospital. Another nursing note dated 4/1/2018 documented that Resident #1 was placed on 1:1 while waiting for pick up. The Resident left facility at 11:45 PM via stretcher. The Director of Nursing (DON) was interviewed on 4/13/2018 at 2:46 PM. The DON responded to a question regarding reporting the incident to the DOH within 24 hours. She stated that on 4/3/2018, the facility reached out to the DOH for advisement on what to do and the facility received a call from DOH on 4/4/2018 instructing the facility to readmit Resident #1. She stated that subsequently, on 4/4/2018 at approximately 4:33 PM, the facility submitted to DOH, the resident to resident altercation occurred on 4/1/2018. 415.4(b)(I)(i)

Based on interviews and record review during an abbreviated survey, the facility's nursing staff did not ensure that each resident on anti-coagulant therapy was adequately monitored and provided in accordance with professional standards of quality. This was evidenced by 1 out of 3 sampled residents (Resident #1). Specifically, Resident #1 had Medical Doctor (MD) orders for blood tests ([MEDICATION NAME] Time (PT) and International Normalized Ratio (INR)) to be done on admission and every Monday and Thursday thereafter. The blood tests for 1/25, 1/28, 2/1 and 2/4 were not done. Subsequently, the resident was hospitalized due to low hemoglobin and required blood [MEDICAL CONDITION]. Complaint # NY 193 The findings are: Resident #1 is an [AGE] year old female re-admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Minimum Data Set 3.0 dated 2/3/16 documented intact cognition. Review of the MD order dated 1/21/16 documented [MEDICATION NAME] Sodium ([MEDICATION NAME]) 4 mg by mouth at bedtime and PT/INR for 1/22/16 and each Monday and Thursday. Review of the lab results dated 1/22/16 documented PT=33.9 (10.1 -13.2) and INR=2.99 (Therapeutic range = 2.00 - 3.00). Review of the [MEDICATION NAME] Flow Sheet dated 1/22/16 documented lab results were received at 4:30pm, indicating therapeutic level. The MD was notified and there was no new order given. This is the only lab result on the flow sheet. Review of the policy and procedure on Taking and Transcribing of Physician Orders, Electronically Transition to EMR, effective date 9/2005 and updated 7/2015 documented: Licensed nurse will transcribe the order (electronically) exactly as dictated by MD. The order will contain name of drug/treatment, dose, and frequency, clinical indication of use and date of duration if indicated. Licensed nurse will repeat order to physician. Licensed nurse will transcribe order electronically. Once the order is picked up; the nurse will print out order and forward electronically to the pharmacy. Clearly block off time limited orders, all slips, laboratory work, consult and X- rays ordered to be printed out. If laboratory work ordered daily, weekly, monthly, nurse will make out slips and place in laboratory requisition book. Accuracy will be verified by the nurse on the next shift (Reviewed by One Nurse Only). This is done by the nurse on the next shift reviewing orders and signing at the bottom of the order sheet with date and time. Review of Laboratory Requisition Book revealed: lab requests for 1/25/16, 1/28/16, 2/1/16 and 2/4/16 were not printed out and therefore not done. On 2/18/16 at 1:10pm the Registered Nurse Unit Manager (RNUM) #1 on the 7-3 shift was interviewed. She stated that on 1/21/16 she re - admitted Resident #1. The primary MD ordered [MEDICATION NAME] 4mg orally at bedtime, PT/INR to be collected on 1/22/16 and PT/INR every Monday and Thursday. She stated that she printed out 2 copies of the lab requisition on PT/INR for 1/22/16 and placed it in the Lab Book. She stated that the Licensed Practical Nurse (LPN) #1 on the 3-11 shift was supposed to verify the MD orders for accuracy and to co-sign the MD orders as per policy and procedure. She stated that the RN Unit Manager #2 on the 7-3 shift should check, verify and follow through if all the MD orders were accurate and print any existing orders to be done. She stated that Unit Manager #2 was responsible to check and print out the lab order for PT/INR. On 2/18/16 at 11:25am the primary MD was interviewed. He stated that Resident #1 is on [MEDICATION NAME] and he ordered PT/INR for 1/22/16 and every Monday and Thursday. He stated that the PT/INR were supposed to be done on Monday and Thursday, but they were not done. On 2/18/16 at 5:25pm the Director of Nursing (DON) was interviewed. She stated that on 2/9/16 she was informed by RNS #2 on the 11-7 shift of an elevated INR result for Resident #1. RNS #2 told her that the MD was notified and ordered to transfer the resident to the hospital for low hemoglobin and elevated INR. The DON also stated that during the investigation, she found out that the last PT/INR was done on 1/22/16. The MD orders for PT/INR for Monday and Thursday were not done for 2 weeks. On 2/19/16 at 2:30pm telephone interview was conducted with the LPN #1 on the 3-11 shift. She stated that she is not responsible to print the lab requisitions. She stated that the RNUM #1 who re- admitted the resident was supposed to print the lab requisitions for Monday and Thursday (1/25/16 and 1/28/16). She stated, that the RNUM Unit Manager is the only one responsible to print the lab requisitions and to put them in the Lab Book. She stated that she did not know and she did not notify RN Supervisor #1 that the lab requisitions for 1/25/16 and 1/28/16 were not done or printed by the RN Unit Manager #1. In addition, she further stated that the 11-7 shift LPN Nurse is responsible to check all the lab requisitions in the Lab Book for the next morning. On 2/22/16 at 10:50am telephone interview was conducted with RN Supervisor (RNS) #1 on the 3-11 shift. She stated that on 1/21/16 she reviewed the nursing admission assessment and signed the nursing assessment part. RNS #1 stated that she checked to see if the MD orders were carried out but she did not check the Laboratory Book to see if the requisitions were in place. She stated that she does not normally check the Laboratory Book. RNS #1 stated that LPN #1 co-signed the MD orders and added that LPN #1 could print out laboratory requisitions and put it in the Laboratory Book. On 2/22/16 at 11:42am telephone interview was conducted with RNS #2 on the 11-7 shift. She stated that usually the admitting RN carries out, picks up and prints laboratory requisitions. RNS #2 stated that she read and reviewed the RNS communication Book. She did not notice that the PT/INR for Monday and Thursday was not documented in the communication Book. She stated that she paid attention to the medication orders, but did not pay attention to the laboratory and general MD orders. RNS #2 stated that she did not check if the requisitions for PT/INR for Monday and Thursday were printed out. She stated that the admitting Nurse should have printed the laboratory requisitions for 1/25/16 and 1/28/16 and put them in the lab book. §415.11(c)(3)(i)

