Every finding on record at Ditmas Park Care Center

Based on record review and staff interviews during a survey, the facility failed to ensure a comprehensive person-centered care plan develop and implemented to address the residents' medical, physical, mental, and psychosocial needs. This was evident for one out of four residents (Resident #1) sampled. Specifically, a comprehensive care plan was not developed with interventions for use of diuretic medication and Resident #1's diagnoses. The findings are:The facility Policy and Procedure titled Care Plan Policy with a review date of October 1,2025 documented It is the policy of Ditmas children's Nursing and Rehab that a Comprehensive Care Plan will be completed for each new resident in the facility , the Comprehensive Care Plan will reflect the resident's current status and must include the resident's goals and interventions that addresses the resident current needs. All care plans must require measurable and realistic objectives and timetables to meet each identified problem needs. Interdisciplinary Comprehensive Care Plan meeting will be held within 21 days of the admission date. Care planning meeting will be done quarterly, annually and whenever there is change in the resident status that requires an update in the care plan.Resident #1 was a 7-month-old infant born prematurely at 27 weeks, was admitted to the facility on [DATE] with diagnoses including Pulmonary Hypertension (blood vessels in the lungs fail to dilate after birth) of Newborn, Newborn affected by Premature Rupture of Membranes (fetal membranes rupture before the onset of labor of contractions), feeding difficulties, Interstitial Pulmonary Disease (progressive inflammation and scarring in the tissue between the air sacs of the lungs), and Congenital Hypotonia (abnormally low muscle tone that is present at birth).Review of the Physician's order dated 05/04/2026 through 06/04/2026 documented Hydrochlorothiazide (diuretic) oral suspension 10 milligrams /milliliter -give 7 milligrams every 12 hours for diuresis.There was no documented evidence that a care plan for the use of diuretics was developed with interventions. The care plan was developed post medication incident.There was no documented evidence that a care plan for above diagnoses was initiated with interventions.During an interview with Registered Nurse Unit Manager #1 on 06/10/2026 at 3:25 PM, they stated it is the responsibility of the Registered Unit Manager to initiate, revise and update care plans. Registered Nurse Unit Manager #1 stated a care plan should have been initiated for Hydrochlorothiazide medication when the medication was ordered. During a telephone interview with the Assistant Director of Nursing on 07/14/2026 at 2:33 PM, they stated nursing administration and nursing unit managers can initiate care plans. The Assistant Director of Nursing stated that care plans for residents' diagnoses are not immediately initiated on admission, but is done after a family care plan meeting, usually a week after admission. The Assistant Director of Nursing stated that a care plan for the Hydrochlorothiazide was initiated on 06/04/2026. 10 New York Code, Rules and Regulations 415.11(c)(1).

Based on record reviews and staff interviews, during a survey the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice, and comprehensive person-centered care plan. This was evident for one out of four residents (Resident #1) sampled. Specifically, Resident # 1 was given 14 milligrams of Hydrochlorothiazide (diuretic) at once at 10:00 AM on 06/04/2026, instead of 7 milligrams. Registered Nurse #1 did not follow the physician's order for Hydrochlorothiazide 7 milligrams every 12 hours. The findings are:The facility policy and procedure titled 'Medication Administration and Safety in Pediatrics' last revised on 05/15,2026 states that risk in medication administration were due to unique pharmacokinetics, age and development that cause difference in drug absorption, metabolism, and elimination. The unique pediatric considerations are potential for medication errors caused by lack of process for ordering, reconciliation, communications and administration. Medication errors are preventable adverse events and Ditmas Children's nursing and rehab process for medication administration and safety that are evidenced based, safe culturally - competent and quality.Section C of the policy states on administration: Registered Nurse must calculate the dosage based on the weight of the patient prior to administration. Registered Nurse must follow the eight Rs of medication administration which includes, right medication, right dosage and right patient amongst others. On monitoring, all staff must follow the process of reporting and documenting medication adverse events that include medication errors, near misses' drug reactions, and other medications related adverse events. Resident #1, a 7-month-old infant born prematurely at 27 weeks, was admitted to the facility on [DATE] with diagnoses including Pulmonary Hypertension (blood vessels in the lungs fail to dilate after birth) of Newborn, Newborn affected by Premature Rupture of Membranes (fetal membranes rupture before the onset of labor of contractions), feeding difficulties, Interstitial Pulmonary Disease (progressive inflammation and scarring in the tissue between the air sacs of the lungs), and Congenital Hypotonia (abnormally low muscle tone that is present at birth). A Physician's Order dated 05/04/2026 through 06/04/2026 documented Hydrochlorothiazide oral suspension 10 milligrams/milliliter give 7 milligrams every 12 hours for diuretic.A review of the Medication Administration Record dated 05/2026 through 06/2026, revealed Hydrochlorothiazide scheduled to be administered at 11:00 AM and 11:00 PM.A Physician's note by Attending Physician #1 dated 06/04/2026 documented at approximately 10:00 AM they were notified by Registered Nurse #2 that a second dose of Hydrochlorothiazide was accidentally administered to Resident #1. Resident #1's Parent was at their bedside and was notified. The Hydrochlorothiazide scheduled to be given at 11:00 PM was put on hold. Medications to resume tomorrow (06/05/2026). Resident #1 was assessed and remained at baseline. A review of the facility summary of investigation done on 06/04/2026 concluded the following: The incident was promptly identified, immediately addressed and appropriately managed with physician notification. Assessment and monitoring of Resident #1 are ongoing. No adverse outcomes were observed. The investigation also determined that the error was primarily related to workflow disruptions and failure to complete a final Electronic Medical Administration Record verification before medication administration. No system -wide deficiencies in pharmacy dispensing or physician ordering were identified. Immediate corrective actions were implemented, including staff removal from assignment, re- education and suspension pending review. During this investigation, there was no evidence to support abuse, neglect, mistreatment or misappropriation.During a telephone interview on 06/12/2026 at 2:00 PM and 6:00 PM, Registered Nurse #2 stated they went back to Resident #1's room and gave them medications that include Hydrochlorothiazide 7 milligrams at 10:45 AM on 06/04/2026. They stated they returned to Resident #1's room at 11:00 AM and gave them two medications, including Hydrochlorothiazide 7 milligrams. They stated after Resident #1's Parent asked why they gave the resident a second dose of Hydrochlorothiazide, they checked and realized they had given a second dosage of Hydrochlorothiazide to Resident #1. They stated they immediately notified Attending Physician #1 who told them the 14 milligrams could be given at once or in divided dosages. They stated the physician's order is for Hydrochlorothiazide 7 milligrams every 12 hours (11:00 AM and 11:00 PM) so the 11:00 PM dosage was put on hold. They stated they were distracted. During an interview with Attending Physician # 1 on 06/10/2026 at 3:00 PM, they stated that the Hydrochlorothiazide could be given in one dose or divided doses, however, they ordered to hold the 11:00PM dose. They stated they went to Resident #1's room and explained and reassured the resident's Parent. They stated they examined and evaluated Resident #1 and the resident remained at baseline with no changes in regular urine output.During an interview with the Assistant Director of Nursing on 06/10/2026 at 3:15 PM, they stated as soon as they were informed of the medication error, Attending Physician #1 assessed the resident with orders to continue monitoring and to hold the 11:00PM dose. They stated they immediately removed Registered Nurse from the unit and initiated an investigation. 10 New York Codes, Rules, and Regulations 415.12

