Every finding on record at Corning Center for Rehabilitation and Healthcare

Based on observations, interviews, and record review, the facility failed to ensure infection prevention and control practices were followed to prevent the development and spread of infections for six of six residents reviewed (Residents #5, #31, #33, #72, #86, and #123). Specifically, staff did not follow aseptic technique (practices used to prevent contamination during care) during wound care for Resident #86; staff did not follow Enhanced Barrier Precautions (an infection prevention strategy requiring gowns and gloves during certain high-contact care activities) for Residents #72 and #123; staff did not remove soiled gloves or perform hand hygiene after providing incontinence care to Resident #5; and a nurse did not perform hand hygiene between medication administration for Residents #31 and #33. Additionally, laundry staff did not wear a gown when sorting soiled resident laundry.The findings include:Issue One:The facility policy titled Wound - Treatment, dated 04/29/2026, included aseptic or clean wound treatment procedures would be followed unless otherwise ordered by the healthcare provider. Wound care was to follow infection prevention and control practices, including hand hygiene before and after wound care. The policy included placing a barrier on the treatment surface to reduce contamination, removing gloves and performing hand hygiene after removing a soiled dressing, putting on new gloves, and disposal of contaminated supplies.Resident #86 had diagnoses including diabetes (a condition in which the body does not make enough insulin or cannot use insulin properly), chronic obstructive pulmonary disease (a lung disease that makes breathing difficult), and dementia (a condition affecting memory and thinking). The Minimum Data Set (a resident assessment tool) dated 06/24/2026 included Resident #86 had severe cognitive impairment and did not have any unhealed pressure injuries (areas of skin or tissue damage caused by pressure).Review of Resident #86's Comprehensive Care Plan dated 07/24/2026 revealed Resident #86 had stage two pressure injuries to the right and left buttocks and a stage three pressure injury to the right buttock. Interventions included providing treatments as ordered.Resident #86 had a physician order dated 07/23/2026 to cleanse the right buttock wound with wound cleanser (a solution used to clean a wound), pat the wound dry with gauze, apply Medihoney (a medical-grade honey product used to help wounds heal), and secure the treatment with bordered gauze.During an observation and interview on 07/29/2026 at 1:10 PM, Resident #86 exited the bathroom without clothing covering their buttocks and sat on a blanket on the bed. Licensed Practical Nurse Supervisor #2 provided wound care. Licensed Practical Nurse Supervisor #2 used gloves taken from their clothing pocket, placed a barrier with clean wound care supplies on the blanket, and tucked part of the barrier under Resident #86's right buttock. Licensed Practical Nurse Supervisor #2 did not change gloves after removing the soiled dressing and used the same gloves to touch clean supplies and cleanse the wound. Licensed Practical Nurse Supervisor #2 did not perform hand hygiene after removing the gloves. The Medihoney became contaminated during wound care and was returned to the treatment cart. Licensed Practical Nurse Supervisor #2 stated the gloves taken from their pocket were contaminated and should not have been used. Licensed Practical Nurse Supervisor #2 stated the barrier should not have been placed on the bed, hand hygiene should have been performed after removing the soiled dressing and gloves, and the contaminated Medihoney should have been discarded. Licensed Practical Nurse Supervisor #2 stated if wound care supplies became contaminated during a dressing change, the wound care should be started again with clean supplies.During an interview on 07/30/2026 at 10:05 AM, the Director of Nursing/Infection Preventionist stated gloves stored in a nurse's clothing pocket were not clean and should not be used for wound care. The Director of Nursing/Infection Preventionist stated hand hygiene should be performed after removing gloves, a resident's bed was considered contaminated and should not be used as a surface for wound care supplies, and supplies placed on a barrier in contact with a resident's bare buttocks were not clean.During an interview on 08/03/2026 at 2:40 PM, Registered Nurse Manager #1 stated hand hygiene should be performed after removing a dressing and gloves. Registered Nurse Manager #1 stated gloves and hand sanitizer should not be stored in personal clothing. Registered Nurse Manager #1 stated a barrier in contact with a resident's buttocks was soiled, and supplies placed on the barrier or touched with a soiled glove were contaminated and should be discarded.Issue Two:The facility policy titled Hand Hygiene, revised 01/21/2026, included staff were to perform hand hygiene before and after resident contact, after contact with blood or body fluids, and after removing personal protective equipment (equipment worn to reduce exposure to infection).Resident #5 had diagnoses including chronic obstructive pulmonary disease, dementia, and diabetes. The Minimum Data Set, dated [DATE] included Resident #5 had moderate cognitive impairment and required staff assistance with toileting.Review of the Comprehensive Care Plan last reviewed 07/01/2026 revealed Resident #5 had weakness, deconditioning (loss of physical function from inactivity or bedrest), multiple medical conditions, and low motivation. Interventions included staff assistance with rolling in bed, toileting, and toileting hygiene.During an observation and interview on 07/28/2026 at 9:26 AM, Certified Nursing Assistant #4 provided care to Resident #5, who was incontinent of urine. Certified Nursing Assistant #4 did not remove their soiled gloves or perform hand hygiene before applying a clean brief and draw sheets, touching clean linens, the bed control and bedside table, placing clean moisture pads under Resident #5's arms, washing the resident's face with a washcloth, and placing the oxygen nasal cannula (a device used to provide oxygen through the nose) into the resident's nose.Certified Nursing Assistant #4 stated they did not change their gloves or wash their hands after changing Resident #5's brief and should have done so before touching other objects in the room.During an interview on 08/03/2026 at 1:31 PM, the Director of Nursing/Infection Preventionist stated staff should change gloves and perform hand hygiene after contact with something soiled and when moving from a soiled task to a clean task. The Director of Nursing/Infection Preventionist stated failure to perform hand hygiene after providing care could spread germs and bacteria.Issue Three:The facility policy titled Enhanced Barrier Precautions, revised 02/25/2026, included Enhanced Barrier Precautions were to be used for residents with an infection or colonization (the presence of germs on or in the body without causing illness) with a multidrug-resistant organism (a germ resistant to several medications used to treat infections), any wound requiring a dressing, or an indwelling medical device (a device that remains in the body), such as a urinary catheter. Staff were required to wear disposable gloves and an isolation gown for high-contact care activities, including dressing, bathing, transferring, hygiene care, handling linens, toileting, device care, and wound care.Resident #123 had diagnoses including obstructive uropathy (a blockage of the normal flow of urine), benign prostatic hyperplasia (an enlarged prostate that can block the flow of urine), and diabetes. The Minimum Data Set, dated [DATE] included Resident #123 was cognitively intact and had an indwelling urinary catheter (a tube placed into the bladder to drain urine).During an observation and interview on 07/27/2026 at 11:10 AM, an Enhanced Barrier Precautions sign was posted outside Resident #123's room. The sign directed staff to wear a gown and gloves during high-contact resident care, including urinary catheter care. A black star sticker was posted next to Resident #123's name. Assistant Nurse Manager #4 stated the black star identified residents who required Enhanced Barrier Precautions.During an observation on 07/29/2026 at 1:46 PM, Certified Nursing Assistant #1 entered Resident #123's room and emptied the resident's urinary catheter bag while wearing gloves but no gown.During an interview on 07/29/2026 at 1:50 PM, Certified Nursing Assistant #1 stated they should have worn a gown while emptying Resident #123's urinary catheter bag.During an interview on 07/30/2026 at 10:05 AM, Licensed Practical Nurse Manager #3 stated Certified Nursing Assistant #1 should have worn a gown when emptying Resident #123's urinary catheter bag because Resident #123 required Enhanced Barrier Precautions.Issue Four:The facility policy titled Environmental Services, revised March 2018, included staff were to wear gloves and a precaution gown when sorting soiled laundry.During an observation and interview on 07/29/2026 at 8:47 AM, Laundry Attendant #1 demonstrated the process used to sort resident laundry. Laundry Attendant #1 stated they wore gloves when handling all soiled laundry but only wore a gown when laundry arrived in a separate plastic bag. Laundry Attendant #1 stated they received monthly infection control education, but the education did not include wearing a gown when sorting laundry. Laundry Attendant #1 stated sorting soiled laundry without a gown could contaminate their clothing.During an interview on 07/30/2026 at 10:05 AM, the Director of Nursing/Infection Preventionist stated laundry staff should wear a gown when sorting soiled laundry because they could contaminate clean laundry. The Director of Nursing/Infection Preventionist stated they did not provide infection control education to laundry staff unless an issue was identified.Issue Five:The facility policy titled Medication Administration, revised December 2019, included staff were to follow the facility's infection control procedures, including handwashing, when administering medications.During a medication administration observation and interview on 07/29/2026 at 8:29 AM, Licensed Practical Nurse #3 prepared and administered medications to Residents #31 and #33 without performing hand hygiene between the residents. Licensed Practical Nurse #3 stated they used hand sanitizer every three residents because the hand sanitizer made their hands sticky. Licensed Practical Nurse #3 stated they were trained at the facility to perform hand hygiene after administering medications to every three residents instead of after each resident.During an interview on 08/03/2026 at 1:31 PM, the Director of Nursing/Infection Preventionist stated nurses were taught to perform hand hygiene after administering medications to each resident and performing hand hygiene after every three residents was incorrect.Title 10 New York Codes, Rules and Regulations 415.19(a)(1)-(2), (b)(2), (b)(4), (c)

Based on observations, interviews, and record review, the facility failed to ensure the medication error rate was less than 5 percent. Specifically, during 33 medication administration opportunities, two medication errors were identified for two of four residents reviewed (Resident #31 and Resident #131), resulting in a medication error rate of 6.06 percent.The findings include:The facility policy titled Medication Administration, last revised December 2019, included medications must be administered according to the orders. The individual administering medications must check the medication label three times to verify the correct dose. If a medication dose was believed to be inappropriate or excessive for a resident, the person administering the medication must contact the resident's attending physician or the facility's Medical Director to discuss the concern.Resident #31 had diagnoses including hemiplegia (paralysis on one side of the body), hemiparesis (weakness on one side of the body) following cerebral infarction (death of brain tissue caused by blocked blood flow), muscle weakness, and diabetes (a condition in which the body cannot properly control blood sugar). The Minimum Data Set (a resident assessment tool) dated 05/09/2026 documented Resident #31 was cognitively intact.Review of Resident #31's current medical orders on 07/29/2026 included Clearlax (a medication used to treat or prevent constipation), 34 grams in six to eight ounces of water once daily.During a medication pass observation on 07/29/2026 at 8:29 AM, Licensed Practical Nurse #3 prepared and administered Resident #31's medications. Licensed Practical Nurse #3 administered 17 grams of Clearlax in three ounces of water instead of the ordered 34 grams in six to eight ounces of water.During an interview on 07/29/2026 at 12:23 PM, Licensed Practical Nurse #3 stated Resident #31's Clearlax order was 34 grams in six to eight ounces of water once daily. Licensed Practical Nurse #3 stated they administered 17 grams in three ounces of water and did not follow the order.Resident #131 had diagnoses including obstructive sleep apnea (a sleep disorder causing repeated pauses in breathing), hypertension (high blood pressure), and depression (a condition causing ongoing feelings of sadness or loss of interest). The Minimum Data Set, dated [DATE] documented Resident #131 was cognitively intact.Review of Resident #131's current medical orders on 07/29/2026 included folic acid (a vitamin needed for healthy blood), 400 microgram tablets, give two tablets by mouth for a total dose of 800 micrograms.During a medication pass observation and interview on 07/30/2026 at 9:46 AM, Registered Nurse #2 prepared and administered Resident #131's medications. Registered Nurse #2 administered one 400 microgram tablet of folic acid instead of the ordered two tablets for a total dose of 800 micrograms. Registered Nurse #2 confirmed the medication administration was complete and verified through a medication count in the medication cart only one folic acid tablet was administered. Registered Nurse #2 stated Resident #131 did not receive the full ordered dose.During an interview on 08/04/2026 at 2:40 PM, Registered Nurse Manager #1 stated nurses should check medications before administration to prevent medication errors. Registered Nurse Manager #1 stated not giving the full ordered dose was a medication error and administering a partial dose was a health concern.During an interview on 08/04/2026 at 4:56 PM, the Director of Nursing stated nurses should verify the medication dose with the order before administration. The Director of Nursing stated not giving the full ordered dose was a medication error and a partial dose would not provide the full effect of the medication as ordered.Title 10 New York Codes, Rules and Regulations 415.12(m)(1)

