Every finding on record at Briarcliffe Manor

Based on surveyor observation, staff interview, and clinical record review, the facility failed to ensure medications were stored and labeled in accordance with currently accepted professional standards of practice for 2 of 3 Certified Medication Technician (CMT) carts reviewed and for 1 of 1 medication room.Findings are as follows:1a. During a surveyor observation on 6/8/2026 at approximately 8:30 AM in the presence of CMT, Staff C, the following was observed:-One opened bottle of Pro-Stat liquid protein supplement, open and undated. Review of the manufacturer's instructions indicated the bottle must be labeled and dated upon opening and discarded 3 months after opening.-One Breo Ellipta inhaler: The inhaler was open and undated. Review of the manufacturer's instructions indicated the device must be discarded 6 weeks after the protective foil tray is opened.-One box of Artificial Tears: The bottle was open, undated, and failed to have a resident-specific label identifying the resident for whom it was prescribed.-One Trelegy Ellipta inhaler: The inhaler was open and undated. Review of the manufacturer's instructions indicated the device must be discarded 6 weeks after opening.During a surveyor interview at the time of the above observation, Staff C acknowledged the medications were open, actively being used, and failed to indicate the date they were opened in order to track expiration. Additionally, she acknowledged that the eye drops failed to have a resident specific label identifying the resident for whom it was prescribed.1b. During a surveyor observation on 6/8/2026 at approximately 9:00 AM in the presence of CMT, Staff D, the following was observed:-One Qvar Redihaler: the device was labeled as opened on 3/18/2026. Record review revealed this medication was discontinued on 3/20/2026; however, it remained in storage in the cart available for administration.-One box of Artificial Tears: The bottle was open and undated.-Three boxes of Artificial Tears: The bottles were stored in the cart but failed to have a resident-specific label identifying the resident(s) for whom they were prescribed.During a surveyor interview at the time of the observations, Staff D acknowledged the findings, confirmed the presence of the discontinued medication and the multiple undated/labeled items in the cart.2. During a surveyor observation on 6/8/2026 at approximately 10:15 AM, an inspection of the 3rd Floor Medication Room was conducted in the presence of Licensed Practical Nurse, Staff E, and the following was observed:-The medication room refrigerator was observed to have a heavy accumulation of ice buildup inside of the freezer, which extended down into the refrigerator compartment where resident medications were stored. This ice buildup was actively melting and dripping water into the main refrigerator. During a surveyor interview at the time of the above observation, Staff E acknowledged the heavy ice accumulation and the water dripping into the refrigerator where medication was being stored. During an interview on 6/9/2026 at approximately 8:56 AM, with the Director of Nursing Services (DNS), she acknowledged that medications stored in CMT carts must be labeled with a resident-specific identifier to ensure administration to the correct resident. She also acknowledged that discontinued medications should be removed from the medication carts. The DNS stated that the refrigerator was cleaned and the ice was removed after the surveyor identified the concern. Additionally, she confirmed that pharmacy instructions require artificial tears to be labeled upon opening, however, she was unable to provide evidence that medications with shortened expiration dates after opening were labeled in accordance with manufacturer guidelines.

Based on surveyor observation and staff interview, the facility failed to ensure that appropriate infection control practices were maintained to prevent the potential spread of communicable diseases and cross-contamination. This deficient practice was identified during the observations made during the medication administration task of blood glucose monitoring and insulin administration for 2 of 3 residents reviewed, Resident ID #s 133 and 136. Furthermore, the facility failed to implement Enhanced Barrier Precautions (EBP) for 1 of 2 residents reviewed with a non-pressure wound, Resident ID #78.Findings are as follows:1. According to Centers for Disease Control and Prevention (CDC) infection control guidelines titled, HOW TO SAFELY REMOVE PERSONAL PROTECTIVE EQUIPMENT (PPE) revealed that all PPE must be completely removed and discarded before exiting the resident's room.During a surveyor observation on 6/8/2026 at approximately 11:30 AM, Licensed Practical Nurse, Staff B, entered Resident ID #136's room to obtain a blood sugar reading via a fingerstick (the pricking of a finger in order to obtain a small sample of blood). Further observation revealed that Resident ID #136 room, had signage posted at his/her doorway indicating the use of Droplet Precautions, due to a respiratory infection.Upon completing the fingerstick, Staff B exited the resident's room into the unit's hallway while still wearing the contaminated isolation gown and surgical mask that was worn inside the droplet precaution room. Staff B went directly to her medication cart, obtained Resident ID #136's insulin from the medication cart, and re-entered the resident's room.During a surveyor interview immediately following the above observation, Staff B acknowledged that the resident was on droplet precautions due to an active respiratory infection. She acknowledged that after obtaining the resident's the blood sugar fingerstick, she exited the isolation room and went into the unit's hallway to the medication cart and retrieved the resident's insulin while still wearing the contaminated isolation gown and surgical mask that had been worn inside the droplet precaution room. Additionally, Staff B acknowledged that she should have removed the contaminated gown and mask prior to exiting the resident's room.2. Review of an undated facility policy