Every finding on record at Bedford Hills Center

Based on interview and record review, it was determined that the facility failed to ensure that a resident was free from significant medication errors for 1 resident out of 3 residents reviewed for anticoagulant medications (Resident Identifier #3). Findings include: Review on 10/3/24 of Resident #3's Hospital Discharge Medication Record, dated 7/11/24, revealed the following: Resident #3 has a discharge diagnosis of a saddle pulmonary embolism. Review also revealed that Resident #3 had an order for Apixaban 5 mg [milligrams] oral tablet [medication used to prevent blood clots], take 2 tablets, 10 mg, by mouth twice a day for 7 days followed by 1 tablet (5 mg) twice daily. Review on 10/3/24 of Resident #3's July and August 2024 Medication Administration Record revealed that Resident #3 received 10 mg of Apixaban from 7/11/24 to 7/18/22 and received 5 mg of Apixaban from 7/18/24 to 7/22/24. Resident #3 did not received Apixaban from 7/22/24 to 8/29/24. Interview on 10/3/24 at 11:00 a.m. with Staff A (Director of Nursing) confirmed that Resident #3 did not receive anticoagulation therapy from 7/22/24 to 8/29/24. Staff A stated that they had identified the medication error on 8/28/24. Review on 10/3/24 of the facility's corrective action plan revealed the following: Provider was notified of the medication error on 8/28/24, a Quality Assurance meeting was held on 8/29/24, Facility wide audits of all medication orders were completed on 9/9/24, all nurses and medication nursing assistants were educated on medication ordering and reconciliation protocols on 8/31/24, and weekly audits of all medication orders, including anticoagulant medications, was started on 9/9/24.

Based on interview and record review, it was determined that the facility failed to inform the resident and/or the resident's representative of the risks and benefits of antipsychotic medication for 1 of 5 residents reviewed for unnecessary medications in a final sample of 26 residents (Resident Identifier #60). Findings include: Review on 7/31/24 of Resident #60's physician orders revealed the following order: Zyprexa 2.5 milligrams (mg) by mouth every afternoon for delusions, dated 11/9/23 and Zyprexa 5 mg by mouth every evening for delusions, dated 11/9/23. Review on 7/31/24 of Resident #60's medical record revealed that there was no consent or evidence of discussion with Resident #60 or the resident representative about the risk and benefits of Zyprexa. Interview on 7/31/24 at approximately 2:20 p.m. with Staff A (Unit Manager) confirmed above findings. Review on 7/31/24 of Facility Policy 3.8 Psychotropic Medication Use with a revised date of 10/24/22, revealed: .16. Facility staff should inform the resident and/or resident representative of the initiation, reason for use, and risks associated with the use of psychotropic medications .

Based on observation, interview, and policy review, it was determined that the facility failed to ensure that expired medications were removed from stock in 1 of 2 medication rooms observed. Findings include: Observation on 7/29/24 at approximately 8:15 a.m. with Staff A (Unit Manager) of the [NAME] Unit medication room revealed two opened multi dose bottles of APLISOL (Tuberculin Purified Protein Derivative, diluted) in the refrigerator, in one box labeled with an open date of 6/20/24 and a do not use after date of 7/20/24. Interview on 7/29/24 at approximately 8:20 a.m. with Staff A confirmed the above findings. Review on 7/29/24 of manufacturers instructions for APLISOL revealed: .Storage .Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency . Review on 7/30/24 of facility policy titled, Disposal/Destruction of Expired or Discontinued Medication revealed: .4. Facility should place all discontinued or outdated medications in a designated, secure location which is solely for discontinued medications .

Based on interview and record review, it was determined that the facility failed to ensure that the resident and/or resident representative was informed timely of the Skilled Nursing Facility (SNF) Notice of Medicare Non-Coverage (NOMNC) or Advance Beneficiary Notice (ABN) for 2 out of 3 residents reviewed for beneficiary notices (Resident Identifiers are #110 and #131). Findings include: Resident #110 Review on 7/30/24 of Beneficiary Notice - Residents discharged Within the Last Six Months form, completed by the facility, revealed that Resident #110 was discharged from Medicare Services on 6/10/24 and remained in the facility. Review on 7/30/24 of Resident #110's SNF Beneficiary Notification Review form, completed by the facility, revealed that Resident #110's last covered day of Medicare Part A Skilled Services was 6/10/24 and that the facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. Further review revealed that the SNF ABN notice was not provided to the resident. Interview on 7/30/24 at 11:21 a.m. with Staff D (Minimum Data Set Coordinator) confirmed that the SNF ABN was not provided to Resident #110. Resident #131 Review on 7/30/24 of Beneficiary Notice - Residents discharged Within the Last Six Months form revealed that Resident #131 was discharged from Medicare Services on 6/10/24 and discharged home. Review on 7/30/24 of Resident #131's SNF Beneficiary Notification Review form revealed that Resident #131's last covered day of Medicare Part A Skilled Services was 6/10/24 and that NOMNC form was not provided to Resident #131. Interview on 7/30/24 at 11:21 a.m. with Staff D confirmed that the NOMNC was not provided to Resident #131. Interview on 7/30/24 at 11:23 a.m. with Staff E (Director of Social Services) revealed that Resident #131 had reached their baseline and no longer needed skilled Medicare services. Interview on 7/30/24 at 2:48 p.m. with Staff C (Administrator) confirmed that the facility initiated the discharge from Medicare Part A for Resident #131 and should have issued a NOMNC.

