Every finding on record at Edna Tina Wilson Living Center

Based on observation, interviews, and record review conducted during a Recertification Survey from 04/07/2025 to 04/11/2025, the facility did not 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 disease and infections for one (1) (Resident #25) of five (5) residents reviewed. Specifically, the resident had an unstageable pressure ulcer (full-thickness skin and tissue loss in which the extent of tissue damage cannot be confirmed because the wound bed is obscured by dead tissue), was not placed on enhanced barrier precautions (interventions designed to reduce transmission of multidrug-resistant organisms), and staff did not wear appropriate personal protective equipment (PPE-equipment worn to minimize exposure to potential hazards such as a facemask, gloves and/or gown) during incontinence and wound care. The findings include: The facility's Enhanced Barrier Precautions Policy, reviewed April 2025, documented enhanced barrier precautions should be used for residents with wounds. Gowns and gloves should be worn for high-contact resident activities including transferring, providing hygiene care, and for any skin opening (wound) care requiring a dressing. Resident #25 had diagnoses including dementia, a stroke, and high blood pressure. The Minimum Data Set (a resident assessment tool), dated 02/28/2025, included the resident had severe impairment of cognitive function and was at risk for pressure ulcers. Resident #25's current Comprehensive Care Plan and Certified Nursing Assistant Care Card, reviewed on 04/10/2025, both documented the resident had an unstageable pressure ulcer of on their coccyx (area at the base of the spine and above the buttocks). There was no documented evidence that either care plan included that the resident required enhanced barrier precautions. In a nursing progress note, dated 03/31/2025, Registered Nurse Clinical Leader #1 documented Resident #25 had a new unstageable pressure ulcer on the coccyx. Current physician's orders, reviewed on 04/10/2025, documented to clean the wound every three days with normal saline, dry and apply skin prep (protective skin treatment) to the peri areas (skin surrounding the wound), and cover it with a foam dressing. Physician's orders did not include enhanced barrier precautions. During an observation on 04/09/2025 at 10:00 AM, Licensed Practical Nurse #1 and Certified Nursing Assistant #1 assisted Resident #25 to stand using a stand lift (a mechanical lift that assists the resident to stand and transfer) in the unit's common shower/bathroom. Wearing gloves and no gowns, Licensed Practical Nurse #1 and Certified Nursing Assistant #1 provided incontinence care for stool and urine and did wound care to the resident's pressure ulcer. During an observation on 04/10/2025 at 10:18 AM, outside of Resident #25's room there was no personal protective equipment available or a sign to indicate enhanced barrier precautions should be used with direct care. During an interview on 04/11/2025 at 11:25 AM, Certified Nursing Assistant #2 stated residents with open wounds should be on enhanced barrier precautions, have an enhanced barrier sign in their room, and have personal protective equipment available. During an interview on 04/11/2025 at 11:38 AM, Licensed Practical Nurse #2 stated residents with open wounds should be on enhanced barrier precautions and should have a sign on their door. Licensed Practical Nurse #2 stated they did not think any residents on the unit were currently on enhanced barrier precautions. During an interview on 04/10/2025 at 2:56 PM, the Infection Preventionist/Assistant Director of Nursing stated any resident with a wound should be on enhanced barrier precautions, have a sign on their door, and have personal protective supplies outside of their room. Staff should wear a gown and gloves when providing care to prevent the spread of infection. The Infection Preventionist/Assistant Director of Nursing also stated all residents with wounds should be on enhanced barrier precautions and were unsure why some residents were missed. During an interview on 04/11/2025 at 10:48 AM, the Director of Nursing stated any resident with a wound should be on enhanced barrier precautions. The Director of Nursing stated five residents were recently identified who should have been on enhanced barrier precautions but were not. 10 NYCCRR 415.19(a)(1-3)

Based on observation, interview, and record review conducted during a Recertification Survey [DATE]-[DATE] it was determined that for two (Residents #32 and #109) of 32 residents reviewed, the facility did not ensure that the residents had the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive that would be honored. Specifically, the facility did not ensure Residents #32 and #109 advance directive identifiers were consistent with the resident's wishes. This is evidenced by the following: The facility policy Advance Directives for Long Term Care, revised [DATE], documented that prior to or upon admission, the Social Worker will review advance directive wishes with the patient and/or the patient's representative and review those directives for completeness. Completed forms regarding code status (the level of medical interventions a person wishes to have started if their heart or breathing stops) are placed in the Advance Directives section of the medical record. Do Not Resuscitate (DNR- meaning do not initiate cardiopulmonary resuscitation or CPR-manual chest compressions and rescue breathing to restore cardiac function and/or to support ventilation in the event of a cardiac or respiratory arrest) will not be attempted in the event a patient suffers cardiac or respiratory arrest. The DNR status will be communicated through the application of a purple DNR sticker on the patient's wristband. For any patient who is unable to or chooses not to wear a wristband and has a DNR order, a licensed nurse will provide education to patients and/or patient representative that CPR will be initiated until code status is confirmed. 1. Resident #32 had diagnoses including malignant neoplasm of the breast (breast cancer), dementia, and hypertension. The Minimum Data Set (MDS - a resident assessment tool) dated [DATE] documented the resident had moderate impairment of cognitive function and had a DNR code status. The active physician orders initiated [DATE] documented DNR/Comfort Care only status. The Medical Orders for Life-Sustaining Treatment (MOLST - medical orders to provide, withhold, or withdraw life-sustaining treatment) dated [DATE], documented DNR. The current (active) Comprehensive Care Plan (CCP) and the current Certified Nursing Assistant (CNA) care card posted in the resident's room documented Resident #32's code status as DNR. During intermittent observations on [DATE] from 8:42 AM to 10:53 AM, Resident #32s' wristband did not include a purple DNR sticker. During an interview on [DATE] at 10:45 a.m., Licensed Practical Nurse (LPN) #2 stated if a resident was found unresponsive, they would check the resident's wristband for a purple DNR sticker, if there were no purple DNR sticker, LPN #2 would initiate CPR. During an interview on [DATE] at 10:48 AM, LPN #3 stated if they found a resident unresponsive, they would check the electronic medical record (EMR) or care plan in the resident's room for code status. LPN #3 was unaware if the resident's wristband included code status information. During on observation/interview on [DATE] at 10:53 a.m., Registered Nurse Manager (RNM) #2, stated residents code status is indicated by a purple DNR sticker on the wristband. Additionally, RN #2 stated some residents do not wear wristbands and the wristband may be taped to the resident's wall or on the resident's wheelchair instead. RNM #2 stated Resident #32, who was participating in an activity in the common area, did not have a purple sticker on their wristband indicating their DNR code status. 2. Resident #109 had diagnoses including bipolar disorder (serious mental illness affecting mood), hypertension and dementia. The MDS assessment dated [DATE], documented the resident had severely impaired cognitive skills. Review of the active Physician's orders revealed DNR and DNI (do not intubate) status. Review of the MOLST form dated [DATE], revealed Resident #109 wishes for DNR status. The MOLST form was completed by the Social Worker (SW), signed by the Health Care Proxy, and witnessed by the SW. The current (active) CCP and the current CNA care card posted in the resident's room documented Resident #109's code status as DNR. During an observation on [DATE] at 11:12 AM Resident #109 was not wearing a wristband. A handwritten wristband was located on the resident's wheelchair and did not include a purple sticker indicating the resident's wishes for DNR status. The Resident stated at this time that they do not want to wear a wristband. During an observation on [DATE] at 8:55 AM Resident #109's wristband was taped to their room wall and had a purple DNR sticker. At this time, Resident #109 was seated at the table in the main dining room eating breakfast and was not wearing a wristband. During an interview on [DATE] at 10:43 AM CNA#1 said the DNR (or Full Code) status for residents was on the care card in the bathroom cabinet, and also in a binder at the nurse's station. If a resident became unresponsive, they would call the nurse. During an interview on [DATE] at 10:44 AM, LPN#1 said the resident's code status was on their wristband, care card, and in the EMR. If a resident became unresponsive, they would look on the resident's wristband to know the code status. If a resident did not have a wristband, they could start CPR. During an interview on [DATE] at 10:51 AM, RNM#1 stated that if a resident became unresponsive, they would look in the EMR, on the resident's wristband, on their wheelchair, or the MOLST form. If the resident did not have a wristband, they would presume the resident was a full code and start CPR. During an interview on [DATE] at 11:05 AM, The Assistant Director of Nursing (ADON) stated residents who have DNR status have a purple DNR sticker on their wristband. The ADON stated staff cannot rely on the wristbands as the purple DNR stickers come off the wristbands. During an interview on [DATE] at 11:13 AM, the Director of Nursing stated they were unaware the purple DNR stickers were not adhering to the resident's wristbands. During an interview on [DATE] at 1:39 p.m., the Administrator stated they were unaware the purple DNR stickers were not adhering to the resident's wristbands. 10 NYCRR 415.3(f)(1)(ii)

Based on observations, interviews and record reviews conducted during the Recertification Survey completed on 6/16/23, it was determined that for two (Residents #54 and #64) of four residents reviewed for activities of daily living (ADLs), the facility did not ensure the residents received the necessary services to maintain good grooming and personal hygiene. Specifically, both residents were observed with dirty and uncut nails. This is evidenced by the following: The facility policy Quality of Life and Quality of Care, dated as revised January 2020, included that the facility must provide care and services in accordance with resident's comprehensive assessment for the following ADLs (that include but not limited to hygiene. 1.Resident #54 had diagnoses including dementia with behavioral disturbance and insomnia. The Minimum Data Set (MDS) Assessment, dated 2/25/23, documented the resident was severely impaired cognitively and required extensive assistance of staff for personal hygiene. The current Certified Nursing Assistant (CNA) Care Card (care plan used by the CNAs for daily care and posted in the resident room) included that Resident #54 required extensive assist of staff for bathing and grooming and instructed staff to use caution when providing hygiene as resident's skin is thin and fragile and prone to skin tears. Resident #54's shower day was Tuesday. During an observation on 6/12/23 at 10:00 AM, Resident #54's nails were long with peeling nail polish and brown debris under all nails. During observations on 6/14/23 (Wednesday) at 09:00 AM, Resident #54 nails remained long and jagged with peeling nail polish on several fingers and no polish are the rest and continued to have brown debris under all nails. At 12:01 PM Resident #54 was observed eating a sandwich with their hands. During an interview on 6/14/23 at 12:51 PM CNA #4 stated they were unsure what the brown debris was under Resident #54's nails. During an interview on 6/15/23 at 1:16 PM Licensed Practical Nurse (LPN) #1 said that every staff person is responsible for nail care. LPN #1 stated that nail care was not part of the shower day routine but that it should be done with daily care and then documented in the progress notes. During an interview on 6/15/23 at 1:34 PM, Registered Nurse Manager (RNM) #1 stated nail care should be provided by the CNAs on shower day and then communicated to the LPN to document in the progress notes. 