Based on observations, interviews, and record review conducted during the Recertification Survey and complaint investigation (NY00328090), it was determined that for one (Resident #93) of two residents reviewed, the facility did not ensure that the resident was free from significant medication errors. Specifically, Resident #93 did not receive an antibiotic medication as ordered by the physician for several days. This is evidenced by the following: The facility policy and procedure, Medication Errors, dated August 2019, included that the staff and practitioner should strive to minimize adverse consequences by following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication; defining appropriate indications for use; and determining that the resident receive the medication as prescribed and timely. The facility policy and procedure, Medication Administration Review, dated August 2019, included that Licensed Nurses (Registered Nurse/Licensed Practical Nurse) must ensure prior to the end of their shift that all medications or treatments that were administered, refused, held, etc., were properly documented on the Medication Administration Record. Failure to do so was considered an omission in the medical record. The facility policy, Physician Orders, dated February 2020, included when there were order changes the current order was to be discontinued prior to initiating the new order. The Licensed Nurse receiving or accepting an order was required to transcribe the order to the Medication Administration Record, containing all the required information. The facility policy and procedure, Physician Orders - Transcription, dated August 2018, included a Clinical Nurse should transcribe and review all physician orders in order to affect their implementation. A Clinical Nurse could accept a telephone order from the physician only or Physician Assistant or Nurse Practitioner (as per state stature). The order should be repeated back to the physician for their verbal confirmation. The order should be transcribed to all appropriate areas (Medication Administration Record, Treatment Administration Record, etc.). Resident #93 had diagnoses that included diabetes, chronic kidney disease, and hypertension. The Minimum Data Set assessment dated [DATE], revealed that Resident #93 was cognitively intact. Review of physician orders revealed: A. Cefepime (an antibiotic) two grams intravenously (administered into a vein) every 12 hours for five days for pneumonia ordered on 11/3/23 at 12:59 PM by Physician #1. The order was discontinued on 11/3/23 at 6:35 PM by Licensed Practical Nurse #1 (per verbal order by Physician #1) with a reason of 'changed to intramuscular' (injected into a muscle). B. Cefepime one gram intramuscularly two times a day for five days for pneumonia, reconstitute (mix) with 2.1 milliliters of 1% Lidocaine ordered on 11/3/23 at 6:56 PM by Licensed Practical Nurse #1 (per telephone order by Physician #1). The order was discontinued on 11/4/23 at 10:42 AM by Licensed Practical Nurse Supervisor #1 with a reason of 'concentration corrected by Pharmacy.' C. Cefepime one gram intramuscularly two times a day for five days for pneumonia, reconstitute with 2.4 milliliters of 1% Lidocaine ordered on 11/5/23 at 11:31 AM by Licensed Practical Nurse Manager #1 (per verbal order by Physician #1). Review of the November 2023 Medication Administration Record revealed no documented evidence that the antibiotic was administered on 11/3/23, 11/4/23, or 11/5/23. For the evening dose scheduled for 11/5/23, the code '9' (see nurse notes) was documented. Review of a Medication Administration Note dated 11/5/23 at 10:07 PM revealed the antibiotic was on order. A progress note dated 11/3/23 at 9:10 PM and documented by Licensed Practical Nurse #1 included that new orders for an intravenous (administered into a vein) antibiotic were received from Physician #1. Licensed Practical Nurse #1 spoke with the Assistant Director of Nursing and the antibiotic order was changed to an intramuscular injection. The antibiotic was administered to Resident #93's right thigh. Additional review of progress notes from 11/4/23 to 11/5/23 did not include documentation that the antibiotic was administered or that a medical provider was notified that the medication was unavailable. Review of the scanned documents section in Resident #93's electronic health record did not reveal a Medication Administration Record that included documentation that the antibiotic was administered on 11/4/23 or 11/5/23. Additionally, the facility could not provide other documentation that showed evidence the antibiotic was administered on those dates. Review of the Daily Staffing dated 11/3/23 revealed at least one Registered Nurse was scheduled for the day shift and evening shift. There were no Registered Nurses scheduled for the night shift. During an interview on 2/29/24 at 10:40 AM, Physician #1 stated they saw Resident #93 for an acute visit related to a cough, sore throat, and crackles in their right lung. Physician #1 stated they diagnosed the resident with pneumonia and ordered an intravenous antibiotic. Physician #1 stated they had been told the facility did not have a Registered Nurse on every shift to administer an intravenous antibiotic, so they were ok with changing the order to be given intramuscularly. Physician #1 stated they stopped in the facility after 11/5/23 and was informed by the nursing supervisor that the resident had not received their antibiotic over the weekend, but they were unsure why. Physician #1 saw Resident #93 at that time and the resident said they did not get their shots over the weekend. Physician #1 stated they had not discontinued the intramuscular antibiotic order and did not recall being notified that the medication was unavailable. Physician #1 stated they would consider an antibiotic a significant medication and not receiving the medication for two days could have resulted in Resident #93's condition not improving. During an interview on 2/29/24 at 12:40 PM, Licensed Practical Nurse #2 stated nurses administered medications that were ordered by a medical provider and when the medication was given to the resident, the nurse documented in the Medication Administration Record. If a medication was not available, they would document it in a progress note and notify the supervisor. Licensed Practical Nurse #2 stated Licensed Practical Nurses were not able to administer intravenous medications, only a Registered Nurse could. During an interview on 3/1/24 at 9:41 AM, Licensed Practical Nurse Manager #1 stated medical providers ordered antibiotics and determined how they should be administered (i.e., intravenously, intramuscularly, orally, etc.). Nurses could receive telephone, verbal, or written orders from the medical provider and could enter or discontinue orders with a medical provider's directive. Some antibiotics were stocked in the Cubex (a cabinet used for medication storage and inventory management) which could be accessed if needed. A Registered Nurse would administer all intravenous medications. Licensed Practical Nurse Manager #1 stated if a medication was not available, the nurse could call the Pharmacy to have it sent on the next delivery; there were at least two deliveries daily. Additionally, the nurses should call the provider to see if there was another medication that could be given. Licensed Practical Nurse Manager #1 stated when a medication was given, the nurse should document it on the Medication Administration Record. A blank box on the Medication Administration Record indicated the medication was not given. Licensed Practical Nurse Manager #1 stated if the medical provider had not signed off on an order, the nurse was unable to document on the electronic Medication Administration Record that a medication was given. In that case, the nurse should print the Medication Administration Record and sign that the medication was given on the paper record. The paper record was then uploaded into the resident's electronic record. Licensed Practical Nurse Manager #1 stated that not giving a medication would be considered a medication error. Licensed Practical Nurse Manager #1 said they did recall Resident #93 being diagnosed with pneumonia but could not remember specific dates. While reviewing Resident #93's electronic health record at this time, Licensed Practical Nurse Manager #1 was unable to find documented evidence that the antibiotic had been administered on 11/4/23 or 11/5/23 or that the medical provider was notified that the antibiotic was unavailable. During an interview on 3/1/24 at 10:35 AM, the Director of Nursing stated they would expect medications to be administered as they were ordered, and nurses could enter or change orders with a medical provider's direction. The Director of Nursing stated the facility had at least eight hours of Registered Nurse coverage every day but did not routinely have a Registered Nurse on every shift. The Director of Nursing stated if an order was not signed by the provider, the nurse could not document the administration of the medication on the electronic Medication Administration Record. In those cases, the nurse would print the Medication Administration Record and document on the paper record or document the medication administration in a progress note. The Director of Nursing stated a blank box on the Medication Administration Record indicated the medication was not given. They would expect the medical provider to be informed if a medication was unavailable to determine if another medication could be given. The Director of Nursing stated they did not recall Resident #93 not being administered their prescribed antibiotic and would have to investigate the concern further. The Director of Nursing stated at that time, there were new medical providers at the facility. Since Licensed Practical Nurses could not administer intravenous antibiotics and there was not always a Registered Nurse available to give it, nursing may have requested the antibiotic order be changed to intramuscular so the antibiotic could be given immediately. The Director of Nursing stated an antibiotic not being administered would be considered a medication error. During an interview on 3/1/24 at 11:25 AM, Licensed Practical Nurse Supervisor #1 stated they vaguely remembered when Resident #93 was ordered an intravenous antibiotic and intravenous medications could not be given if a Registered Nurse was not in the facility. Licensed Practical Nurse Supervisor #1 said the covering medical provider was notified and the order was changed from intravenous to intramuscular. Licensed Practical Nurse Supervisor #1 stated they were assigned to the medication cart on 11/4/23 and would not have been able to document in the electronic Medication Administration Record that the antibiotic was administered because the order had been changed and was awaiting the medical provider's signature. Licensed Practical Nurse Supervisor #1 stated when they changed the antibiotic order on 11/4/23, they forgot to change the start time, which had defaulted to start on 11/5/23 at 8:00 PM. 10 NYCRR 415.12(m)(2)

Based on observations, interviews and record review conducted during the Recertification Survey, it was determined that for one (Resident #84) of one resident reviewed, the facility did not assist with obtaining dental services to meet the needs of each resident. Specifically, Resident #84 reported a broken tooth to facility staff on or around 2/12/24 and the resident was not evaluated by a provider or assisted with scheduling an appointment for dental services until following surveyor intervention. This is evidenced by the following: The facility policy and procedure, Dental Services, dated 2/2019 documented that both routine and emergency dental services were available to meet the resident's oral health care needs and were provided to residents through a licensed dentist that came to the facility monthly or by referral to the resident's personal dentist, community dentist, or other health care organizations that provide dental services. Resident #84 had diagnoses including osteoporosis (a condition causing bones to become weak and brittle), atrial fibrillation (an irregular heart rate) and congestive heart failure. The Minimum Data Set Assessment, dated 1/12/24, revealed the resident was cognitively intact and had no dental concerns. Review of the Comprehensive Care Plan, dated 6/29/21, revealed Resident #84 had oral and dental health problems related to the need for a full upper denture and their own teeth on the bottom. Interventions included to monitor, document, and report signs or symptoms of dental problems; including broken teeth, to the medical provider as needed and refer to the dentist and coordinate arrangements for dental care as needed. Review of the current physician orders included a dental consult as needed. Review of Resident #84's electronic medical record from 12/1/23-2/28/24 revealed no interdisciplinary notes related to the evaluation or assessment of the broken tooth or dental evaluations. During an interview on 2/26/24 at 3:04 PM, Resident #84 stated their tooth broke approximately two weeks ago and nothing had been done about it. They reported the broken tooth to their primary aide, Certified Nursing Assistant #1, who then told a nurse. Resident #84 stated that Certified Nursing Assistant #1 confirmed with them that the nurse had been told about the broken tooth. When interviewed on 2/28/24 at 8:41 AM, Resident #84 stated their tooth had broken at the gum line while eating lunch. During an interview on 3/1/24 at 8:30 AM, Certified Nursing Assistant #1 stated Resident #84's tooth broke while they were in the room and the resident denied having pain at that time. Certified Nursing Assistant #1 stated they had notified Licensed Practical Nurse Manager #2 about the broken tooth. During an interview on 3/1/24 at 8:44 AM, Licensed Practical Nurse Manager #2 stated they did not remember Certified Nursing Assistant #1 reporting the resident's broken tooth. Licensed Practical Nurse Manager #2 added Resident #84 to the facilities monthly dental list following surveyor intervention. During an interview on 3/1/24 at 11:26 AM, the Director of Nursing stated they would expect that if a resident was having any dental issues the resident would be placed on the facilities dental list to be seen. During an interview on 03/01/24 at 12:59 PM, the Administrator stated they were unsure why the Resident's broken tooth was an issue. Resident #84 had told a Certified Nursing Assistant but had not told any other staff member. The Administrator stated that a broken tooth with no pain or infection and that was not affecting the resident's chewing, was not emergent. If the broken tooth was causing them pain, Resident #84 would have been seen emergently. 10 NYCRR 415.17(a-d)