Based on record review and interview, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the residents' status for 3 of 26 residents in a final sample of 26 residents (Resident Identifiers are #1, #62, and #128). Resident #128 Review on 7/31/24 of Resident #128's Discharge - return not anticipated MDS, with an Assessment Reference Date (ARD) date of 5/1/24, revealed under section A0301G, Type of Discharge: Unplanned was coded. Review on 7/31/24 of Resident #128's discharge assessment dated [DATE] revealed that Resident #42 was a planned discharge to home. Interview on 7/31/24 at 8:46 a.m. with Staff B (MDS Coordinator) revealed that the MDS dated [DATE], was coded incorrectly. 48515 Resident #1 Review on 7/30/204 of Resident #1's Annual MDS assessment dated [DATE], revealed that Section O, Special Treatments, indicated that Resident #1 was receiving Hospice services. Review on 7/30/24 of Resident #1's medical record revealed no order or care plan for hospice services. Interview on 7/31/24 at approximately 12:20 p.m. with Staff B confirmed that Resident #1 was not receiving Hospice services and that the MDS assessment was coded incorrectly. 50163 Resident #62 Review on 7/31/2024 of Resident #62's Annual MDS assessment dated [DATE], revealed that Section O0110, Special Treatments, Procedures, and Programs, indicated that Resident #62 was receiving Hospice services. Interview on 7/31/2024 at approximately 12:45 p.m. with Staff B confirmed that Resident #62 was not receiving Hospice services and that the MDS assessment was coded incorrectly.

Based on interview and record review, it was determined that the facility failed to ensure residents remain free from significant medication errors, which resulted in a resident needing interventions for hypoglycemia, including hospital observation for one of three residents reviewed for insulin use. (Resident Identifier #1). Findings include: Interview on 5/22/24 at approximately 10:00 a.m. with Resident #1 revealed he/she had received too much insulin a little while ago and ended up going to the hospital as a result. Review on 5/22/24 of Resident #1's March 2024 Medication Administration Record revealed the following Humulin R U-500 (Insulin) orders: Humulin R U-500 kwik pen 12 units one time only for CBG= 507 mg/dl, with a start date and time of 3/31/24 at 12:15 p.m.; Humulin R U-500 kwik pen 12 units one time only for CBG= 487 mg/dl, Administer in addition to scheduled 45 units for a total of 57 units, with a start date and time of 3/31/24 at 4:30 p.m. Interview on 5/22/24 at approximately 11:20 a.m. with Staff B (Registered Nurse) revealed that at approximatley 12:15 p.m., they used a U-100 insulin syringe instead of a U-500 syringe to withdraw 12 units of Humulin U-500 from the resident's insulin pen (total concentration administerd was equal to 60 units, not the ordered 12 units). Staff B revealed that at approximatley 4:30 p.m., they used a U-100 insulin syringe instead of a U-500 syringe to withdraw 12 units of Humulin U-500 from the resident's insulin pen (total concentration administered equal to 60 units, not the ordered 12 units). Review on 5/22/24 of the manufacturers' instructions for Humulin R U-500 kwik pen revealed, .HUMULIN R U-500 is a concentrated insulin. Do not transfer HUMULIN R U-500 insulin from your Pen into a syringe. A severe overdose can happen, causing very low blood sugar, which may put your life in danger . Interview on 5/22/24 at approximately 11:20 a.m. with Staff B revealed that the Humlim R U-500 Kwik pen only allows administration in 5 unit increments. Staff B used a syringe in order administer be able to administer 12 units because the pen could only deliver 10 or 15 units. Interview on 5/22/24 at approximately 11:00 a.m. with Staff A (Director of Nursing) revealed that Resident #1 had received the wrong dose of Humulin R U-500 twice on 3/31/24. Staff A confirmed that Staff B used the wrong syringe to administer the above insulin and therefore the resident recieved five times the dose ordered. Review on 5/22/24 of Resident #1's medical record revealed a nurses note dated 4/1/24, entered at 9:50 p.m., Resident returned from hospital s/p [status post] accidental insulin overdose . Further review of Resident #1's medical record revealed an eInteract Transfer Form V5, dated 4/1/24, that revealed .5. Additional Relevant Information: notified by previous nurse during report that resident had several episodes of hypoglycemia overnight. Upon assessment resident had CBG [Capillary Blood Glucose] of 42 [mg/dl (milligrams per deciliter)]. Resident lethargic, only arousable with repeated stimuli, insta glucose gel administered, per orders to send to ED [Emergency Department] for eval [evaluation] and tx [treatment]. CBG rechecked and increased to 56 [mg/dl]. Transferred to [Hospital name omitted] ED via [by way of] EMS [Emergency Medical Services] @ [at] 0755 [7:55 a.m.]. Review on 5/22/24 of Resident #1's recorded blood sugars for 3/31/24-4/1/24 revealed the following: 3/31/24 at 9:36 a.m. 375 mg/dl; 3/31/24 at 11:55 a.m. 507 mg/dl; 3/31/24 at 4:21 p.m. 487 mg/dl; 3/31/24 at 7:00 p.m. 291 mg/dl; 3/31/24 8:39 p.m. 168 mg/dl; 4/1/24 at 12:51 a.m. 115 mg/dl; 4/1/24 at 3:30 a.m. 97 mg/dl; 4/1/24 at 5:33 a.m. 57 mg/dl; 4/1/24 at 6:12 a.m. 94 mg/dl; 4/1/24 at 7:38 a.m. 42 mg/dl;4/1/24 at 7:39 a.m. 40 mg/dl. Review of glucose references rangs, retrieved from: https://emedicine.medscape.com/article/2087913-overview?form=fpf revealed the following: Normal glucose, for elderly patients: 82-115 mg/dL Review on 5/22/24 of The American Diabetes Association website article, Using U-500 Insulin, found at diabetesjournals.org/clinical/article/30/2/86/31636/Using-U-500-Insulin, updated on April 1,2012, revealed: .U-500 is 5 times more concentrated than U-100 insulin. This means that every 1 unit of U-500 is the same as 5 units of your usual insulin. This makes it a more powerful medicine. It also means that you need to be careful about giving yourself the right amount of U-500 Review on 5/22/24 of the facility's documentation of corrective action for the above insulin error revealed the facility updated the policy titled: Insulin [NAME] 4/2/24, completed in-service education to all nurses on the administration of insulin with an insulin pen specific to Humulin R U-500 on 4/2/24, conducted competencies with all nurses on the administration of insulin with an insulin pen from 4/4/24-4/15/24, are monitoring insulin administration through weekly audits and are reviewing these audits at quarterly Quality Assurance and Performance Improvement meetings.