titled Blood Sampling - Capillary (Finger Sticks), revealed to .ensure blood glucose meters [glucometer] intended for reuse are cleaned and disinfected between resident use.Review of the manufacturer's usage instructions for Clorox Helathcare Bleach Germicidal Wipes, revealed, .Wipe the surface until completely wet. Wait for the contact time (3 minutes for C. diff, fungi, TB and select viruses; 30 second for bacteria; 1 minute for most viruses) .Discard the wipe.During a surveyor observation on 6/8/2026 at approximately 12:06 PM, Registered Nurse (RN), Staff F, was observed performing a fingerstick blood glucose test on Resident ID #133. Prior to the procedure, Staff F utilized a manufacturer-approved bleach wipe to clean the glucometer. Staff F failed to allow the disinfectant to remain wet on the surface of the device for the required manufacturer-specified contact time (dwell time) of 3 minutes. Immediately after applying the bleach wipe, Staff F took a dry paper towel and wiped the liquid disinfectant off of the glucometer, rendering the disinfection process ineffective. Additionally, as the glucometer became wet internally, it displayed an error code after a test strip was inserted. Staff F repeated this process two additional times because of the error code reading. During a surveyor interview immediately following the above observation, Staff F acknowledged that he utilized a manufacturer-approved bleach wipe to clean the glucometer but failed to allow the chemical disinfectant to remain wet on the device's surface for the required manufacturer-specified contact time of 3 minutes. He acknowledged that the device should have remained wet for the full dwell time to achieve proper disinfection.During a surveyor interview on 6/9/2026 at 8:49 AM, the Director of Nursing Services (DNS) revealed it is her expectation that all staff follow manufacturer guidelines for equipment disinfection. Additionally, she acknowledged that staff should not exit an isolation room wearing contaminated PPE.3. According to the CDC, EBP is required for all residents with chronic wounds during high-contact activities, regardless of MDRO (multi-drug resistant organisms) status. The CDC defines a chronic wound as any skin injury requiring specialized treatment beyond a simple adhesive bandage. Staff must wear gowns and gloves during the high contact activities (such as dressing, bathing, transfers, and wound care) to prevent pathogen transmission.Record review revealed Resident ID #78 was readmitted to the facility in October of 2024 with a diagnosis including, but not limited to, diabetes. S/he subsequently developed a left foot/heel skin tear on 4/6/2026. The wound healing was stalled, requiring a referral to an external wound clinic initiated on 6/5/2026.Review of a physician's order originally dated 5/27/2026, and reordered continuously every 7 days, revealed the wound required a specialized, multi-step treatment, rather than a simple bandage. The active order dated 6/3/2026 was to cleanse the left foot/heel skin tear with Normal Saline (NS, a sterile salt water solution used to flush and clean debris from wounds), apply Santyl ointment 250 units/gram (a specialized enzymatic debriding agent used to actively remove dead, non-viable tissue from the wound bed), followed by Maxsorb (a highly absorbent alginate dressing designed to manage heavy wound drainage and maintain a moist environment), then cover the wound with a foam dressing (a thick protective barrier that cushions the area and locks in moisture) daily.Review of a nursing progress note dated 6/10/2026, authored by RN Supervisor, Staff G, revealed an alteration in skin assessment detailing that the resident's left foot/heel skin tear continued with scant serosanguineous (a pink wound fluid) drainage noted with no odor. The wound bed was noted to be pink with white and dark spots present, with no swelling, no warmth, and no signs or symptoms of infection. The resident was scheduled for an external wound clinic appointment for the following week and was to continue with the same wound care order listed above.Surveyor observations from 6/8/2026 through 6/11/2026 revealed, EBP was not implement, as there was no isolation signage posted nor were there any PPE carts by the resident's doorway.During a surveyor interview on 6/11/2026 at 7:42 AM with RN, Staff H, she acknowledged that Resident #78 was not placed on EBP, confirming that no orders for the resident to be placed on EBP and PPE was not being utilized by the nursing staff during care.During a surveyor interview on 6/11/2026 at 9:49 AM, Staff G stated she completed the wound assessment on 6/10/2026 and described the wound as being the size of a half-dollar with a pink wound bed and scattered small dark/brown areas of tissue which is opened and draining. The wound was a skin tear that originally developed in April 2026. She revealed that the skin flap has been open and has remained stagnant and unchanged since April. She revealed that a wound clinic referral was made due to lack of progression, resident comorbidities, and vascular issues. When asked why Resident #78 was not on EBP, Staff G acknowledged the resident's history of diabetes and confirmed that the treatment required a complex dressing rather than a simple bandage; however, she stated the resident was not placed on EBP because it was a skin tear and was still considered fairly new. When asked to define a chronic wound, she stated it was a wound that is being maintained for a long period of time and noted there had been no progression since the skin tear was first identified two months prior. She stated that the Interdisciplinary Team (IDT) determines precautions, and that the IDT reviewed the resident and decided to order a wound clinic consult due to the lack of progression but did not initiate EBP.During surveyor interviews on 6/11/2026 at 9:26 AM and 11:17 AM with the DNS, she acknowledged that EBP was not initiated for Resident ID #78 as it was not a chronic wound. Additionally, when questioned on facility protocol and federal guidelines, the DNS was unable to define what constitutes a wound as chronic.