Based on observations, interviews and record review conducted during the Recertification Survey, it was determined for two (2nd floor and 3rd floor) of two residential units reviewed, the facility did not ensure that an accurate reconciliation of all controlled substances was maintained. Specifically, the narcotic count logs which included reconciliation of narcotic medications and the signatures of staff members for each shift-to-shift count, were not consistently signed to indicate the count was complete and the correct count was verified. This was evidenced by the following: The facility policy and procedure, Medication - Narcotic Management, dated April 2019, included that narcotics and schedule two medications would be counted with two professional nurses and documentation that the count was completed and accurate would be completed at the beginning and end of each shift. Any discrepancy in a shift-to-shift count must be immediately communicated to the Director of Nursing. Review of the Narcotic Count logs for the second and third floor residential units from 1/1/24 to 2/29/24, revealed multiple missing nurse signatures to verify that the controlled substance count had been completed and was accurate for the following: a) Records labeled 2nd Even, had 76 missing signatures out of 336 opportunities. b) Records labeled 2nd Even Wrap, had 94 missing signatures out of 334 opportunities. c) Records labeled 2nd Odd, had 101 missing signatures out of 304 opportunities. d) Records labeled, 2nd Odd Wrap, had 107 missing signatures out of 312 opportunities. e) Records labeled 3rd Even, had 47 missing signatures out of 346 opportunities. f) Records labeled, 3rd Even Wrap, had 27 missing signatures out of 346 opportunities. g) Records labeled, 3rd Odd had 45 missing signatures out of 364 opportunities. h) Records labeled, 3rd Odd Wrap, had 61 missing signatures out of 374 opportunities. During an observation of medication storage on 2/28/24 at 12:29 PM, review of the third-floor Narcotic Count Log books labeled Odd and Odd Wrap, revealed multiple missing nurse signatures. When interviewed at that time, Licensed Practical Nurse #3 stated at the change of shift, the arriving and leaving nurses counted the narcotics and signed the log if the count was correct. During an observation of medication storage on 2/28/24 at 3:11 PM, review of the third-floor Narcotic Count Log book labeled, Even, revealed multiple missing nurse signatures. When interviewed at that time, Licensed Practical Nurse #1 stated the arriving nurse and leaving nurse sign the narcotic log at the change of shift. Licensed Practical Nurse #1 stated a blank box on the log meant a nurse did not sign. During an observation of medication storage on 2/29/24 at 9:08 AM, review of the second-floor Narcotic books labeled Even, Even Wrap, Odd, and Odd Wrap, revealed multiple missing nurse signatures. During an interview on 2/29/24 at 9:22 AM, Licensed Practical Nurse Manager #3 stated the narcotic medications were counted by the nurses arriving and leaving from shift-to-shift, who then signed the log when the count was done. Licensed Practical Nurse #3 stated the logs should not have missing signatures. During an interview on 3/1/24 at 9:41 AM, Licensed Practical Nurse Manager #1 stated when a nurse arrived for their shift, they counted the narcotics with the nurse that was leaving. All narcotics, including discontinued ones, were counted to make sure the number matched what was in the narcotic log. At the end of the narcotic book, both nurses signed that the count was correct. Licensed Practical Nurse Manager #1 stated they had identified a couple missing signatures a few days prior. They found that one nurse would sign, but the other had not. Licensed Practical Nurse Manager #1 stated the missing signatures may have been due to the nurse forgetting to sign while they were holding the narcotics during the count. During an interview on 3/1/24 at 10:35 AM, the Director of Nursing stated the nurses were supposed to count all narcotics at the beginning and end of their shift, and sign if the counts were correct. When asked what a blank box or missing signature indicated, the Director of Nursing stated if it was not signed, it was not done. Copies of the narcotic count sheets were reviewed at that time. The Director of Nursing stated some entries included one nurse's signature, but the other nurse's signature was missing. 10 NYCRR 415.18(b)(1)(2)(3)

Based on observations, interviews, and record reviews conducted during the Recertification Survey, completed on 1/7/22, it was determined that for one (Resident #47) of one resident reviewed for hearing aids, the facility did not ensure the resident's care plan was implemented regarding their hearing aid. Specifically, a hearing-impaired resident did not have their hearing aid provided to optimize communication abilities. This was evidenced by the following: Resident #47 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set Assessment, dated 11/4/21, revealed the resident was moderately impaired cognitively, had minimal difficulty hearing and required the use of a hearing aid. The current Comprehensive Care Plan and the Certified Nursing Assistant (CNA) Kardex documented that the resident wore a hearing aid in their right ear. An audiology consultation report dated 11/22/21, documented that Resident #47's, hearing aid was dead at the time of the appointment and that the charger for the device had been misplaced. The consult included that the device should be charged each evening and returned to the resident each morning. During an observation and interview on 1/3/22 at 12:00 p.m., Resident #47 was observed in bed. No hearing aid was in use at the time. Resident #47 stated they were deaf and that they wore a hearing aid. Resident #47 said that the hearing aid was kept at the nurse's station and that they were unsure as to why they never got it that day but that they would like to wear it. During an observation and interview on 1/4/22 at 1:30 p.m., Resident #47 was in their room and again no hearing aid was present in their ear. Resident #47 stated that their hearing aid was still at the nurse's station and they would like to have it in. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 1/4/22 2:17 p.m., the Licensed Practical Nurse stated that Residents #47 hearing aid should be locked in the medication room every night to be charged because Resident #47 can be forgetful. The LPN stated it was the responsibility of the nurses to retrieve the device from the resident and place it on the charger each night because the CNAs do not have access to the medication room. At this time the LPN retrieved Resident #47 hearing aid from the medication cart and stated it was dead and had not been charged overnight. During an interview on 1/4/22 at 2:50 p.m., The Nurse Manager (NM) stated that while they were doing the medication pass for Resident #47 they had asked the resident if they had their hearing aid in and the resident had replied yes so they documented that the hearing aid had been inserted. 10 NYCRR415.11(c)(1)

Based on observations, interviews, and record reviews conducted during the Recertification Survey and complaint investigations (#NY 699 and #NY 038) completed on 1/7/21, it was determined that one (Resident #64) of four residents reviewed for Activities of Daily Living (ADLs) did not receive the necessary services to maintain good grooming and personal hygiene. Specifically, Resident # 64 was not provided with assistance for facial hair and nail care. This is evidenced by the following: The facility policy, ADL-Bath (Shower)'' dated July 2019, included that showers are given to residents to cleanse and refresh the resident, observe the skin, and to provide increase circulation. The facility policy, ADL-Nail Care'' dated March 2021, included that nail care is done to clean the nail bed, to keep nails trimmed, and to prevent infections. Resident #64 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set assessment dated [DATE], documented that the resident was cognitively intact. The Comprehensive Care Plan, dated 1/11/21, revealed Resident #64 required the assistance of one staff member for personal hygiene, and nail care should be provided at the time of their shower. During observations on 1/3/22 at 12:31p.m., and again on 1/4/22 at 1:15 p.m., Resident #64 had numerous long chin hairs (approximately 1/2 inches in length) and covering their entire chin and their fingernails were long with brown debris under the nails. In an interview on 1/4/22 at 1:15 p.m., Resident #64 stated that they would like the hair on their chin shaved, but that staff had not offered to shave the chin or cut their nails and that the staff said they did not have time. The resident said that they would like a shower, but has not received one in awhile. When observed on 1/5/22 at 9:04 a.m., Resident #64 was eating a breakfast sandwich with their hands. The nails remained long, uncut and filled with brown debris and the resident continued with the numerous long chin hairs. During a joint observation and interview on 1/5/22 at 9:23 a.m., the Certified Nursing Assistant (CNA) observed Resident #64's nails and the hair under their chin and stated that the resident's chin needed to be shaved and the nails on both hands were long. During an interview on 1/5/22 at 9:26 a.m., the LPN #1 stated that the the CNAs should perform nail care on shower days and should assist the resident with removing chin hairs. The LPN stated that they were able to see the long chin hairs from where they were standing outside of the resident's room. During an interview on 1/5/22 at 9: 37 a.m., the LPN Manager stated that the resident should have been shaved and that the fingernails should have been trimmed when the resident received their shower. [NYCRR 415.12 (a)(3)]