Based on staff interview and medical record review during an abbreviated survey, the facility did not ensure that each resident's drug regimen was adequately monitored. This was evidenced by 1 out of 3 sampled residents (Resident #1). Specifically, for Resident #1 the facility did not complete laboratory blood testing to monitor the efficacy of anticoagulant therapy. Resident #1 was on [MEDICATION NAME] (anticoagulant and blood thinning medication), which required monitoring of the laboratory blood test results. The [MEDICATION NAME] Time (PT) and International Normalized Ratio (INR) blood tests ordered by the Medical Doctor (MD) were not completed and or results reported. Subsequently, Resident #1's PT and INR results were elevated above the normal range for PT (10.1 -13.2, and therapeutic range for INR 2.00-3.00), which resulted in an acute care hospital admission and required transfusion of 4 units of Packed Red Blood Cells and 2 Units of Fresh Frozen Plasma. Complaint # NY 193 The findings are: Resident #1 is an [AGE] year old female re-admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Minimum Data Set 3.0 dated 2/3/16 documented intact cognition. A review of the Comprehensive Care Plan (CCP) dated 1/28/16 documented Anticoagulant Therapy/Risk for Bleeding related to abnormal PT, PTT, INR levels, [MEDICAL CONDITION] Fibrillation, [MEDICAL CONDITION], history of stent, on [MEDICATION NAME] and Aspirin. Interventions included observe for sign/symptom of bleeding gums, tarry stools, petechiae, blood in urine, skin bruises and report to MD, check skin for ecchymosis, oral care with soft toothbrush and monitor lab values PT, PTT, INR. A review of MD order dated 1/21/16 documented [MEDICATION NAME] Sodium ([MEDICATION NAME]) 4 mg by mouth at bedtime and PT/INR every Monday and Thursday. The MD order was signed by the admitting Registered Nurse Unit Manager #1 (RNUM) on the 7-3 shift, co-signed by the Licensed Practical Nurse (LPN) #1 on the 3-11 shift. A review of the policy and procedure on Taking and Transcribing of Physician Orders; Electronically Transition to Electronic Medication Record (EMR), effective date 9/2005 and updated 7/2015 documented: Licensed nurse will transcribe order (electronically) exactly as dictated by MD. The Licensed nurse will transcribe order electronically and nurse picks up order, prints out order and forwards electronically to the pharmacy and calls the pharmacy. All slips, lab work, consults and x-rays ordered to be printed out. If the lab work is ordered daily, weekly, monthly, nurse will make out slips and place in lab book. Accuracy will be verified by the nurse on the next shift (Reviewed by One Nurse Only). This is done by the nurse on the next shift reviewing orders and signing at the bottom of the order sheet with the date and time. A review of the Policy and Procedure, [MEDICATION NAME] Therapy states: 1. A physician's orders [REDACTED]. 2. Physician will determine the frequency of PT/INR monitoring. 3. [MEDICATION NAME] is to be administered at bedtime unless time is specified by the physician. 4. Licensed Nurse administering [MEDICATION NAME] will check for PT/INR results and inform Supervisor who in turn will inform the Physician for changes in [MEDICATION NAME] dosage if needed and for repeat PT/INR if necessary. 5. All PT/INR results, normal or abnormal will be reported to the Physician and documented in the 24 hour Report and Medical Record. (Chart). 6. Lab reports indicating PT/INR will be filed in the Lab Section of the Medical Record after Physician's review. A review of Policy and Procedure, [MEDICATION NAME] Flow Sheet states, All residents with [MEDICATION NAME] ordered will have a [MEDICATION NAME] Flow sheet initiated and will record all PT/INR results. The RNS/RNMU will review all results and notify the physician. Licensed Nurse will note any physician's orders [REDACTED]. Nursing staff will oobserve resident for any adverse effects of [MEDICATION NAME] i.e., bleeding in gums, epistaxis, and petichiae and notify the RNS, RNMU, Charge Nurse and Physician. A review of the Electronic Medication Administration Record [REDACTED]. The PT/INR MD order each Monday and Thursday was not transcribed as per MD order. Review of the [MEDICATION NAME] Flow Sheer dated 1/22/16 documented lab results were received at 4:30pm. [MEDICATION NAME] Time = 33.9 (10.1-13.2), INR = 2.99 (2.00-3.00). The MD was notified, there was no new order. There were no other lab results documented on the flow sheet. Review of the nurse's notes dated 1/31/2016 documented resident was noted with small amount of blood on the diaper. The MD was notified, and ordered a Complete Blood Count (CBC), Urine Analysis (U/A) and Culture and Sensitivity (C+S). laboratory results dated [DATE] - Red Blood Cell (RBC) = 3.15 (normal range 3.70-5.20), Hemoglobin (Hgb) = 9.3 (11.0-15.5), Hematocrit (Hct) 29.7 (34.0-47.0) The MD was notified of the abnormalities and no new orders were given. On 2/4/2016 the laboratory reported the results of the urine for C&S = Pseudomonas Aeruginosa greater than 100,000. On 2//5/2016 the MD [MEDICATION NAME] every 12 hours x 10 days and PT/INR every Tuesday and Thursday times 1 week until after the completion of the antibiotics then resume previous order for PT/INR. On 2/4/16 the resident's foley catheter was dislodged. The diaper was noted with blood-tinged urine and feces mixed with blood. The MD was notified and ordered to discontinue the foley catheter. The resident was noted to have moderate bleeding at 6:40am, 11:40am, 3:00pm and 10:30pm. On 2/8/2016 - The MD was notified of bleeding for 2 days. The MD examined the resident and no new orders were given. Advised to continue to monitor. On 2/8/2016 at 3:05pm the resident's diaper was changed twice and the MD was notified. The MD ordered STAT PT, PTT, INR and CBC. On 2/8/16 the CNA reported there was blood on the resident's diaper. On assessment, she observed pinkish blood-tinged urine was noted. The MD was notified, there was no order given. On 2/8/16 at 3:15pm the same CNA reported that there was blood on the diaper. RNUM #4 stated that she notified the MD. The MD ordered STAT PT, PTT, INR and CBC. On 2/9/16 at 5:00am laboratory results documented: White Blood Cell (WBC) - 13.6 (4.0 -11.0), Red Blood Cell (RBC) - 1.87 (3.70 -5.20), Hemoglobin - 5.5 (11.0 -15.5), Hematocrit - 17.9 (34.0 -47.0. The results of the PT and INR were pending. The MD was notified, ordered to transfer the resident to the hospital. On 2/9/16 at 12:10pm the resident was admitted to the hospital with [REDACTED].