Based on observation, interview, and record review, it was determined that the facility failed to follow professional standards for following physician orders and medication administration for 2 out of 4 residents observed during medication administration. (Resident identifiers are #7 and #98.) Findings include: Resident #7 Observation on 6/27/23 at 10:27 a.m. of Resident #7 during medication administration with Staff C (Registered Nurse) revealed Resident #7 had a Lidocaine External Patch located on his/her left shoulder dated 6/26/23. Review on 6/27/23 at 10:30 a.m. of Resident #7's physican orders revealed an order dated 1/23/2023 for Lidocaine External Patch apply to left shoulder topically in the morning for DJD [Degenerative Joint Disease] and remove at HS [hours of sleep] start date in January 2023 through June 2023. Interview on 6/27/23 at 10:45 a.m. with Staff C revealed that the patch should have been removed at HS on 6/26/23 and had not been. Standards: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 7th ed. St. [NAME], Missouri: Mosby Elsevier, 2009. Page 336- Physicians' Orders: The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Resident #98 Observation on 6/28/23 at 7:50 a.m. with Staff D (Licensed Practical Nurse) on the Solona unit, Medication Cart 1, revealed that Staff D dropped a 1 milligram (mg) Anastrozole tablet on top of the cart when preparing medications for Resident #98. Staff D picked up the dropped tablet with his/her bare hands and placed it in the cup with other medications ready to be administered. Interview on 6/28/23 at 7:53 a.m. with Staff D confirmed the above findings and revealed they should have discarded the dropped tablet. Standard [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 7th ed. St. [NAME], Missouri: Mosby Elsevier, 2009. pg. 720; 'Administering Oral Medications'; Step 7; item h.Do not touch medication with fingers.Break prescored medications if needed by using a gloved hand or a clean pillating device.

Based on observation, interview, and record review, it was determined that the facility failed to provide oral hygiene for 1 out of 1 resident reviewed for Activities of Daily Living (ADL) (Resident identifier is #86). Findings Include: Observation on 6/27/23 at 9:30 a.m. revealed that resident #86 had not had oral hygiene completed after breakfast. Interview on 6/27/23 at 10:15 a.m with Staff A (Licensed Nursing Assistant) revealed Staff A was assigned to Resident #98 and he/she had not provided Resident #86's with oral hygiene that morning. Interview on 6/27/23 at 9:30 a.m. with Resident #86's Durable Power of Attorney (DPOA) revealed that he/she had concerns with Resident #86's oral hygiene not being provided regularly. Review on 6/27/23 of the Licensed Nursing Assitant Task List for ADLs called Mouth Care-cleaning of teeth/dentures/mouth), dated 6/27/23, showed documentation that oral hygiene had been completed by the resident. Further review of documentation revealed that between 6/16/23 and 6/28/23 the resident completed their own oral hygiene on six of the days (6/17/23, 6/19/23, 6/20/23, 6/24/23, 6/25/23, and 6/27/23). Interview on 6/27/23 at 2:00 p.m with Staff B (Unit Manager) revealed Resident #86 is unable to complete his/her own oral hygiene and requires total assist of staff.

Based on record review and interview, it was determined that the facility failed to ensure that routine testing for COVID-19 was performed on staff who are not up to date based with COVID-19 vaccination on the extent of the virus in the community for 1 out of 6 staff reviewed for staff COVID-19 vaccination. Finding include: Review on 6/14/22 of the facility's staff COVID-19 vaccination log revealed that Staff I (Licensed Practical Nurse)received thier first dose of the COVID-19 vaccination on 04/27/21 and their second dose of COVID-19 vaccination on 5/25/21 and had not received a COVID-19 booster shot. Review on 6/14/22 of the facility's COVID-19 testing line listing revealed that Staff I had not had a COVID-19 test since 5/7/22. Interview on 6/14/22 at approximately 9:30 a.m. with Staff J (Infection Preventionist) confirmed that Staff I had not been tested since 5/7/22 week. Staff J stated that Staff I worked at the facility on 5/14/22, 5/15/22, 5/21/22, 5/22/22, 5/28/22, 5/29/22. Staff J revealed the County CIVUD-19 Level of Community Transmission was High during the above weeks and Staff I should have been tested twice a week. Review on 6/16/22 of the CMS memo QSO-20-38-NH titled, Interim Final Rule (IFR), CMS-340-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements and Revised COVID-19 Focused Survey Tool, revision date of 3/10/22 revealed that: Routine testing of staff, who are not up-to-date, should be based on the extent of the virus in the community When the County COVID-19 Level of Community Transmission is HIgh, the Mimimum Testing Frequency of Staff who are not up-to-date is twice a week.

Based on record review, policy review, and interview it was determined that the facility failed to ensure that the resident or the resident's Durable Power of Attorney (DPOA) was fully informed of the risk of treatment from antipsychotic medications for 2 of 6 residents reviewed for [CONDITION(S)] medications in a final sample of 26 residents. (Resident identifiers are #189 and #16.) Resident #189 Review on 6/16/22 of Resident #189's physicians orders revealed the following: [MEDICATION(S)] ([MEDICATION(S)]) Give 1 tablet by mouth one time a day for mood disorder, Order start 4/25/22. Ariprazole Tablet 30 mg (milligrams) by mouth one time a day for mood disorder, Order start 4/25/22. [MEDICATION(S)], Tablet 0.5 mg Give 0.5 tablet by mouth one time a day for anxiety 0.5 tab =0.25 mg, Order start 5/20/22. Review on 6/16/22 of the Resident #189's [CONDITION(S)] Medication Administration Disclosure revealed, that Resident #184 signed the document consenting to taking medications on 4/24/22. The document did not indicated which medication medication or what were the associated risks. Interview on 6/16/22 at approximately 2:00 p.m. with Staff A (Director of Nursing) confirmed that Resident #189's medications were not indicated on the consent form. Resident #16 Review on 6/14/22 of Resident #16's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 15 mg (milligram), Give 1 tablet by mouth one time a day for depression, start date 4/21/22. Trazadone HCL 100 mg, Give 2 tablets by mouth one time a day for sleep, start date 7/17/21. Trazadone HCL 50 mg, Give 1 tablet by mouth one time a day for sleep, give this in addition to 200mg for total of 250 mg, start date 7/17/21. Review on 6/14/22 of Resident #16's medical record revealed there was no signed consent documented in the medical record for the use of [MEDICATION(S)] and [MEDICATION(S)]. Interview on 6/15/22 at approximately 1:30 p.m. with Staff A confirmed the above finding.