Based on observation, record review and staff interviews during a survey, the facility failed to ensure the physician write, sign, and date a telephone order. This was evident for one out of four residents (Resident #1). Specifically, Resident #1 was administered Tylenol suppository 240 milligrams rectally on 05/15/2026 at 9:30 PM. Resident #1 was transferred to the emergency room on [DATE] to be evaluated for Tylenol toxicity. Resident #1 returned to facility same day with no interventions recommended. Attending Physician #1 did not write, sign, or date the telephone order received by Registered Nurse #1 on 05/15/2026. The findings are: A facility policy titled 'Physician Telephone Orders and verbal Orders' dated 01/01/2026 states to ensure that physician telephone orders and verbal orders are obtained, transcribed, verified, implemented, and authenticated accurately and promptly to promote resident safety, continuity or care and regulatory compliance. All physician telephone and verbal orders shall be documented, read back for verification, and authenticated by the ordering practitioner in accordance with federal, state, and facility requirements. Subtopic: Receiving a Physician Telephone Order states - verify the identity of practitioner: full name, professional credentials, and callback verification if necessary. Secondly, verify the resident name, date of birth and/or medical record number. Read-Back Physician Telephone Orders, the nurse shall write down the order, document the order exactly as communicated before implementation. The nurse should clearly repeat the entire order back to the practitioner, including medication name, dose, and route. Subtopic: Transcribing and Implementing Orders states - after varication, the physician and nurse practitioner will enter the order into the Electronic Health Record within 24 hours. Resident #1 was a 7-month-old infant born prematurely at 27 weeks, was admitted to the facility on [DATE] with diagnoses including Pulmonary Hypertension (blood vessels in the lungs fail to dilate after birth) of Newborn, Newborn affected by Premature Rupture of Membranes (fetal membranes rupture before the onset of labor of contractions), feeding difficulties, Interstitial Pulmonary Disease (progressive inflammation and scarring in the tissue between the air sacs of the lungs), and Congenital Hypotonia (abnormally low muscle tone that is present at birth). A nursing note dated 05/15/2026, by Registered Nurse #1, who took the telephone order for Tylenol suppository, documented that at around 8:30 PM, Resident #1's parent requested Tylenol (for Resident #1) for irritation. Attending Physician #1 was called, and they gave a telephone order for Tylenol suppository 240 milligrams that was given at 9:30 PM (on 05/15/2026). At around 7:00 AM (05/16/2026), Resident #1's parent reported Resident #1 had a large emesis (vomiting) and feed was paused. There was no documented evidence that Attending Physician #1 wrote, sign, or date a telephone order for Tylenol suppositories 240 milligrams that was administered to Resident #1 on 05/15/2026. A Significant Event note dated 05/16/2026 at 9:00 AM, by Nurse Practitioner #1 documented that they were notified by Registered Nurse #1 that Resident #1 received 240 milligrams Tylenol suppository rectally at around 9:30 PM (on 05/15/2026). Resident #1's parent reported Resident #1 had multiple small episodes of emesis overnight with noted irritability. This morning, Registered Nurse #1 reported one large emesis at around 7:00 AM. Resident appeared sleepier than usual. Also documented, 240 milligrams suppository exceeds Tylenol loading dose for age and weight. Poison Control called and urged Resident #1 to be transferred to the nearest Emergency Room. They examined Resident #1 who was lethargic but arousable. Vital Signs are stable and within normal limits. Lung sounds clear bilaterally with good air entry. No adventitious breath sounds noted. Peripheral pulses are palpable and strong. Abdomen soft, flat, and non-distended. Non tender to touch. Skin color consistent with Ethnic background. Review of the Hospital Discharge summary dated [DATE] documented assessment revealed no abnormal findings. According to Emergency Department Doctor, they spoke with Poison Control Doctor who stated low concern for acute Tylenol toxicity given the amount and route administered. Resident #1 at baseline.oxicity given the amount and route administered. Resident #1 at baseline. During an interview on 06/09/2026 at 1:00 PM, Nurse Practitioner #1 stated that the incident (Resident #1 received the Tylenol) occurred on 05/15/2026 at 9:30 PM. They stated they went to the unit on Saturday (05/16/2026) at 8:00 AM and Registered Nurse #1 who worked on the night shift, reported that Resident #1 had a big vomiting at 7:00 AM and multiple small emesis. They stated they were also notified that Resident #1 was given Tylenol 240 milligrams rectally. They stated that they assessed Resident #1, and the resident was at their baseline and had no changes in vital signs. They stated Resident #1 was calm and was swinging in their chair and had no vomiting or short breath. They stated they called Poison Control (about Tylenol 240 milligrams), and they were instructed to transfer Resident #1 to the hospital for evaluation. They stated Resident #1 was transferred to the hospital on [DATE] and return to the facility same day with no interventions and no blood work done. They stated they called back Poison Control and were told the Tylenol live span in the body is 8 hours and there was no need for blood work. During an interview on 06/08/2026 at 12:05 PM, Attending Physician #1 stated Registered Nurse #1 called them on the telephone about Resident #1 being irritable. They stated they gave a telephone order to give Tylenol suppositories, 240 milligrams rectally Stat (immediately or without delay). They stated when they gave the Stat order to Registered Nurse #1, they were thinking about another resident whose dosage is 240 milligrams. They stated Nurse Practitioner #1 notified them on Saturday (05/16/2026) that Resident #1 received double dosage and should have received 120 milligrams. Physician #1 stated they do not recall Registered Nurse #1 reading back the dosage to them. They stated they were also notified that Poison Control suggested Resident #1 be transferred to the Emergency room. They stated Resident #1 was initially admitted to the facility from the hospital due to spitting up and feeding issue. They stated they did not have access to a computer, so they did not enter or sign the telephone order (Tylenol suppository 240 milligrams Stat). During an interview on 06/10/2026 at 11:34 AM, the Chief Medical Officer stated they were notified (unsure of date/time) of the incident, and they met and conducted a peer review with the Pharmacy, Assistant Director of Nursing and Attending Physician #1. The Policy and Procedure for Telephone Orders was reviewed and revised to add two patient identifiers. Staff will read back the order, and the Physician and Nurse Practitioner will sign the order within 24 to 48 hours. They stated that all nursing staff, physicians, and nurse practitioners received in-service on the revised policy. They stated Root Cause Analysis was initiated, audit tool developed, and audits were initiated. They stated Resident #1 was admitted to the facility because of spitting up and not being able to keep their feeding down. They stated Resident #1's spitting up and vomiting was not associated with possible Tylenol overdose. They stated that Tylenol life span in the body only last for 8 hours. They stated that Tylenol 240 milligrams dosage did not reach a level to be considered toxic level and that Poison Control did not recommend the need for blood works. During a telephone interview on 06/10/2026 at 12:55 PM, Registered Nurse #1 stated that Resident #1's Parent came to the nursing station requesting for Tylenol because Resident #1 was irritable after receiving a vaccine. They stated they called Attending Physician #1 who gave them an order for Tylenol suppository 240 milligrams and they observed Resident #1's parent administered the suppository then left the room at 9:30 PM. They stated they monitored Resident #1 throughout the night and did not observe any vomiting or spitting up. They stated they monitored Resident #1's vital signs, oxygen saturation and heart rate throughout the night and they were good, and Resident #1 was at their baseline. They stated during the morning (05/16/2026) at around 7:00 AM, Resident #1's parent reported that the resident had a little vomiting with the feeding and that it was a little more than they normally spit up. Registered Nurse #1 stated they did not witness any vomitus. During a follow -up interview on 06/11/2026 at 1:20 PM, Resident #1's Parent stated that Resident #1 was vaccinated the day before (05/14/2026) and was fussy and sleepy after the vaccination. They stated after Tylenol was administered (on 05/15/2026) Resident #1 remained fussy and sleepy and vomited a few times during the night. Resident #1's Parent stated they did not call the nurse and none of the staff witnessed the vomiting. They stated they cleaned up the vomitus themself. 10 New York Codes, Rules, and Regulations 415.15(b)(2)(iii)