Based on record review and staff interview, the facility failed to send a copy of the written notices for all resident discharges to a representative of the State Office of the Long-Term Care (LTC) Ombudsman, at the same time it was issued to the residents and their representative(s).Findings are as follows:Review of a document titled, Highlights of Federal Nursing Facility Requirements and Guidance Regarding Transfer and Discharge Notices, authored by The National Long-Term Care Ombudsman Resource Center, last revised on 7/23/2025, states in part, .Discharge refers to the movement of a resident from a bed in one certified facility to a bed in another facility or other location in the community, when return to the original facility is not expected.The facility must not transfer or discharge the resident from the facility unless: The resident's needs cannot be met in the facility; The resident's health has improved and the resident no longer needs the services provided by the facility; The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; The health of individuals in the facility would otherwise be endangered; The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility; or The facility ceases to operate.Further review of the Highlights of Federal Nursing Facility Requirements and Guidance Regarding Transfer and Discharge Notices, states in part, .Before a facility transfers or discharges a resident, the facility must .send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.Review of the facility's discharges from March 1 through May 31, 2026, failed to reveal evidence that a notification to the representative of the State LTC Ombudsman was provided for residents who were discharged to another facility or other location in the community, when the return to the original facility was not expected, or for a resident that left the facility against medical advice.During a surveyor interview on 6/9/2026 at 12:56 PM, with Social Services Staff A, she revealed that the facility does not provide notification to a representative of the State LTC Ombudsman when a resident is discharged , indicating they only provide notification of residents who have been transferred to the hospital.During a surveyor interview on 6/11/2026 at 9:09 AM, the Director of Nursing Services stated that the facility only issues notifications to the State LTC Ombudsman when a resident is transferred to the hospital or when a resident is discharged following a formal 30-day notice. Additionally, she revealed that the facility does not notify the State LTC Ombudsman of any other type of discharges.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections for 1 of 1 resident reviewed who is positive for Methicillin Resistant Staphylococcus Aureus (MRSA), Resident ID #316. Findings are as follows: Record review of a document titled, Guidelines for the Management of Methicillin Resistant Staphylococcus aureus [MRSA, an antibiotic resistive infection, Multidrug-Resistant Organism, MDRO] in Rhode Island Long Term Care Facilities states in part, .Contact precautions [gown and gloves when entering the resident's room] are indicated for all residents infected with MRSA and those colonized residents who are more likely to shed MRSA into the environment . Review of a facility policy titled, Categories of Transmission-Based Precautions Isolations states in part, .Transmission-Based Precautions shall be used when caring for residents who are documented or suspected to have communicable disease or infections that can be transmitted to others .Gown .Wear a gown to protect the skin and prevent soiling or contamination of clothing during procedures and care when contact with blood, bodily fluids, excretions, or secretions is anticipated . Record review revealed the resident was admitted to the facility in January of 2024 with diagnoses including, but not limited to, osteomyelitis (infection in the bone) and surgical removal of the left second toe. Record review of a document titled, Continuity of Care-Post-Acute Facility [COC] dated 1/26/2024 revealed, the resident's left 2nd toe surgical cultures were positive for MRSA. The resident was started on an oral antibiotic for 3 weeks with instructions to follow up with infectious disease. Further review of the COC revealed the resident was to be placed on infection control precautions of isolation related to his/her diagnosis of MRSA. Review of the Admission Minimum Data Set assessment dated [DATE] failed to indicate that the resident had an MDRO. It further revealed that s/he was receiving surgical wound care with an application of a dressing to his/her foot. Review of the comprehensive care plan dated 2/8/2024 failed to reveal evidence of documentation that the resident had MRSA in his/her surgical site or that the facility implemented contact precautions related to the positive MRSA cultures, in order to mitigate the risk of transmission of this infectious disease to others in the facility. Surveyor observations on 2/14/2024 and 2/15/2024, failed to reveal evidence that the resident was on contact precautions for MRSA. During a surveyor observation on 2/15/2024 at 10:00 AM of the dressing change with Licensed Practical Nurse, Staff A, she was observed to perform wound care to the MRSA positive surgical site without donning a gown, as required per the facility policy, and the Guidelines for the Management of Methicillin Resistant Staphylococcus aureus [MRSA, an antibiotic resistive infection, Multidrug-Resistant Organism, MDRO] in Rhode Island Long Term Care Facilities. During a surveyor interview on 2/15/2024 at 10:59 AM with Staff A, she indicated that she was unaware that the resident was positive for MRSA in his/her left second toe until it was brought to her attention by the surveyor. Additionally, she acknowledged that the resident was not currently on isolation precautions. During a surveyor interview on 2/15/2024 at 11:52 AM with the Infection Preventionist, she was unable to provide evidence that the facility placed the resident on contact precautions for MRSA when s/he was admitted to the facility to prevent the transmission of his/her infectious disease to staff, residents, and visitors. Further review of the care plan revealed that it was updated on 2/15/2024 to indicate that the resident was admitted with MRSA to his/her left second toe surgical site and was to be placed on standard/contact precautions.