Based on observations, interviews and record reviews conducted during an Abbreviated Survey(#NY 564 and #NY 509) completed on 6/28/21, it was determined that for five (Residents #2, #4, #10, #11 and #12) of five residents reviewed, the facility did not ensure the services provided by the facility as outlined in the resident's Comprehensive Care Plan (CCP) met professional standards of quality. Specifically, there was inconsistent documentation that prescribed treatments were administered as ordered on multiple occasions. This is evidenced by, but not limited to, the following: The facility policy, Wound Treatment Guidelines, dated April 2019, included ensuring that physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The facility policy, Medication Administration, last revised December 2019, included that topical medications used in treatments must be recorded on the resident's Treatment Administration Record (TAR), and documented immediately after given. 1.Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) Assessment, dated 7/10/20, revealed that the resident was cognitively intact. Physician orders, dated 7/9/20 to 8/31/20, included [CONDITION(S)] care (assessing the site the [CONDITION(S)] and giving care if required) every shift and as needed (PRN). Review of the TAR from 7/9/20 to 7/31/20 revealed there was no documentation that prescribed treatments were administered as ordered for 8 of 67 opportunities. Review of the TAR from 8/1/20 to 8/31/20 revealed there was no documentation that prescribed treatments were administered as ordered for 13 of 93 opportunities. Physician orders, dated 7/20/20 to 8/31/20, included to cleanse the [CONDITION(S)] site and change the ostomy appliance every three days and PRN. Review of the TARs from 7/20/20 to 8/31/20 revealed that there was no documentation for 4 of 14 opportunities that the treatment was provided. Physician orders, dated 7/16/20 to 8/31/20, included to cleanse the wound daily with normal saline, pack the wound with [MEDICATION(S)] (a gauze saturated with an antimicrobial) and cover with a dry dressing every day shift for wound care. Review of TARs from 7/16/20 to 8/31/20 revealed that there was no documentation for 10 of 47 opportunities that the daily wound care was completed. Review of the nursing progress notes from 7/16/21 to 8/31/20 did not include any documentation related to the administration of treatments as ordered or refusals. 2.Resident #10 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Assessment, dated 6/1/21, revealed that the resident was cognitively intact. Physician orders, dated from 4/30/21 through 6/24/21 included several changes for wound care to the right leg with time frames as follows: a. On 4/38/21 wound care to be done Monday, Wednesday and Friday. b. On 5/5/21 wound care orders changed to Monday through Friday. c. On 5/14/21 wound care orders changed to daily. Review of the TAR from 5/1/21 to 6/30/21 revealed that there was no documentation that wound care was completed as ordered on 16 of 60 opportunities. Physician orders, dated 6/9/21, included to apply an ace wrap to the right leg every day shift and remove every evening shift for [CONDITION(S)]. Review of TAR from 6/10/21 to 6/27/21 revealed that there was no documentation that the ace wraps were applied or removed as ordered on 4 of 18 days. During an observation and interview on 6/28/21 at 4:10 p.m., Resident #10's right leg wound did not have a dressing applied and was open to air. The wound was approximately 3 x 3 centimeters (cm) with redness on each side approximately 8 cm in length with no drainage noted. When interviewed, Resident #10 stated that staff had dropped the ball as far as dressing changes and that the wound had nothing on it today or yesterday. Resident #10 stated that the facility was short of staff, and that they had come here with the wound a year and a half ago. Resident #10 stated that the wound was not supposed to be red. When interviewed on 6/28/21 at 4:25 p.m., the Licensed Practical Nurse (LPN) stated that she should have completed Resident #10's treatment this morning but did not. The LPN stated that there is usually a third nurse to complete treatments, but the treatment nurse was on vacation. 3. Resident #11 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS Assessment, dated 6/10/21, revealed that the resident was cognitively intact. Physician orders, dated 12/3/20 to 6/12/21, included Dakins (a wound care treatment), 1/4 strength solution, to apply to the back wound topically every day shift. Review of TAR 5/1/21 to 5/31/21 revealed that there was no documentation that wound care was completed for 5 of 31 opportunities. Review of TAR 6/1/21 to 6/28/21 revealed that there was no documentation of wound care for 4 of 28 opportunities. Review of the nursing progress notes from 5/1/21 to 6/28/21 did not include any documentation related to the administration of treatments as ordered or refusals of care. During an observation on 6/24/21 at 1:40 p.m., Resident #11's back wound was approximately 6.5 x 6.5 cm, open and reddened with no drainage noted. When interviewed on 6/28/21 at 4:35 p.m., Resident #11 stated that they knew their dressings were not done daily but was not sure how many times it had been missed. When interviewed on 6/28/21 at 4:50 p.m., the Director of Nursing (DON) stated that when treatments are missed, they would first check to see if the nurse completed it and forgot to sign for it and, if missed, it is written up and the provider is notified. The DON stated that there are no treatment error reports for any of the missing documentation. When interviewed at 4:55 p.m., the Administrator stated that blanks in the TARs are checked periodically but not on a routine basis. The Administrator said that the previous treatment nurse was not completing the treatments and is no longer at the facility, adding that the new treatment nurse started in March 2021, but was off today. [10 NYCRR 415.11(c)(3)(i)]

Based on record reviews and interviews during an Abbreviated Survey (Complaint #NY 996) conducted on 1/15/21 it was determined for one (Resident #1) of three residents reviewed the facility did not ensure that its residents were free from significant medication errors. Specifically, Resident #1 did not receive multiple medications, including insulin for diabetes, medications for high blood pressure, ulcerative [MEDICAL CONDITION], and anxiety disorder. Resident #1 did receive multiple medications ordered for Resident #4. Resident #1 was subsequently admitted to the hospital with [REDACTED]. This resulted in actual harm to Resident #1 that was not immediate jeopardy and is evidenced by the following: The facility policy Medication Orders, dated May 2020, documented the licensed nurse will transcribe or transfer written orders into the Electronic Medication Administration Record (EMAR) system. For new admissions or readmissions, all medications will be reconciled with the Physician prior to entering into the EMAR system. All orders are noted by the nurse receiving the order which refers to ensuring the right medication, dose, route and duration and that the accompanied documentation for orders is carried out such as labs, diagnostics, rehabilitation, and dietary consults. New orders will be printed and placed in the resident's chart for Physician signature and verification of accuracy. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 1/13/21, documented the resident had moderately impaired cognition. Review of resident information that accompanied Resident #1 on 1/8/21 from the transferring facility included a three-page medication list that was labeled with Resident #1's name and identifying information. The medication list included but was not limited to the following: a) [MEDICATION NAME] (a medication used to treat high blood pressure)10 milligrams (mg) daily b) [MEDICATION NAME] (a medication used to treat anxiety) 1 mg three times a day c) [MEDICATION NAME] (a medication used to treat ulcerative [MEDICAL CONDITION]) 10 mg daily d) [MEDICATION NAME] (an oral anti-diabetic medication) 500 mg every morning e) [MEDICATION NAME] (an injectable insulin for diabetes) 15 units subcutaneous daily f) duloxetine (medication used to treat depression, anxiety, and diabetic pain) 30 mg daily g) [MEDICATION NAME] (a medication used to treat high cholesterol) 20mg daily h) [MEDICATION NAME] XR (a medication used to treat ulcerative [MEDICAL CONDITION]) 1500 mg daily i) Humalog (a 2nd injectable insulin for diabetes) before meals by sliding scale (a gradual increase in pre-meal or nighttime insulin doses based on pre-defined blood glucose ranges) j) iron supplements 325 mg three times a day. The January 2021 Medication Administration Record (MAR) documented that these medications were not the medications that were transcribed and ordered by the medical team prior to 1/12/21 and had not been administered to Resident #1 from 1/8/21 through 1/12/21. Review of information faxed from the transferring skilled nursing facility on 1/7/21 prior to Resident #1's admission included a two-page medication list that was labeled with Resident #4 name and identifying information. It is noted on this medication list that the Registered Nurse Manager (RNM) #1 reviewed this medication list (as opposed to the medication list that was sent with Resident #1 on 1/8/21) with Nurse Practitioner (NP)#1 on 1/8/21 who verbally ordered these medications. The facility Medication Review Report (physician orders) dated 1/9/21 included but was not limited to, orders for the following: a. [MEDICATION NAME] (a narcotic medication used to treat severe pain) 5-325 mg four times a day b. [MEDICATION NAME] oxalate (a medication used to treat depression and anxiety)10 mg once daily c. duloxetine 60 mg once daily d. [MEDICATION NAME] chloride extended release (a medication used to treat overactive bladder) 5 mg once daily e. [MEDICATION NAME] (a medication used to treat excess fluid in body tissues) 60 mg once daily The orders did not include Resident #1's medications listed on the 1/8/21 medication list. The January 2021 MAR dated 1/8/21 evening shift through 1/12/21 day shift documented Resident #1 received [MEDICATION NAME] for a total of 14 doses, [MEDICATION NAME] oxalate for 4 doses, duloxetine for 4 doses, [MEDICATION NAME] chloride for 4 doses and [MEDICATION NAME] for 4 doses. The Physician history and physical, dated 1/10/21, documented a current medication list consistent with medications that were listed in the packet of information sent with Resident #1 on 1/8/21 versus the incorrect medications that were faxed to the facility on [DATE]. The history and physical note also documented the resident was on insulin and blood sugars should be monitored every shift. This same note documented the resident appeared to be in no acute distress, was conversational and speech was clear and appropriate. Resident #1's medical record did not contain any documented evidence that blood sugars were monitored prior to 1/12/21. The medical progress note, dated 1/11/21 and signed by NP#2, documented the resident was seen for nausea and vomiting over the past 2 days. The note documented the resident appeared to be a reliable historian and the assessment was constipation. The medical progress note, dated 1/12/21 and signed by NP#1, documented the resident was evaluated for confusion. On physical exam the resident was drowsy, had difficulty maintaining alertness and had signs of dehydration. NP#1 noted that the resident's medications were reviewed, and multiple changes were made due to the resident's confusion and vital signs. A finger stick blood glucose (FSBG) level was checked which read high, and insulin was ordered. The resident did not appear stable, exhibiting signs of low oxygen levels and low blood pressure and was transferred to the hospital. Review of hospital records revealed that Resident #1 was admitted to the Emergency Department (ED) on 1/12/21 at 4:44 p.m. Upon arrival to the ED, the resident was somewhat awake but unable to participate in the examination due to their mental status. Resident #1's systolic blood pressure (the top number of the blood pressure; the maximum pressure the heart exerts while beating) was 56 millimeters of mercury (mm Hg) (normal range: 90 to 120 mm Hg) and the initial blood glucose level was 857 (normal range: 70-99 milligram/deciliter (mg/dL). Admitting [DIAGNOSES REDACTED]. Resident#1 was admitted to the Intensive Care Unit. During an interview on 1/15/21 at 1:12 p.m., the Licensed Practical Nurse (LPN) stated she reviewed the medication orders with Resident #1 on 1/8/21 and the resident voiced no concerns. The LPN could not recall if insulin or FSBG checks were on the orders. She said that normally with new admissions who have diabetes they check blood glucose levels for 5 days before meals and at bedtime, then review them with medical but did not know if this was completed for this resident. During an interview on 1/15/21 at 1:20 p.m., the Registered Nurse Manager (RNM)#1 stated the resident was a lateral transfer from another nursing home and she could not recall how she had obtained the medication orders. She said the resident had a packet of information of about 30 pages including the medication orders that she entered into the EMAR and reviewed with NP #1. The RNM#1 said the resident was seen by the Physician on 1/10/21 for a history and physical, on 1/11/21 by NP#2 for nausea and vomiting and again on 1/12/21 by NP#1 when they were found to have a high blood glucose level and transferred to the hospital. She said she that on 1/13/21 she discovered the medication orders were not Resident #1s and that the medication lists for both residents were very similar. The RNM#1 stated she did not identify the incorrect name on the transfer orders. During an interview on 1/15/21 at 1:34 p.m., NP #2 stated she saw Resident #1 on 1/11/21 for vomiting and nausea and was able to obtain a good history from the resident but did not review their medication orders at that time. NP#2 stated she attributed the nausea and vomiting to constipation because the resident told her they sometimes get backed up. NP #2 requested monitoring Resident #1's intake and output and to begin checking blood sugars. NP #2 said she did not become aware there were no admission orders [REDACTED]. NP #2 stated she thought Resident #1 not receiving insulin from 1/8/21 to 1/12/21 may have contributed to the resident's change in condition. During an interview on 1/15/21 at 2:32 p.m., NP #1 stated she was on call when nursing called her to review the admission orders [REDACTED]. The first time she saw Resident #1 was on 1/12/21 and the resident did not look good. She reviewed Resident #1's medication list at that time, knew the resident was diabetic and inquired as to see why the resident was not on diabetic medications. NP#1 made the decision to send the resident out because the FSBG readings were High and the resident was plummeting. NP #1 said not having the insulin likely lead to the resident's change in condition. During an interview on 1/15/21 at 3:23 p.m., the RNM #2 stated for new admissions she would normally look at the discharge summary and see what the resident was receiving upon discharge. RNM #2 stated she had looked at the discharge paperwork and what was entered by RNM #1 but never caught that the orders were for Resident #4. During an interview on 1/15/21 at 5:34 p.m., the Director of Nursing (DON) stated it did not appear that three checks of the admission orders [REDACTED]. The DON stated the orders are then checked by another nurse, and then again by a third nurse comparing them with the admission orders [REDACTED]. During an interview on 1/15/21 at 3:58 p.m. the Administrator stated that there is no documentation that the three checks were completed for Resident #1. She said we did not know we had a process issue until the medication error was identified. During an interview on 1/15/21 at 4:10 p.m., the Physician stated he saw Resident #1 as he usually sees the new admissions. He said that his process is to review the discharge summary and the history and physical and to his knowledge the medication list was accurate. He said he was informed by the facility that there was a mix up between two charts and two residents and that he thought what happened was that Resident#1's diabetes medication was not given to them causing a major issue. If proper medication is not given, this could unfortunately have hurt the resident. 415.12 (m)(2)