Based on observation, record review, and interview conducted during the Recertification Survey from [DATE] to [DATE], the facility did not ensure that food was stored, prepared, and distributed in accordance with professional standards for food service safety. Specifically, 1.) Staff was observed handling resident's food with bare hands. This was evident in 1 (6th Floor) of 6 units during dining observation. 2.) The kitchen walk-in refrigerator contained expired and undated food items. The findings are: 1.) The facility policy titled Resident Dining with a revision date of [DATE] documented that employees may not use bare hand contact with any foods, ready to eat or otherwise. Staff must utilize disposable, single use gloves, when directly touching ready to eat food items and should discard gloves after each use. During dining observation conducted on [DATE] from 12:30 PM to 12:45 PM, Certified Nursing Assistant #2 was observed assisting Resident #503 with meals. Certified Nursing Assistant #2 opened the sliced bread from the plastic wrapper, opened the margarine, held the bread with their bare hands, buttered the bread with a knife and placed it on the Resident's lunch tray. During an interview on [DATE] at 12:45 PM, Certified Nursing Assistant #2 stated they were aware that they held the bread with their bare hands. They stated they received an in-service that they should not be touching residents' food with bare hands. During an interview on [DATE] at 2:55 PM, the Licensed Practical Nurse #1 stated staff must wear gloves when handling residents' food. During an interview on [DATE] at 2:56 PM, Registered Nurse #3 stated their policy states staff should never touch residents' food with their bare hands. During an interview on [DATE] at 4:34 PM, the Infection Preventionist stated staff must wash their hands or perform hand hygiene before assisting residents with their meals. The Infection Preventionist stated if staff are sure that their hands were clean, then they can touch the resident's food and hold the bread with their bare hands. 48876 2.) The facility policy titled Food Storage and Labeling with a revised date of [DATE] documented all food stored in the refrigerator will be checked to ascertain that they are stored in a manner that assures that they are appropriate for use and free from potential cross contamination. All items not in the original container must be labeled. Ready-to-Eat food must be marked if held for longer than 24 hours. All food in the refrigerator and freezer should be covered, labeled, and dated. Ready-to-Eat temperature controlled for safety food can be stored for up to 5 days if held at internal temperature of 41 degrees Fahrenheit or lower. Casseroles or chicken salad should not be kept for longer than 48 hours. Any food that appears expired or unsafe will be discarded even if the expiration date has not passed. On [DATE] at 9:20 AM, the kitchen walk-in refrigerator was observed with the Food Service Director. The walk-in refrigerator contained: (3) 8 ounce cups of tuna dated [DATE], (7) 8 ounce tuna cups dated [DATE], 1 aluminum pan containing cream of rice puree dated [DATE], 1 aluminum pan containing 4 potato knishes dated [DATE], (2) 6 ounce fruit cups dated [DATE], 1 undated plastic bowl of egg salad, and 1 undated plastic bowl of tuna salad. On [DATE] at 9:30 AM, an interview was conducted with the Food Service Director who stated that the cups of tuna should have been discarded on [DATE] since 3 days had passed from the preparation date. The cream of rice puree should have been discarded on [DATE] and the potato knishes should have been discarded 3 days from the labeled date. On [DATE] at 3:28 PM, a subsequent interview with the Food Service Director was conducted. They stated that the tuna and fruit cups must have been mislabeled by the dietary aide who prepared the food. The potato knishes were missed since the tray was all the way in the back of the refrigerator. The Food Service Director stated that the bowls of tuna and egg salad should have been dated. The Food Service Director stated that the food service aides, the Supervisor, and the Director checks the refrigerator daily for expired food to be discarded, but these items were missed. 10 NYCRR 415.14(h)