2. Resident #64 was admitted to the facility with diagnoses that included chronic obstructive pulmonary disease (COPD), and anxiety. The MDS assessment dated [DATE], documented that Resident #64 was severely impaired cognitively, and required the extensive assistance of staff for personal hygiene. Review of the Comprehensive Care Plan and the CNA Care Card revealed that Resident #64 required the extensive assistance of staff for bathing, dressing, and grooming, and that the resident preferred a weekly shower on Monday evenings. During an observation on 6/12/23 at 10:06 AM, Resident #64's several nails on the resident's left hand were long and curled over their fingertip. The resident's right hand was not visible at the time. During an observation on 6/15/23 (Thursday) at 1:12 PM, Resident #64's left hand also had several nails that were also long and curled and the left-hand nails remained uncut. During an interview on 6/15/23 at 1:36 PM, LPN #6 stated that all nursing staff can provide nail care, except for diabetic residents (the CNAs cannot cut their nails). LPN #6 stated that Recreational Therapy staff also provide nail care and paint residents' nails with polish. LPN #6 stated that if nail care is done during a resident's shower, the nurse would document it in the electronic medical record. LPN #6 stated that Resident #64 came into the facility with thick long fingernails and that they try to file the resident's nails, but it does not do anything. During an interview on 6/15/23 at 1:52 PM, CNA #3 stated that they check residents' nails every day, and typically file and trim nails on shower days. CNA #3 stated that Resident #64's nails were thick, so they were unable to clip them and that some of the nails were starting to curl. During an interview on 6/15/23 at 1:56 PM, RNM #2 stated that nail care should be done at a minimum on shower days and that there should be no chipped nails or jagged edges. RNM #2 stated that Resident #64's fingernails were very thick and some of them were curled and described them as atrocious. RNM #2 stated that Resident #64 liked their fingernails long, but that they could talk to the resident or their representative and the nurse practitioner (NP) about the issue. During an observation on 6/16/23 at 8:04 AM, Resident #64's nails remained long and uncut. During an interview on 6/16/23 at 8:10 AM, RNM #2 stated that the NP #1 evaluated Resident #64's fingernails earlier in the morning and that NP #2 was looking for thicker nail clippers. RNM #2 stated that they were not aware that Resident #64's fingernails were that bad. During an interview on 6/16/23 at 8:20 AM, Nurse Practitioner (NP) #1 stated that they looked at Resident #64's nails at staff request and that the nails were long unable to be trimmed. NP #1 stated that if it had been brought to their attention earlier, they would have bought nail clippers. During an interview on 6/16/23 at 9:35 AM, RNM #2 stated that Resident #64's fingernails were successfully trimmed, and that the resident and their representative were 'ecstatic. During an interview on 6/15/23 at 2:53 p.m., the Director of Nursing (DON) said nail care should be done with the shower and that both CNAs and nurses could provide nail care and document it. 10 NYCRR 415.12(a)(3)

Based on observations, interviews and record review conducted during the Recertification Survey, completed on 9/17/21, it was determined that for one (Resident #41) of three residents reviewed for grievances, the facility did not make efforts to resolve the resident's grievance. Specifically, the resident voiced concerns about several other residents coming into their room unannounced at various times of the day and night. This is evidenced by the following: Review of the facility's, Grievance Policy, dated December 2020, revealed that the facility had a Resident Relations Coordinator who will assign a grievance to a responsible individual for an investigation and for providing feedback to the complainant. Review of the facility's grievance log revealed no documented grievances for the past six months. Resident #41 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set Assessment, dated 6/29/21, revealed the resident was cognitively intact. Review of Resident #41's Comprehensive Care Plan did not reveal any interventions for wandering residents. During an interview on 9/14/21 at 1:09 p.m., Resident #41 complained that other residents come into their room, especially a male resident who at times comes in only in their underwear. Resident #41 said that different residents come in up to 4-5 times a night. The resident stated they have told everyone (staff), but nothing has changed. During an interview on 9/15/21 at 4:19 p.m., the Certified Nursing Assistant (CNA) said that residents who wander in the facility will wander into Resident #41's room as often as every other day. When this happens, Resident #41 will put their call light on, and staff will assist the wandering resident out of Resident #41's room. The CNA stated they have reported the wandering issue to the supervising nurse. During an interview on 9/15/21 at 4:28 p.m., the Licensed Practical Nurse (LPN) said there are a lot of wandering residents who wander nonstop. The LPN said wandering residents will go into the Resident's room, including Resident #41's room, and if the resident does not like it, they will put on the call light and ask the staff to redirect the wandering resident. During in interview on 9/16/21 at 10:10 a.m., the Registered Nurse Manager (RNM) said that residents have complained about other wandering residents wandering into their room, including Resident #41. The RNM said that those residents who have complained can hold their own and will alert staff to have the wandering resident removed from their room. Interventions have not been tried because they have heard the alert residents direct the wandering resident to go out of their room or they notify staff. During an interview on 9/17/21 at 11:20 a.m., the Director of Nursing said the expectation for a resident who has a grievance is to have an interdisciplinary team meeting to resolve the issue and then document the intervention in plan of care. Additionally, the expectations would be that nursing and social work would document the team meeting and outcomes with a thorough note in the resident's progress notes. [10NYCRR 415.3(c)(1)(i)]

Based on observations, interviews and record review conducted during the Recertification Survey, completed 9/17/21, for one (Resident #59) of one resident reviewed, the facility did not ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, the facility did not consistently provide oxygen (O2) as ordered or monitor the oxygen saturation levels (amount of oxygen in the blood stream). This is evidenced by the following: Review of facility policy Oxygen Therapy Protocol, dated October 2020, directed staff to provide ongoing observation and reporting for changes in level of consciousness, behavior, respiratory character/effort, and skin color. Staff should be monitoring and collaborating with physical medicine team for parameters of treatment, stopping points for therapy and frequency of diagnostic data. Resident #59 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set Assessment, dated 4/2/21, revealed Resident #59 had severely impaired cognition and used oxygen. Current Physician orders, initiated 3/23/21, directed continuous use of O2 at four liters (4L) per minute via nasal cannula (NC). On 8/27/21 a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] The Comprehensive Care Plan, dated 3/23/21, and the Certified Nursing Assistant bedside care plan, dated 9/14/21, directed O2 via NC at 4L and for staff to remind the resident to keep the O2 on. Review of a physician note, dated 7/20/21, revealed that Resident # 59 reported being short of breath at times and that oxygen helps this. The medical plan was to continue the oxygen and monitor symptoms. Review of Resident #59's medical record 8/27/21 through 9/15/21, revealed that on 9 of 21 days there was no documented evidence that the resident's oxygen was monitored in any way either liter flow rate or O2 saturation levels. Review of a medical progress note, dated 9/16/21, revealed that Resident #59's oxygen setting was not at the correct flow rate as ordered and that the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] Multiple observations from 9/14/21 to 9/16/21, between 8:30 a.m. to 4:00 p.m., revealed Resident #59's O2 was consistently set at 2L. When interviewed on 9/16/21 at 9:01 a.m., Resident #59 stated that their O2 flow rate was supposed to be set to 3L. During an interview on 9/16/21 at 9:06 a.m., the Licensed Practical Nurse (LPN) (primary medication nurse) said they went into Resident #59's room earlier this morning but did not verify the liter flow and would have to check the order to know what the flow rate was supposed to be. At 9:17 a.m., the LPN went into room with surveyors and verified that the O2 was set at 2L which was too low and reset the flow to 4L. The LPN said there was no order to check the O2 saturation level, but that they would because the liter flow rate was incorrect. In an interview on 9/16/21at 9:25 a.m., the Registered Nurse (RN) and the RN Supervisor both said that O2 is ordered by the physician and that there should also be an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 9/16/21 at 3:22 p.m., the RN Supervisor said that best nursing practice is to check the liter flow rate every shift or at least daily and document, as well as the O2 saturation level. If the O2 saturation level is below 92% it should be rechecked and medical notified. If the patient has [CONDITION(S)] and the O2 saturation level is 88% or less, that would be significant and the medical team should be notified. 10NYCRR 415.12 (k)(6)

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for two of four residents reviewed for choices, the facility did not allow each resident the right to make choices about aspects of life that were significant to them. Specifically, the residents were not showered per their plan of care or their stated choice (Residents #58 and #81). This is evidenced by the following: The facility policy, Resident Rights, dated (MONTH) (YEAR), revealed that the facility will ensure the resident or representative participate in the development of the resident's person-centered plan of care which includes setting care goals and outcomes of care, the type, amount, frequency, and duration of care. The resident has the right to make choices about aspects of their life in the facility that is significant to the resident such as schedules. 