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for eight (Residents #33, #50, #85, #89, #99, #259, #309 and #315) of ten residents reviewed for Baseline Care Plans, the facility did not develop a Baseline Care Plan within 48 hours of admissions that included the minimum required information, and/or the resident or resident's representative were not provided with a written summary of the plan. This is evidenced by, but not limited, to the following: 1. Resident #33 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 7/10/19, revealed the resident was cognitively intact. The Baseline Care Plan, dated 12/21/18, did not include a summary of the resident's medications and/or physician orders [REDACTED]. There was no documented evidence that the facility provided the resident and/or the representative with a summary of the Baseline Care Plan. 2. Resident #259 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 9/19/19, revealed that the resident had moderately impaired cognition. Review of medication orders, dated 9/13/19 through 9/18/19, revealed orders for 11 different medications including three different [MEDICAL CONDITION] medications that were ordered on admission or soon after and included dose changes. The Baseline Care Plan, dated 9/12/19, revealed, the medication section was blank. There was no documentation that the physician orders [REDACTED]. The Baseline Care Plan Summary, dated 9/20/19, revealed that the care plan was reviewed with the resident's representative on 9/20/19 via a phone call. There was no documentation that medications were reviewed, or that a list of medications were sent to the representative. When interviewed on 9/25/19 at 2:23 p.m., the Licensed Practical Nurse (LPN) stated that she reviewed the Baseline Care Plan Summary with the resident's representative but did not review the medications because there were none listed. She said that the representative told her that she was aware of the medications from the hospital, but she did not document that anywhere. When asked, the LPN said that the medications added or changed since admission and prior to her phone call with the representative were not reviewed with the representative. When interviewed on 9/25/19 at 4:04 p.m., the Director of Nursing (DON) stated that she would expect staff to review the resident's medications, including changes with the representative at the time the Baseline Care Plan Summary was reviewed. In an interview on 9/26/19 at 12:22 p.m., the Registered Nurse Manager stated that the resident's Baseline Care Plan was reviewed over the phone with the representative who was out of town. She said that she did not know if a written copy of the Baseline Care Plan and medications were sent to the representative. 3. Resident #85 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 8/29/19, revealed the resident had moderately impaired cognition. The Baseline Care Plan, dated 8/22/19, was signed as completed 9/9/19, and was also signed by the resident. The Baseline Care Plan did not include a summary of the resident's medications and/or physician orders [REDACTED]. A progress note, dated 9/4/19, revealed the Baseline Care Plan was reviewed with the resident's representative. There was no documented evidence a copy of the Baseline Care Plan, including a medication list, was provided to the resident and or representative. When interviewed on 9/25/19 at 11:29 a.m., the DON stated the Baseline Care Plan should be completed within 48 hours and presented to the resident/representative within 21 days of admission. The DON stated a copy off the summary should be offered. She said there was no documentation as to whether it was accepted or declined. The DON stated the staff do not offer a copy of the medication list.

Based on observations, interviews and record reviews conducted during the Recertification Survey and complaint investigation (#NY 411) completed on 9/27/19, it was determined that for one (Resident #79) of three residents reviewed for pressure ulcers, the facility did not provide care and services to address the resident's skin and wound care needs in accordance with professional standards of practice based on the comprehensive assessment, person-centered care plan and the resident's choice. Specifically, multiple areas of skin breakdown were not assessed and/or treated according to medical orders and/or wound clinic recommendations. Additionally, an ointment was utilized that was on the resident's list of allergies [REDACTED]. This is evidenced by the following: Resident #79 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 8/20/19, included that the resident was cognitively intact and required extensive assist of staff for personal hygiene and toileting, was incontinent of bowel and bladder, and had one Stage 4 (full thickness tissue loss) pressure ulcer. In an interview on 9/23/19 at 2:17 p.m. and again on 9/25/19 at 10:34 a.m., the resident stated that she had sores on the back of her legs that are infected. She said staff are supposed to change it twice a day, but they do not change it on the evening shift due to a lack of staff. The resident later said that whatever they are [MEDICAL CONDITION] itches. She said she was allergic to [MEDICATION NAME] and does not want them using anything with [MEDICATION NAME] in it and would refuse the treatment. In an observation of wound care on 9/25/19 at 9:47 a.m., the bottom of the resident's right foot was covered with a hydrofoam (foam pad) only (no other padding or gauze) and had a minimum amount of serous drainage. The open wound was approximately 3 by 2 centimeters (cm) and covered with black eschar (dead tissue). The depth was unknown due to the eschar. The area was cleansed with wound cleaner, covered with a hydrofoam dressing, an ABD (thick absorbent dry pad) dressing and then wrapped with gauze. The Licensed Practical Nurse (LPN) stated at that time that there were no further dressings for the resident. The resident stated that the back of her thighs were burning and when rolled over the resident had a large (greater than 7 centimeters long) area of excoriated skin with several areas of denuded skin to the back of her right thigh that was bleeding. There was no dressing on the area and the resident was incontinent of urine. Additionally, there were two open areas that measured approximately 1 cm x 1 cm each on the right upper buttocks and in the crease. The LPN returned to the room and applied a large [MEDICATION NAME] (wound dressing often used for heavy draining wounds) to the back of the thigh. The LPN stated that she put alginate (highly absorbent wound treatment) on the [MEDICATION NAME] prior to applying it. Nothing was applied to the anterior groin creases or the abdominal folds. Review of the current physician orders [REDACTED]. a. To the thighs, groin and abdominal folds: apply 'C-LID3-NYST-ZN10 1:1:1' cream twice daily for excoriation (initiated on 5/15/19) b. To the bottom of the right foot wound: daily clean with normal saline, apply hydrofoam, an ABD pad and wrap the foot with gauze (initiated 6/14/19). c. To the thighs: apply Sensicare body cream every evening (initiated on 6/13/19). It did not include any specific area of the thighs. d. To the right outer buttocks wound: clean with wound cleanser, apply an alginate dressing to the open area and cover with a 6 cm x 6 cm [MEDICATION NAME] dressing every three days and as needed if loose or leaking (initiated on 9/6/19). Review of medical progress notes revealed the following: a. On 8/26/19, the outpatient wound clinic progress note revealed that the resident had a non-pressure related right plantar (bottom) foot wound of mixed vascular, [MEDICAL CONDITION] and traumatic etiology. The size was 0.4 cm x 0.2 cm x 0.1 cm with no eschar. The recommended treatment was to apply [MEDICATION NAME] liquid around the wound, Puracol (a collagen based wound treatment of [REDACTED]. The note included that a right posterior thigh wound was closed on the last visit, but recommendations included to apply Sensicare ointment and cover with an ABD pad to the area each time incontinence care was provided and as needed if it falls off. b. The Nurse Practitioner note, dated 9/5/19, revealed that the resident was being seen for an open wound on her right buttocks that started as moisture related skin damage but was now bleeding quite a bit and that the current treatment (C-LID3-NYST-ZN10 1:1:1) was not working. Recommendations included to clean the area with wound cleanser, apply alginate wound dressing and cover with [MEDICATION NAME] every three days and as needed. The note did not include any mention of the 8/26/19 wound clinic recommendations regarding the other wounds. c. On 9/12/19, the outpatient wound clinic note included that the right plantar foot wound was now 1.5 x 1.0 cm x 0.1 cm, debridement was done, and treatment was to remain the same: [MEDICATION NAME], Puracol (or collagen type substitute), [MEDICATION NAME] blue and gauze wrap. Instructions for the thigh area were to remain the same, Sensicare ointment and ABD cover and to change with every incontinence care. Review of the (MONTH) 2019 and (MONTH) 2019 Treatment Administration Records (TARs) revealed that the 'C-LID3-NYST-ZN10 1:1:1' ointment was signed off as applied twice daily to the thigh. The wound clinic recommendations were not implemented after either of the two visits for the foot wound or for the thigh skin damage. Both TARs included [MEDICATION NAME] as an allergy. Review of the progress notes did not include any documented reason why the wound clinic recommendations were not instituted. Interviews conducted on 9/25/19 included the following: a. At 12:02 p.m., the Certified Nursing Assistant stated that the resident has had the skin breakdown on her leg for quite a while and that it gets worse when the resident refuses to go back to bed in the afternoon. She stated she puts barrier cream on it but no dressing. She said she has seen a dressing on it occasionally. b. At 1:04 p.m. and again on 9/26/19 at 11:52 a.m., Registered Nurse (RN) Manager #1 stated that she has only been the Manager for about a week, but she has worked with the resident as a supervisor. She said she assessed the macerated skin of the thigh last week and saw the open areas. She said that she just put the special ointment on it that was made in the pharmacy. RN Manager #1 said she thought that the wound clinic ordered the alginate but was not sure. She said the residents return from wound clinic with a packet of information that goes to the providers for review of the recommendations and orders. She said then the information is sent to medical records to be scanned into the electronic medical record. She said that process takes a while and things sometimes get missed. RN Manager #1 said she knew the resident was allergic to [MEDICATION NAME] but thought it was for oral [MEDICATION NAME] and not the cream. She said she was not aware that the resident complained that it was burning and itching. c. At 1:59 p.m., the LPN stated that she does not use the 'C-LID3-NYST-ZN10 1:1:1' ointment because it had [MEDICATION NAME] in it and the resident refuses it due to an allergy. She said she told the Nurse Manager that the resident was refusing the ointment. The LPN later stated that she spoke with the evening nurse who told her that she uses that ointment every evening. Interviews conducted on 9/26/19 included the following: a. At 9:16 a.m., the pharmacist stated that the ointment contained [MEDICATION NAME] and zinc. He stated he was aware that the resident had an allergy to [MEDICATION NAME] but did not think it was a true allergy as they have been using it for quite a while. He said he was not aware that the resident said it burned and itched. He said that a wound clinic follow-up would be helpful to determine what to use. b. At 11:31 a.m., the wound clinic RN stated that when the clinic saw the resident on 9/12/19 they were not told of the new issues to the resident's posterior thigh, so they did not assess it but recommended to continue the Sensicare to prevent further issues. She said she would not recommend covering that area with [MEDICATION NAME]. The wound clinic RN said that the foot wound needed Puracol or a collagen substitute for healing and [MEDICATION NAME] Blue which is an anti-bacterial treatment. The wound clinic RN said that hydrofoam had no antibacterial properties in it and would not be an appropriate substitute. c. At 12:41 p.m., RN Manager #2 (previous manager) stated that they did not receive any paperwork from the wound clinic when the resident returned on 9/12/19 and no one picked up on it. He said when the surveyor requested the information, the facility called the wound clinic and obtained the information. (10 NYCRR 415.12)

Based on interview and record review conducted during the Recertification Survey, it was deteremined that for one (Resident #315) of six residents reviewed for Admission Comprehensive Assessments, the facility did not ensure that a comprehensive assessment was completed within 14 calendar days after admission. This was evidenced by the following: Resident #315 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 9/10/19, was coded as the admission assessment with an entry date of 9/3/19. Review of the MDS Assessment revealed as of 9/25/19 the assessment had not been completed. When interviewed on 9/25/19 at 11:12 a.m., the Registered Nurse MDS Coordinator, stated an admisson MDS Assessment should be completed within 14 days of admission. He stated that the resident's admission MDS Assessment was not completed. He said the Assessment should have been completed by 9/16/19. He said the resident had a care plan meeting on 9/24/19. When asked how the care plan was completed when the MDS Assessment and the Care Area Assessment were not completed, he said he would have to get back to the surveyor. (10 NYCRR 415.11(a)(3)(i)