Based on observation, record review, and interviews conducted during the Recertification Survey from 08/21/2024 to 08/28/2024, the facility did not ensure that infection control prevention practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. This was evident in 1 (Resident #90) of 2 residents reviewed for Pressure Ulcer / Injury. Specifically, Enhanced Barrier Precautions were not maintained during wound care. The findings are: The Centers for Medicare and Medicaid Services, Center for Clinical Standards and Quality/Quality, Safety & Oversight Group memorandum titled Enhanced Barrier Precautions in Nursing Homes, Ref: QSO-24-08-NH dated 03/20/2024 documented that effective 04/01/2024, Centers for Medicare and Medicaid Services is issuing a new guidance for long term care facilities on the use of enhanced barrier precautions to align with nationally accepted standards. Enhanced Barrier Precautions recommendations now include use of enhanced barrier precautions for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multidrug-resistant organism status. The new guidance related to enhanced barrier precautions is being incorporated into F880 Infection prevention and Control. The facility policy and procedure titled Infection Control - Enhanced Barrier Precautions dated 04/02/2024 documented that the Facility will implement enhanced barrier precautions to include any resident with chronic wounds regardless of Multi Drug Resistant Organism colonization or infection status. The facility will use an orange sticker identifier to alert staff when Enhanced Barrier Precaution use is necessary. Staff will perform hand hygiene and before entering a resident's room, don gown and gloves when providing high contact care activities. Resident #90 was admitted to the facility with diagnoses that include Cerebral Palsy and Metabolic Encephalopathy. The Minimum Data Set assessment dated [DATE] documented that Resident #90 had moderately impaired cognitive skills for daily decision making and had unhealed Stage 4 sacral pressure ulcer. A physician's order dated 05/02/2024 documented enhanced barrier precautions secondary to wounds. A Physician Treatment Order dated 07/25/2024 documented to apply Calcium Alginate Silver Pad to right hip topically in the morning for wound care after cleansing with normal saline and to cover with silicone foam dressing. During wound treatment observation on 08/23/2024 at 10:44 AM, Licensed Practical Nurse #2 was observed performing wound care for Resident #90 with gloves but without wearing a gown. There was no signage posted that Resident #90 was to be maintained on Enhanced Barrier Precautions. On 08/23/2024 at 11:00AM, Licensed Practical Nurse #2 was interviewed and stated that at the time of the dressing change they did not know that Enhanced Barrier Precautions were needed as the signage was removed from the door by the Assistant Director of Nursing/Educator. On 08/23/2024 at 12:29 PM, The Assistant Director of Nursing/Educator was interviewed and stated that Licensed Practical Nurse #2 should have followed Enhanced Barrier Precautions because Resident #90 had a wound and all residents with wounds require staff to wear a gown for all contact. The Assistant Director of Nursing/Educator stated they removed the Enhanced Barrier Precaution signage on Resident #90's door because they thought the wound was healed. On 08/26/2024 at 12:24 PM, the Infection Control Preventionist was interviewed and stated staff is required to wear isolation gowns and gloves for all residents with wounds or indwelling devices. On 08/26/2024 at 4:37 PM, The Director of Nursing was interviewed and stated staff is to wear gowns and gloves for all direct care contact with residents who have wounds and indwelling medical devices. 10 NYCRR 415.19 (a)(1-3)