= <117 (10.1-13.2), INR= < 10.0 (2.00-3.00). On 2/9/2016 at 5:00am the laboratory reported the following results: White Blood Count (WBC)= 13.6 (4.0-11.0), red Blood Cell Count (RBC) = 1.87 (3.70-5.20), Hemaglobin (Hgb)= 5.5 (11.0-15.5), Hematocrit (Hct)= 17.9 (34.0-47.0) and the results of the PT/INR were pending. The MD was notified and ordered the resident transferred to the hospital for [MEDICAL CONDITION] and Occult Blood and abnormal blood values. On 2/9/2016 at 12:10pm the resident was transferred to the hospital and was subsequently admitted . The laboratory results received for the resident after the resident was transferred to the hospital were documented: PT = Greater than 117 (10.1-13.2), INR, very high = 10.0 (2.0-3.0), and PTT =109.6 (26.6-42.3). There was no evidence of monitoring of the PT/INR blood values for this resident that was on anticoagulant therapy for 2 weeks. On 2/18/16 at 11:25am the primary MD was interviewed. He stated that the resident was re-admitted on [DATE]. The resident is on [MEDICATION NAME]; he ordered PT/INR for 1/22/16 and every Monday and Thursday. He stated that the PT/INR are supposed to be done on Monday and Thursday; but they were not done. On 1/31/16 he was notified by the 7-3 Charge Nurse that there was small amount of blood on the diaper. He ordered U/A, C+S and CBC. The resident has a standing order for PT/INR twice a week. He stated that nobody called him regarding PT/INR results and he did not ask the nurse for the results. On 2/1/16 he evaluated and examined the resident due to scant blood on the diaper. The resident has history of frequent UTI, the foley catheter was in place. MD stated that nobody informed him of abnormal lab results. On 2/3/16 the foley was discharged and reinserted, light blood tinged urine was noted in the foley. On 2/4/16 he was notified that the foley catheter was dislodged, he ordered to discontinue the foley and to observe the resident for free voiding. MD examined the resident on 2/4/16, the urine was blood-tinged. He stated that the nurse's notes dated 2/4/16 documented the feces was mixed with blood. MD stated that nobody informed him of the PT/INR results, he did not ask or look for the results and he had not signed any. On 2/5/16 U/A, C+S results revealed positive for Pseudomonas. He ordered antibiotics for 10 days. On 2/8/16, he was in the facility; and he was informed by LPN # 3 on the 7-3 shift that the resident had small amount of blood on the diaper on 2/6/16 and 2/7/16. Nobody called him for PT/INR results. MD stated that on 2/8/16 he examined the resident; she was pale, normal and white as a ghost. He stated that he never asked, looked or checked the PT/INR results. MD stated that he ordered STAT CBC, PT/INR. On 2/9/16 at 5:00am he was notified by RNS #2 that the hemoglobin result was 5.5 (11.0 -15.5). He asked for the PT/INR results, as per RNS #2 the results were still pending. The resident was transferred to the hospital, with [DIAGNOSES REDACTED]. On 2/18/16 at 1:10pm the RN Unit Manager (RNUM) #1 on the 7-3 shift was interviewed. She stated that on 1/21/16 she readmitted Resident #1. The primary MD ordered [MEDICATION NAME] 4mg orally at bedtime, PT/INR to be collected on 1/22/16 and PT/INR every Monday and Thursday. RNUM #1 stated that she printed out 2 copies of the lab requisition on PT/INR for 1/22/16 and placed it in the Lab Book. She stated that LPN #1 on the 3-11 shift was supposed verify the MD orders for accuracy and co-sign the MD orders on 1/21/16. The RNUM #2 on the 7-3 shift should check, verify and follow through if all the MD orders were accurate and print any existing orders to be done. She stated that RNUM #2 was responsible to check and print out the lab order for PT/INR. As per protocol, the MD is notified of all the lab results; normal and abnormal. She stated that an LPN could print out lab requisitions, lab results and notify MD of lab results. On Fridays, the RNUM on the 7-3 shift is responsible to print all lab requisitions due on Monday, and makes sure that all meds and narcotics are well stocked for the weekend. On 2/18/16 at 5:25pm the Director of Nursing (DON) was interviewed. She stated that on 2/9/16 she was informed by RNS #2 regarding elevated INR result for Resident #1. The RNS #2 told her that the MD was notified and ordered to transfer the resident to the hospital for low hemoglobin and elevated INR. Investigation was initiated, she found out that the last PT/INR was done on 1/22/16. The MD order for PT/INR for Monday and Thursday were not done for 2 weeks. The resident is on Aspirin and [MEDICATION NAME]. DON stated that nursing staffs missed lab monitoring and MD orders. The primary MD did not follow up on the lab results. The nurses and the MD focused on the resident's foley catheter secondary [MEDICAL CONDITION] and UTI when admitted from the hospital. The MD ordered blood work and to transfer the resident in the hospital due to low hemoglobin. The elevated INR results were available after the resident was transferred to the hospital. The resident was transfused with 4 units Packed Red Blood Cells (PRBC) and 2 units of Fresh Frozen Plasma (FFP). On 2/19/16 at 10:20am the RNUM #4 (new orientee) on the 7-3 shift was interviewed. She stated that on 2/4/16 the resident's foley catheter was dislodged; the feces was noted with small amount of blood. The MD was notified and ordered do not re-insert the foley; let the resident void freely. She stated that she does not recall checking the MD order for [MEDICATION NAME] or PT/INR. On 2/5/16, the 11-7 RNS #2 endorsed the U/A and C+S positive results to LPN #3 and LPN #3 informed her that the resident is on [MEDICATION NAME]. RNUM #4 stated that when she checked the MD order, she noted that the resident is on [MEDICATION NAME]. She notified the MD, and the MD [MEDICATION NAME] orally every 12 hours for 10 days and PT/INR on Tuesday and Thursday (2/8/16 and 2/11/16) for 1 week. RNUM #4 stated she did not look or check the previous lab results for 2/1/16 and 2/4/16. On 2/19/16 at 2:30pm telephone interview was conducted with the LPN #1 on the 3-11 shift. She stated that she is not responsible to print the lab requisitions and the RNUM #1 was supposed to print the lab requisitions for Monday and Thursday. The LPN continued to state that the RNUM is the only one responsible to print the lab requisitions and put them in the Lab Book. She did not know and did not notify RNS #1 that the lab requisitions for 1/25/16 and 1/28/16 were not done or printed by RNUM #1. LPN #1 stated that the 11-7 shift LPN is responsible to check all the lab requisitions in the Lab Book for the next morning. On 2/22/16 at 10:50am telephone interview was conducted with RNS #1 on the 3-11 shift. She stated that on 1/21/16 she reviewed the nursing admission assessment and signed the nursing assessment part. She checked if the MD orders were carried out, but she did not check the Lab Book if the requisitions were in place. She does not normally check the Lab Book. She stated that it was documented in the RNS Communication Book that the resident had spotting on the diaper. She did not question nor investigate the resident's PT/INR results because there were no results coming out from the computer. She thought that the [MEDICATION NAME] was on hold but she did not check nor verify in the EMAR for MD orders. She stated that the LPN is responsible to document PT/INR results and update any changes in MD orders on the [MEDICATION NAME] Flow Sheet. On 2/22/16 at 11:42am telephone interview was conducted with RNS #2 on the 11-7 shift. She stated that usually the admitting RN carries out, picks up and prints lab requisitions. She stated that on 1/21/16 she read and reviewed the RNS communication Book. She did not notice that the PT/INR for Monday and Thursday was documented on the communication Book. She stated that she paid attention on the medication orders, but did not pay attention to the lab and general MD orders. RNS #2 stated that she did not check if the requisitions for PT/INR for Monday and Thursday were printed out. She stated that the 11-7 Nurse is responsible to check and review that all lab requisitions are in their specific dates per MD order in the lab book. §415.12(l)(1)