Based on interview, and review of the facility policy, it was determined that the facility failed to report an allegation of neglect to the facility administrator for 1 out of 5 residents reviewed for abuse in a final sample of 26 residents. (Resident identifier is #87.) Findings include: Interview on 6/14/22 at approximately 7:50 a.m. with Resident #87 revealed that he/she was concerned with an incident that happened last week on Monday evening. A nurse last week tried to give me someone else's medications, I told [pronoun omitted] that the medications were not mine and I was not taking them. I know my medications. I was surprised when [pronoun omitted] came back about an hour later and told me to use an inhaler that [pronoun omitted] brought in. I told [pronoun omitted] that I don't take an inhaler. Further interview with Resident #87 revealed that he/she reported the incident to the nurse working the day after. He/She stated, I could report it but it won't do you any good, it's your word against [pronoun omitted]. Interview with Staff ? on 6/14/22 at approximately 1 p.m. revealed that that Staff ? Was informed by reisdenty #87 about the above medication and did not report it to the administrator. Review on 6/16/22 of the facility policy titled, OPS Abuse Prohibition, Revision Date: 5/1/22 revealed: .Process . 7. Immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the CED (Center Executive Director) or designee will perform the following:

Based on observation, interview, record review, and policy review, it was determined that the facility failed to ensure the physician followed physcian orders for 1 of 5 residents reviewed for abuse (Resident identifier is #84) and the facility failed to meet professional standards for medication administration for 1 out of 2 nurse observed Findings include: The Potter-Perry, 2009, Fundamentals of Nursing 7th Edition, St. Louis, Missouri: Mosby, Chapter 23 Legal Implications in Nursing Practice, on page 336- Physicians' Orders states, The physician is responsible for directing medical treatment. Nurses follow physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . and Page 707 Because the nurse who administers the medication is responsible for any errors related to that medication, nurses administer only the medications they prepare . Observation on 6/13/22 at approximately 9:30 a.m. of Resident #84's left elbow revealed a dressing dated 6/11/22. Interview on 6/1/322 at approximately 9:30 a.m. with Resident #84 revealed that Resident #84 was unable to recall what happened to his/her elbow. Interview on 6/13/22 at approximately 9:35 a.m. with Staff H (Licensed Practical Nurse) revealed that there was no order for Resident #84's left elbow. Staff H removed the dressing dated, 6/11/22 and revealed an area with dried blood and a steri strip approximately 1 inch in length applied to the skin tear and stated I have no idea about this, I was not told anything about this in report this morning. Interview on 6/14/22 at approximately 2:30 p.m. with Staff A (Director of Nurses) confirmed that there was no physicians order for the treatment to Resident #84's left elbow. Interview further revealed that Resident #84 obtained the skin tear to the left elbow during a fall on 6/9/22. Observation on 6/13/22 at approximately 11:00 a.m. revealed Staff D (Licensed Practical Nurse) handed a cup of medications to Resident #42. Resident #42 asked Staff D if the cup of medications included [pronoun omitted] pain medication. Staff D stated that she did not know because Staff E (Unit Manager) had prepared Resident #42's medications. Interview on 6/13/22 at approximately 12:21 a.m. with Staff D and Staff E confirmed that Staff D administered medications to Resident #42 that were prepared by Staff E. Staff D and Staff E confirmed this was not the normal practice of the facility. Review on 6/14/22 of the facility policy titled, NSG305 Medication: Administration: General revised 5/31/19 revealed: .Policy .A licensed nurse, Med Tech, or medication aide, per state regulations, will administer medications to patients, Accepted standards of practice will be followed . Practice Standards .4. Medications will be administered as soon as possible, but no more than two hours after doses are prepared, and will be administered by the same person who prepares the doses for administration .

Based on observation, interview, and medical record review, it was determined that the facility failed to provide supervision/assistance at meals for 1 of 1 residents reviewed for Activities of Daily Living in a final survey sample of 26 residents. (Resident identifier is #64.) Findings include: Observation on 6/14/22 at approximately 7:45 a.m. of Resident #64 revealed Resident #64 was sitting in bed with the privacy curtain closed. Further observation revealed Resident #64 was eating their breakfast with no staff in the area. Observation on 6/15/22 at approximately 7:45 a.m. of Resident #64 revealed Resident #64 sitting in bed eating breakfast with no staff in the area. Interview on 6/15/22 at approximately 7:50 a.m. with Staff C (Licensed Nursing Assistant) revealed Resident #64 eats breakfast in bed independently and is out of bed for other meals. Review on 6/15/22 at approximately 8:32 a.m. of Resident #64's active physican orders revealed the following: Regular/ Liberalized diet Dysphagia Puree texture, Thick Liquids-Nectar/thick consistency, with a start date of 5/4/22; Feed with assistance every shift, with a start date of 5/2/22; Out of bed for meals every shift, with a start date of 5/4/22; Please assist with all meals every shift, with a start date of 5/4/22. Review on 6/15/22 at approximately 8:15 a.m. of Resident #64's active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 6/15/22 at approximately 8:35 a.m. of Resident #64's nutritional assessment dated [DATE], revealed the following information to be checked off as applying to Resident #64: .C. Swallowing .1b. Holding food in mouth/cheeks or residual food in mouth after meals 1c. Coughing or choking during meals or when swallowing medications 1d. Complaints of difficulty or pain when swallowing . Review on 6/15/22 at approximately 8:35 a.m. of Resident #64's active care plan revealed the following focus and interventions: .Focus: [name omitted] is at risk for decreased ability to perform ADL's .eating .created date 5/2/22 ., .interventions .Provide [ name omitted] with a set-up assist of one for eating .date created 5/2/22 . Focus .Resident exhibits impaired swallowing related to progressive dementia, Hx [history] lacunar infarct . with a created date of 5/5/22, .Interventions .Resident will be at 90 degrees upright position/out of bed when swallowing food or drink, Date created 5/5/22 .Observe for signs/symptoms of aspiration .date created: 5/5/22 . Review of facility policy titled NSG212 Dysphagia Protocol revised on 6/1/21, revealed .3. Notify physician/advanced practical provider or evaluation results. Obtain orders as indicated .