Based on observations, record review and interviews conducted during the Recertification survey, the facility did not ensure infection control practices were maintained. This was evident for 1 of 5 units (4th floor), 1 of 3 residents reviewed for Respiratory Care (Resident #179), and 1 of 4 residents reviewed for Infections (Resident #496) out of a sample of 38 residents. Specifically, 1) a Registered Nurse (RN) was observed wearing a surgical mask improperly; 2) there were multiple observations of Resident #179's oxygen tubing on the floor; and 3) Resident #496 was not placed on contact/droplet precautions (CDP) following exposure and positive test for COVID-19. The findings are: The facility policy titled Personal Protective Equipment (PPE) Donning and Doffing revised [DATE] documented all staff will use a surgical mask in all patient care areas and all non-clinical areas. The facility policy titled Oxygen Administration revised [DATE] documented oxygen tubing observed touching the floor must be discarded immediately and resident will be provided with a new one. The facility policy titled COVID-19 Protocol: Exposed Residents revised [DATE] documented the unvaccinated and partially vaccinated residents who had close contact with a COVID-19 positive staff member should be place on CDP for 14 days from date of last exposure. 1) On [DATE] from 12:06 PM to 3:45 PM, [DATE] from 10:03 to 12:12 PM, [DATE] from 10:38 AM to 2:58 PM, and [DATE] from 09:30 AM to 10:18 AM, RN #3 was observed at the nursing station on the 4th floor resident unit with a surgical mask worn below their chin exposing their nose and mouth. On [DATE] at 10:53 AM, RN #3 was interviewed and stated they know the surgical mask should cover their nose and mouth to prevent the transmission of COVID-19. Wearing the mask makes it difficult for RN #3 to breath. On [DATE] at 01:15 PM, the Director of Nursing Services (DNS) was interviewed and stated everyone entering the facility must wear a mask to comply with infection control regulations and to protect residents and staff from transmission of respiratory infections, including COVID-19. The DNS and nursing supervisors make rounds on the resident units throughout the day to observe staff for infection control compliance. 2) Resident # 179 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident # 179 had moderate cognitive impairments, shortness of breath, and received oxygen treatment. On [DATE] at 10:33 AM and [DATE] at 09:32 AM, the oxygen tubing connecting the oxygen concentrator to the nasal canula (NC) in Resident #179's nose was observed touching the floor. physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #179 received continuous oxygen via NC at ,d+[DATE] liters per minute for shortness of breath. On [DATE] at 09:34 AM, Certified Nursing Assistant (CNA) # 1 observed Resident #179's oxygen tubing on the floor and stated Resident#179 received continuous oxygen and the oxygen tubing should not be touching the floor. When oxygen tubing is observed on the floor, CNA #1 notifies the nurse so the oxygen tubing can be changed. On [DATE] at 10:38 AM, RN # 1 was interviewed and stated the oxygen tubing for Resident #179 was long and should be attached to the head of the bed to promote infection control by preventing the oxygen tubing from touching the ground. Visual rounds are made every 1 to 2 hours on the unit to ensure compliance with resident care and infection control. On [DATE] at 09:14 AM, Infection Preventionist (IP) was interviewed and stated the CNAs are tasked with securing the oxygen tubing so that it does not touch the floor and the nurse must change the oxygen tubing if they observe it touching the floor. 3) Resident #496 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS assessment dated [DATE] documented Resident #496 was cognitively intact. The facility's written email communication with the NYSDOH on [DATE] documented a staff member tested positive for COVID-19 on [DATE] and all residents on the ventilator unit were placed on quarantine for 14 days due to COVID-19 exposure. Facility-wide testing was initiated. Therefore, all resident and staff working in the vent unit for possible exposure and the vent unit started quarantine for 14 days. It further documented that facility wide testing will be initiated. A polymerase chain reaction (PCR) lab test dated [DATE] documented Resident #496 was positive for COVID-19. Nursing Note (NN) dated [DATE] documented Resident #496 had labored breathing and was transferred to the hospital. NN dated [DATE] documented Resident expired in the hospital on [DATE]. There was no documented evidence Resident #496 was placed on Contact Droplet Precaution (CDP) following exposure to COVID-19 staff member and after a positive COVID-19. On [DATE] at 4:11 PM, Licensed Practice Nurse (LPN #1) was interviewed and stated Resident #496 was not monitored for COVID-19 symptoms because LPN #1 was unaware Resident #496 was exposed to a COVID-19 positive staff member and was unaware residents were being tested for COVID-19. On [DATE] at 9:38 AM, Infection Preventionist (IP) was interviewed and stated Resident #496 was identified as having close contact with a staff who tested positive COVID-19. Resident #496 had a negative PCR test result on [DATE] and a positive PCR test result on [DATE]. RN supervisors are responsible for placing exposed or COVID-19 positive residents on quarantine and CDP. The IP did not know the reason Resident #496 was not quarantined or placed on CDP. On [DATE] at 1:12 PM, Assistant Director of Nursing (ADON) was interviewed and stated residents exposed to COVID-19 are immediately placed on quarantine and CDP and monitored for symptoms for COVID-19. Resident #496 was exposed to a COVID-19 positive staff member and was not placed on quarantine or CDP. 415.19(a)

Based on record review, and interview during the Recertification survey, the facility did not ensure a baseline care plan (BCP) was developed within 48 hours of admission. This was evident for 1 of 38 residents reviewed (Resident #8). Specifically, a BCP was not completed for Resident #8 within 48 hours of admission to the facility. The findings are: The facility's policy titled Baseline Care Plan revised 4/6/2022 documented the baseline care plan will be developed within 48 hours of the resident's admission. Resident #8 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented resident was cognitively intact. The BCP dated 1/7/2022 documented Error and sections for social service, nursing, and rehabilitation contained no documentation. There was no documented evidence in Resident #8's medical record that a BCP was developed. On 5/3/2022 at 9:25 AM, Registered Nurse (RN #1) was interviewed and stated BCPs are initiated by the admitting nurse immediately upon a resident's admission to the facility. The interdisciplinary team (IDT) then fills out the BCP in the resident's medical record. RN #1 was unaware Resident #8's BCP was not developed. On 5/3/2022 at 11:54 AM, Social Worker (SW) #1 was interviewed and stated they complete the BCP for newly admitted residents within 48 hours. There were staffing issues at the time Resident #8 was admitted to the facility and this was the reason a BCP was not developed for Resident #8. 415.11(c)

Based on record review and staff interviews conducted during the Recertification survey, the facility did not ensure the comprehensive care plan was prepared by an interdisciplinary team that includes the resident and the resident's representative for 1 (Resident #137) of 38 sampled residents. Specifically, Resident #137's Comprehensive Care Plan (CCP) was created within 21 days after admission on 12/9/21, but there was no documented evidence Resident #137 was invited to a care plan meeting until after the care plan was complete. A care plan meeting was not held until 2/3/22. The findings are: The policy titled Interdisciplinary (IDT) CPM - Social Work (SW) revised 5/26/2020 documented the SW will inform and invite the resident to scheduled CPMs. Resident # 137 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident # 137 was cognitively intact and participated in the assessment. A Care Plan Meeting (CPM) Schedule dated 12/2021 documented Resident #137's admission CPM was scheduled for 12/22/2021. There was no documented evidence in the medical record that Resident #137 was invited to the CPM scheduled for 12/22/2021 or that the CPM was ever held. The CCP was created in 12/2021 without involvement of the resident. A Social Service - Multidisciplinary Care Conference note dated 2/3/2022 documented the admission CPM was held on 02/03/2022. The nurse, SW, rehab and Resident #137 attended the care plan meeting. On 04/29/22 at 11:41 AM, Registered Nurse (RN) # 1 was interviewed and stated residents were invited to attend all CPMs by the SW. Resident #137 was cognitively intact and made their own decisions. On 04/29/22 at 11:59 AM, Social Worker (SW) # 1 was interviewed and stated SWs were responsible for inviting residents to scheduled CPMs. After checking the medical record, SW #1 stated Resident #137's admission CCP meeting was held on 02/03/2022 and could not explain the reason the admission CPM was not held within 21 days of Resident #137's admission to the facility. On 04/29/22 at 02:01 PM, the Social Work Consultant (SWC) was interviewed and stated the facility experienced staffing shortages in 12/2021. The SWC stated this may be the reason the admission CPM was not held in 12/2021. 415.11(c)(2) (i-iii)