1. Resident #58 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 12/24/18, revealed the resident was cognitively intact and had no behaviors or rejection of care. The Comprehensive Care Plan (CCP) for Activities of Daily Living (ADL), dated 10/24/18, revealed that the resident was ok with one shower a week. The CCP was revised on 2/18/19 and documented that two people should take the resident to the shower to ensure she is getting a shower or refusing. For privacy only one Certified Nursing Assistant (CNA) will be present in the shower room during the shower. The facility assignment sheet and the CNA Care Card revealed that the resident was scheduled for one shower a week on Friday evening. The Resident Bathing Type by Day Chart revealed that from 12/23/18 through 2/21/19 the resident received one shower on 1/11/19 which was also documented in the progress notes. There was no documentation in the nursing progress notes of any refusals during that time. The ADL Detailed Entry Report documented that bathing activity did not occur on two Fridays (2/8/19 and 2/15/19). When interviewed on 2/19/19 at 11:20 a.m., a family member said that the resident's choice was to have two showers a week. The family member said when the resident did not receive two showers a week, she met with the Registered Nurse Manager (RNM) and agreed to one shower a week. The family member said that the resident was not receiving the one shower a week, and she communicated her concerns to the Administrator, the past Director of Nursing (DON), and the Registered Nurse Manager (RNM). She said there have been no changes. Interviews conducted on 2/21/19 included the following: a. At 10:51 a.m., the primary CNA said the resident never refuses anything and if she did, she would report that to the nurse. b. At 10:56 a.m., the Licensed Practical Nurse (LPN) said that the resident does not refuse anything. She said if she refused anything, the CNAs would report that, and it would be documented and passed along in report. c. At 12:19 p.m., the RNM said the resident's family had concerns about the resident not receiving a shower. She said when she talked to the resident she reported that she did not get a shower. She said that the staff, including the supervisor, told her that the resident refuses her shower but it was not documented. d. At 12:45 p.m., the resident was in the main lobby with family. She said she would really like one shower a week in the evening. The resident said she wants to be asked if she wants the shower or not, and if not, like feeling sick, she would like it offered the following day. 2. Resident #81 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 1/11/19, revealed that the resident had severely impaired cognition, was totally dependent upon one staff to assist with bathing, and there was no rejection of cares. A Social Work note, dated 1/3/19, documented that during the care conference it was discussed with the resident's family member to add another shower weekly. The CCP for ADLs, last updated 1/3/19, and the CNA Care Card, dated 2/20/19, revealed that the resident would like to receive two showers a week. The facility assignment sheet revealed the resident was scheduled for two showers a week on Monday (days) and Friday (evenings.) Review of the Resident Bathing Type by Day Chart revealed that the resident did not receive a shower from 12/22/18 through 1/13/19 and from 1/14/19 through 2/20/19 the resident received six showers. There was no documentation in the nursing progress notes of any refusals during that time. When interviewed on 2/20/19 at 2:42 p.m., a family member said the resident was sent to a doctor's appointment with a dirty face, and he was not receiving two showers a week. Interviews conducted on 2/21/19 included the following: a. At 9:17 a.m., the LPN said the CNAs never reported that the resident refused a shower. She said if they did she would have seen the resident and documented. b. At 9:34 a.m., the primary CNA said she does not know what happened in January, but this past Monday (2/18/19) the resident had an appointment and the CNA could not get the shower done that day, but it was done the following day. c. At 10:44 a.m., the RNM said that she had not received any reports that the resident was refusing showers. She said she was aware that the family member requested the resident receive two showers a week. She said it was the responsibility of the LPN to make sure the resident received the shower. She said if the resident was refusing, it should have been reported and documented. (10 NYCRR 415.5(b)(3))

Based on observations and interviews conducted during the Recertification Survey, it was determined for one of one main kitchen the facility did not store, distribute, or serve food under sanitary conditions. The issues included improper sanitization in a three-bay sink, lack of air drying of dishware, unclean food and non-food contact surfaces, improperly stored chemicals, boxes of food left on the floor, and a dirty dish machine. This is evidenced by the following: 1. Observations and interviews in the Main Kitchen on 2/13/19, beginning at 9:15 a.m. revealed the following: a. There were approximately 50 cardboard boxes of food items directly on the kitchen floor. b. The three-compartment sink (wash-rinse-sanitize) was filled and ready to use. The Recreation Specialist (covering for the Food Service Director) was asked to verify the concentration of the sanitizing sink, and she said she really did not know how to do that and called over a Team Leader who proceeded to use a sanitizer test strip to check the concentration. The Team Leader said the strip was reading 50 parts per million and that was too low. She said the sink had just been filled with water and there needed to be more water added. c. A blender was ready for use and when the base was removed, there was visible residue and water in the bottom of the blender. d. There was a large blender stored on top of a stainless-steel table with black sticky residue on the surfaces of the table. There was also a black oily substance underneath coming from beneath a mixer. e. There was paint chipping and flaking on the walls in the kitchen where the steamer was hooked up. f. The doors and interior surfaces of the hot food holding boxes were dirty. g. The floor was soiled with visible dirt and debris. h. Cleaning chemicals were stored in the main kitchen near the three-bay sink. i. There was visible debris on the can opener blade, and the Recreation Specialist said she thought it was food. 2. On 2/14/19 at 3:00 p.m., chemicals were observed stored in the same room as dry packaged foods. 3. Observations on 2/20/19 at 9:40 a.m. in the main kitchen revealed the top of the Hobart dishwashing machine was covered in tan crumbs and food debris. (10 NYCRR: Subpart 14-1.43(a), 14-1.60(a), 14-1.110, 14-1.111, 14-1.170, 14-1.171)

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that the facility did not act upon grievances of residents affecting resident care and life in the facility. Specifically, the facility did not address grievances brought up by the residents in Resident Council Meetings in a timely, thorough, and effective manner. This is evidenced by the following: During an interview on 2/15/19 at 11:19 a.m., Resident Council (RC) Representatives said that the facility administration had not reported back to the RC regarding the issues of call bell response times and a lack of provision of care. They said these issues have been ongoing problems and no one has ever informed the RC of resolutions. Resident #74 said she has waited an hour and a half for care after activating the call bell, and soiled herself because Mother nature cannot wait that long. She said that staff also do not respond to call bells activated during meal times. Resident #104 said staff come in and turn the bell off, and then say they will be back but whether they come back quick enough all depends on when you push the button, like during a meal. They tell you they are busy serving food and cannot help you until after the meal. Review of RC Meeting Minutes from (MONTH) (YEAR) to (MONTH) 2019 revealed the following: a. (MONTH) (YEAR): A Social Work Coordinator (SWC) announced that the Director of Nursing (DON) would be implementing call bell audits periodically and educating Certified Nursing Assistants (CNAs) that they are to provide care before turning the call bell off. b. (MONTH) (YEAR): The DON attended the meeting and gave staffing updates but no information on results of call bell audits or staffing education were presented. c. (MONTH) (YEAR): No group meeting was held. The Resident Council President (Resident #74) was interviewed privately by SWC and responded that staff respond timely to her call light. The question regarding getting help and care without waiting a long time was not answered. Interviews conducted on 2/21/19 included the following: a. At 10:16 a.m., the Administrator and DON reviewed Incident Response Statistics Reports for call bell response times, from 10/1/18 to 10/3/18. The Administrator and DON said the previous DON had completed the audit, but it only showed response times. The Administrator said there was no follow up to verify that provision of care was being done. The Administrator and the DON reviewed the (MONTH) (YEAR) Resident Council Meeting minutes and said call bells were answered timely, but provision of care had not been addressed. b. At 10:26 a.m., the DON said she would look for additional information, including staff education to provide care at the time of call bell response, and report back to the surveyor. At the time of exit, 2/21/19 at 4:00 p.m., no additional information had been provided. (10 NYCRR 415.5(c)(5)(6))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #12) of two residents reviewed for notification of changes, the facility did not ensure that medical providers were notified of significant deterioration in oral health status. Specifically, dental consults and recommendations were not provided to the medical staff for review and assessment. This is evidenced by the following: Resident #12 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 11/16/18, revealed that the resident had severely impaired cognition, no rejections of care, and required the extensive assistance of one staff member for personal hygiene. The Dental Consultation Report, dated 7/26/18, revealed the resident had four cavities diagnosed that day due to a complete lack of dental care. The resident presented with both heavy plaque and actual food debris on the teeth. The resident's oral hygiene was severely suffering, and the nursing home care should consist of brushing morning, afternoon, and before bed for two minutes with assistance followed by an antiseptic mouthwash. The resident needs to return for fillings and a six month cleaning. The Dental Consultation Report, dated 1/29/19, revealed the resident had food debris left on her teeth and gum tissues, oral hygiene was still poor with clinical evidence of gingival irritation and inflammation due to foreign debris on the teeth. There are additional areas to watch for decay related to food and plaque impaction. Interviews conducted on 2/21/19 included the following: a. At 8:40 a.m., a Nurse Practitioner (NP) said consult notes are placed on a Physician's Assistant (PA) board for all medical providers to review and sign. She said she was out on medical leave during (MONTH) (YEAR) but another provider should have reviewed and signed the report. The NP reviewed both Dental Consultation Reports, dated 7/26/18 and 1/29/19, and said neither report was signed for medical review. She said the reports should not have been filed until read by a provider. The NP said she would have immediately discussed these issues with the Registered Nurse Manager (RNM) and would have directed the RNM to step up the dental care. The NP said the resident was showing ongoing tooth decay and staff were not providing the care and service she required. b. At 8:39 a.m., the Medical Director reviewed both dental consult reports. She said the consult notes are placed on the PA board for a medical provider to review and sign. She said she had no excuse as to why the forms were not reviewed. The Medical Director said she would have discussed the situation with the family and talked to the RNM about the care plan not being followed. She said the dental care was not appropriate and oversight falls to nursing. c. At 10:03 a.m., the Administrator said she had just discussed the lack of the medical assessment with the Medical Director. She said due to a dental deficiency from the last survey, the previous Director of Nursing said he would handle all the paperwork for dental consults and did not pass the consults on to medical for their evaluation and assessment. (10 NYCRR 415.3(e)(2)(ii)(c))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for 4 of 30 residents reviewed for care plan development and/or implementation, the facility did not develop or implement a comprehensive person-centered care plan for each resident that addressed the resident's medical, physical, mental and or psychosocial needs. The issues involved the lack of applying a splint to the resident's contracted hand (Resident #95), the lack of a care plan for the use of an anticoagulant (medication that thins the blood to help prevent blood clots, Resident #108), lack of maintaining a low bed to prevent falls and the lack of a washcloth in the resident's hand (Resident #8), and the lack of offering the resident's choice of food as outlined in the care plan (Resident #92). This is evidenced by the following: 1. Resident #95 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 1/29/19, includes that the resident was unable to be interviewed because she was rarely or never