1. Based on observation, interview, and record review, it was determined the facility failed to ensure that drugs were labeled and stored in accordance with current accepted professional principles for 2 of 5 medications carts and on 1 (Frost Unit) of 4 units observed. (Resident identifiers are #92 and #114.) Findings include: Observation on 6/13/22 at approximately 9:30 a.m. of the Pierce unit medication cart 1 with Staff D (Licensed Practical Nurse) revealed an open insulin [MEDICATION(S)] pen in the bottom of the insulin pen section. Further observation revealed a sticker with a hand written open date of 5/26/22 and no resident identification on the insulin pen. Interview on 6/13/22 at approximately 9:30 a.m. with Staff D confirmed the above findings. Staff D stated they could not identify which resident the insulin pen belonged to. Resident #92 Observation on 6/13/22 at approximately 9:40 a.m. of the Pierce unit medication cart 2 with Staff E (unit manager) revealed Residents #92's open [MEDICATION(S)] insulin with an open date written as 5/11/22. Further observation revealed a pharmacy sticker that read discard after 28 days from opening and a hand written date of 6/18/22. No other insulin for Resident #92 was found on the medication cart. Interview on 6/13/22 at approximately 9:40 a.m. with Staff E confirmed the above findings. Staff E stated that the correct discard date should have been 6/8/22. Staff E confirmed that Resident #92 received their insulin daily. Review on 6/13/22 of Resident #92's electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 6/14/22 of manufacturer's instructions for [MEDICATION(S)] insulin revealed the storage at room temperature of in-use open insulin should not be used after 28 days of of opening. Review on 6/14/22 of facility policy titled 5.3 Storage and Expiration Dating of Medications, Biological's ,Syringes and Needles revised on 10/31/16, revealed .5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dated for opened medications . Resident #114 Observation on 6/13/22 at approximately 10:50 a.m. on Resident #114's night stand revealed a vial of Ipatroprium-[MEDICATION(S)] Solution 0.5-2.5 (3) mg (milligram)/3 ml (milliliters). Interview on 6/13/22 at approximately 10:50 a.m. with Resident #114 revealed., Someone left this here for me to put in my machine (nebulizer). Interview on 6/13/22 at approximately 11:05 a.m. with Staff B (Licensed Practical Nurse) revealed that Resident #114 is his/her resident, and that he/she did not leave the medication on the night stand, [pronoun omitted] nebulizer treatments have changed to PRN (As Needed), I did not leave it there. Review on 6/13/22 of Resident #114's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Ipatropium-[MEDICATION(S)] Solution 0.5-2.5 (3) mg/3 ml, 1 vial inhale orally every 6 hours as needed for SOB (Shortness of Breath), Order date 6/13/22. Review on 6/15/22 of the facility policy titled, 5.3 Storage and Expiration Dating of Medications, Biological's, Syringes and Needles, Revision Date 10/31/16 revealed: . Procedure . 3.3 Facility should ensure that all medications and biological's, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. .

Based on observation and interview, it was determined that the facility failed to accommodate resident's choices for Residents on one unit out of 3 units reviewed for choices. (Resident identifiers are #22, #62, #91, #52, #128) Findings include: Resident #91 Interview and observation on 6/14/22 at approximately 8:52 a.m. with Resident #91 revealed that his/her preferences that were listed on their meal ticket was not received on his/her meal tray. Their preference and choice was to receive raisin toast every day, they received white toast. Resident #22 Interview and observation on 6/14/22 at approximately 8:55 a.m. with Resident #22 revealed that his/her preferences on their meal ticket was to receive cranberry orange coffee cake or an alternative of a muffin neither of these items were not present on his/her meal tray and no substitute was provided. Resident #62 Interview and observation on 6/14/22 at approximately 9:00 a.m. with Resident #62 revealed that his/her choice or preferences listed on their meal ticket was to received a banana, glazed cinnamon roll and coffee these items were not present on his/her meal tray. Resident #128 Interview and observation on 6/14/22 at approximately 9:03 a.m. with Resident #128 revealed that his/her choice and preference listed on their meal ticket was to receive wheat bread and banana mash these items were not present on their meal tray. Resident #128 also stated that they have requested frequently to receive Raisin Bran cereal daily and has not received it. Resident #52 Interview and observation on 6/14/22 at approximately 9:05 a.m. with Resident # 52 revealed that the need for a lip plate was listed on the meal ticket and not present on his/her tray during the breakfast meal. Also the request for 2 toast and received one toast cut in half which was the only item on her tray as per the ticket.