Based on surveyor observation and staff interview, it has been determined that the facility failed to ensure that food is served and distributed in accordance with professional standards for food service safety, relative to the main kitchen. Findings are as follows: 1. The Rhode Island Food Code 2018 Edition 4-501.114, states in part, .a chemical sanitizer for a manual or mechanical operation at contact times .shall be used as follows: (A) A chlorine solution shall have a minimum concentration range 50-99 MG/L . During the initial tour of the main kitchen on 1/3/2023 at approximately 8:45 AM the sanitizing test strip registered 10 MG/L (milligrams per liter) on dinnerware that was being washed and sanitized. Immediately following this observation the surveyor interviewed the [NAME] President of Operations and he indicated that he would contact the service representative for the dishwasher. Record review revealed that the service representative repaired the dishwasher on 1/3/2023. During an additional surveyor observation on 1/5/2023 at approximately 9:50 AM the chlorine test strip read 10 MG/L on dinnerware that was being washed and sanitized. Immediately following this observation the surveyor interviewed the [NAME] President of Operations and he indicated that he would contact the service representative for the dishwasher. Record review revealed that the service representative repaired the dishwasher on 1/5/2023. An additional surveyor observation on 1/6/2022 at approximately 10:15 AM the chlorine test strip read 10 MG/L. Immediately following this observation the surveyor interviewed the [NAME] President of Operations and he acknowledged the above findings and indicated at this time the dishwasher would not be utilized for warewashing. 2. The Rhode Island Food Code 2018 Edition 4-501.110 states in part, .The temperature of the wash solution in a spray type ware washer that use chemicals to sanitize may not be less than 49 degrees Celsius (120 degrees F) . During a surveyor observation on 1/4/2023 at approximately 1:20 PM the wash cycle gauge was not registering a wash temperature. During a surveyor interview with the Administrator and the [NAME] President of Operations on 1/4/2023 at approximately 1:30 PM they acknowledged that the wash cycle gauge was not registering a temperature and they indicated that they would contact the service representative for the dishwasher. 3. The Rhode Island Food Code 2018 Edition 2-402.11, states in part, Food Employees shall wear hair restraints such as hats, hair covering, beard restraints that covers body hair . During surveyor observations of Dietary Aide, Staff B, on 1/3/2023 at approximately 12:30 PM and 1/4/2023 at 1:25 PM and 3:30 PM revealed he was not wearing a beard restraint while delivering residents lunch meal trays and washing dishes. An additional surveyor observation on 1/5/2023 at 8:45 AM revealed Dietary Aide, Staff D without a beard restraint while on the breakfast serving line. 4) The Rhode Island Food Code 2018 Edition 3-501.19 Time as a Public Health Control reveals in part; .the food shall have an initial temperature of 5 degrees Celsius (41 degrees Fahrenheit) or less when removed from cold holding temperature control . During a surveyor observation on 1/4/2023 at approximately 12:20 PM revealed super pudding, a product made on premise with whole milk for resident meal consumption, had a serving temperature of 61 degrees Fahrenheit at the serving line. During a surveyor interview on 1/5/2023 at approximately 2:00 PM with the Food Service Director she acknowledged the serving temperature of the super pudding was not within the acceptable temperature parameter and the two dietary staff members were not wearing beard restraints.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that residents maintain acceptable parameters of nutritional status for 1 of 9 residents reviewed, Resident ID #53. Findings are as follows: Review of the resident's record revealed that s/he was admitted to the facility in April of 2022 with a diagnosis including, but not limited to, celiac disease (an immune reaction to eating gluten, a protein found in wheat, barley, and rye). Review of the weight documentation revealed that s/he weighed 132.4 pounds (lbs.) on 4/18/2022. Further review of the weights from August 2022 through January 2023 revealed the following: - 8/4/2022: 129.0 lbs - 9/2/2022: 122.2 lbs., loss of 6.8 lbs. in 1 month - 10/10/2022: 117.4 lbs, loss of 4.8 lbs. in approximately 1 month - 10/20/2022: 113.2 lbs., loss of 4.2 lbs. in 10 days - 11/4/2022: 111.2 lbs., loss of 3 lbs. in 11 days - 11/25/2022: 110.2 lbs. - 12/1/2022: 108.8 lbs. - 12/17/2022: 106.4 lbs. - 12/23/2022: 104.0 lbs. - 12/31/2022: 104.3 lbs., loss of 5.9 lbs. in approximately 1 month - 1/5/2023: 103.8 lbs. Review