understood by others, only sometimes understands others (responds adequately to simple direct communication only), and is totally dependent on staff for personal hygiene and dressing. Review of the Occupational Therapy discharge summary, dated 12/28/18, revealed that the resident had contractures of the left shoulder, elbow, and hand. Recommendations included a rolled foam palm guard to the left hand. The summary includes that staff were educated on donning/doffing the foam roll to prevent further contractures of the left hand and for checking skin integrity. Review of the current Comprehensive Care Plan (CCP) and the Certified Nursing Assistant (CNA) Care Card directed a black foam roll to the resident's left hand at all times except for care. Physician orders, dated 1/22/19, included to check to make sure a rolled washcloth was in the resident's left hand. The (MONTH) 2019 treatment administration sheet was signed off as completed three times a day from 2/1/19 through 2/19/19 day shift. Observations conducted on 2/13/19 day shift, on 2/14/19 at 10:54 a.m., and on 2/19/19 at 9:36 a.m. and 1:30 p.m., the resident was up, dressed, and seated in a bucket chair. There was no foam roll in her left hand. In an interview on 2/14/19 at 4:07 p.m., CNA #1 stated that she provided care for the resident on the day shift but was unaware of any splint. In an observation and interview on 2/20/19 at 9:21 a.m. with the Registered Nurse Manager (RNM), the resident's room was searched and no foam roll was found. The RNM stated that the resident should have it on at all times. In an interview on 2/20/19 at 9:43 a.m., CNA #2 stated she provided care for the resident on the previous day. She said there were not any rolls in the resident's room to use in her hand, but she did not tell anyone. When interviewed on 2/20/19 at 1:52 p.m., the day Licensed Practical Nurse (LPN) stated she did not know the roll was missing. She said she signed off that the resident had the roll on. The LPN said that she usually asks the CNAs if they are following the care plan. She said the CNAs should have reported the roll was missing. 2. Resident #92 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The MDS Assessment, dated 1/12/19, included that the resident had severely impaired cognition and required set up assistance for eating. The facility policy, Importance of Mealtime, included that all items listed on the meal ticket should be provided to the resident. The CCP, dated 2/12/19, included that the resident was at risk for malnutrition due to age, dementia, and past medical history, and has not had any significant weight changes recently. Approaches included, but were not limited to, providing the resident's diet per medical orders and add extra items on the meal trays that that the resident enjoys per the family's request such as ice cream, toast, and chocolate milk. The CCP includes that the resident may refuse these items at times but family would like them to be provided regardless. Review of the Electronic Medical Record revealed the following: a. On 9/26/18, the Registered Dietician (RD) documented that she received a note from the family that the resident was not getting all items on the meal tickets, especially ice cream and toast at each meal as requested, and the RD would discuss with food service. b. On 12/19/18, the RD documented that a nutrition review was done with the family who would like to continue to offer ice cream and toast at all meals in addition to the regular diet. c. On 1/14/19, the RD documented that the resident loves ice cream, and food preferences include ice cream and toast at all meals per family request. The resident's meal tickets for all three meals included ice cream and toast with jelly. Observations and interviews included the following: a. On 2/13/19 at 9:25 a.m., a family member stated that the resident was not a good eater but does like ice cream and toast and despite requesting at all meals it is not always provided. b. On 2/13/19 at 12:01 p.m., the resident ate approximately 25 percent of her lunch after approximately 30 to 45 minutes. There was no ice cream or toast provided. c. On 2/14/19 from 8:24 a.m. to 9:19 a.m., the resident was not eating her waffle or eggs and was not provided with ice cream or toast. d. On 2/14/19 at 12:49 p.m., the resident was not eating her lunch of ravioli and peas and was not provided with ice cream or toast. When interviewed at that time and again at 2:13 p.m., the RD stated that the resident should be provided with ice cream and toast at every meal. The RD said she did not know why the resident did not have it, but it may be because the resident refused. The RD later said that the staff told her the resident was refusing the ice cream and toast, but that was never brought to her attention and it should have been. The RD stated that she has spoken to the kitchen staff before and asked that it be provided at each meal regardless. e. On 2/14/19 at 3:48 p.m., the LPN stated that the ice cream and toast are to be provided at each meal. She said that sometimes the resident eats it and sometimes not, but it should be provided f. On 2/19/19 at 9:14 a.m. and again on 2/20/19 at 12:15 p.m. after surveyor intervention, the resident was eating both the toast and ice cream during her meals. 3. Resident #108 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The MDS Assessment, dated 10/2/18, revealed the resident was cognitively intact and received an anticoagulant. Review of the current physician orders [REDACTED]. Review of the current CCP and CNA Care Card did not include any information regarding anticoagulation therapy. During an interview on 2/20/19 at 4:16 p.m., the Registered Nurse Manager said she forgot to add the [MEDICATION NAME] on the care plan. 4. Resident #8 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The MDS Assessment, dated 2/4/19, revealed that the resident had severely impaired cognition. Review of the CCP, dated 4/12/17, and the CNA Care Card, dated 12/6/18, revealed that the resident was at high risk for falls. Approaches included a low bed with a floor mat next to the bed, frequent monitoring when in bed, and to wash and dry left hand and place a clean dry washcloth in the hand in the morning and evening. During observations on 2/14/19 at 2:46 p.m. and at 3:42 p.m., the resident did not have a washcloth in the left hand. Observations and interviews conducted on 2/15/19 included the following: a. At 9:07 a.m., the resident did not have any washcloth placed in her left hand. b. At 2:21 p.m., the resident was in her room alone and in bed. The bed was not in the low position and there was no hand roll in her left hand. When interviewed at that time, CNA #1 said the resident's bed needs to be in the low position. CNA #1 said that the resident should have a washcloth in her hand. She said the resident clenches her fingers tightly. c. At 2:45 p.m., CNA #2 said that he had put the resident to bed that afternoon and got distracted because he had to go help another staff member. He said the bed should be in the low position and a hand roll in place. (10 NYCRR 415.11(c)(1))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for 2 of 30 residents reviewed for care planning, the facility did not ensure that each resident's care plan was reviewed or revised to reflect the resident's current condition. Specifically, the resident's care plan did not include person centered behavioral interventions (Resident #15), and the resident's plan of care lacked revisions for ace wraps, a splint, compression stockings, and statements made by the resident (Resident #32). This is evidenced by the following: The facility policy for Comprehensive Care Plans, dated (MONTH) (YEAR), includes a comprehensive person-centered interdisciplinary care plan will be developed for each individual receiving care, which includes measurable objectives and timetables to meet an individual's medical, nursing, nutritional, rehabilitative, psychosocial needs and preferences that are identified in the comprehensive assessment. As individual preferences change, the care plan will be modified. An individual member of the interdisciplinary team, except the CNA, can make a change to the care plan. It is then the team member's responsibility to communicate the change to other team members. If an individual refuses recommended services or treatments, whether verbalized or determined by observation of behavior, the care plan must identify the care or service being declined, the risk that poses to the individual, the effort by the interdisciplinary team to educate the individual and designated representative, and the attempts to find alternative means to address the identified risk/need. 1. Resident #15 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 2/7/19, revealed that the resident's cognitive skills for daily decision making were severely impaired and she had no behaviors. The Comprehensive Care Plan (CCP) for behaviors, dated 10/23/18, and the Certified Nursing Assistant (CNA) Care Card, dated 2/19/19, revealed that the resident can be resistive with care and may at times become combative. Approaches include to re-approach the resident. A nursing note, dated 11/26/18, documented that the resident was told she would be laid down after lunch. She was calm during lunch and politely asked to be laid down and took her meds without difficulty. A nursing note, dated 12/12/18, documented that right before lunch the resident was yelling out she wanted to lay down. The staff told the resident she could lay down after lunch. The resident's behaviors escalated, and she was saying, I'm sick, I'm sick, and tried to throw herself on the floor. The resident was taken to her room and laid down. The psychiatrist notes, dated 12/13/18, included that the primary nurse reported that the resident's bad days surround around arguments regarding time in bed. The resident always wants to return to bed after meals and does not like to get up when told to do so. A nursing note, dated 12/14/18, revealed that the resident was yelling in the hall that she was dying. The writer tried to calm down the resident, but she slapped at the writer multiple times. The resident was taken to her room, provided with pain medication, and assisted to bed. The resident appeared comfortable. A nursing note, dated 1/20/19, revealed that the resident had behaviors after breakfast as she wanted to lay back down. The resident began to hit and kick at staff and refused her medications. When observed on 2/14/19 at 2:30 p.m., the resident was asleep in her room. When interviewed on 2/15/19 at 2:32 p.m., the primary CNA said that sometimes the resident does not want to get out of bed. The CNA said that she can convince the resident to get up by telling her if she gets up for the meal she will put her back to bed right after the meal. When interviewed on 2/19/19 at 11:37 a.m., two other CNAs said if the resident repeats a question and staff try to redirect her, her behaviors escalate. They said if staff continue to try to talk to the resident, her behaviors get worse. They said the resident usually wants to go to bed. They said if the resident has been told she will be put to bed and if it is not done, then she has behaviors. Interviews conducted on 2/20/19 included the following: a. At 9:12 a.m., the Licensed Practical Nurse (LPN) said that the resident wants to lay down after lunch, and if it is not done, then she has behaviors. The LPN said she tells the CNAs to lay the resident down and she will be fine. She said usually when the resident has behaviors she wants to lay down. The LPN said if the resident does not go to bed, then she sits and spends time with the resident and she will engage. The LPN said the resident likes calendars or books with pictures like old farms and flowers. She said that information should be documented on the care plan. b. At 10:14 a.m., the Physician/Medical Director said if there was a pattern to the resident's behaviors, that should be documented in the care plan. When interviewed on 2/21/19 at 10:52 am., the Registered Nurse Manager said that she writes the care plans. She said she can select general or individualized approaches. She said the resident's specific behaviors and approaches should be documented on the care plan. 2. Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 12/5/18, revealed that the resident had severely impaired cognition and no rejection of cares. Review of physician orders, initiated on 6/28/18 and continuing through 12/13/18, included ace wraps to both lower extremities on in the morning and off at bedtime for [MEDICAL CONDITION]. Physician orders, dated 12/3/18, included the resident is to wear a splint on the left ankle at all times for an ankle sprain. Physician orders, dated 1/17/19, included to discontinue the order for the splint. Review of the CNA Care Card, last updated 2/15/19, included to apply a TED (compression) stocking on the resident's right leg in the morning and remove in the evening, a left ankle brace worn at all times, and the resident often makes statements that she wants to die. Review of the Treatment Administration Record, from (MONTH) (YEAR) through (MONTH) 2019, revealed the ace wraps have been circled (indicating the treatment was not done) every day and shift each month. When observed on 2/14/19 at 2:38 p.m., on 2/15/19 at 9:14 a.m., and on 2/19/19 at 9:27 a.m, the resident was in her room. She was not wearing ace wraps, TEDs, or an ankle brace. During an observation and interview on 2/19/19 at 9:44 a.m., the primary CNA reviewed the CNA Care Card and said he did not know anything about a leg brace or TED stockings for the resident. When asked what the statement, often makes statements that she wants to die and asks meant, he said he did not know as it was not a complete sentence. When interviewed at that time, the resident said that she has not had a brace, TEDs, or ace wraps in a long, long time. Interviews conducted on 2/20/19 included the following: a. At 11:16 a.m., the LPN said the resident refused the ace wraps, she never wore them. She said the resident used to have [MEDICAL CONDITION] but has not for a long time. After reviewing the CNA Care Card, the LPN said the resident does not wear an ankle brace, that was also a long time ago when she broke her ankle. The LPN said the resident does not wear TEDs either, and she does not know where the order is for TEDs. The LPN said she did not know what the incompleted sentence on the CNA Care Care should say. b. At 12:00 p.m., LPN #2 said it is the secretary's responsibility to maintain the CNA Care Cards, but currently there is no secretary. LPN #2 said that the RNM provides the information to the CNA, and the CNA updates the Care Cards. When interviewed on 2/21/19 at 10:47 a.m., the RNM said the CNA Care Card should not have the ankle brace on it because it was discontinued. The RNM said she did not know about the TEDs, or why the order for the ace wraps continued when the resident does not wear them. The RNM said she used to have a clinical leader that was responsible for ensuring that the information was up to date. She said the area of the care card that says the resident often makes statements that she wants to die and asks, should have been completed to say, staff to kill her. (10 NYCRR 415.11(c)(2)(iii))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined for two (Residents #12 and #38) of eight residents reviewed for medications, the facility did provide services consistent with professional standards of practice. Specifically, there was a lack of consistent documentation of bowel movements for each resident. This is evidenced by the following: The facility Competency/Policy/Procedure for Bowel Protocol for Certified Nursing Assistants (CNA) and Nurses included signs and symptoms of constipation and documentation. Bowel elimination will be recorded by the CNA or nurse on the bowel movement log in the care tracker (computer program). The information will include both frequency and amount. The nurse will assure completion of the bowel movement board or care tracker every shift to determine if the bowel management regime is to be initiated. If the resident has not had a bowel movement in nine shifts or has deviated from their usual bowel habit, the nurse will identify that and begin administering cathartics per order. The Nurse Manger will ensure compliance with the above every day. 1. Resident #12 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 11/16/18, revealed that the resident had severely impaired cognition, required the extensive assistance of one staff for toileting, and was frequently incontinent of bowel. The Certified Nursing Care Card, dated 11/12/18, included to offer toileting every two to three hours and as needed, and the resident was incontinent at times. The current physician orders [REDACTED]. The Bowel and Bladder Chart Detail Report, dated 2/1/19 to 2/20/19, revealed that the resident had no documented bowel movements from 2/7/19 to 2/11/19 (15 shifts) and no documented bowel movements from 2/16/19 to 2/20/19 (15 shifts). The (MONTH) 2019 Medication Administration Record [REDACTED]. 2. Resident #38 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The MDS Assessment, dated 12/5/18, revealed the resident had severely impaired cognition, no rejection of cares, required extensive assistance of two staff to toilet, and was occasionally incontinent of bowels. The CNA Care Card, dated 2/21/19, included the resident requires a mechanical lift for toileting with the assistance of two staff members and to toilet every two to three hours and as needed. Physician orders, dated 1/24/19, included MOM 30 mls to be given once as needed, [MEDICATION NAME] suppository insert one daily as needed, and Senna S (laxative) two tablets every evening. The Bowel and Bladder Chart Detail Report, dated 2/1/19 to 2/20/19, revealed the resident had no documented bowel movements from 2/1/19 to 2/6/19 (16 shifts) and no documented bowel movements from 2/8/19 to 2/20/19 (38 shifts). The (MONTH) 2019 MAR indicated [REDACTED]. There was no documentation that the as needed suppository was administered. Interviews conducted on 2/20/19 included the following: a. At 11:05 a.m., a Licensed Practical Nurse (LPN) said she could not be certain if Resident #38 had a bowel movement. She said she was instructed to follow the policy and procedure and give MOM. The LPN said she gave Resident #38 MOM on 2/20/19, even though she could not tell if the resident had a bowel movement or not. The LPN said she did not know what to do about Resident #12 because there was incomplete bowel documentation. At that time, she contacted the Nurse Practitioner (NP) to assess the resident. b. At 11:20 a.m. and 1:09 p.m., the NP said documentation of bowel movements is a problem. She said bowel movements are either not being documented at all or are inaccurately documented. She said if staff are unsure about giving bowel meds, they need to notify a Registered Nurse (RN) to perform a bowel assessment. Interviews conducted on 2/21/19 included the following: a. At 9:37 a.m., a CNA said she was unable to document bowel movements in care tracker for one day in (MONTH) 2019 because they were short staffed, and she could not get to it. The CNA said she reported that to an LPN. b. At 9:46 a.m., the LPN said she had been told about the CNAs inability to document, but she did not do anything with that information because she did no know what to do. c. At 12:02 p.m., a RN Manager (RNM) said the nurse on every shift should print out and review the bowel report. She said the bowel protocol was to administer MOM after three days without a bowel movement. She said then the next shift prints out a report and if no bowel movement, a suppository is given, and on the next shift if the report still shows no bowel movement, an enema is given. The RNM said at that point, medical should also be notified. She said the nurses have told her the CNAs are not completing bowel documentation, and she has addressed that with each shift but there is still a lack of documentation. (10 NYCRR 415.11(c)(3)(i))

Based on observations, interviews, and record reviews conducted during the Recertification Survey and complaint investigation (#NY 641), it was determined that for three of six residents reviewed for Activities of Daily Living (ADLs), the facility did not provide the necessary care and services to maintain personal hygiene. The issues involved lack of oral care (Residents #17 and #12), and lack of nail care (Resident #21). This is evidenced by the following: 1. Resident #17 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 11/30/18, revealed the resident had moderately impaired cognition, was totally dependent on staff for personal hygiene, and had no behaviors or rejection of care. The current Comprehensive Care Plan (CCP) and the current Certified Nursing Assistant (CNA) Care Card included that the resident requires assistance with grooming and has many missing teeth. The goal was that the resident has no evidence of debris in his mouth. Approaches included for staff to assist with personal care morning and evening and to cue the resident and assist with oral care. Neither care plan included that the resident refused care. In the most recent dental exam, dated 9/12/18, the dentist documented that the resident's cooperation level was excellent and oral hygiene was poor. The dentist added the word very to poor oral hygiene. On 9/21/18, the dental hygienist documented that the resident needed to brush each day due to heavy plaque. In observations on 2/13/19 at 11:26 a.m., on 2/14/19 at 11:50 a.m., and on 2/19/19 at 10:14 a.m. all after morning care, the resident's teeth were filled with gross amounts of food debris and white debris between all teeth crevices. Interviews conducted on 2/19/19 included the following: a. At 10:51 a.m., the CNA stated that the teeth do not look good, that it looked like it had been a long time since they had been cleaned. The CNA said that the resident refused oral care that morning, but she did not tell anyone or re-attempt. b. At 10:55 a.m., the Licensed Practical Nurse (LPN) stated that sometimes the resident refuses care. The LPN observed the resident's teeth and then stated that she could not tell how long it had been since the resident's teeth were cleaned. c. At 11:16 a.m., the Registered Nurse (RN) stated that the resident's teeth looked awful. The RN said she was not aware that the resident refused care, and there was nothing in the care plan related to refusing care. She said if the resident refused oral care, the staff should have re-approached and tried again. 2. Resident #21 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The MDS Assessment, dated 11/23/18, revealed that the resident had moderately impaired cognition and required the extensive assist of staff for personal hygiene. The current CCP and CNA Care Card included that the resident required assistance with bathing and grooming, keep nails short so that the resident can self-propel the wheelchair, and if nail care is refused, staff should encourage the resident to have nails trimmed when possible. The CCP included that the resident had a [MEDICAL CONDITION] and required assistance to change. The CNA Care Card included the resident received two showers a week. Observations on 2/13/19 at 1:34 p.m., and on 2/14/19 at 2:25 p.m., the resident's nails were untrimmed, some jagged, and multiple nails were filled with brown debris. When notified at that time and again at 4:14 p.m., the CNA stated that the resident's nails needed to be cut and cleaned, but they have to be done by the nurse as the resident has diabetes. The CNA said that she did not know what the brown debris in the nails was but the resident does pick at her [MEDICAL CONDITION] and sometimes pulls the bag off. When interviewed on 2/14/19 at 4:15 p.m. and again on 2/19/19 at 1:13 p.m., the LPN stated that the resident's nails should be done on shower days but observed daily and done as needed. The LPN said on 2/19/19 that the resident allowed her to cut and clean her nails without resistance. The LPN said that the brown debris was either stool or food, she was not sure which. Review of the CNA bathing log in the electronic health record revealed that the resident had not had a shower documented in the past 24 days. There were three showers documented for the past two months and no documentation that the resident refused. 