Based on observations, interviews and record reviews conducted during the Recertification Survey and complaint investigation (#NY 650), it was determined for one of one resident (Resident #27) reviewed for enteral nutrition, the facility did not have a mechanism in place to ensure that the administration of enteral nutrition and additional water ordered for flushes was consistent with and followed physician orders. This is evidenced by the following: Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 7/3/19, revealed the resident was cognitively intact, had no significant weight loss or gain in the past one or six months. The resident received 51 percent or more of total caloric intake through a tube feeding and averaged a fluid intake of 501 cubic centimeters (ccs) per day or more through the tube feeding. The current physician orders [REDACTED]. of 640 mls. Mix Prostat (liquid protein supplement) with 120 mls water, and flush tube with 10 ml of water before and after administration daily . The Comprehensive Care Plans for nutrition and hydration, dated 6/20/19, directed to give enteral feedings and water flushes as ordered. Give [MEDICATION NAME] 1.2 at 80 mls per hour for a total volume of 1,500 mls per day with water flushes of 160 mls four times daily for a total of 640 mls per day. Give Prostat 30 mls daily, monitor and document intake per facility protocol. Review of a Medication Administration Record [REDACTED]. The amount of water given with Prostat was not documented at all, and there was no tally for total water given in the 24-hour period. Additionally, the tube feeding was documented as held on 9/14/19 with no volume documented and no explanation as to why or how long the feeding was held. On 9/24/19, it was documented that 1500 ml of tube feeding was delivered which was the date that 100 mls was left in the bottle. During an observation and interview on 9/24/19 at 1:50 p.m., Licensed Practical Nurse (LPN) #1 entered the room and said she was going to start the feeding. The spike set was not labelled or dated. LPN #1 said a Compat (brand name) feeding pump was in use. Review of an inspection label revealed the last inspection was (MONTH) (YEAR), and the next inspection was due (MONTH) (YEAR). Observations and interviews conducted on 9/25/19 included the following: a. At 10:04 a.m., LPN #2 said the tube feeding pump displayed that 1,500 mls had been delivered so she took down the container and put it in the trash. She said there was tube feeding nutrient remaining in the container and the spike set had not been labelled or dated. LPN #2 measured the remaining amount of nutrient which was 100 mls. When asked, LPN #2 said the container was 1,500 mls and the pump displayed 1,500 mls had been delivered. She said that could not be right. b. At 10:19 a.m. and 9/26/19 at 11:30 a.m., the Registered Nurse (RN) Manager observed the tube feeding set up and said the spike set should have been labelled and dated when hung on 9/24/19. She observed the inspection label and said the pump had not been serviced since (MONTH) (YEAR) and she would notify maintenance. The RN Manager said that any amount of tube feeding left in the container must be from the manufacturer overfilling the bottle. She said the amount of tube feeding and water flushes given each shift was not reviewed at the end of the 24 hours. When interviewed on 9/26/19 at 2:05 p.m. and 2:10 p.m., LPN #3 said there was no process in place to tally the total amount of water given in a 24-hour period. She said the tube feeding container held 1,500 mls so it should be empty. LPN #4 said she thinks the night shift was supposed to tally the amount of water given in a 24-hour period. During an interview on 9/27/19 at 9:49 a.m., a Registered Dietitian/Nutritionist (RDN) said she had written the order for the tube feeding and the daily use of one 1500 ml container. The RDN said that the tube feeding runs for approximately 18.75 hours and when the container was empty the tube feeding was complete. She said the nurses should be looking for an empty container, not just at the pump. The RDN said she reviewed the MARs and saw that some documented water amounts were different from what was ordered. She said there was no documentation for the amount of water given with the liquid protein. (10 NYCRR 415.12(g)(2))

Based on observations, interviews, and record review conducted during the Recertification Survey, it was determined that the facility did not post the required daily staffing information for licensed and unlicensed nursing staff directly responsible for resident care. Specifically, the facility staffing sheets were not updated at the beginning of each shift to include the actual hours worked by nursing staff. This is evidenced by the following: Observations of the posted staffing information on 9/23/19 at 11:32 a.m., 9/24/19 at 1:31 p.m., 9/25/19 at 11:54 a.m., and 9/26/19 at 11:57 a.m., did not include the actual hours worked for Licensed Practical Nurses (LPN), Registered Nurses (RN), and Certified Nurse Aides (CNA) for the day, evening, and night shifts on each of the corresponding dates. When interviewed on 9/27/19 at 9:51 a.m., the Director of Nursing (DON) stated that nurse staffing was completed and posted daily by the staff scheduler. The DON said she was not sure if the staff scheduler was aware that the actual hours worked by nursing staff needed to be included in the posted staffing. When interviewed on 9/27/19 at 10:17 a.m., the staff scheduler stated that she was responsible for posting the daily nurse staffing. She said the staffing information for all shifts was posted in the morning when she starts her shift and was not usually changed or updated throughout the day. She said the actual hours worked for each shift was not reflected on the posting.

Based on interview and record reviews conducted during the Recertification Survey, it was determined that for three of three residents reviewed for resident rights, the facility did not provide the appropriate liability and appeal notices to Medicare beneficiaries to notify them of their appeal rights under the regulations. Specifically, the facility did not provide Advanced Beneficiary Notices (ABN) to Residents #77 and #260 following termination of Medicare benefits and did not provide a Notice of Medicare Noncoverage (NOMNC) to Resident #261 prior to discharge home. This is evidenced by the following: Resident #261 was admitted to the facility on [DATE] under Medicare A benefits and discharged home on[DATE]. There was no evidence that a NOMNC was provided prior to discharge to notify them of their appeal rights under the regulations. Resident #77 was admitted to the facility on [DATE] under Medicare A benefits. A NOMNC letter was provided on 8/12/19 that Medicare A benefits were being terminated effective 8/16/19. The resident remained in the facility with days remaining. There was no evidence that an ABN letter was provided to the resident or resident representative to provide them with appropriate liability and appeal rights under the regulation. Resident #260 was admitted to the facility on [DATE] under Medicare A benefits. A NOMNC letter was provided on 8/6/19 that Medicare A benefits were being terminated effective 8/8/19. The resident remained in the facility with days remaining. There was no evidence that an ABN letter was provided to the resident or resident representative to provide them with appropriate liability and appeal rights under the regulation. In an interview on 9/26/19 at 9:40 a.m., the Business Office Manager stated that she took over the task of appeal notices in (MONTH) but was not aware of which notice to give and when until recently. She said she was still not sure which ABN to give and was not aware that residents going home required a NOMNC letter. (10 NYCRR 415.3(g)(2)(i))