Based on interview and record review during an abbreviated survey, the facility did not ensure that each resident on Anti-coagulant therapy was adequately monitored by laboratory testing to determine the effectiveness of the medication and prevent complications related to anti-coagulant therapy. Specifically, the physician did not monitor the laboratory tests that he ordered for Resident #1 who was receiving anti-coagulant therapy. Resident #1 [MEDICATION NAME] Time (PT) and International Normalized Ratio (INR) were not done for 2 weeks. Resident #1 was transferred to the hospital on [DATE] for low hemoglobin and occult blood. Subsequently, the resident was admitted to the hospital and was transfused with 4 units Packed Red Blood Cells (PRBC) and 2 units of Fresh Frozen Plasma (FFP). This was evidenced by 1 out of 3 sampled residents (Resident #1). Complaint # NY 193 The findings are: A review of the Policy and Procedure, [MEDICATION NAME] Therapy states: 1. A physician's orders [REDACTED]. 2. Physician will determine the frequency of PT/INR monitoring. 3. [MEDICATION NAME] is to be administered at bedtime unless time is specified by the physician. 4. Licensed Nurse administering [MEDICATION NAME] will check for PT/INR results and inform Supervisor who in turn will inform the Physician for changes in [MEDICATION NAME] dosage if needed and for repeat PT/INR if necessary. 5. All PT/INR results, normal or abnormal will be reported to the Physician and documented in the 24 hour Report and Medical Record (Chart). 6. Lab reports indicating PT/INR will be filed in the Lab Section of the Medical Record after Physician's review. A review of Policy and Procedure, [MEDICATION NAME] Flow Sheet states, All residents with [MEDICATION NAME] ordered will have a [MEDICATION NAME] Flow sheet initiated and will record all PT/INR results. The RNS/RNMU will review all results and notify the physician. Licensed Nurse will note any physician's orders [REDACTED]. Nursing staff will observe resident for any adverse effects of [MEDICATION NAME] i.e., bleeding in gums, epistaxis, and petichiae and notify the RNS, RNMU Charge Nurse and Physician. On 2/18/16 at 11:25am the Medical Doctor (MD) was interviewed. He stated that the resident was re-admitted on [DATE], and she is on [MEDICATION NAME]. He ordered PT/INR for 1/22/16 and every Monday and Thursday. He stated that the PT/INR lab tests ordered to be done on Monday and Thursday were not done. On 1/31/16 he was notified by the 7-3 Charge Nurse that there was small amount of blood on the diaper. He ordered U/A, C+S and CBC. The resident has standing order for PT/INR twice a week. He stated that nobody called him regarding PT/INR results and he did not ask the nurse for the results. On 2/1/16 he evaluated and examined the resident due to scant blood on the diaper. The resident has history of frequent UTI and she had foley catheter. MD stated that nobody informed him of abnormal lab results. On 2/3/16 the foley was discharged and reinserted, light blood - tinged urine was noted in the foley. On 2/4/16 he was notified that the foley catheter was dislodged, he ordered to discontinue the foley and to observe the resident for free voiding. The MD stated that when he examined the resident on 2/4/16, the urine was blood-tinged. He stated that the nurse's notes dated 2/4/16 documented that feces was mixed with blood. He stated that nobody informed him of the PT/INR results, he did not ask or look for the results and he had not signed any. On 2/5/16 U/A, C+S results revealed positive for Pseudomonas; he ordered antibiotics for 10 days. On 2/8/16 he was in the facility and he was informed by LPN # 3 on the 7-3 shift that the resident had small amount of bleeding on the diaper on 2/6/16 and 2/7/16. Nobody called him with PT/INR results. MD stated that on 2/8/16 he examined the resident; she was pale, normal and white as a ghost. He stated that he never asked, looked or checked the PT/INR results. MD stated that he ordered STAT complete blood count (CBC), PT and INR. On 2/9/16 at 5:00am he was notified by Registered Nurse Supervisor (RNS) #2 that the hemoglobin result was 5.5 (11.0 -15.5). He asked for the PT/INR results; as per RNS #2 the results were still pending. The resident was transferred to the hospital, with [DIAGNOSES REDACTED]. On 2/18/16 at 5:25pm the Director of Nursing (DON) was interviewed. She stated that on 2/9/16 she was informed by RNS #2 regarding elevated INR result for Resident #1. RNS #2 told her that the MD was notified and ordered to transfer the resident to the hospital for low hemoglobin and elevated INR. On investigation, she found out that the last PT/INR was done on 1/22/16. She stated that the MD orders for PT/INR for Monday and Thursday were not done for 2 weeks. The resident is on Aspirin and [MEDICATION NAME]. She stated that the primary MD did not follow up on lab results. The MD ordered to transfer the resident in the hospital due to low hemoglobin and elevated INR results. The resident required blood transfusion. On 2/18/16 at 3:10pm the Medical Director was interviewed. He stated that during interview with the primary MD he did not agree or disagree that he actually monitored the PT/INR. He stated, during the interview, that there were only 2 labs done for the resident; a PT/INR on 1/22/16 and a urine analysis and Culture and Sensitivity on 2/5/16. §415.15(b)(1)(i)(ii)