of a Dietitian note, dated 12/27/2022 at 5:47 PM, revealed that the resident continues to lose weight and an intervention of gluten free milkshakes was added to his/her meals the previous week. Review of the daily dietary meal ticket for this resident for all days of the survey, 1/3/2023 through 1/6/2023, revealed that s/he is to be provided two 4 fluid ounce lactaid milkshakes (8-ounce gluten free, lactose free milkshake) on his/her meal tray for all meals. Surveyor observations of the following meals failed to reveal evidence the that above mentioned gluten free milkshakes were provided to the resident: - 1/4/2023, approximately 9:00 AM at breakfast - 1/5/2023, approximately 1:00 PM at lunch - 1/6/2023, approximately 9:00 AM at breakfast During an additional surveyor observation of the resident's meal tray in the presence of Certified Nursing Assistant, Staff A, and subsequent interview on 1/6/2023 at 9:17 AM, it was revealed that she did not administer the gluten free milkshake to the resident and it was not provided on the resident's breakfast tray. During an interview with the Dietitian on 1/5/2023 at approximately 5:00 PM, and an additional interview on 1/6/2023 at approximately 9:30 AM, she indicated that goal for the resident is to gain weight and the weights are measured to see if the facility interventions are working. She could not provide evidence that the gluten free milkshakes were provided to the resident as indicated on the meal ticket on the above-mentioned dates and mealtimes.

Based on record review and staff interview it has been determined that the facility failed to have a tracking mechanism that identified each staff 's role, assigned work area, and how they interact with residents for individuals who provide care, treatment, or other services for the facility and/or its residents, under contract or by other arrangement. Findings are as follows: Review of the facility's COVID-19 document titled HOSPICE updated 1/6/2023, failed to reveal evidence of COVID-19 vaccination tracking documentation for the following individuals who provided care, treatment, or other services for the facility and/or its residents, under contract or by other arrangement, including, but not limited to the following individuals: 1. Hospice Nurse Practitioner, Staff E documented in the building on 10/11/2022 2. Hospice Music Therapist, Staff F documented in the building on 11/15/2022 3. Hospice Spiritual Counselor, Staff G documented in the building on 11/10/2022 4. Hospice Nursing Assistant, Staff H documented in the building on 11/18/2022 5. Palliative Provider, Staff I documented in the building on 10/26/2022 During an interview with the Director of Nursing Service on 1/6/2023 at approximately 2:00 PM, she was unable to provide a tracking document with the above-mentioned vendors listed.

Based on record review and staff interview, it has been determined that the facility failed to protect identifying information for 9 residents listed in the facility's survey results binder. Findings are as follows: Record review of the survey results binder, displayed on a counter, located in a common area of the facility, on 1/6/2023 at 12:28 PM, revealed one resident/staff roster listing for the previous annual survey, conducted in October of 2021. The 2021 survey with the attached roster contained information including but not limited to physician's orders and medical diagnoses. During a surveyor interview on 1/6/2023 at 12:30 PM, with the Director of Nursing Services, she was unable to provide evidence that the facility protected the identifying information of the 9 residents listed in the survey results binder.

Based on surveyor observations and staff interview, it has been determined that the facility failed to properly store, prepare, distribute, and serve food under sanitary conditions relative to the main kitchen and 1 of 3 units (2nd floor kitchenette). Findings are as follows: 1. Surveyor observation during the initial tour of the kitchen on 10/5/2021 at approximately 10:00 AM revealed two containers of strawberries with a moderate amount of white fuzzy matter. During a surveyor interview with the Food Service Director (FSD), at the time of the above observation, she acknowledged that the strawberries should have been discarded. 2. During a surveyor observation of the 2nd floor on 10/7/2021 at 10:13 AM, the following was found: - There was no air gap present between the ice machine drain and the floor drain to prevent backflow. - The mini freezer had a heavy accumulation of ice build up on the ceiling of the freezer and part of the first shelf. During a surveyor interview with the FSD on 10/7/2021 at 10:51 AM, she acknowledged that there was not an air gap on the ice machine to prevent backflow and there was ice buildup in the freezer.