3. Resident #12 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The MDS Assessment, dated 11/16/18, revealed that the resident had severely impaired cognition, no rejections of care, and required the extensive assistance of one staff for personal hygiene. The dental consults, dated 7/26/18 and 1/29/19, revealed that the resident's oral hygiene was poor with plaque build up and food debris on teeth. The 7/26/18 consult included the resident had cavities and to brush the resident's teeth morning, afternoon, and before bed for two minutes followed by an antiseptic mouthwash. The current CNA Care Card revealed that the resident required the assistance of one staff member for oral care and directs to brush the resident's teeth three times daily after each meal, floss after all meals, rinse with antiseptic mouthwash three times a day, and monitor for bleeding. Review of the Oral Care Audits, from 12/20/18 through 2/20/19, revealed that oral care was never documented as being provided three times a day. Observations and interviews conducted on 2/19/19 included the following: a. At 10:00 a.m., the resident had visible tan colored food debris on and between the teeth. b. At 12:59 p.m., a family member said the resident had beautiful teeth her whole life and at the time of admission. She said the dental office had sent poor oral hygiene reviews back to the nursing home. She said the resident needs more cavities filled. Observations and interviews conducted on 2/20/19 included the following: a. At 9:01 a.m., the resident had a visible build-up of creamy and brown colored debris all around her lower teeth, side-to-side, and some on the top teeth. A second family member said they provided a water flosser for daily use, or as often as possible. b. At 11:16 a.m., LPN #1 said the resident does have a water flosser and it is supposed to be used daily. She said that information should be on the CNA Care Card and if it is not, it should be. LPN #1 said the RNM was responsible for updating the CNA Care Cards. c. At 11:29 a.m., the water flosser was set on the bathroom sink and was dry. There was no water in it, and there was no moisture observed on the interior surfaces. Additionally, an electric spin brush was sitting on the sink and the brush was caked with dried toothpaste. d. At 11:35 a.m., CNA #2 said the resident can brush her own teeth with set up. She said the resident brushes twice a day, once in the morning and once in the evening. CNA #2 said she knows the family brought in the water flosser, but she did not know how often it was to be used. e. At 11:41 a.m., the resident opened her mouth and the debris remained on her teeth. f. At 11:47 a.m., CNA #1 said the resident brushes her own teeth with set up. She said she gave the resident the electric toothbrush with toothpaste on it earlier that day. CNA #1 said she did not floss, nor has she ever flossed the resident's teeth. CNA #1 said she does not know which resident in the room owns the water flosser. She said she knows it has not been used. CNA #1 said, on her shift, the resident is supposed to brush her teeth before breakfast, and she does not know what other shifts provide. g. At 1:56 p.m., LPN #1 said the Nurse Practitioner told her about the resident's teeth having food in them. LPN #1 said the resident's primary aide (not working that week) had told her, about three times, that the resident does not want to brush her own teeth, but no one else has reported that. LPN #1 said when that is reported, she will go in and attempt to brush the resident's teeth because if left alone, she will only brush the front of her teeth and that is it. LPN #1 said the back teeth need cleaning too. LPN #1 said staff must put the water pick on the lowest setting or it hurts, and the resident will not use it. She said the CNAs must make sure oral care gets done and if there is a problem, let her know. She said it appears they are not telling her, so she will have to start checking the resident's teeth herself. Observations and interviews conducted on 2/21/19 included the following: a. At 3:31 p.m., the RNM said the resident should be flossed three times a day and there is floss in the resident's medicine cabinet. At that time, the RNM and surveyor opened the cabinet and there was no floss found. The RNM also checked the bedside stand and could not find dental floss. She said the staff should have told her the resident needed dental floss. b. At 3:32 p.m., LPN #1 said the resident has flosser saws which are in the bathroom. LPN #1 looked in the medicine cabinet and said there are not any. She said there was no floss and the water flosser was bone dry. (10 NYCRR 415.12(a)(3))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #99) of five residents reviewed for accidents, the facility did not provide adequate supervision to prevent accidents. Specifically, a resident who was recommended by therapy to be assisted with all transfers and toileting and to be non-ambulatory except in therapy, was noted by staff to be independent with transfers, toileting and ambulation and staff did not intervene or inform therapy. This is evidenced by the following: Resident #99 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 12/14/18, revealed that the resident was cognitively intact. The current Comprehensive Care Plan revealed that the resident was at risk for falls due to a history of falls, self-transfers, an unsteady gait, and weakness. Review of a physical therapy evaluation, dated 1/31/19, revealed that the resident was receiving therapy following a recent hospital stay. Therapy was focusing on the resident's ambulation, safety with transfers, ambulation, endurance, and balance. The resident was non-ambulatory, and the current level for transfers was maximum assist of staff with a two wheeled walker. The Certified Nursing Assistant (CNA) Care Card, dated 2/18/19, directed no ambulation, and the resident required the assistance of two staff members for transfers and toileting. The Care Card revealed that the resident sometimes transfers herself without assistance and if noted, staff should assist her and remind her to ask for help. Review of the interdisciplinary progress notes revealed that on 2/10/19, 2/15/19, and 2/16/19 the two Licensed Practical Nurses (LPNs) documented that the resident was independent with transfers and toileting and was able to ambulate independently short distances with a walker. There was no mention of re-education to the resident or therapy notification. Review of the CNA Activities of Daily Living Report revealed documentation that the resident transferred independently or with one assist on 23 occasions, from 2/6/19 through 2/19/19, and ambulated in her room or in the corridor on ten occasions for the same time period. In an interview on 2/14/19 at 10:43 a.m., the resident stated that she is still in therapy and can toilet herself and walk with a walker. The resident said that she should be more careful because she has had a lot of falls. Interviews conducted on 2/20/19 included the following: a. At 10:35 a.m., the CNA stated that the resident was independent with transfers and toilets herself. The CNA said that she did not know if the resident was able to walk independently or not. b. At 12:58 p.m., the Physical Therapist (PT) stated that staff should notify therapy if the resident is doing more than the recommendations due to safety concerns. The PT said that they are upgrading the resident to a one staff assist that day but the resident should not be independent. (10 NYCRR 415.12(h)(1-2))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #15) of five residents reviewed for unnecessary medications, the facility did not ensure that each resident's drug regimen remained free from unnecessary medications. The issues involved the lack of documentation of a specific, diagnosed , documented condition with use of an antipsychotic medication, and the lack of consistent documentation of non-pharmacological interventions used when the resident experiences behaviors. This is evidenced by the following: Resident #15 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 2/7/19, revealed that the resident's cognitive skills for daily decision making were severely impaired and the resident had no behaviors. The facility policy for [MEDICAL CONDITION] Drugs, dated (MONTH) (YEAR), includes residents who have not used [MEDICAL CONDITION] medications are not given these medications unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. Physician orders, dated 1/11/18, included to start [MEDICATION NAME] (an antipsychotic medication used to treat certain mental and mood conditions) for agitation. Subsequent orders through 1/17/19 included [MEDICATION NAME] for agitation. The Comprehensive Care Plan for Behaviors, dated 10/23/18, and the Certified Nursing Assistant (CNA) Care Card, dated 2/19/19, included that the resident tends to be resistive with care and may at times become combative. Approaches included to re-approach the resident. A nursing note, dated 11/26/18, revealed that the resident was agitated, attempting to fall out of the wheelchair onto the floor while saying, kill me, just kill me, don't you have a soul. A nursing note, dated 11/28/18, documented that the resident refused all medications, was combative, and covered her mouth. A nursing note, dated 11/29/18, included that the resident refused all medications, smacked the spoon out the of writer's hand, and scratched the writer. The resident was scratching, hitting and slapping, yelling, and screaming. A nursing note, dated 1/20/19, revealed that the resident had behaviors after breakfast. The resident refused medications and kicked and hit at the staff. There was no documentation regarding what staff did when the resident experienced these behaviors. During an observation on 2/14/19 at 2:30 p.m., the resident was lying in bed asleep. Interviews conducted on 2/20/19 included the following: a. At 9:12 a.m., the Licensed Practical Nurse (LPN) who documented one of the nursing notes said that non-pharmacological interventions should be documented in the medical record, and she should have included them in her note. b. At 10:14 a.m., the Medical Director said the resident has a complex psychiatric history. She said the [MEDICATION NAME] was prescribed for agitation. She said the resident has several [DIAGNOSES REDACTED]. The Medical Director said she believed her [DIAGNOSES REDACTED]. She said she was aware the [DIAGNOSES REDACTED]. She also said she expects the nurses to use non-pharmacological interventions when the resident has behaviors and document what they have done and how it has worked. c. At 4:04 p.m., the evening LPN who wrote two of the nursing notes documented above, said that the staff try to redirect the resident's behaviors by providing 1:1 time and sometimes that works well. She said that should be documented in the resident's record. When interviewed on 2/21/19 at 10:52 a.m., the Registered Nurse Manager said she was not aware that a specific diagnosed documented condition needed to be identified when antipsychotic medications are ordered. She said the nurses should all be documenting behaviors, non- pharmacological interventions, and how well they worked. (10 NYCRR 415.12(l)(1-2))

Based on interviews conducted during the Recertification Survey, it was determined that for one of one main kitchen, the facility did not employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and [DIAGNOSES REDACTED]. Specifically, the current Qualified Dietitian does not have food service management or safety responsibilities for the food and nutrition service, and the current Food Service Supervisor does not meet the required educational credentials or receive frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional. This is evidenced by the following: In an interview on 2/15/19 at 3:57 p.m., the Diet Technician (DT) said the current Registered Dietitian (RD) had been out of work and would be returning to work, fulltime, next week. The DT said she and the RD do not provide any guidance or education to the Food Service Supervisor. She said they work with the Food Service Supervisor when there are concerns about food preferences and menu choices. The DT said neither she or the RD have any supervisory or educational role concerning kitchen operations. The DT said the Food Service Superviors was out that week and would return next week. Interviews conducted on 2/19/19 included the following: a. At 10:32 a.m., the Food Service Superviosr said she had completed ServSafe (a program providing comprehensive food safety educational materials and training) training in (YEAR). b. At 11:02 a.m., the Assistant Administrator/Interim Food and Nutrition Manager said she oversees the kitchen operation. She said the kitchen staff included the Food Service Supervisor, a Team Leader, a RD, and a part-time DT. The Assistant Administrator said the Food Service Supervisor has a bachelor's degree but not in food service. She said the role of the RD was to perform meal rounds, create and update meal tickets for the residents, meet with residents for their preferences, and work with kitchen staff to be sure they are following recipes. The Assistant Administrator said the RD does not have any supervisory role in the kitchen. c. At 11:09 a.m., the Food Service Supervisor said her four year degree is in criminal justice. Interviews conducted on 2/20/19 included the following: a. At 9:37 a.m., the Assistant Administrator said she was not aware of the change in regulation or the requirements for the Food Service Supervisor if the qualified dietitian does not carry out required functions of food and nutrition service. She said the RD does go into the kitchen to talk about things, like food consistencies. b. At 11:01 a.m., the Assistant Administrator said there was no documentation that the Food Service Supervisor had received any regular scheduled consultations on food service management and safety. During an interview on 2/21/19 at 4:20 p.m., the RD said she does not provide any supervision or oversight of food service management or safety and was not aware she had to do that. She said she was not aware of the change in regulation. (10 NYCRR 415.14(a)(1)(2))