Based on record review and staff interview during an abbreviated survey, the facility did not ensure that each resident remained free from mistreatment, neglect and misappropriation of property. This was evident for 1 of 3 sampled residents (Resident #1). Specifically, Resident #1 was admitted on [DATE], the Medical Doctor (MD) ordered [MEDICATION NAME] 4mg orally at bedtime, [MEDICATION NAME] Time (PT) and International Normalized Ratio (INR) on 1/22/16 and on each following Monday and Thursday. The PT/INR due for 1/25/16, 1/28/16, 2/1/16 and 2/4/16 were not done. Subsequently, the resident was transferred to the hospital with [DIAGNOSES REDACTED]. The resident required blood [MEDICAL CONDITION]. Complaint # NY 193 The findings include: Resident #1 is an [AGE] year old female re-admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Minimum Data Set 3.0 dated 2/3/16 documented intact cognition. A review of the Comprehensive Care Plan (CCP) dated 1/28/16 documented Anticoagulant Therapy/Risk for Bleeding related to abnormal PT, PTT, INR levels, [MEDICAL CONDITION] Fibrillation, [MEDICAL CONDITION], history of stent, on [MEDICATION NAME] and Aspirin. Interventions included observe for signs/symptoms of bleeding gums, tarry stools, petechiae, blood in urine, skin bruises and report to MD, check skin for ecchymosis, oral care with soft toothbrush and monitor lab values PT, Partial [MEDICAL CONDITION] Time (PTT), INR. A review of MD order dated 1/21/16 documented [MEDICATION NAME] Sodium ([MEDICATION NAME]) 4 mg by mouth at bedtime and PT/INR every Monday and Thursday. The Medical Doctor (MD) order was signed by the admitting Registered Nurse Unit Manager #1 (RNUM) on the 7-3 shift, co-signed by the Licensed Practical Nurse (LPN) #1 on the 3-11 shift. A review of the policy and procedure on Taking and Transcribing of Physician Orders; Electronically Transition to Electronic Medication Record (EMR), effective date 9/2005 and updated 7/2015 documented: Licensed nurse will transcribe the order (electronically) exactly as dictated by MD. Licensed nurse will transcribe order electronically and nurse picks up order, prints out order and forwards electronically to the pharmacy and calls the pharmacy. All slips, lab work, consults and x-rays ordered are to be printed out. If the lab work is ordered daily, weekly, monthly, nurse will make out slips and place in lab book. Accuracy will be verified by the nurse on the next shift (Reviewed by One Nurse Only). This is done by the nurse on the next shift reviewing orders and signing at the bottom of the order sheet with the date and time. A review of the electronic medical record Electronic Medication Administration Record [REDACTED]. The PT/INR MD order every Monday and Thursday was not transcribed as per MD order. Review of the [MEDICATION NAME] Flow Sheet dated 1/22/16 documented lab results were received at 4:30pm. The MD was notified, there was no new order. There were no other lab results documented on the flow sheet. Review of the laboratory results dated [DATE] documented PT=33.9 (normal range 10.1 -13.2), INR = 2.99 (normal range 2.00-3.00). MD made aware of abnormal blood values, and no new orders were given. Review of the nurse's notes documented on 1/31/16 small amount of blood was noted on the diaper. The MD was notified, ordered Complete Blood Count (CBC), Urine Analysis (U/A) and Culture and Sensitivity (C+S). The 2/1/16 laboratory results revealed Red Blood Cell (RBC) = 3.15 (normal range 3.70 -5.20), Hemoglobin (Hgb) =9.3 (11.0 -15.5), Hematocrit (Hct) 29.7 (34.0 - 47.0). The 2/4/2016 lab results revealed Pseudomonas Aeruginosa greater than 100,000. On 2/5/2016 at 10:26am the MD was notified of the laboratory results and that the diaper was saturated with vaginal blood and urine. The MD [MEDICATION NAME] mg orally every 12 hours for 10 days. PT/INR on Tuesday and Thursday (2/9/2016, 2/11/2016), for 1 week while on antibiotic then back to routine PT/INR when antibiotic completed. On 2/7/2016 at 6:45am, vaginal bleeding persists and at 2:00pm diaper changed twice again noted with blood and urine. At 10:30pm diaper changed twice and noted with moderate blood. The RNS was notifed. The RNS advised to continue to monitor and if bleeding persists to notify her. On 2/8/2016 at 6:25am the diaper was saturated with blood and urine. At 12:20pm the MD examined the resident due to hematuria; no new orders were given and continue to monitor. At 3:05pm the diaper was changed twice and resident was noted to be pale. MD was notified and ordered STAT PT, PTT, INR and Complete Blood Count (CBC). At 3:20pm diaper again noted to be saturated with blood. MD was notified. On 2/8/16 11pm diaper again noted to have some blood in the diaper. Continue to monitor. Stat blood tests were drawn on the 3-11 shift. laboratory results dated [DATE] at 5am documented: White Blood Cells (WBC) - 13.6-(4.0-11.0), Red Blood Cells (RBC) - 1.87-(3.7-5.20), Hemaglobin - 5.5 (11.0-15.5). PT and INR pending. MD was notified and ordered resident to be transferred to the hospital. On 2/9/16 at 12:10pm the resident was admitted to the hospital with [REDACTED].#1 was transferred to the hospital: The results were: PT - greater than 117 (10.1 -13.2), INR - very high (VH), 10.0 (2.00 - 3.00) and PTT - 109.6 (26.6 -42.3).There was no evidence of monitoring of the PT/INR lab results for the prior 2 weeks (1/25/2016-2/9/2016), while resident #1 was on anticoagulation therapy as ordered by the MD. On 2/18/16 at 11:25am the primary MD was interviewed. He stated that the resident was re-admitted on [DATE]. The resident is on [MEDICATION NAME]; he ordered PT/INR for 1/22/16 and every Monday and Thursday. He stated that the PT/INR are supposed to be done on Monday and Thursday; but they were not done. On 1/31/16 he was notified by the 7-3 Charge Nurse that there was small amount of blood on the diaper. He ordered U/A, C+S and CBC; the resident has a standing order for PT/INR twice a week. He stated that nobody called him regarding PT/INR results and he did not ask the nurse for the results. On 2/1/16 he evaluated and examined the resident due to scant blood on the diaper. The resident has history of frequent UTI, the foley catheter was in place. MD stated that nobody informed him of abnormal lab results. On 2/3/16 the foley was discharged and reinserted, light blood - tinged urine was noted in the foley. On 2/4/16 he was notified that the foley catheter was dislodged, he ordered to discontinue the foley and to observe the resident for free voiding. He examined the resident on 2/4/16, the urine was blood-tinged. He stated that the nurse's notes dated 2/4/16 documented the feces was mixed with blood. He stated that nobody informed him of the PT/INR results, he did not ask or look for the results and he had not signed any. On 2/5/16 U/A, C+S results revealed positive for Pseudomonas; he ordered antibiotics for 10 days. On 2/8/16, he was in the facility; he was informed by LPN # 3 on the 7-3 shift that the resident had small amount of blood on the diaper on 2/6/16 and 2/7/16. Nobody called him with PT/INR results. He stated that on 2/8/16 he examined the resident; she was pale, normal and white as a ghost. He stated that he never asked, looked or checked for the PT/INR results. He stated that he ordered STAT CBC, PT/INR. On 2/9/16 at 5:00am he was notified by RNS #2 that the hemoglobin result was 5.5 (11.0 -15.5). He asked for the PT/INR results, as