Based on observations, interviews, and record reviews conducted during the Recertification Survey and complaint investigation (#NY 234), it was determined that for one of four residents observed for incontinence care and for two of two resident floors, the facility did not properly establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, there was improper incontinence care and lack of glove changing and handwashing for Resident #89, and shower stretchers used for multiple residents were not clean. This is evidenced by the following: 1. Resident #89 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The resident was currently on contact precautions for shingles (highly contagious rash). The Minimum Data Set Assessment, dated 2/16/18, included that the resident had severely impaired cognition, had a Foley catheter (tube inserted into the bladder to drain urine), and required extensive assistance for care. Review of the Comprehensive Care Plan, dated 11/1/17, and the Certified Nursing Assistant (CNA) Care Guide revealed the resident has a Foley catheter and was totally dependent on staff for care. When observed on 2/28/18 at 10:52 a.m., the Licensed Practical Nurse (LPN) donned gloves to do a pressure ulcer dressing change and found the resident was incontinent of feces. The CNA donned gloves to assist and cleansed the perineal area around the Foley catheter in a scrubbing motion with feces visible on the disposable wipes. Then without removing gloves or washing hands, the CNA applied the incontinence brief and touched the resident's pillow, the resident's arm, and the blanket before removing gloves and washing hands. Interviews conducted on 2/28/18 included the following: a. At 1:42 p.m., the CNA said she should have washed the perineum front to back only, changing the surface of the disposable wipe with each stroke, not in a scrubbing manner. She stated that she should have taken off her gloves after cleaning the resident and washed her hands before touching anything else. b. At 1:47 p.m., the LPN stated that the CNA should have cleaned the perineum with one stroke from the front to the back. She said she should have changed her gloves before touching anything but she did not notice that the CNA did not do that. c. At 1:52 p.m., the Registered Nurse Manager (RNM) stated that she expects staff to wash the perineum from the front to back, one stroke only. She said staff should change their gloves when they are soiled or when they have finished cleaning the resident. d. At 2:07 p.m., the Director of Nursing(DON)/Infection Control Nurse said that she expects perineal care to be provided front to back, not in a scrubbing motion or numerous times with the same surface of the wipe. She stated that there was a risk for infection, especially with a resident with a Foley catheter because the tube gives direct access for bacteria right into the bladder. She said she expects staff to change gloves after providing care and before touching anything else. The (MONTH) (YEAR) facility policy, Urinary Catheter Care, included to use one area of the washcloth for each downward, cleansing stroke. Change the position of the washcloth with each downward stroke. 2. In an observation on 2/26/18 at 10:30 a.m., the shower stretcher in the hallway on the second floor (even side rooms) had numerous brown spots (feces smelling) on the underside of the blue mat and on the mesh underneath it. Observations on 2/26/18 at 10:46 a.m. revealed the blue mesh under the white mat on a shower stretcher (third floor by room [ROOM NUMBER]) had white material and residue. Observations on 2/28/18 at 1:02 p.m. revealed the blue mesh under a white mat on a shower stretcher (third floor by room [ROOM NUMBER]) had a razor cover, white material/residue, and brownish gray globular material. Additionally, there was a large amount of hair on the underside of the white mat. When interviewed at that time, the CNA said that a total of 18 residents on the third floor would use the shower stretcher and that the underside of the mat should be cleaned if someone is given a shower. The CNA looked under the mat and agreed that it was not clean. A subsequent interview with the third floor RNM revealed the shower stretcher should be cleaned after every shower and that the CNA (or whoever used it) is responsible for cleaning it. When interviewed on 3/2/18 at 10:30 a.m., the DON/Infection Control Nurse stated that she expects the shower stretcher to be washed after every shower. She said the CNA should wash it down with soap and water, and then use a disinfectant and wash the top mattress and wash underneath it. She stated that additionally, the housekeeping personnel should clean the entire stretcher once a week with a detergent disinfectant solution. The (MONTH) 2012 facility policy, Cleaning Shower Stretcher/Tub, included to clean the shower stretcher fabric and mattress with a detergent disinfectant solution after each use by the nursing staff. Once a week on Wednesday the shower stretchers are cleaned by housekeeping personnel with a detergent disinfectant solution. (10 NYCRR 415.19(b)(4) & 415.29(j)(1))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of three dining areas reviewed for appropriate meal consistency, the facility did not ensure that the resident environment remained as free of accident hazards as possible. The issue was that Resident #110, who was on a mechanical soft diet with ground meats, was served sliced turkey. This is evidenced by the following: Resident #110 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was readmitted to the facility on [DATE] after a hospital stay for [MEDICAL CONDITION]. Review of the Minimum Data Set Assessment, dated 2/17/18, revealed that the resident was cognitively intact and required set up and supervision for eating. Review of the 2/5/18 physician orders, 2/6/18 Comprehensive Care Plan, the current Certified Nursing Assistant Kardex, and the 2/19/18 Nutrition Assessment revealed the resident was on a mechanical soft diet. When observed on 2/26/18 at 12:14 p.m., the resident was in the first floor dining room with a hot turkey sandwich with sliced turkey on her lunch tray. The tray ticket included mechanical soft diet with ground meats. At that time, the resident said she was sick of turkey and not that hungry so she would not eat the sliced turkey. Interviews conducted on 2/26/18 included the following: a. At 12:16 p.m., the Licensed Practical Nurse said that according to the tray ticket, the resident should have received ground turkey, not sliced. b. At 12:20 p.m., the Speech/Language Therapist stated that the turkey was not ground and should be. She removed the plate from in front of the resident. c. At 12:25 p.m., the Director of Food Services said that the resident should have been given ground turkey and that someone on the tray line must have made a mistake. When interviewed on 3/2/18 at 8:15 a.m., the Registered Dietician (RD) stated that sometimes she works on the tray line in the kitchen to watch the food consistency but did not do that on 2/26/18. She said multiple staff on the tray line and the staff passing the tray to the resident should have caught the mistake. The RD said that the resident was on ground meats because she has dysphagia due to oral and pharyngeal function causing her to have trouble chewing and swallowing. She said the danger of giving the wrong consistency was choking and aspiration into the lungs. The (MONTH) (YEAR) facility policy, Modified Food Consistency, included that the food and nutrition services department will be responsible for preparing and serving the diet texture as ordered. The mechanical soft diet includes food to avoid including whole meats and poultry. (10 NYCRR 415.12(h)(1))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #79) of four residents reviewed for pressure ulcers, and one (Resident #14) of five residents reviewed for unnecessary medications, the facility did not develop a plan of care for each resident that included measurable objectives and interventions to address care and treatment related to clinical [DIAGNOSES REDACTED]. Specifically, there was no Comprehensive Care Plans for the use of an anticoagulant (blood thinner) medication. This is evidenced by the following: 1. Resident #79 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 1/24/18, included that the resident had severely impaired cognition and was on an anticoagulant. The Medical Progress Notes, dated 1/24/18, included that the resident had redness and swelling of the left leg. The Doppler Study revealed a [MEDICAL CONDITION] ([MEDICAL CONDITION], blood clot) and the resident will be started on Xarelto (a blood thinner medication). The physician's orders [REDACTED]. Review of the 2/1/18 Comprehensive Care Plan (CCP) and the current Certified Nursing Assistant (CNA) Care Plan did not include that the resident previously had a blood clot in her leg and the use of a blood thinner. During an interview on 2/28/18 at 1:54 p.m., the Registered Nurse (RN) Unit Manager (UM) stated that she would expect a care plan for a resident with a [MEDICAL CONDITION] and receiving a blood thinner medication. The RN/UM said she was responsible for developing the CCP. She said she thinks that when the resident had the recent [MEDICAL CONDITION] and was put back on a blood thinner, she forgot to add it back on the care plan. She said it is documented on the care plan and CNA Kardex (care plan) so staff can watch for bleeding and bruising. 2. Resident #14 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The MDS Assessment, dated 2/11/18, revealed the resident was cognitively intact. Review of physician orders, dated 11/2/17, revealed orders for [MEDICATION NAME] (a blood thinning medication to prevent blood clots) 150 mg twice daily for anticoagulation (prevention of blood clots). Observations and interviews on 2/26/18 at 2:00 p.m., on 2/27/18 at 2:15 p.m., and on 2/28/18 at 10:52 a.m., the resident was noted to have a large bruise to her left hand and several bruises along both arms. The resident stated that she was unaware of how she got the bruises and that she bruises easily. Review of an Incident/Accident Report, dated 2/17/18, included that the resident had a bruise to her right knee and was not aware of how she got it. Review of the current CCP and the CNA Care Card revealed that the resident has an alteration in cardiovascular function and was at high risk for impaired skin integrity related to fragile skin and a history of blood clots. Neither care plan included that the resident was on a blood thinning medication. When interviewed on 2/28/18 at 2:03 p.m. and again on 3/1/18 at 9:38 a.m., the Director of Nursing stated that she would expect residents with a history of [MEDICAL CONDITION], as in Resident #79, and on blood thinners to have it documented in their care plans because of the health risk. She said that was the responsibility of nursing. She said that these residents need to be monitored for bleeding. In an interview on 3/1/18 at 1:54 p.m., the CNA stated that staff are not informed of which residents are on blood thinners. She said she felt it meant that residents have fragile skin and bruise easily. She said they should put lotion on their skin and that sometimes they use geri sleeves (protective covering for the arms) for these residents but that they (CNAs) do not know which residents are on these medications or what other side effects they should watch for. In an interview on 3/2/18 at 9:38 a.m., the RN/UM stated that they have care plans for residents on anti-coagulant medications to monitor for bleeding and nose bleeds. She said they also document that information on the CNA Care Plans. The RN/UM said she does not see a care plan for anticoagulant medications for Resident #14 but there should be one. (10 NYCRR 415.11(c)(1))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for 1 (Resident #93) of 12 residents reviewed for Activities of Daily Living (ADLs), the facility did not provide the necessary care and services to maintain the resident's personal hygiene. Issues involved the lack of oral care. This is evidenced by the following: Resident #93 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 2/1/18, included that the resident had severely impaired cognition, required extensive assistance of one staff member for personal hygiene, had no dental issues, and had no rejection of care during the seven day look back period. The Comprehensive Care Plan and the Certified Nursing Assistant (CNA) Care Kardex included that the resident had oral/dental health problems and directed staff to provide mouth care. The Dental Consult Notes, dated 1/2/17 and 12/20/17, included to complete dental care twice a day. Progress notes reviewed for the past month and the CNA Task documentation for personal hygiene for the past 14 days did not include any documentation related to rejection of oral care. When interviewed on 2/26/18 at 4:07 p.m., a family member said that his biggest concern had been that the resident's teeth were not being cleaned. He said that caring for the resident's teeth was always important to her. The family member said they used to brush the resident's teeth but because of her swallowing issues did not feel comfortable doing it any more. At that time, the resident's teeth were observed to have a large amount of white buildup on and in between the upper and lower teeth. When observed on 2/27/18 at 9:18 a.m. and on 2/28/18 at 9:13 a.m., the resident continued to have a large amount of white build up/debris on and in between the teeth. When interviewed on 2/28/18 at 9:56 a.m., the primary day CNA said that the night shift gets the resident up and completes morning cares. She said the resident has all her own teeth. When she observed the resident's teeth at that time, she said that they appeared to not have been cleaned in a while and she would get a toothette to clean them. At 10:03 a.m., the resident did not resist care as the CNA was observed to clean the resident's teeth using toothettes and a toothbrush. After swabbing the teeth, the toothettes had a large amount of yellow substance on them and the CNA said the resident's teeth appeared to have a lot of plaque on them. The CNA said she did not pay attention to the resident's teeth because the night shift got the resident up and her husband normally took care of her teeth when he came in. The CNA said she was not aware that the resident's husband was not comfortable caring for her teeth anymore. When interviewed on 2/28/18 at 2:08 p.m., the Registered Nurse Manager (RNM) said that she monitors the computerized program under personal hygiene as well as spot checking to ensure that personal hygiene is completed. Residents are to receive oral care at least twice a day, first thing in the morning and before bed. The RNM said because the resident is on a full liquid diet she may need care after meals as well. She said staff are to use a toothbrush to complete oral care. The RNM said that she was aware that the husband was not going to complete oral care anymore because he did not feel safe doing it. (10 NYCRR 415.12(a)(3))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #69) of seven residents reviewed for accidents, the facility did not ensure that the resident received treatment and care in accordance with professional standards of practice in order to meet the resident's physical, mental and psychosocial needs. Specifically, the facility did not notify the medical team in a timely manner and/or ensure timely follow-up after a resident's verbalization of a fall and ongoing complaints of pain. This is evidenced by the following: Resident #69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 1/18/18, revealed that the resident had severely impaired cognition, was independent with transfers, able to walk independently while in his room, walk with the assistance of one person on the unit with a wheeled walker, and was without any limitations in Range of Motion. The undated facility policy, Falls - Clinical Protocol, revealed under the heading, Cause Identification, directs that after more than one fall, the physician should review the resident's gait, balance, and current medications that may be associated with dizziness or falling. Under the heading Monitoring and Follow-Up, it directs that the staff, with the physician's guidance, will follow-up on any fall with an associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out. Delayed complications such as late fractures and major bruising may occur hours or several days after a fall. A Rehab Screening Request Form, dated 2/8/18, included that the resident had decreased lower body strength, shuffled gait, limited lower body Range of Motion, pain in lower extremities and weakness. The Licensed Practical Nurse (LPN) completing the form also wrote that the resident's entire left side from ribs to knee was very painful, had x-rays that were negative, and that both the physician and unit manager were aware. The Physical Therapist wrote, under Finding/Observation, that the resident was currently on Physical Therapy (PT). PT is trying to address posture while ambulating and strength but due to the resident's cognitive status and level of dementia the resident is a poor rehab candidate because he has poor carry over of learned tasks and varying participation levels. The therapist checked that an evaluation was not indicated. An Incident/Accident (I/A) Report form, dated 2/9/18 at 1:20 a.m. and signed by all disciplines, included that the resident came to his room door and told the Certified Nursing Assistant (CNA) that he had fallen and got himself up. It was documented that the resident was complaining of left leg pain and left rib and side pain. The written statement from the CNA in the investigation noted that the resident takes himself to the bathroom. The LPN statement included that the Supervisor had been contacted at 1:34 a.m. The Falls Observation Protocol Worksheet attached to the I/A documented that the resident complained of left leg and knee pain and left rib and side pain and showed evidence of localized weakness in his legs. The Initial Event Documentation form completed by the Registered Nurse (RN)/Unit Manager (UM) on 2/9/18 at 8:38 a.m. included the most recent vital signs and noted that at 1:30 a.m. the resident came out of his room and told the supervisor that he fell and got himself up, that it was not witnessed and there were no injuries. The pain presence/location/description sections were all blank, the skin assessment was blank, and there was no documentation that any Range of Motion was assessed. Review of interdisciplinary progress notes revealed the following: a. On 2/9/18 at 8:36 a.m., the RN Assessment note revealed that the resident continued to complain of left hip pain, left leg pain, and was having more difficulty walking with his walker. The RN noted that the physician was aware and said that he would see the resident, and that the resident receives Tylenol for pain with relief. b. On 2/9/18 at 9:21 p.m., the LPN noted that the resident had increased anxiety on the evening shift, was yelling in the hallway, was very agitated and complaining of hip and knee pain. Tylenol and [MEDICATION NAME] were administered with positive effect. c. On 2/13/18 at 12:32 p.m., the LPN documented that the resident refused all his medications, yelled loudly and was unsteady on his feet while using his walker. Redirection was very difficult and that both the physician and the Unit Manager were aware. d. On 2/14/18 at 12:37 p.m., the LPN documented that the resident continues to complain of left side hip and leg pain and is having difficulty walking with the walker. e. On 2/16/18, the Registered Dietician documented that the resident was reviewed by the team for overall functional decline and weight loss and labs and a hip x-ray were requested. f. On 2/17/18, the LPN wrote that the resident was admitted to the hospital with [REDACTED]. In a written statement, dated 3/1/18 and signed by the Physical Therapist, the therapist documented that he provided therapy to the resident on 2/9/18 day shift and that the resident proceeded as normal with participation with a trip to the bathroom. He added that the resident did not report pain above his normal baseline. Review of medical team notes in the medical record revealed the following: a. A Physician's Communication Log, dated 2/13/18 and written by an RN, revealed the resident was status [REDACTED]. The entry was initialed, crossed off and dated 2/18/18 with the word hospital written by it. b. A Physician's Assistant (PA) progress note, dated 2/16/18, revealed that the resident was seen with the chief complaint of left hip pain and lethargy, that the resident had a fall and an x-ray was done at that time that was negative. He included that the resident would not move his hip for an evaluation of Range of Motion, had no obvious deformity, and was sent to the emergency department for further evaluation. There were no other medical notes in the medical record following the unwitnessed fall on 2/9/18 and no other reports of any other falls. Review of the only x-ray report in the medical record, dated 2/16/18, revealed the left hip was suspicious for a fracture. A Physician Readmission History and Physical, dated 2/22/18, revealed that the resident was readmitted following a left [MEDICAL CONDITION] which was surgically repaired, and he has returned to the facility in a very weak and frail state. Interviews conducted on 2/28/18 included the following: a. At 10:05 a.m., the RN/UM said that an x-ray of the resident's left hip and leg was not done until 2/16/18. When asked if the resident had been seen by a physician on 2/9/18, the RN/UM stated that she did not believe that the physician had seen the resident on 2/9/18 and could not recall if she had left a note for the physician or spoken to him regarding seeing the resident. When asked when the resident first started having complaints of left hip pain, the RN/UM stated that she did not know when the pain started and that she believed it was after the resident had a fall. b. At 10:09 a.m., the PA stated that he had made a mistake regarding his 2/16/18 documentation. He said that the resident had a negative x-ray but it had been a previous x-ray and was not of his left hip. c. At 12:42 p.m., the RN/UM stated that if an unwitnessed fall was reported, neurological checks should have been completed and Range of Motion completed. The RN/UM stated that she was unable to find documentation of neurological checks or Range of Motion. d. At 12:49 p.m., RN #1 stated that when she saw the resident, she noted that he was pulling down his pants, pointing to his left hip, and saying that it hurt him. The RN stated she wrote a note on the Physician's Communication Log on 2/13/18 for the resident to be seen with a question for an x-ray. The RN stated that it was presented that he already had an x-ray, and every day in team meeting, it was asked what was happening with the resident and it was stated that he already had an x-ray until it was realized that he had not had a left hip x-ray so it was ordered on [DATE]. The RN said that the physician was scheduled to be in the building on 2/13/18 (Tuesday). e. At 1:35 p.m. and again at 3:15 p.m., the Director of Nursing stated that a head to toe Range of Motion and looking at the skin would be expected following a reported fall with complaints of pain. She said that she was told the morning of 2/9/18 that the resident reported a fall. She said that the RN/UM took over to write the I/A and complete the assessment because an RN was on-call that night. There was no RN in the building at the time of the fall. f. At 1:53 p.m., the physician stated that he last saw the resident on 2/5/18 and did not know if anyone saw him on 2/13/18. He said that if a resident falls and complains of hip and leg pain, he would check the resident and order x-rays or send to the hospital and would not expect a seven-day delay between a fall and x-rays ordered. g. At 4:01 p.m., the Administrator stated that she expects medical to review the Communication Log daily when in the building. She said the PA was sick that week and was not sure if anyone was covering. Interviews conducted on 3/1/18 included the following: a. At 6:50 a.m., LPN #1 stated that she was the LPN on the night shift of 2/9/18. She said the resident told her he fell , but she did not believe him because he would not have been able to get himself up. She said he was always complaining of pain so she did not think it was new. She stated she told the LPN supervisor on that night that the resident complained of left leg pain but she did not really believe he fell . b. At 7:25 a.m., RN #2 stated that she was the on-call RN and the LPN supervisor called her, told her the resident fell but did not inform her he was complaining of leg pain. c. At 3:35 p.m., the LPN supervisor stated that she went in and looked at the resident who did complain of pain but she did not ask him to walk as she thought it was normal for the resident. When interviewed on 3/2/18 at 8:20 a.m., the night shift CNA stated that the resident told her he fell on [DATE] and that he was limping. She said she believed him because he was pointing at his hip, saying it hurt and he did not normally do that. She said the LPN did not believe her that he fell . (10 NYCRR 415.12)