Based on observations, interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #44) of four residents reviewed for dignity, the facility staff did not promote care for the resident in a manner that maintains or enhances the resident's dignity. Specifically, staff continued to provide care while the resident was moaning and crying. This is evidenced by the following: Resident #44 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 6/2/17, revealed that the resident's cognitive skills for daily decision making were moderately impaired. The Comprehensive Care Plan, dated 6/8/17, revealed that the resident had cognitive loss, and signs of depression as evidenced by paranoia and anxiety. Approaches included to speak to the resident in a calm manner, and to speak clearly and slowly to enhance her understanding. During an observation on 9/21/17 at 2:00 p.m., the Certified Nursing Assistant (CNA), without talking to or explaining the process, hooked the resident's sling to a mechanical lift. When the resident was lifted, she yelled, Help, and the CNA responded, Cross your hands. After the resident was placed in bed, the CNA, in an abrupt manner and without speaking, turned the resident away from her and the resident said, Don't hurt me. Then again, without talking to the resident, the CNA positioned the resident on her back and removed her brief. At that time, the resident said, Oh, oh. The CNA took the wet washcloth and, without engaging in conversation, the CNA washed the resident. Again, the resident started to moan and said, Oh my God, I can't take it. The CNA said to the resident, Open your legs. She then turned the resident to the left and the resident said, Oh. The surveyor asked the CNA why the resident was moaning, and she responded the resident always does that. When interviewed on 9/21/17 at 2:26 p.m., the CNA said that she knows that she should have explained to the resident what she was going to do prior to providing care. (10 NYCRR 415.5(a))

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #18) of three residents reviewed for pressure ulcers, the facility did not ensure that care was provided in accordance with the resident's written plan of care. Specifically, the resident did not have a cushion in the wheelchair. This is evidenced by the following: Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 7/28/17, revealed that the resident was cognitively intact and at risk for pressure ulcers. The current Comprehensive Care Plan revealed that the resident had a diabetic right heel ulcer and a left buttock Stage II (partial thickness skin loss) pressure ulcer. The current Resident Profile directed to put a dycem (non-slip product) mat on top of the wheelchair cushion to prevent sliding. Observation and interviews conducted on 9/22/17 included the following: a. At 9:00 a.m., the resident's wheelchair cushion was observed in the resident's recliner chair and was covered with a white pad. b. From 9:05 a.m. until 12:00 p.m., the resident was sitting in the small living room in her wheelchair. There was no pressure cushion in the wheelchair and the resident was sitting on a dycem mat. At 12:00 p.m., the resident's family member asked if someone would assist the resident to the bathroom. c. At 12:10 p.m., the Nurse Manager stated that she expects staff to read residents' care plans every day because something could have changed from the day before. d. At 12:45 p.m., the Certified Nursing Assistant (CNA) stated that she saw the cushion in the resident's recliner. She said that she did not know what that was about. She said she put the dycem mat underneath the resident while she was sitting in her wheelchair. The CNA said that the resident should have had a cushion in her wheelchair. (10 NYCRR 415.11(c)(3)(ii))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #86) of three residents reviewed for Activities of Daily Living (ADL), the facility did not provide the necessary care and services to maintain or improve ADL function. Specifically, the resident was not provided assistance with oral care as care planned. This is evidenced by the following: Resident #86 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Dental Consult exam, dated 1/5/17, included that the resident had very heavy calculus (tartar) throughout her mouth. The annual Minimum Data Set Assessment, dated 7/18/17, included that the resident was moderately cognitively impaired and required extensive assistance with personal hygiene. The Comprehensive Care Plan for Dental Care, last updated 5/20/14, included that the resident had moderate plaque and calculus accumulation with gingival (gum) inflammation with a goal to have no evidence of debris in her mouth. The resident was to be provided with mouth care twice a day and as needed, required cueing to brush her teeth, and if she resisted mouth care, she was supposed to be reapproached later. The current Certified Nursing Assistant (CNA) Care Card included that the resident required set up and cueing with morning and evening care. When observed on 9/19/17 at 10:22 a.m., 9/20/17 at 1:45 p.m., and 9/21/17 at 9:32 a.m., the resident's upper and lower teeth had thick white buildup. During an observation and interview on 9/21/17 at 11:35 a.m., the CNA said she tried to brush the resident's teeth that morning but the resident was agitated and would not allow her teeth to be brushed. When the resident was asked to smile, her teeth had thick white buildup. The CNA said that the resident needed to have her teeth cleaned. When observed on 9/21/17 at 11:55 a.m., the resident said that the CNA helped her to brush her teeth. The resident smiled, revealing clean teeth. When interviewed on 9/21/17 at 12:11 p.m., the Assistant Director of Nursing (ADON) said that everyone is supposed to receive mouth care. She looked in care tracker (computerized documentation of care provided) and said the resident is scheduled to have oral care set up and cueing in the morning and evening. The ADON said the resident can have some behaviors but when she looked in care tracker there was no documentation of behaviors or rejection of care for the past week. (10 NYCRR 415.12(a)(2))

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #44) of three residents reviewed for pressure sores, the facility did not provide the necessary services to prevent the development of, or promote healing of, pressure sores. The issues involved the lack of timely repositioning and a skin assessment. This is evidenced by the following: Resident #44 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 6/2/17, documented that the resident's cognitive skills for decision making were moderately impaired, was always incontinent of bowel and bladder, no toileting program and at risk for pressure ulcers. The Comprehensive Care Plan (CCP), dated 6/8/17, revealed that the resident was at risk for pressure ulcers related to incontinence and the goal was for the resident's skin to remain clear. Approaches included to check the resident's skin each day, to assist with mobility needs, and to provide incontinence care. The CCP was updated on 9/18/17 to reflect that the resident currently had a pressure ulcer on the heel, to monitor the area weekly and document changes. The current Resident Profile directs to check and change the resident's position every two to three hours while in the chair. The Skin Observation Sheets, dated 9/7/17 and 9/13/17, revealed no skin issues on the resident's buttocks. An Interdisciplinary Note, dated 9/19/17, documented that the resident did not have any skin issues observed. The Medical Communication Note, dated 9/20/17, revealed that the resident's buttocks were red. The physician order, written on 9/21/17 at 8:00 a.m., directs to apply barrier cream (helps protect the skin) twice daily to bilateral buttocks for contact [MEDICAL CONDITION]. During a continuous observation on 9/21/17 from 8:55 a.m. until 2:00 p.m., the resident was sitting in her wheelchair. When taken to her room at 2:00 p.m. and placed in bed, the staff turned the resident onto her right hip. The resident had a circular Stage II (partial thickness skin loss) pressure ulcer measuring approximately 1 inch in diameter near the left gluteal fold. The buttocks had what appeared to be denuded (loss of some or all of the epidermis) skin near the anal area with a small blister on the left buttock. There were two reddened areas that appeared to be Stage II pressure ulcers both measuring approximately 1 inch in diameter on the right buttock. The resident had diffuse areas of redness down her thighs. Interviews conducted on 9/21/17 included the following: a. At 2:00 p.m. and 2:26 p.m., the assigned CNA said that she did not know how often the resident should be repositioned. She said maybe every two to three hours. The CNA said that she knows what to do for the resident because it is on her assignment. The CNA and the surveyor together reviewed the assignment sheet. The CNA was carrying a list of residents' names on her assignment, not the actual resident care information. The CNA said the resident was put in her wheelchair around 9:00 a.m., and then to bed at 2:00 p.m. She said she does not know why the resident was not repositioned sooner. The CNA said that she reported the areas on the resident's buttocks to the Licensed Practical Nurse (LPN) the previous week and was told to put some cream on it. b. At 2:50 p.m., the Registered Nurse (RN) Clinical Leader said that she was not aware of any skin issues with the resident. She said no one reported anything to her. She said the resident could be toileted every two to four hours, but that specific information would be on the resident's care card. Interviews conducted on 9/22/17 included the following: a. At 10:53 a.m., the Nurse Practitioner (NP) said she was told that the resident had a contact [MEDICAL CONDITION], but was unable to recall who reported that to her. The NP said that she ordered the barrier cream that morning based on the note in the Medical Communication Book written on 9/20/17. She said she did not assess the resident's skin at that time. The NP said when she assessed the resident's buttock on 9/21/17, it was not a contact [MEDICAL CONDITION]. She said she documented it in the medical record. The NP Note, dated 9/21/17, revealed that the resident had an unstageable pressure ulcer on the sacrum and a Stage II pressure ulcer on the right buttock. b. At 2:01 p.m., the Medical Director and the Director of Nursing said that the LPN reported to them that the CNA reported the areas on the buttocks, but it was the end of the shift and she did not have time to look at the areas so she added an entry into the Medical Communication Book. They both said that a lack of repositioning the resident for a prolonged period could have made the areas worse. The LPN, who was not available for interview, reported to Administration that the CNA came to her at the end of the shift and reported that the resident's buttocks were red, but she did not look at the area. c. At 2:34 p.m., the Registered Nurse Manager (RNM) said when there is a problem with a resident's skin, the CNA reports the concern to a nurse, and then it should be documented in the Medical Communication Book, and the medical record. She said the LPN that received the report should have looked at the area, documented it, and notified the RNM. (10 NYCRR 415.12(c)(1-2))