Based on observation, interview, and record review the facility failed to ensure that residents were free from significant medication errors which resulted in actual harm that was immediate in which the resident had pain and vision changes to both eyes for 1 of 1 residents reviewed. (Resident Identifier is #1.) Findings include: Review on 3/18/22 at approximately 9:00 a.m. of Resident #1's February 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of February 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Scheduled to be given at 6 a.m., 2 p.m. and 8 p.m. Interview on 3/18/22 at approximately 9:40 a.m. with Resident #1 revealed that on 2/20/22 they received ear drops instead of their scheduled eye drops to both eyes. They stated that immediately it started to burn and it was like watching fireworks go off. Review on 3/18/22 at approximately 11:30 a.m. of Resident #1's Eye Doctor consult note dated 2/28/22 revealed positive for blurred vision, pain and redness. Encounter diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Plan: Significant corneal thinning OU (both eyes) pH 7 in both eyes today, irrigated both eyes, start [MEDICATION(S)] ointment 4-6 times a day, Recommend wearing an eye shield over each eye at bedtime. Review on 3/18/22 at approximately 11:45 a.m. of [MEDICATION(S)] manufacturer's instructions revealed purpose Earwax removal aid .when using this product .avoid contact with eyes . Directions for use FOR USE IN EAR ONLY . Interview on 3/18/22 at approximately 1: 00 p.m. with Staff A (Director of Nursing) confirmed the above medication error was made and as a corrective action for this medication error the facility separated the storage of the eye and ear drops and this is audited by unit managers. Staff A stated that the nurse was reeducated via watching a video on the rights of medication administration. Observation on 3/18/22 at approximately 8:10 a.m. with Staff D (Licensed Practical Nurse) of the [NAME] unit medication cart 2 revealed that [MEDICATION(S)] ear drops were being stored in with multiple eye drop containers. Interview on 3/18/22 at approximately 8:10 a.m. with Staff D confirmed the findings of ear drops in with the eye drops on medication cart. Staff stated they should be in a separate spot. Interview on 3/21/22 at approximately 1:00 p.m. with Staff F (Licensed Practical Nurse) confirmed that on 2/28/22, they administered [MEDICATION(S)] ear drops on Resident #1's bilateral eyes instead of Resident #1's scheduled eye drops. Staff F stated that during 2/28/22 2:00 p.m. medication administration for Resident #1 eye drops, they went to grab the eye drops in the medication cart, saw Resident #1's name on a plastic bag with a bottle of medication which was stored with the other residents eye drops. Staff F also stated that they did not visually check the bottle of medication prior to administering it to Resident #1's eyes. Resident #1 had immediately complained of burning and Staff F realized that they had given [MEDICATION(S)] ear drops. Staff F also stated that they flushed Resident #1's eyes with water and the nurse practitioner was notified.

Based on observation, interview, and record review, the facility failed to ensure that a resident was free from neglect when a medication was administered via the wrong route and evaluation and treatment by a specialist was delayed for eight days which resulted in actual harm in which the resident had pain and vision changes to both eyes for 1 of 1 residents reviewed for neglect. (Resident identifier is #1.) Findings include: Review on 3/18/22 at 9:00 a.m. of Resident #1's February 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of February 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Scheduled to be given at 6 a.m., 2 p.m. and 8 p.m. Interview on 3/18/22 at approximately 9:40 a.m. with Resident #1 revealed that on 2/20/22 they received ear drops instead of their scheduled eye drops to both their eyes. They stated that immediately it started to burn and it was like watching fireworks go off. Resident #1 stated that they informed the staff that something was wrong and notified them of the pain and vision changes they were experiencing. Resident #1 stated that they requested to go to the emergency room and was told by a staff member that it was not necessary. Interview on 3/18/22 at approximately 3:00 p.m. with Staff A (Director of Nursing) confirmed that Resident #1 was not seen until the following day by the nurse practitioner. Review on 3/18/22 at approximately 10:30 a.m. of Resident #1's nurse practitioner note dated 2/21/22 revealed a description of the event on 2/20/22 of receiving the ear drops into eyes, stated they were called yesterday about this. Further review of note revealed the following: The patient denies any changes in [their] vision at this time; however, [he/she] reports a slight burning sensation on and off. Right eye pink no drainage, it was fully reactive to light. I will ask that [he/she] goes to follow up with an eye doctor to be more precautionary than anything . 2/21/22 8:17 a.m. - resident reported feeling like film over both eyes and seeing a halo. Denies pain, NP notified. NP to evaluate, resident reported to NP discomfort to right eye and denied any other complaints. New orders obtained for eye appointment. 2/22/22 1:20 p.m. - nursing reached out to both medical eye and NH eye for need for appointment. Continues with minor discomfort to right eye, minimal redness to right eye noted, resolving. 2/23/22 2:45 p.m. - continues with minor discomfort to right eye, minimal redness to right eye noted, resolving. Appointment at medical eye scheduled for 2/28/22. 2/23/22 resident continues with redness to bilateral eyes, right more than left. [Resident] complains of pain to bilateral eyes, managed well with current pain meds. Review on 3/18/22 at approximately 11:30 a.m. of Resident #1's Eye Doctor consult note dated 2/28/22 (8 days following medication error) revealed positive for blurred vision, pain and redness. Encounter diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Plan: Significant corneal thinning OU (both eyes) pH 7 in both eyes today, irrigated both eyes, start [MEDICATION(S)] ointment 4-6 times a day, Recommend wearing an eye shield over each eye at bedtime Interview on 3/18/22 at approximately 3:00 p.m. with Staff A (Director of Nursing) confirmed that Resident #1 was initially seen by the eye doctor eight days after receiving ear drops into his eyes. Interview on 3/21/22 at approximately 1:00 p.m. with Staff F (Licensed Practical Nurse) confirmed that on 2/20/22, they administered [MEDICATION(S)] ear drops in Resident #1's bilateral eyes instead of Resident #1's scheduled eye drops. Staff F stated that they flushed Resident #1's eyes with water and the nurse practitioner was notified. Staff F also stated that they were instructed to monitor Resident #1 and to flush eyes as needed for discomfort. Staff F also stated that Resident #1 complained of on and off burning in the corner of their eyes a couple hours later.