per RNS #2 the results were still pending. The resident was transferred to the hospital, with [DIAGNOSES REDACTED]. The PT/INR results were available after the transfer of the resident to the hospital, the results were: PT- <117 (10.1-13.2), INR - <10.0 (2.00-3.00). On 2/18/16 at 1:10pm the RN Unit Manager (UM) #1 on the 7-3 shift was interviewed. She stated that on 1/21/16 she readmitted Resident #1. The primary MD ordered [MEDICATION NAME] 4mg orally at bedtime, PT/INR to be collected on 1/22/16 and PT/INR every Monday and Thursday. RNUM #1 stated that she printed out 2 copies of the laboratory requisition on PT/INR for 1/22/16 and placed it in the Laboratory Book. She stated that LPN #1 on the 3-11 shift was supposed to verify the MD orders for accuracy and co-sign the MD orders on 1/21/16. She stated, the RNUM #2 on the 7-3 shift should check, verify and follow through if all the MD orders were accurate and print any existing orders to be done. She stated that RNUM #2 was responsible to check and print out the lab order for PT/INR. As per protocol, the MD is notified of all the laboratory results; normal and abnormal. She stated that an LPN could print out laboratory requisitions, lab results and notify MD of laboratory results. On Fridays, the RNUM on the 7-3 shift is responsible to print all laboratory requisitions due on Monday, and make sure that all meds and narcotics are well stocked for the weekend. On 2/18/16 at 5:25pm the Director of Nursing (DON) was interviewed. She stated that on 2/9/16 she was informed by RNS #2 regarding elevated INR result for Resident #1. The RNS #2 told her that the MD was notified and ordered to transfer the resident to the hospital for low hemoglobin and elevated INR. Investigation was initiated, she found out that the last PT/INR was done on 1/22/16. The MD order for PT/INR for every Monday and Thursday were not done for 2 weeks. The resident is on Aspirin and [MEDICATION NAME]. DON stated that nursing staff missed lab monitoring and MD orders. The primary MD did not follow up on the lab results. The nurses and the MD focused on the resident's foley catheter secondary [MEDICAL CONDITION] and UTI when admitted from the hospital. The MD ordered blood work and to transfer the resident to the hospital due to a low hemoglobin and elevated INR results. The resident was admitted to the hospital and had a blood transfusion. On 2/19/16 at 10:20am the RNUM #4 (new orientee) on the 7-3 shift was interviewed. She stated that on 2/4/16 the resident's foley catheter was dislodged, and that feces was noted with small amount of blood. The MD was notified and ordered do not re-insert the foley; let the resident void freely. She stated that she does not recall checking the MD order for [MEDICATION NAME] or PT/INR. On 2/19/16 at 2:30pm telephone interview was conducted with the LPN #1 on the 3-11 shift. She stated that she is not responsible to print the laboratory requisitions. She stated, RNUM #1 was supposed to print the lab requisitions for Monday and Thursday. The RNUM #1 is the only one responsible to print the laboratory requisitions and put them in the Laboratory Book. LPN #1 continued to state that she did not know and did not notify RNS #1 that the laboratory requisitions for 1/25/16 and 1/28/16 were not done or printed by RNUM #1. LPN #1 stated that the 11-7 shift LPN is responsible to check all the laboratory requisitions in the Laboratory Book for the next morning. On 2/22/16 at 10:50am telephone interview was conducted with RNS #1 on the 3-11 shift. She stated that on 1/21/16 she reviewed the nursing admission assessment and signed the nursing assessment part. She checked if the MD orders were carried out, but she did not check the Laboratory Book to see if the requisitions were in place. She does not normally check the Laboratory Requisition Book. She stated that it was documented in the RNS Communication Book that the resident had spotting on the diaper. She did not question nor investigate the resident's PT/INR results because there were no results coming out from the computer. She thought that the [MEDICATION NAME] was on hold, but she did not check nor verify in the E- MAR for MD orders. She stated that the LPN is responsible to document PT/INR result, and update any changes in MD orders on the [MEDICATION NAME] Flow Sheet. On 2/22/16 at 11:42am telephone interview was conducted with RNS #2 on the 11-7 shift. She stated that usually the admitting RN carries out, picks up and prints lab requisitions. She stated that on 1/21/16 she read and reviewed the RNS communication Book. She did not notice that the PT/INR for Monday and Thursday was documented on the communication Book. She stated that she paid attention on the medication orders, but did not pay attention to the lab and general MD orders. RNS #2 stated that she did not check if the requisition for PT/INR for Monday and Thursday were printed out. She stated that the admitting nurse should have printed the laboratory requisitions for 1/25/2016 and 1/28/2016 and put them in the laboratory book. The 11-7 Nurse is responsible to check and review that all lab requisitions are in their specific dates per MD order in the lab book. On 2/5/16, the 11-7 RNS #2 endorsed the positive U/A and C+S result for UTI to the 7-3 RNUM #4. LPN #3 told her that the resident #1 is on [MEDICATION NAME]. RNUM #4 stated that when she checked the MD order, she noted that the resident is on [MEDICATION NAME] and then she notified the MD. The MD [MEDICATION NAME] orally every 12 hours for 10 days and PT/INR on Tuesday and Thursday (2/8/16 and 2/11/16) for 1 week. RNMU #4 stated she did not look or check the previous laboratory results for 2/1/16 and 2/4/16. On 2/8/16 the Certified Nurses Aide (CNA) reported there was blood on the resident's diaper. On assessment, she observed pinkish blood-tinged urine was noted. The MD was notified, there was no new order given. On 2/8/16 at 3:15pm the same CNA reported that there was blood on the diaper. RNUM #4 stated that she notified the MD. The MD ordered STAT PT, PTT, INR and CBC. On 2/9/16 the resident was transferred to the hospital due to abnormal lab results. § 415.4(b)