Based on observation, record review, and interviews conducted during the Recertification survey, the facility did not ensure that all medications and biologicals were stored in accordance with professional standards of practice. This was evident for 1 of 5 units (4th floor). Specifically, 1) a bag of prescribed medications was not stored in a locked compartment; and 2) an expired [MEDICATION(S)] of [MEDICATION(S)] was found in the emergency medication box. The findings are: The facility policy titled Non-Controlled Medication (Discontinued/Returned/Disposal) revised 01/27/2022 documented medication may be returned to the pharmacy in accordance with state and federal regulations. The facility policy titled Back Up Box/Stat Emergency Kit of Medications revised 01/27/2022 documented Emergency Kits were available at every nursing station. All Emergency Kits list the contents and their expiration dates. Items about to expire are returned to the pharmacy upon facility notification. 1) On 04/28/22 at 04:26 PM, a paper bag containing prescribed medication was observed on a shelf at the 4th floor nursing station. The medications were not observed to be in a locked compartment or storage area and there were no staff observed at the nursing station. The paper bag contained the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . On 04/29/22 at 11:35 AM, Registered Nurse (RN) #3 was interviewed and stated unused medications are sent back to the pharmacy. The evening shift of nurses were responsible for bringing the medication to the nursing office to await pharmacy pickup. Medications should not be left in an unsecured unlocked area. On 04/28/2022 at 5:10 PM, the RN Supervisor (RNS) was interviewed and stated they do rounds every evening to check for medications that should be returned to the pharmacy. The medications should not be in an unsecured unlocked area and should be brought to the nursing office immediately so they can be secured for pharmacy pickup. 2) On 04/29/2022 at 11:14 AM, the 4th floor medication room was observed to have an emergency medication box with a list of all contents attached. The list documented: [MEDICATION(S)] 0.25mg [MEDICATION(S)], expiration date 03/2022. Registered Nurse (RN) #3 was present in the medication room, removed the green seal, opened the emergency medication box, and observed the expired [MEDICATION(S)] of [MEDICATION(S)] contained inside the box. On 04/29/22 at 11:28 AM, Registered Nurse (RN) #3 was interviewed and stated they were responsible for checking the emergency medication box daily to ensure medications about to expire are sent back to the pharmacy. RN #3 changed the emergency box on the 4th floor recently and did not look at the attached medication list documenting the [MEDICATION(S)] expired in 3/2022. On 04/29/2022 at 12:35 PM, the Assistant Director of Nursing (ADNS) was interviewed and stated that the emergency medication box is checked daily by the RN to ensure the box is returned to the pharmacy if it is about to expire. The box with the expired [MEDICATION(S)] was delivered by the pharmacy and RN #3 brought it to the unit the previous week. The nurse receiving the emergency medication boxes from the pharmacy should check the list of contents and their expiration dates. On 05/03/2022 at 01:26 PM, the Director of Nursing Services (DNS) was interviewed and stated the pharmacy checks the emergency medication boxes to ensure there are no expired medications. The ADNS was responsible for checking the emergency medication boxes upon delivery. 415.18(e)(1-4)

Based on observations, record reviews and interviews, the facility did not ensure that timely identification and removal of medication to be disposed occurred. Specifically, an expired controlled substance was observed in the narcotic cabinet in the medication room. This was observed during the Medication Storage Task. The facility's undated policy and procedure titled Narcotic Count documented that all controlled substances are not available to other than Licensed Nurses, Pharmacists and Medical personnel designated by the facility. Purpose included to assure controlled drugs are handled, stored and disposed of properly. The finding is: Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Physician order [REDACTED]. Medication Administration Record [REDACTED]. On 08/08/19 at 09:47 AM, during the Medication Storage Task a blister pack was observed for Resident #53 for [MEDICATION NAME] 50 MG in the narcotics cabinet. The label affixed to the back of the blister pack documented an expiration date of 07/22/2018. The Controlled Substance Record for Resident #53 documented that medication was last reconciled for the resident on 12/11/18. On 08/08/19 at 09:47 AM, the Registered Nurse (RN) #1 who was completing the task with the State Agent was interviewed. RN#1 stated that the LPN medication nurses of the incoming and outgoing shifts are responsible for reconciling the narcotics and checking the narcotics cabinet every shift. RN #1 also stated that it is the responsibility of the Nurse Supervisor to remove the expired medication along with medications not in use and return them to the Nursing Office. On 08/08/19 at 12:10 PM, LPN #1 was interviewed. LPN #1 stated that when medications are finished or discontinued the Supervisor is informed and they take the medication right away. LPN#1 also stated the narcotics are checked for expiration date and should be checked by staff on all shifts. On 08/12/19 at 11:23 AM, RN#2 was interviewed. RN #2 stated that narcotics are counted by 2 nurses on each shift. RN #2 also stated if any narcotics were discontinued, the information is documented on the Controlled Substance Inventory Form, and the medication is returned to the nursing office. RN#2 further stated that expired medication can be removed by any of the nurses. RN #2 also stated that the expiration dates of medication should be checked on every shift. On 08/12/19 at 01:21 PM, the Director of Nursing (DON) was interviewed. The DON stated nursing staff is usually very good with checking expiration dates and this was an isolated incident. The DON also stated that a Pharmacy consultant visits the facility once a month to do medication checks, storage, expiration dates, and the drug medication review for admissions and readmissions. The DON further stated that there is a Pharmacy Account Representative who comes to the facility on ce a month. On 08/12/19 at 01:27 PM, the Specialty Account Representative was interviewed via phone. The Representative stated that she checks the back-up boxes, emergency medications and if she finds something that expires she will remove the medication. The Representative also stated that she does not check the narcotics cabinet and only reviews the narcotic books/records. The Representative further stated that Specialty would be contacted to pick up and discard of expired medications. Attempts to reach the Pharmacy Consultant via telephone were unsuccessful. 415.18(a)