Based on interview, observation, and manufacturer's instruction review it was determined that the facility failed to ensure that drugs were labeled and stored in accordance with accepted professional principals for 1 of 4 medication carts observed. (Resident identifier is #3.) Findings include: Observation on 3/18/22 at approximately 9:30 a.m. with Staff E (Registered Nurse) of the Webster medication cart 2 revealed Resident #3's open [MEDICATION(S)] insulin pen with an open date of 2/16/22 and pharmacy sticker on the pen that read do not use after 3/14/22. Interview on 3/18/22 at approximately 9:30 a.m. with Staff E confirmed that Resident #3's [MEDICATION(S)] insulin pen was labeled not to use after 3/14/22. Staff E stated they did use Resident #3's [MEDICATION(S)] pen to administer the sliding scale dose of insulin earlier that day. Staff E confirmed that this was the only [MEDICATION(S)] on the medication cart for Resident #3. Review on 3/18/22 at approximately 11:00 a.m. of Resident #3's March 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 3/14/22 11:30 a.m. 3 units; 5:00 p.m. 2 units; 3/15/22 7:30 a.m. 1 unit; 11:30 a.m. 1 unit; 5:00 p.m. 4 units; 3/16/22 7:30 a.m. 1 unit; 11:30 a.m. 5 units; 5:00 p.m. 4 units; 3/17/22 11:30 a.m. 4 units; 5:00 p.m. 3 units; 3/18/22 7:30 a.m. 2 units. Review on 3/18/22 of [MEDICATION(S)] manufacturer's instructions revealed .Throw away a used cartridge or prefilled pen after 28 days, even if there is insulin left in the cartridge or pen .

Based on interview and record review, it was determined that the facility failed to ensure that residents were able to exercise their right to access retail services in the community during outings. Findings include: Review on 3/18/22 at approximately 10:00 a.m. of Resident #2's medical record revealed that Resident #2 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed that Resident #2's cognitive status is alert and oriented and on the quarterly MDS (minimum data set) dated 1/15/22 their BIMS (brief interview for mental status) was 15/15. Additionally, Resident #2 self propels throughout the facility independently in a wheelchair. Interview on 3/18/22 at approximately 10:30 a.m. with Resident #2 revealed that on 3/15/22 the facility had an outing to a department store which offered motorized scooters to shoppers. Resident #2 revealed that Staff C (Activities Director) informed Resident #2 that they were not allowed to utilize the motorized scooter per facility policy. Interview on 3/18/22 at approximately 10:56 a.m. with Staff C confirmed that on the 3/15/22 outing Resident #2 requested to use a motorized scooter at the department store and Staff C informed Resident #2 that they could not as it was the facility's policy to not allow residents to use them unless they were assessed.

Based on review of a facility reported incident it was determined that the facility failed to report a significant medication error to the state survey agency within the allotted time frame and a missing narcotic to local authorities and the Board of Nursing. Findings include: Review of the document titled Facility Initial Report Transmittal Form dated 2/28/22 revealed that an initial incident report marked as Other with Resident #1's Admission Record facesheet was faxed to the state certification agency. Review of the document titled Facility Report dated 3/9/22 revealed the investigation into Resident #1's incident that occurred on 2/20/22 at 1320 in Resident #1's room was faxed to the state certification agency. Further review revealed that on 2/20/22 at 1320 Resident #1 was administered [MEDICATION(S)] (ear drops) into Resident #1's right and left eyes. Additional review revealed that the initial report was submitted to the state survey agency 8 days after the incident occurred, and that the final investigation was submitted to the state agency 9 days after the initial report was made. Review of document titled Facility Initial Report Transmittal Form dated 2/22/22 revealed that an initial report marked as other misappropriation with Resident #4's Admission Record face sheet was faxed to the state survey agency. Review of the facility document titled Facility Report dated 2/27/22 revealed the investigation into Resident #4's incident that occurred on 2/20/22 at 3:00 p.m. was faxed to the state certification agency. Further review revealed that on 2/20/22 at 3:00 p.m. Resident #4's [MEDICATION(S)] was unaccounted for during narcotic count. Additional review revealed that the local authorities and the Board of Nursing were never notified of a missing narcotic pill. Interview on 3/18/22 at approximately 3:00 p.m. with Staff A (Director of Nursing) confirmed that before 3/18/22 no one had notified the local authorities or the Board of Nursing for the missing narcotic pill.

Based on record review and interview, it was determined that the facility failed to ensure agency staff were accurately trained/oriented on the facility's policies for infection control for insulin pens, failed to identify infection control risks associated with insulin pens, and failed to protect a resident from and subsequently address potential cross contamination of blood borne pathogens for 1 of 3 residents with diabetes in a survey sample resulting in Immediate Jeopardy. (Resident identifier is #2.) Findings include: Immediate Jeopardy (IJ) was identified on 10/24/19 for failing to ensure that staff followed Center for Disease Control (CDC) guidelines for single patient use of insulin pens placing one resident at risk for exposure to the potential of blood borne pathogens when an insulin pen from one resident was used for another resident. Review on 10/25/19 of the CDC Clinical Reminder: Insulin Pens Must Never Be Used for More than One Person revealed that insulin pens not be used for more than one person because the potential of blood borne pathogens transmission risk is still present due to the regurgitation of blood into the insulin cartridge. Retrieved from https://www.cdc.gov/injectionsafety/clinical-reminders/insulin-pens.html accessed on 10/25/19 Review on 10/24/19 of the facility policy and procedure titled, Insulin Pens, date reviewed 3/1/19, revealed: Insulin pens containing multiple doses of insulin are meant for single patient use only and must never be used for more than one person, even when the needle is changed. Insulin pens will be clearly labeled with the patient name or other identifier to verify that the correct pen is used on the correct patient .To prevent risk of bloodborne pathogen exposure. Review of a facility generated report dated 10/15/19 revealed on 10/15/19, Staff A (Registered Nurse) used Resident #1's [MEDICATION NAME] Solution Pen Injector to administer insulin to Resident #2. Interview on 10/24/19 at approximately 10:00 a.m. with Resident #2 revealed that Resident #2 was aware that they had received insulin in error but was what not informed of any infection control risk related to the incident. Interview on 10/24/19 at approximately 11:15 a.m. with Staff B (Center Nurse Executive) revealed that Staff B had not realized during their investigation that another resident's insulin pen had been used on Resident #2 and put Resident #2 at risk for exposure to blood borne pathogens. Staff B also had not informed the infection preventionist about the incident. Interview also revealed that Resident #2 had not been informed that receiving insulin from another resident's pen could result in potential exposure to blood borne pathogens. Interview on 10/24/19 at approximately 11:35 a.m. with Staff C (Infection Preventionist) confirmed that Staff C had not been informed that Resident #2 had received insulin from another resident's insulin pen. Phone interview on 10/31/19 at 12:51 p.m. with Staff A, revealed that Staff A had no orientation as a agency nurse to the facility's polices and the facility's environment (where supplies are kept), had many interruptions with the medication pass that evening, and many supplies were missing from the medication cart. While getting the insulin pen ready for Resident #1, Staff A could not find a pen needle so Staff A took a syringe and withdraw 5 units from the insulin pen and injected (Resident #2) with it. Staff A did not think that the incident was an infection control issue.