Based on surveyor observation, record review and staff interview, it has been determined that the facility failed to ensure that services provided by the facility meet professional standards of quality relative to PICC (peripherally inserted central catheter) line measurements for 1 of 1 sample resident reviewed with a PICC line, Resident ID #135. Findings are as follows: Review of the facility policy titled, Central Venous Catheter Dressing Changes under Procedure to remove old dressing states in part, .While stabilizing the catheter, measure the external catheter from insertion site to the tip. Record review revealed the resident was admitted to the facility in September of 2021. The resident's medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the hospital Continuity of Care (COC) form, dated 9/28/2021, revealed that on 9/24/2021 a single lumen Power PICC was placed in the resident's left basilic vein. Further review of the COC revealed the following measurements obtained at the hospital on 9/24/2021, after the PICC line placement: -line length (entire line length) 46 centimeters (cm) -circumference above insertion 37 cm -circumference below insertion 28 cm -initial (external) exposed catheter 1 cm Record review revealed a physician's order dated 9/28/2021 and 10/5/2021 to .1) Measure upper arm circumference 10 cm above antecubital upon admission and with each dressing change. 2) Measure external catheter length upon admission and with each dressing change. Review of the September Nurse's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The external catheter measurement of 46 cm did not match the measurement of 1 cm, which was documented on the COC form. Review of the October 2021 Nurse's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . These measurements did not match the previous measurements obtained on 9/28/2021 or the measurements documented on the COC form. Additional record review failed to reveal evidence that the physician was notified of the discrepancy in the measurements on 9/28/2021 and 10/5/2021. Further, the record failed to reveal that the external catheter was measured again between 9/29/2021 and 10/4/2021, after the discrepancy was identified by the facility. During a surveyor interview on 10/8/2021 at approximately 10:00 AM with Staff Nurse A, she revealed that she was the nurse that obtained the PICC line measurements on 10/5/2021. She indicated that she did not compare her measurements with the previous measurements obtained on 9/28/2021. During a subsequent observation of Staff Nurse A, demonstrating how she obtains the PICC line measurements, it was observed that Staff Nurse A measured the arm circumference at the insertion site which measured 33 cm and the external catheter was now measured as 10.5 cm. During a surveyor interview on 10/8/2021 at approximately 11:30 AM with the Director of Nursing Services, she acknowledged that there was a discrepancy in the PICC line measurements, further stating that the nurse that documented the measurements on 9/28/2021 made an error when documenting the measurements. Additionally, she was unable to provide evidence that the external catheter measurements were retaken after the error in documentation was made on 9/28/2021 and that the physician was notified of these discrepancies.

Based on record review and staff interview, it has been determined that the facility failed to ensure residents were seen by a physician at least once every 30 days for the first 90 days after admission for 1 of 4 residents who were admitted to the facility within the last 90 days, Resident ID #16. Findings are as follows: Record review revealed the resident was admitted to the facility in July of 2021. Record review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review failed to reveal evidence that the attending physician had visited and examined the resident face-to-face in August and September of 2021. During a surveyor interview on 10/7/2021 at 10:10 AM with Staff Nurse A, she was unable to provide evidence that the resident was visited and examined face-to-face by the attending physician in August and September of 2021.