Based on staff interviews and record reviews conducted during an Abbreviated Survey (complaint #NY 704) completed on 10/25/13, it was determined that for 2 (Residents #1 and #2) of 11 residents reviewed for anticoagulation therapy, the facility failed to provide necessary care and services to maintain a resident's highest practicable well-being. Specifically, the facility failed to obtain critical blood work in a timely manner for residents receiving anticoagulants used to thin blood and prevent blood clots as ordered by the physician. Resident #1 did not receive [MEDICATION NAME] for nine days after the blood work was missed and subsequently developed a [MEDICAL CONDITION] ([MEDICAL CONDITION], blood clot). Resident #2's critical blood work was not done in a timely manner. This resulted in actual harm for Resident #1 and potential for serious harm for all other residents receiving anticoagulants that is IMMEDIATE JEOPARDY TO RESIDENT HEALTH AND SAFETY and SUBSTANDARD QUALITY OF CARE. This is evidenced by the following: The Immediate Jeopardy was removed on 10/25/13 prior to exit. [MEDICATION NAME] Time (PT) is a ratio used to measure the blood clotting factor for those who take [MEDICATION NAME] ([MEDICATION NAME]). The results are given as a number that represents a ratio called International Normalized Ratio (INR). The INR is a formula that adjusts differences in chemicals used in the laboratory. An INR range of 2 to 3, is generally effective for those who take [MEDICATION NAME] that need anticoagulation. If the INR is higher than this range, that means the blood clots more slowly than desired. A lower INR means blood clots more quickly than desired. The INR is used only for people on oral anticoagulation therapy (Mayo Clinic .com). 1. Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission history and physical, dated 9/27/13, revealed that the resident had pedal (foot) pulses in the right and left foot, and there was no [MEDICAL CONDITION] (fluid retention). It was noted that the resident was on [MEDICATION NAME] and [MEDICATION NAME] ([MEDICATION NAME]). Both medications are used to thin blood. Review of the resident's laboratory results for anticoagulation therapy, Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] On 9/30/13, the resident started to receive [MEDICATION NAME] 4 milligrams (mg) once a day for seven days. Documentation on the October 2013 MAR indicated [REDACTED]. The PT/INR results, dated 10/17/13, were PT 24.9 and INR 2.41. The physician order, dated 10/7/13, included to continue with [MEDICATION NAME] 4 mg for seven days and to obtain blood work (PT/INR) on 10/14/13. There was no documentation to show that the blood work was obtained as ordered on [DATE]. The resident did not receive [MEDICATION NAME] from 10/13/13 through 10/21/13. On 10/24/13, the Director of Nursing called the New York State Department of Health Nursing Home Complaint program to report that on 10/21/13, the resident complained of mild discomfort to her lower left leg. An Ultra Mobile Imaging Report, dated 10/22/13, concluded that the resident had a [MEDICAL CONDITION] in the left calf. The report noted that the resident had bilateral leg [MEDICAL CONDITION] (left greater than right) and pain in the left calf. The physician orders, dated 10/22/13, included Enoxaprin (also known as [MEDICATION NAME] a blood thinning medication) 60 mg subcutaneous (under the skin) injection every 12 hours and [MEDICATION NAME] 4 mg once that day for [DIAGNOSES REDACTED]. On 10/23/13, blood work obtained included an INR of 1.22. A physician order [REDACTED]. A medical visit report, dated 10/23/13, revealed that a Doppler ultrasound study was done to evaluate for left leg pain and revealed a [MEDICAL CONDITION] in the resident's left calf. It was noted that there were no pedal pulses and that the resident would be started on [MEDICATION NAME] until the INR level was therapeutic. The plan was to manage pain and monitor for a [MEDICAL CONDITIONS] (blood clot in lungs). Interviews conducted on 10/24/13 revealed the following: a. At 10:50 a.m., the Senior Director of Nursing (SDON) stated that since the discovery of the error for Resident #1, all records for every resident are currently under review. She said that no other errors were found for blood work. The SDON explained that all physician orders [REDACTED]. b. At 12:10 p.m., the Resident Services Secretary (RSS) said she became aware of the missed lab on 10/23/13. She said that she printed the electronic lab list on 10/11/13 for labs due on 10/14/13 and then completed lab requisitions if they were not done. The RSS said that once she transcribes the information from the lab list to the lab log, the list is not saved. The RSS stated that no one checks to be sure all labs are listed in the lab log book. The RSS said that the current electronic medical record process is the physician writes the order in the electronic order program, and the nurse takes off the order. The RSS said she prints the lab list the day before the labs are due, completes any needed lab requisitions, and then puts the lab requisitions in the lab log book. The RSS explained that prior to electronic records, the nurse would transcribe the order and record it in the lab log book and the unit communication book. The RSS said that when she received training, no one told her the old process was going to stop. She said the nurses are still supposed to communicate to her and fill out a lab requisition. c. At 12:30 p.m., the Registered Nurse Manager (RNM) said that the current process for signing off an order for [REDACTED]. The RNM said the previous process included completing a lab requisition and recording the resident's name in the lab log book. She said this system stopped when the electronic program started. The RNM said that the electronically generated lab list (10/14/13) was not compared with the lab log book to ensure that labs were not missed. The surveyor and the RNM reviewed the electronic lab list for 10/14/13, printed on 10/23/13, and compared it to the lab log book. There were five residents on the electronic list that did not have lab work completed as ordered on [DATE]. The RNM was unable to say why the lab work was missed. d. At 12:55 p.m., the SDON and DON said that when the new electronic record started the third week of September, all medical orders were checked. Ancillary orders, such as lab orders, were checked after the incident for Resident #1 was discovered. The SDON and DON stated that a new "tab" has been included in the system to include labs. They both stated that if the blood work is not signed as completed on the day it was ordered, the system will flag the nurse to check for completion. The SDON and DON stated they were not aware that five residents missed lab work on 10/14/13. e. At 3:40 p.m., the SDON, DON, RNM, and surveyor reviewed the computer medical orders for Resident #1. The physician order [REDACTED]. The RNM said the secretary is now responsible for the requisitions and recording in the lab log book after printing out the lab list from the computer. The RNM said she assumed this was the new process. The SDON, DON, and RNM said that if a lab was missed it would not reappear on any computer generated lab requisition list. They all said there is no system in place, and no one checked the 10/14/13 lab list for accuracy. They said all the lab orders will be checked and an investigation will be started to determine how the five residents' labs were missed on 10/14/13. Interviews conducted on 10/25/13 revealed the following: a. At 9:15 a.m., the SDON said there are 11 residents currently receiving anticoagulation therapy. She said all the orders have been checked to ensure that the PT/INR labs were completed as ordered. She said that she has a manual for the Computerized Physician order [REDACTED]. Also, there is now an outline and there will be written policies for the process. She added that the computer generated lab list will be saved. The SDON said that all identified labs that were missed were reviewed as well as all orders on all units. She said she was only aware that Resident #1 had missing labs. The SDON said the other residents identified as having missing labs have been reviewed and corrected. b. At 10:45 a.m., the Clinical Informatics Representative (CIR) said he was responsible for providing extensive training on the new computer system. He said the unit secretaries were informed during training that it would be their responsibility to complete lab requisitions. He said there is no written documentation for this process. The CIR said that a new order process started that day. He said that all labs need to be signed off in the computer when they are obtained or the electronic system will alert the nurse that the lab is incomplete. c. At 1:35 p.m., the Nurse Practitioner (NP) said she was notified on 10/22/13 that a PT/INR ordered for 10/14/13 was missed for Resident #1. The NP said the 10/23/13 PT/INR results were not therapeutic and could have contributed to the [MEDICAL CONDITION]. d. At 4:45 p.m., the Medical Director said he became aware of the issue that day. He said that he is not involved in reviewing incidents on a systematic basis. However, this incident will be looked at now. 2. Resident #2 has [DIAGNOSES REDACTED]. Review of the resident's anticoagulation laboratory orders revealed that a lab ordered (PT/INR) on 10/14/13 was not completed until 10/16/13. Interviews conducted on 10/24/13 revealed the following: a. At 12:30 p.m., the RNM stated that on 10/16/13 the evening nurse brought to her attention that the resident used to receive [MEDICATION NAME] and questioned why the resident was not receiving the medication. The RNM said that she called the NP, and an order for [REDACTED]. She said that she did not investigate why the resident missed the blood work. The RNM said she assumed it was a "One time error" and did not review the lab list for 10/14/13. She said she closed out the incident and did not investigate any further to determine if any other residents had been affected. b. At 12:55 p.m., the SDON and DON stated that they had no direct knowledge of Resident #2 missing a blood draw (PT/INR) on 10/14/13. c. At 1:35 p.m., the NP said she was notified by the RNM that the resident was not getting her [MEDICATION NAME]. The NP said she gave an order to give a dose of [MEDICATION NAME] and ordered a PT/INR for the next day. She said she is not involved in reviewing medication errors but is notified when it happens. The Immediate Jeopardy was removed prior to exit as a result of the following actions: 1A. All residents on anticoagulation therapy are now flagged in the computerized system. This is present under their picture when the profile is opened. 1B. All laboratory orders for all labs were reviewed to make sure no other residents were missed. 2. All medication Incident Reports were reviewed and no other lab errors were found. 3. Policies were developed to reflect the changes, and an outline of the education provided to licensed nursing staff. 4. All unit secretaries and 48 of 49 licensed nursing staff were educated on the new procedure. 5. The nurses are responsible for signing off on lab orders. Whoever transcribes the order is responsible for the requisitions and places them in the lab log book. 6. All laboratory generated lists will be kept in the lab log book to check if all the labs were drawn at the end of the day. Any discrepancies will be verified with the orders in the computer. 7. All lab orders will include a draw date and will be flagged as incomplete in the computer system if the lab work is not done. This will flag as incomplete until the nurse reviews it was done and initials it electronically. 8. Each shift supervisor will also review reports in the computer for any missed orders. 9. Secretaries will run a lab report in the morning for the previous day and compare it with the lab log book to verify no labs were missed. The secretary will also review a second report for labs and make sure none were missed. 10. When four unit nurses and one nursing supervisor were interviewed, they were able to state the new policies regarding lab draws. 11. The administrative nurses will audit the new policies and report to the Quality Improvement Team. 12. The surveyor checked the computerized system on 10/25/13 and found the new measures in place. (10 NYCRR 415.12)