Based on record review and interview the facility failed to ensure that the resident environment remains as free of accident hazards as possible and that a resident receives adequate supervision and assistance devices to prevent accidents for 1 resident that sustained an ankle fracture. (Resident identifier is: #1.) Findings include: Review of Resident #1's medical record on 11/2/10 reveals a care plan valid through 9/25/10 that indicates under the section for Self Care Deficit related to requires assist with all ADL ' s under the interventions section the approach for transferring Resident #1 is "Hoyer transfers with 2 assist." Review on 11/2/10 of a facility investigation for Resident #1 indicates that on 8/28/10, at 8:00 p.m., Staff E, LNA (Licensed Nursing Assistant) failed to provide a safe environment by transferring Resident #1 into bed independently without using the Hoyer lift (resident is deemed to be a Hoyer lift for transfer.) When Resident #1 was placed into bed Staff E removed Resident #1's TED stockings and noticed some bruising. Resident #1 started yelling out "My leg" and complained of left leg pain. Staff F, LPN (Licensed Practical nurse) entered the room and assessed Resident #1' s legs. Staff F did notice the lower portion of the left leg did have a moderate amount of light blue bruising and minimal swelling. Resident #1 stated to Staff F of being in a lot of pain to the left leg. Staff E did tell Staff F that Staff E had improperly transferred Resident #1 into bed but did not hurt Resident #1's leg. Staff F asked Resident #1 what happened Resident #1 said the left leg got bent backwards while going from chair to bed. Resident #1 stated to Staff F that the twisting of the leg had just happened during the transfer into bed by Staff E. Facility documentation reveals that Resident #1's roommate confirmed that Staff E lifted Resident #1 into bed without the Hoyer lift. Review of the hospital discharge instructions dated 8/29/10 from the hospital indicates that Resident #1 received a simple Tibial Fracture. Treat with a simple immobilization. The x-ray report confirmed an oblique distal tibia fracture minimally displaced During review of the personnel record of Staff E it indicates documented evidence that Staff E confirmed the transfer of Resident #1 was inappropriate resulting in Staff E's termination of employment. During an interview with Staff A, Administrator on 11/2/10, Staff A confirmed that Staff E inappropriately transferred Resident #1.

Based on medical record review, personnel file review and staff interview the facility failed to ensure that it implements the policy and procedure to prohibit the neglect of residents that require the use of a mechanical lift for transfers resulting in a fracture for 1 resident. (Resident identifier is #1.) Findings include: Review of the facility's "Abuse Reporting and Investigation" policy, Under " Introduction " According to the Nursing Home Reform Act of 1987, ... This entitlement includes freedom from neglect, abuse, and misappropriation of funds." Definitions defines Neglect is the withholding of goods or services that are necessary with resulting physical hurt or pain or mental anguish." Review of Resident #1's care plan with a review date of 6/18/10, reveals, " lifted mechanically Hoyer with 2 assists." Review on 11/2/10 of a facility investigation for Resident #1 indicates that on 8/28/10, at 8:00 p.m. Staff E, LNA (Licensed Nursing Assistant) failed to provide a safe environment transferring Resident #1 without the Hoyer lift (resident is deemed to be a Hoyer lift for transfer.) Staff E was getting Resident #1 ready for bed and transferred Resident #1 by self into bed without the Hoyer lift or another staff assist. When Resident #1 was placed into bed, Staff E removed Resident #1's TED stockings and noticed some bruising. Resident #1 started yelling out "My leg" and Resident #1 complained of leg pain. Staff F, LPN (Licensed Practical nurse) entered the room and assessed Resident #1's legs. Staff F did notice the lower portion of the left leg had a moderate amount of light blue bruising and minimal swelling. Resident #1 stated to Staff F being in a lot of pain in the left leg. Staff E did tell Staff F that Staff E had improperly transferred Resident #1 into bed but did not hurt Resident # 1' s leg. When Staff F had asked Resident #1 what happened Resident #1 said the left leg got bent backwards while going from chair to bed. Resident #1 stated to Staff F that the twisting of the leg had just happened during the transfer into bed by Staff E. Review of the hospital discharge instructions dated 8/29/10 from the hospital indicates that Resident #1 received a simple Tibial Fracture. Treat with a simple immobilization. The x-ray report confirmed an oblique distal tibia fracture minimally displaced. During the review of Staff E's personnel record it indicates that Staff E was hired on 11/17/08. Staff E was counseled on 9/3/10 for improper transfer. Documentation by Staff E confirmed that the transfer of Resident #1 was inappropriate and resulted in Staff E's termination of employment. During an interview with Staff A, Administrator on 11/2/10, Staff A confirmed that Staff E inappropriately transferred Resident #1 resulting in Staff E's termination of employment.