Based on observation, record review, and staff interviews during the recertification survey, the facility did not ensure that housekeeping and maintenance services were provided to maintain a sanitary interior. Specifically, soiled feeding pumps and poles were observed on 2 of 5 resident units. (Unit 1 and 2). The findings are: Review of the facility policy for enteral feeding, revised 10/17/2017 documented: Care of enteral feeding pump-all nursing staff will check pump for cleanliness on a regular basis. Wipe off areas that has spots, dried formula. Pumps identified with stained formula will be cleansed/disinfect as needed and every Tuesday by Housekeeping. The Gastric Tube (GT) pumps cleaning audit tool documented the poles and pumps were cleaned on 10/24/2017. During the initial tour of Unit 1 and Unit 2, on 10/30/2017 at 12:08 PM, a total of eighteen (18) feeding pumps and poles were observed soiled with a dried brown substance which was also splattered on the poles the pumps were attached to. This was observed in the following rooms: 201, 202 B, 203, 204, 205, 206, 207, 212 A, 213 A, 216, 217, 218 A, 219 A, 221 B and rooms 102 and 109 on the first floor . An immediate interview was conducted with the Registered Nurse Unit Manager (RN/UM) . The RN/UM stated that the unit housekeeper is primarily responsible for cleaning the pumps and poles. The Licensed nurses are also responsible for cleaning up spills. On 10/30/2017 at 1:00 PM, the unit housekeeper was interviewed and stated the poles are cleaned weekly, there is a schedule for bringing them down and cleaning them. The Housekeeping Supervisor was interviewed on 10/30/2017 at 1:10 PM and stated the poles and feeding pumps are cleaned once a week. 415.5 (h)(2)

Based on observation, record review, and interview during the recertification survey, the facility did not ensure that infection control practices were followed. Specifically, the staff was observed not washing hands and changing gloves properly during a wound care treatment observation. This was evident for 1 of 3 residents reviewed for pressure ulcers (Resident #314). The finding is: The undated facility policy and procedure titled, Hand washing documented: .Wet hands with water and spread a thin film of soap over the entire skin surface and tips of finger . The undated facility policy and procedure titled, Dressings: Change documented: After removing devices which include socks, staff are required to wash hands or use a gel hand sanitizer. New gloves are to be put on when removing old dressings with hand washing and new gloves to be followed. Hand washing and new gloves are required after cleaning the wound to apply treatment as ordered. After discarding all waste, hand washing and new gloves are required again to dress resident. Resident #314 was admitted [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented intact cognition, extensive to total assist for activities of daily living. The MDS further documented one stage one Pressure Ulcer (PU) and one unstageable deep tissue injury (DTI) . The Wound care consultant note dated 10/25/17 documented resident with left heel DTI and right heel stage one PU. Physician orders [REDACTED]. Gently smear the wound with skin prep wipes daily and as needed. On 11/2/17 from 10:17 AM to 10:36 AM, a wound care observation was conducted of the Registered Nurse (RN). After using a sanitizing wipe to clean the white foam tray, the RN did not wash her hands and proceeded with donning gloves and setting up the wound care field. The RN then removed the gloves, donned clean gloves and removed the resident's left darco shoe, socks, and dressing and cleansed the resident's left heel with normal saline, wiped the wound with the skin prep and applied the dressing. The RN removed the gloves and with her bare hands reapplied the darco shoe and then performed hand hygiene. While performing hand hygiene, the RN applied soap and water while rinsing the hands under the running water. The same technique was repeated with the wound care provided to the resident's right foot. On 11/2/17 at 10:37 AM, the RN was interviewed and stated that she was trained to wash hands before donning gloves and removing the old dressings. After completing the treatment, the gloves are removed and hand hygiene performed before treatment is rendered to another site. Gloves should be changed and hands washed after taking off resident shoes and old dressings. The RN further stated that the proper way to wash hands is to wet the hands, use friction for 20 to 30 seconds or sing the happy birthday song twice, dry hands and turn off the water with a paper towel. The RN stated that she did not realize that she had not washed her hands or changed gloves appropriately. On 11/03/17 at 12:16 PM, the RN Infection Control In-service Coordinator was interviewed. The staff are instructed to wash their hands before prepping the supplies. Then wash hands again and put on gloves before taking off the old dressing. Wash hands again and don clean gloves before cleansing the wound and before applying the prescribed treatment. Competency testing is completed annually and as needed for hand washing and wound care. Soap, water and friction is used for hand hygiene. 415.19(a)(1-3)

Based on observations and interviews the facility did not ensure that the sanitary conditions were maintained for food holding temperatures on the tray line to prevent food borne illness; Specifically the hot and cold food holding temperatures on the tray line were not maintained within acceptable parameters. This was evident during observations conducted during the Kitchen Tour. The findings are: On 8/10/16 at 12:00 noon the tray line was observed and temperatures of hot and cold foods were checked. The hot food temperatures on the tray line were observed as follows: Sliced Zucchini temperature was 130 F (Farenheit). The pureed zucchini temperature was 115 F. The steam table well was leaking and a tray was placed underneath the steam table to collect the leaking water. On 8/12/16 at 11:30 AM the cold food temperatures were observed as follows: Pureed peach 50 F (on tray). Another pureed peach 48 F ( Placed in plastic tub with ice). and Skim milk 42 F. The temperature reading in the refrigerator where fruits were stored prior to service was 55F. On 8/10/16 at 12:20 PM the Food Service Director (FSD) was interviewed and stated that the Cook supervises the tray line set up. The steam table wells have drain holes, and he uses cork to plug the holes. The cork is changed two times per week and he did not change the cork this week for these two wells. That is why it is leaking. On 8/10/16 at 12:25 PM, the Food Service Worker (FSW) was interviewed and stated that the wells have been leaking for about 6 weeks and she reported the leak to the FSD. The maintenance had worked on it and it is still leaking. She has set up the trays under the steam table to collect the leaking water, so it does not flow onto the floor. The facility policy, revised 2013 for Handling cold foods for trayline documents that cold foods will be maintained at 41 F or below. The facility policy, revised 2013 for Final cooking, Holding temperatures documents: Ground meat 155 F, Fish 145 F and poultry 165 F. The facility policy on 'Food Storage' revised 2013 documents: Refrigerated foods maintained at or below 41 F. 415.14 (h)