Based on surveyor observation, record review, staff and resident interview, it has been determined that the facility failed to identify a Greivance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions and to implement a system to ensure that residents continue to be aware of the grievance process for 8 of 8 residents reviewed during the Resident Council meeting, Resident ID #'s 4, 13, 43, 47, 51, 69, 135, and 138. Findings are as follows: During the Resident Council meeting on 10/7/2021 at approximately 1:30 PM, all of the above stated residents revealed that they were unaware of how to file a grievance. Additionally, they were not aware of who the Grievance Officer was within the facility and they revealed that no staff have reviewed instructions on how to file a grievance verbally with them. Review of the facility's Admission Information packet dated June of 2018 in the section titled Resident Rights revealed in part, At Briarcliffe Manor, resident has the [right]: .How to file grievances . Further review of the packet in a section titled Grievances revealed in part, Patients shall be encouraged and assisted to voice their grievances through a documented grievance mechanism established by the facility . Review of the facility's Grievance Policy dated June of 2018 revealed in part, .The facility's Grievance Officer is [name redacted] Vice President of Operations [VPO]. He is responsible for overseeing the grievance process including: Receiving and tracking grievance to conclusion .Resident will be notified individually or through postings in prominent locations throughout the facility of the following: .The contact information of the grievance officer (mail, email & phone) . During a surveyor interview on 10/8/2021 at approximately 9:05 AM with the Activities Director who assists with the Resident Council, she revealed that she has never discussed how to file a grievance with the residents and was unaware of who the Grievance Officer was within the facility. During a surveyor interview on 10/8/2021 at approximately 10:55 AM with the VPO, while observing the facility's first floor resident bulletin board, he acknowledged that the instructions on how to file a grievance were not posted and he indicated that he was unaware of how grievances are handled and who the Grievance Officer was within the facility. During a subsequent interview on 10/8/2021 at approximately 11:05 AM with the VPO, he provided a copy of the facility's grievance policy and indicated that he was the Grievance Officer for the facility. The VPO failed to provide evidence of a facility grievance log or a tracking system.

Based on record review and staff interview, it has been determined that the facility failed to ensure the medical care of each resident is supervised by a physician for 1 of 5 sampled resident (ID #1) relative to diabetic monitoring. Findings are as follows: Closed record review for Resident ID #1 revealed a [DIAGNOSES REDACTED]. Record review revealed a drug regimen review dated 8/22/2019 with the pharmacist recommendation to monitor an A1C (bloodwork that tests your average blood glucose levels over the past 3 months) on the next convenient lab day and every 6 months if meeting treatment goals, or every 3 months if therapy has changed or goals are not being met. An A1C level was obtained on 8/26/2019 with results of 5.6 (less than 5.7 decreased risk for diabetes and greater than 6.4 is consistent with diabetes, according to the results range from the laboratory used by the facility). There was no evidence of a subsequent order for an A1C level. Record review revealed a drug regimen review dated 9/26/2019 with the pharmacist recommendation to discontinue Glimepiride (medication that manages blood sugar levels), if appropriate. Glucose monitoring should continue following any change in diabetic therapy. A telephone order dated 9/26/2019 was given to D/C (discontinue) glimepiride 2 mg daily, obtain blood sugar via fingerstick twice daily x 7 days, (1 week), to start 9/27/2019, and then D/C. Record review revealed blood sugars via fingerstick were obtained from 9/27/2019-10/3/2019 with results ranging from 68-223mg/dl (normal range for blood glucose levels according to the laboratory used by the facility is 70-99 mg/dl). There was no evidence that the resident's blood sugar results were reviewed by the physician. Further review of the resident's medical record revealed [REDACTED]. The result of the blood sugar reading was documented as Hi. The on-call provider was contacted by the nurse regarding the resident's assessment and subsequent orders were given to send the resident to the Emergency Department for an evaluation. During a surveyor interview on 12/26/2019 at approximately 2:00 PM with the supervising registered nurse, Staff C, who documented the blood sugar reading as Hi on 12/22/2019, she revealed that a blood sugar result of Hi indicates a fingerstick of greater than 600 mg/dl. In review of the resident's hospital medical record, the resident presented to the emergency department with a glucose level of 686 and the resident was placed on an insulin sliding scale. Additionally, an A1C level was obtained at the hospital on [DATE] with results of 11.4. During a surveyor interview on 12/27/2019 at approximately 1:00 PM with the resident's primary care physician, he revealed that he would expect a fingerstick to be done at least weekly and could not explain why the order for blood sugar monitoring was discontinued.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that each resident's medication regimen is free of medication error rates of 5% or greater. Based on 30 opportunities for error, there were two errors involving two residents (ID #s 77 and 58) resulting in an error rate of 6.67%. Findings are as follows: 1. Record review revealed Resident ID #77 has a physician's orders [REDACTED]. Instructions on the card from the pharmacy indicate not to crush the medication. During the medication administration task on 12/19/2019 at 8:41 AM, Medication Technician, Staff A, was observed preparing Resident ID #77's medications, including the [MEDICATION NAME] ER, which she crushed and put into applesauce. The surveyor intervened prior to the administration of the medication when Staff A revealed that she was ready to administer the medication. During a surveyor interview with Staff A on 12/19/2019 at 8:48 AM, she acknowledged that she crushed the [MEDICATION NAME] ER and that the pharmacy instruction states that the medication should not be crushed. 2. Record review revealed Resident ID #58 has a physician's orders [REDACTED]. Instructions on the card from the pharmacy indicate not to crush the medication. During the medication administration task on 12/19/2019 at 9:08 AM, Medication Technician, Staff B, was observed preparing Resident ID #58's medications, including the [MEDICATION NAME] ER, which she crushed and put into applesauce. The surveyor intervened prior to the administration of the medication when Staff B revealed that she was ready to administer the medication. During a surveyor interview with Staff B on 12/19/2019 at 9:13 AM, she acknowledged that she crushed the [MEDICATION NAME] ER and that the pharmacy instruction states that the medication should not be crushed. On 12/19/2019 at 10:22 AM, the Director of Nursing Services was notified of the medication errors and revealed to the surveyor that she would expect that the Medication Technicians would not crush the [MEDICATION NAME] ER.