Based on interviews, and record review during an abbreviated survey, the facility did not ensure that each resident received the necessary care and services to maintain the highest practicable well-being. This was evidenced by 1 out of 3 sampled residents (Resident #1). Specifically, Resident #1 was admitted on [DATE], the Medical Doctor (MD) ordered [MEDICATION NAME] 4mg orally at bedtime, [MEDICATION NAME] Time (PT)/International Normalized Ratio (INR) on 1/22/16 and every Monday and Thursday. The PT/INR, were not done after 1/22/2016, for 2 weeks. The resident was transferred to the hospital with a [DIAGNOSES REDACTED]. The resident was admitted to the hospital and review of the hosptal records documented that the resident received (4) units of Packed Red Blood Cells (PRBC) and 2 units of Fresh Frozen Plasma (FFP). Complaint #NY 193 The findings are: Resident #1 is an [AGE] year old female re-admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Minimum Data Set 3.0 dated 2/3/16 documented intact cognition. A review of the Comprehensive Care Plan (CCP) dated 1/28/16 documented Anticoagulant Therapy/Risk for Bleeding related to abnormal PT, Partial [MEDICAL CONDITION] Time (PTT), INR levels, [MEDICAL CONDITION] Fibrillation, [MEDICAL CONDITION], history of stent, on [MEDICATION NAME] and Aspirin. Interventions included observe for sign/symptom of bleeding gums, tarry stools, petechiae, blood in urine, skin bruises and report to MD, check skin for ecchymosis, oral care with soft toothbrush and monitor lab values PT, PTT, INR. A review of MD order dated 1/21/16 documented [MEDICATION NAME] Sodium ([MEDICATION NAME]) 4 mg by mouth at bedtime and PT/INR every Monday and Thursday. The MD order was signed by the admitting Registered Nurse Unit Manager (RNUM) #1 on the 7-3 shift, co-signed by the Licensed Practical Nurse (LPN) #1 on the 3-11 shift. A review of the policy and procedure on Taking and Transcribing of Physician Orders; Electronically Transition to Electronic Medication Record (EMR), effective date 9/2005 and updated 7/2015 documented: Licensed nurse will transcribe the order (electronically) exactly as dictated by MD. Licensed nurse will transcribe order electronically and nurse picks up order, prints out order and forwards electronically to the pharmacy and calls the pharmacy. All slips, laboratory work, consults and x-rays ordered to be printed out. If the laboratory work is ordered daily, weekly, monthly, nurse will make out slips and place in laboratory book. Accuracy will be verified by the nurse on the next shift (Reviewed by One Nurse Only). This is done by the nurse on the next shift reviewing orders and signing at the bottom of the order sheet with the date and time. A review of the Policy and Procedure, [MEDICATION NAME] Therapy states: 1. A physician's orders [REDACTED]. 2. Physician will determine the frequency of PT/INR monitoring. 3. [MEDICATION NAME] is to be administered at bedtime unless time is specified by the physician. 4. Licensed Nurse administering [MEDICATION NAME] will check for PT/INR results and inform Supervisor who in turn will inform the Physician for changes in [MEDICATION NAME] dosage if needed and for repeat PT/INR if necessary. 5. All PT/INR results, normal or abnormal will be reported to the Physician and documented in the 24 hour Report and Medical Resord Record (Chart). 6. Lab reports indicating PT/INR will be filed in the Lab Section of the Medical Recored after Physician's review. A review of Policy and Procedure, [MEDICATION NAME] Flow Sheet states, All residents with [MEDICATION NAME] ordered will have a [MEDICATION NAME] Flow sheet initiated and will record all PT/INR results. The RNS/RNMU will review all results and notify the physician. Licensed Nurse will note any physician's orders [REDACTED]. Nursing staff will observe resident for any adverse effects of [MEDICATION NAME] i.e., bleeding in gums, epistaxis, and petichiae and notify the RNS, RNMU Charge Nurse and Physician. A review of the Electronic Medication Administration Record [REDACTED]. The PT/INR MD order for every Monday and Thursday was not transcribed as per MD order. Review of the lab results dated 1/22/16 documented PT=33.9 (10.1 -13.2) and INR=2.99 (2.00 - 3.00). Review of the nurse's notes dated 1/31/2016 documented resident was noted with small amount of blood on the diaper. The Registered Nurse Supervisors (RNS) were notified on all shifts. MD was notified and ordered Complete Blood Count (CBC), Urinanalysis (UA), and Culture + Sensitivity (C+S). On 2/2/16 the diaper was noted with blood-tinged urine and feces mixed with blood. On 2/1/2016 laboratory results documented Red Blood Cell (RBC) = 3.15 (normal range - 3.70-5.20), Hemaglobin (Hgb) = 9.3 (11.0-15.5), Hematocrit (Hct) 29.7 (34.0-47.0) and Pseudomonas Aerginosa greater than 100,000 in the urine C+S. On 2/5/2016 at 10:26am the MD was notified of the laboratory results and that the diaper was saturated with blood and urine. The MD [MEDICATION NAME] mg orally every 12 hours for 10 days. PT/INR on Tuesday and Thursday (2/9/2016, 2/11/2016) for one week while on the antibiotic then back to the routine PT/INR when the antibiotic is finished. On 2/6/2016 a review of the nurses notes revealed that resident was voiding freely. (No documentation of any bleeding noted). On 2/7/2016 at 6:45am, vaginal bleeding persists and at 2:00pm diaper changed twice again and noted with blood and urine. At 10:30pm diaper changed and noted with blood. The RNS was notified. Continue to monitor. On 2/8/2016 at 6:45am the diaper was saturated with blood and urine. On 2/8/16 at 12:20PM the MD examined the resident for complaints of reported hematuria; no new orders were given and told to continue to monitor. On 2/8/16 at 3:05pm the resident's diaper was changed twice, noted to have pale hematuria. The MD was again notified and ordered the following labs: STAT PT/INR and CBC. The STAT laboratory results dated [DATE] at 5:00am documented: White Blood Cell (WBC) - 13.6 (4.0 -11.0), Red Blood Cell (RBC) - 1.87 (3.70 -5.20), Hemoglobin - 5.5 (11.0 -15.5), Hematocrit - 17.9 (34.0 -47.0). The MD was notified and ordered the resident to be transferred to the hospital. On 2/9/16 at 12:10pm the resident was admitted to the hospital with [REDACTED]. After resident was transferred to the hospital the STAT laboratory results were received and showed the following: PT - greater than 117 (10.1 -13.2), INR - greater than 10.0 (2.00 - 3.00) and PTT - 109.6 (26.6 -42.3). On 2/18/16 at 1:10pm the RN Unit Manager (RNUM) #1 on the 7-3 shift was interviewed. She stated that on 1/21/16 she readmitted Resident #1. The primary MD ordered [MEDICATION NAME] 4mg orally at bedtime, PT/INR to be collected on 1/22/16 and PT/INR every Monday and Thursday. RNUM #1 stated that she printed out 2 copies of the lab requisition on PT/INR for 1/22/16 and placed it in the Laboratory Book. She stated that LPN #1 on the 3-11 shift was supposed verify the MD orders for accuracy and co-sign the MD orders on 1/21/16. The RNUM #2 on the 7-3 shift should check, verify and follow through if all the MD orders were accurate and print any existing orders to be done. She stated that RNUM #2 was responsible to check and print out the laboratory order for PT/INR. As per protocol, the MD is notified of all the laboratory results; normal and abnormal. She stated that an LPN could print out laboratory requisitions, laboratory results and notify MD of laboratory results. On Fridays, the RNUM on the 7-3 shift is responsible to print all laboratory requisitions due on Monday, and makes sure that all meds and narcotics are well stocked for the weekend. On 2/18/16 at 11:25am the primary