Based on interviews and record reviews conducted during an Abbreviated Survey (complaint #NY 250) completed on 11/7/13, it was determined that for one (Resident #1) of three residents reviewed for insulin administration, the facility did not ensure that residents were free of significant medication errors. THIS IS A REPEAT DEFICIENCY FROM THE RECERTIFICATION SURVEY OF 2/15/13. Specifically, the resident received an excessive dose of rapid-acting insulin, became unresponsive, and was hospitalized in the Intensive Care Unit with [DIAGNOSES REDACTED] and metabolic [MEDICAL CONDITION] (brain disease, damage, or malfunction). This resulted in actual harm that is not immediate jeopardy, and is evidenced by the following: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The medication list on the physician hospitalist progress note, dated 10/29/13, included a correction scale of [MEDICATION NAME] (Humalog) rapid-acting insulin. The physician's plan was to continue to manage the resident's diabetes mellitus with insulin on a sliding scale based upon blood glucose monitoring. The hospital patient care summary, dated 9/29/13 and signed by the hospital Registered Nurse (RN) on 10/30/13, and the nursing home admission physician orders, signed by the physician on 10/30/13, both included orders that read "Humalog (rapid-acting insulin) 100 units/milliliter (ml) subcutaneous (under the skin) injection three times a day before meals." The facility's physician orders [REDACTED]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Review of the pharmacy's label and documentation faxed to the facility on [DATE] as requested by the surveyor, revealed that the facility was called for clarification of the Humalog insulin physician order. LPN #1 provided the sliding scale insulin information to the pharmacist on 10/30/13 at 4:26 p.m. A facility RN progress note, dated 11/4/13 (late entry for 10/31/13), revealed that she was called to the resident's room at 2:30 p.m. on 10/31/13 because the resident was unresponsive and the resident's blood glucose reading was very low. Emergency Medical Services (EMS) was activated and [MEDICATION NAME] intramuscular was given without effect. The resident's blood glucose was still reading low, less than 30 at that time, and intramuscular [MEDICATION NAME] was repeated. EMS arrived and transported the resident to the hospital. A verbal physician order [REDACTED].#3 that included low dose insulin sliding scale using Humalog before meals: if blood glucose is 100 - 150, 2 units; 151 - 200, 4 units; 201 - 250, 6 units; 251 - 300, 8 units; and 301 - 400, 10 units. Review of the Humalog insulin marked with Resident #1's name on 11/6/13 at 10:40 a.m. in the medication cart revealed that the label read Humalog 100 units/milliliter. No dosage was included. There was another resident's insulin that was stored in a baggie with a pharmacy label that included the dosage instructions. Interviews conducted on 11/6/13 revealed the following: a. At 9:30 a.m., the Director of Nursing (DON) said that LPN #2 gave 100 units of Humalog insulin on 10/31/13 at 7:30 a.m. to Resident #1. The resident was found unresponsive at 2:30 p.m. that day and required admission to the intensive care unit. b. At 10:40 a.m., LPN #5 said that when the insulin vials are dispensed from the pharmacy, they are in a bag with specific instructions. LPN #5 said the insulin vial also has a small label with the resident's name and the name of the medication. Also, the administration instructions are written on the MAR. c. At 10:55 a.m., the RN Manager said that she usually reviews new admission records the day after admission at morning report to ensure everything was done. The RN Manager stated that she did not go to morning report on 10/31/13 or review the resident's admission orders [REDACTED]. d. At 12:45 p.m., in a telephone interview, the pharmacist reported that all insulin vials are delivered to the facility in a baggie with a pharmacy label marked with medication administration instructions. The pharmacy label on this resident's medication read "Humalog blood glucose before meals and the actual sliding scale coverage." Also, the pharmacist called the facility on 10/30/13 at 2:00 p.m. for clarification of the order, and there was no answer. The pharmacist reached the facility at 4:26 p.m. and spoke with LPN #1, who provided the sliding scale information. e. At 1:00 p.m., the DON said that she was not aware the insulin was delivered in baggies with specific instructions on the label. The DON said that she had not spoken with the pharmacy regarding this resident. f. At 1:10 p.m., LPN #3 stated that she worked evenings on 10/30/13 She said she should have completed a second check on the new admission orders [REDACTED]. LPN #3 did not say why she signed the MAR for a medication that she did not administer. She also said the resident's blood glucose was 127 and that her medications did not arrive from the pharmacy until approximately 9:00 p.m. LPN #3 said that she called LPN #1 on 10/31/13, the next morning. LPN #1 asked her if the Nurse Practitioner (NP) had written an order for [REDACTED].#1 that she would check the orders when she reported to work on 10/31/13 at 3:00 p.m. LPN #3 said that she arrived to work on 10/31/13 at approximately 2:30 p.m., checked the physician orders [REDACTED]. LPN #3 said that the sliding scale is a facility policy, and she confirmed with LPN #1 that is what the NP wanted. g. At 2:40 p.m., LPN #4 said that she was assisting nursing on the unit with two new admissions on 10/30/13. LPN #4 said that the physician orders [REDACTED]. She said she noticed that there was no dosage included in the Humalog insulin order. LPN #4 said that she returned to the unit, handed the orders and MARs to the corporate RN and was very direct in communicating that clarifications needed to be done on these orders. LPN #4 said that she did not sign off on the orders because they were incorrect and were not signed by the physician. Also, she wrote the incomplete orders for insulin on the MAR because that is how "it is always done." h. At 3:05 p.m., LPN #2 said that she gave 100 units of insulin on 10/31/13 at 7:30 a.m. because the nurse working the evening before signed off that insulin was administered. LPN #2 reported that the resident's blood glucose at 7:30 a.m. on 10/31/13 was 153 and 70 at 11:30 a.m. She did not record the blood glucose of 70 anywhere. She did report to the corporate RN that the resident was due for 100 units of insulin and her blood glucose was 70. LPN #2 said that the corporate RN told her to hold the insulin. At that time, the resident was confused and would not talk, but was fed 4 to 6 ounces of applesauce. LPN #2 said that she did not document her conversation with the corporate RN and did not notify the physician because the resident's blood glucose was not less than 60 per protocol. Also, LPN #3 added the sliding scale insulin to the MAR indicated [REDACTED]'s Humalog insulin was not in the bag provided by pharmacy. She added the insulin vials are never kept in the baggies provided by pharmacy. She did not know if specific administration instructions are included on the label that pharmacy provides. i. At 4:25 p.m., and on 11/7/13 at 12:25 p.m., the corporate RN said that LPN #4 gave the admission orders [REDACTED]. The corporate RN said that on 10/31/13 at 11:30 a.m., LPN #2 told her that the resident was not doing well, was not eating, and she was concerned because the resident was due for insulin at 11:30 a.m. The corporate RN said she advised the LPN to hold the insulin because she said the resident was not eating or acting herself. She also said that she did not complete an assessment of Resident #1 because there was another resident on the unit that was unresponsive. Interviews conducted on 11/7/13 revealed the following: a. At 10:00 a.m., by telephone, the NP said that she was on the unit on 10/30/13 and did give LPN #1 and LPN #3 a verbal order for low dose insulin sliding scale before meals. The NP said the nurses should have written the verbal order. The NP stated that the resident had an insulin overdose which could cause "serious morbidity or death." The NP reported that the hospital [DIAGNOSES REDACTED] [DIAGNOSES REDACTED]. b. At 10:55 a.m., by telephone, LPN #1 said that she worked days on 10/30/13 and remembered that the pharmacy called for clarification of the Humalog insulin order. LPN #1 said the NP was sitting at the nurses' station with the resident's chart, when the pharmacy called and the sliding scale insulin was clarified. LPN #1 said that she should have written a verbal order for the sliding scale insulin. LPN #1 said that she did not work on 10/31/13, but received a phone call from LPN #3, who reported to her that the sliding scale insulin order was not written. LPN #1 said that LPN #3 should have checked the new admission orders [REDACTED]. Review of the undated facility's policy, "Administering Medications" revealed that if a dosage is believed to be inappropriate or excessive for a resident, the person preparing the medication shall contact the attending physician. The individual administering the medications must check the label three times to verify the right medication, right dosage, right time, right resident, and method of administration before giving the medication. (10 NYCRR 415.12(m)(2))