Based on surveyor observation, record review and staff interviews, the facility failed to meet professional standard of quality for 1 out of 5 residents observed during the medication pass (ID# 93). According to Basic Nursing, Mosby, 3rd, the registered nurse checks all transcribed orders against the original order for accuracy and thoroughness. If an order seems incorrect or inappropriate, the nurse consults the physician . Findings are as followed: Surveyor observation on 2/21/18 at approximately 8:15 AM, during the medication pass on Unit 2, revealed an order on the February 2018 Medication Administration Record [REDACTED]. The Medication Aide (MA) was then observed administering a [MEDICATION NAME] 100 mg extended release capsule and a 50 mg chewable tablet to ID# 93. During surveyor interview on 2/22/18 at 12:05 PM, the resident's physician revealed he was aware that [MEDICATION NAME] 150 mg did not come in an extended release form. The physician acknowledged that his expectation would be to have the order clarified with him and re-written to reflect the dosage/form of the medication on hand.

Based on surveyor observation, record review and staff interviews, the pharmacy failed to report any irregularities to the attending physician, the facility's medical director, and the director of nursing for 1 non- sample resident observed during the medication pass (ID# 93). Findings are as follows: Record review of resident ID# 93's February 2018 MAR indicated [REDACTED]. Surveyor observation on 2/21/18 at approximately 8:15 AM, during the medication pass on Unit 2, revealed an order on the February 2018 Medication Administration Record [REDACTED]. The Medication Aide (MA) was then observed administering a [MEDICATION NAME] 100 mg extended release capsule and a 50 mg chewable tablet to ID# 93. Surveyor record review of the pharmacy reports with the Registered Pharmacist (RPH) on 2/22/2018 at approximately 9:55 AM revealed that the pharmacy had failed to document the irregularity on a separate written report that is sent to the resident's physician, medical director and director of nursing. The report includes at a minimum the resident's name, drug and the irregularity identified by the pharmacist. In addition, the pharmacist stated the computer software system in place between the pharmacy and the facility did not highlight this irregularity and indicated this was a pharmacy system breakdown. You are hereby formally notified that where the above listed deficiencies also constitute non-compliance with applicable provisions of the 'Rules and Regulations for Licensing of Nursing Facilities' they are deficiencies under State Regulations and grounds for licensure sanctions.

Based on surveyor observations and staff interviews, it was determined the facility has failed to provide housekeeping and maintenance services necessary to maintain an orderly and comfortable interior for 3 of 3 residential nursing units. Findings are as follows: 1. First Floor Nursing Unit a. The main dining room left entry door has extensive marring on the lower third. b. The boiler room door, across from the main dining/activity room, has extensive marring on the lower two-thirds. c. The elevator adjacent to the nursing station has heavily worn wooden flooring and an approximate 3'' x 2'' area of missing formica on the lower third of the door. 2. Second Floor Nursing Unit a. The wooden counter top at the nursing station is heavily worn in an approximate 12' x 1.5' area. b. Linoleum flooring at two areas adjacent to the nursing station, an area between room 32 and the common shower room, and an area between rooms 37 and 39, all approximately 8 feet x 1-2 inches, were heavily worn and cracked. c. Linoleum flooring in front of room 28, in an approximate area of 3 feet x 1-2 inches, were heavily worn and cracked. d. The door to room 32 has excessive marring on the lower third. e. The air conditioning unit in room 28 is heavily marred and stained. f. The baseboard heating covers /vents in rooms 19, 28, 34, 35 and 41 were heavily marred and the paint was peeling. g. There was an area of rust around the drain of the sink in room 28. h. The flooring at the entrance to room # 23 has a worn surface in an approximate 3.5' x 8 area. 3. Third Floor Nursing Unit a. The entry door and adjacent door frame to the restorative dining/activity room has excessive marring on the lower third. b. The biohazard room door has a 3' x 3 area of marring on the lower third. c. Doors to the med room, kitchenette and record rooms had extensive marring on the lower third. You are hereby formally notified that where the above listed deficiencies also constitute non-compliance with applicable provisions of the 'Rules and Regulations for Licensing of Nursing Facilities' they are deficiencies under State Regulations and grounds for licensure sanctions.