MD was interviewed. He stated that the resident was readmitted on [DATE]. The resident is on [MEDICATION NAME]; he ordered PT/INR for 1/22/16 and every Monday and Thursday. He stated that the PT/INR are supposed to be done on Monday and Thursday, but they were not done. On 1/31/16 he was notified by the 7-3 Charge Nurse that there was small amount of blood on the diaper. He ordered U/A, C+S and CBC; the resident has standing order for PT/INR twice a week. He stated that nobody called him regarding PT/INR results and he did not ask the nurse the results. On 2/1/16 he evaluated and examined the resident due to scant blood on the diaper. The resident has history of frequent UTI, the foley catheter was in place. He stated that nobody informed him of abnormal lab results. On 2/3/16 the foley was discharged and reinserted, light blood tinged urine was noted in the foley. On 2/4/16 he was notified that the foley catheter was dislodged, he ordered to discontinue the foley and to observe the resident for free voiding. He examined the resident on 2/4/16, the urine was blood-tinged. He stated that the nurse's notes dated 2/4/16 documented the feces was mixed with blood. He stated that nobody informed him of the PT/INR results, he did not ask or look for the results and he had not signed any. On 2/5/16 U/A, C+S results revealed positive for Pseudomonas. He ordered antibiotics for 10 days. On 2/8/16, he was in the facility and he was informed by LPN # 3 on the 7-3 shift that the resident had small amount of blood on the diaper on 2/6/16 and 2/7/16. Nobody called him for PT/INR results. He stated that on 2/8/16 he examined the resident; she was pale, normal and white as a ghost. He stated that he never asked, looked or checked for the PT/INR results. He stated that he ordered STAT CBC, PT/INR. On 2/9/16 at 5:00am he was notified by RNS #2 that the hemoglobin result was 5.5 (11.0 -15.5). He asked for the PT/INR results, as per RNS #2 the results were still pending. The resident was transferred to the hospital, with [DIAGNOSES REDACTED]. On 2/18/16 at 5:25pm the Director of Nursing (DON) was interviewed. She stated that on 2/9/16 she was informed by RNS #2 regarding elevated INR result for Resident #1. The RNS #2 told her that the MD was notified and ordered to transfer the resident to the hospital for low hemoglobin and an elevated INR. Investigation was initiated, she found out that the last PT/INR was done on 1/22/16. The MD order for PT/INR for Monday and Thursday were not done for 2 weeks. The resident is on Aspirin and [MEDICATION NAME]. DON stated that nursing staffs missed lab monitoring and MD orders. The primary MD did not follow up on the laboratory results. The nurses and the MD focused on the resident's foley catheter secondary [MEDICAL CONDITION] and UTI when admitted from the hospital. The MD ordered blood work and to transfer the resident in the hospital due to low hemoglobin and elevated INR results. In the hospital, the resident had blood [MEDICAL CONDITION]. On 2/19/16 at 2:30pm telephone interview was conducted with the LPN #1 on the 3-11 shift. She stated that she is not responsible to print the laboratory requisitions. She stated that the RNUM #1 was supposed to print the laboratory requisitions for Monday and Thursday. The RNUM is the only one responsible to print the laboratory requisitions and put them in the Laboratory Book. She stated that she did not know and did not notify RNS #1 that the laboratory requisitions for 1/25/16 and 1/28/16 were not done or printed by RNUM #1. LPN #1 stated that the 11-7 shift LPN is responsible to check all the laboratory requisitions in the Lab Book for the next morning. On 2/19/16 at 10:20am the RNUM #4 (new orientee) on the 7-3 shift was interviewed. She stated that on 2/4/16 the resident's foley catheter was dislodged; the feces was noted with small amount of blood. The MD was notified and ordered do not re-insert the foley; let the resident void freely. She stated that she does not recall checking the MD order for [MEDICATION NAME] or PT/INR. On 2/5/16, the 11-7 RNS#2 endorsed urinalysis (U/A) and culture and sensitivity (C+S) result was positive for Urinary Tract Infection [MEDICAL CONDITION]. LPN #3 told her that the resident is on [MEDICATION NAME]. RNUM #4 stated that when she checked the MD order, she noted that the resident is on [MEDICATION NAME] and then she notified the MD. The MD [MEDICATION NAME] orally every 12 hours for 10 days and PT/INR on Tuesday and Thursday (2/8/16 and 2/11/16) for 1 week. RNUM #4 stated that she did not look or check the previous lab results for 2/1/16 and 2/4/16. She stated that on 2/8/16 the Certified Nurses Aide (CNA) reported there was blood on the resident's diaper. On assessment, she observed pinkish blood-tinged urine was noted. The MD was notified, there was no order given. RNUM #4 stated that on 2/8/16 at 3:15pm the same CNA reported that there was blood on the diaper. RNUM #4 stated that she notified the MD. The MD ordered STAT PT, PTT, INR and CBC. On 2/9/16 the resident was transferred to the hospital due to abnormal lab results; Hemoglobin (Hgb) = 5.5 (11.0 -15.5). The PT and INR results were reported after the MD transferred the resident to the hospital: PT =117 (10.1 -13.2) and INR very high 10.0 (2.00 -3.00). On 2/22/16 at 10:50am telephone interview was conducted with RNS #1 on the 3-11 shift. She stated that on 1/21/16 she reviewed the nursing admission assessment and signed the nursing assessment part. She checked if the MD orders were carried out but she did not check the Laboratory Requisition Book to see if the requisitions were in place. She does not normally check the Laboratory Book. She stated that it was documented in the RNS Communication Book that the resident had spotting on the diaper. She did not question nor investigate the resident's PT/INR results because there were no results coming out from the computer. She thought that the [MEDICATION NAME] was on hold, but she did not check nor verify in the EMAR for MD orders. She stated that the LPN is responsible to document PT/INR results and update any changes in MD orders on the [MEDICATION NAME] Flow Sheet. On 2/22/16 at 11:42am telephone interview was conducted with RNS #2 on the 11-7 shift. She stated that usually the admitting RN carries out, picks up and prints laboratory requisitions. She stated that on 1/21/16 she read and reviewed the RNS communication Book. She did not notice if the PT/INR for Monday and Thursday was documented in the communication Book. She stated that she paid attention to the medication orders, but did not pay attention to the laboratory and general MD orders. RNS #2 stated that she did not check if the requisition for PT/INR for Monday and Thursday were printed out. She stated that the 11-7 Nurse is responsible to check and review that all laboratory requisitions are in their specific dates per MD order in the laboratory book. §415.12