Based on observations and interviews the facility did not ensure that the essential kitchen equipment was maintained in safe operating condition. Specifically, the steam table wells were observed leaking during the tray line resulting in hot food holding temperatures below the required parameters. This was evident during observations conducted during the Kitchen Tour. The findings are: On 8/10/16 at 12:00 noon the tray line was observed and temperatures of hot and cold foods were checked. The hot food temperatures on the tray line were observed as follows: Sliced Zucchini temperature was 130 F (Farenheit). The pureed zucchini temperature was 115 F. The steam table well was leaking and a tray was placed underneath the steam table to collect the leaking water. On 8/12/16 at 11:30 AM the cold food temperatures were observed as follows: Pureed peach 50 F (on tray). Another pureed peach 48 F ( Placed in plastic tub with ice). and Skim milk 42 F. The temperature reading in the refrigerator where fruits were stored prior to service was 55F. On 8/10/16 at 12:20 PM the Food Service Director (FSD) was interviewed and stated that the Cook supervises the tray line set up. The steam table wells have drain holes, and he uses cork to plug the holes. The cork is changed two times per week and he did not change the cork this week for these two wells. That is why it is leaking. On 8/10/16 at 12:25 PM, the Food Service Worker (FSW) was interviewed and stated that the wells have been leaking for about 6 weeks and she reported the leak to the FSD. The maintenance had worked on it and it is still leaking. She has set up the trays under the steam table to collect the leaking water, so it does not flow onto the floor. 415.5 (e) (1) (2)

Based on observation and interview, the facility did not ensure that drugs were labeled in accordance with currently accepted professional principles. Specifically, (1) an open vial of insulin was not dated; and (2) open insulin vials were not discarded after 28 days. This was evident for 2 of 5 resident floors (Floor #3 and #5). This resulted in no actual harm with potential for more than minimal harm. The findings are: 1) On 5/31/14 at 9:39am, the 5th floor medication room was observed. There was one open vial of Levemir insulin that was not dated. The Registered Nurse (RN) was immediately interviewed and stated that all insulin vials should be dated upon opening. She further stated that the insulin vials are discarded 28 days after opening. 2) On 5/31/14 at 10:30am three open vials of lantus insulin was observed on the 3rd floor medication refrigerator, dated 5/1/14.. The Register Nurse was immediately interviewed and stated that insulin vials are dated when opened. She further stated that vials of lantus insulin should be discarded twenty eight (28) days after being opened. On 6/2/14 at 12:03pm Staff Educator stated opened vials of insulin should be discarded twenty-eight days (28) after vials are opened. The facility policy and procedure for "Multi Dose Medication Vials" dated 1/2014 documented: "All multi dose medication vials must be dated when opened and discarded as appropriate (see attached list)." The policy further documented that all insulin's should be discarded 28 days after opening or removing from the fridge.

Based on record review and resident and staff interviews, the facility did not ensure that a resident's verbal grievance about missing clothing was addressed in a timely manner. This was evident for 1 of 3 residents reviewed for Personal Property (Resident #212). This resulted in no actual harm with potential for more than minimal harm. The finding is: Resident # 212 is a [AGE] year-old with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident was cognitively intact (Brief Interview of Mental Status Score of 15). On 5/3/12 at 1:36 pm, the resident was interviewed and stated that she sent 3 pairs of pants to the laundry 2 months ago and never received them back. She reported it to the Director of Housekeeping and was told he would look into it. On 5/8/12 at 2:32 pm, the resident was interviewed and stated that the pants were sent to the laundry because they were soiled.She further stated that her daughter usually does her laundry, and that the facility staff were aware that the pants were not labeled, but there was not time for labeling. She stated that one pair was light brown, one was black, and one was gray. She also stated that she did not think any paperwork regarding the missing pants was completed. There was no documented evidence in the medical record or the grievance log that the grievance regarding the missing pants was addressed by the facility. On 5/8/12 at 3:36pm, the Assistant Director of Housekeeping was interviewed and stated that the Director of Housekeeping told him about the missing pants about a week ago before going on vacation so that he could follow-up with the person who picks up the laundry. He further stated that he had not spoken to anyone about the pants. He also stated that when clothing is missing, housekeeping attempts to locate the items within 24 to 48 hours and informs social work if the clothing is not found. He stated that social work will then speak to the family and decide whether the resident will be reimbursed. On 5/8/12 at 3:53 pm and 5/9/12 at 12:37 pm, the Social Worker was interviewed and stated that she had not been informed about the resident's grievance regarding missing pants. She further stated that when staff are informed of any grievance regarding missing clothing, they should inform Social Work so that it can be documented on a grievance form. She also stated that a copy would be given to the Director of Housekeeping, and an investigation would be initiated within 24 to 48 hours. She added that the facility attempts to resolve grievances within a week, and if items are not found, reimbursement or replacement is discussed with the resident. 415.3(c)(1)(ii)

Based on observation and staff interview, the facility did not ensure that medications were labeled and stored in accordance with currently accepted professional principles. Specifically, (1) one open vial of Lantus Insulin was un- dated and (2) a resident's yellow ring was stored in the narcotic box. This was evident for 2 of 5 units (Units 4 and 5) reviewed for Medication Storage. This resulted in no actual harm with potential for more than minimal harm. The findings are: 1) On 5/3/12 at 9:02am, the surveyor observed a resident's yellow ring stored inside the 5th floor medication room narcotic box. The Registered Nurse ( RN) was immediately interviewed and stated the ring should be given to the social worker so that it can be given to the family. She further stated that only narcotics should be stored in the narcotic box. 2) On 5/3/12 at 9:22am, the 4th floor medication room refrigerator was observed with one undated open vial of Lantus Insulin. The RN Supervisor was immediately interviewed and stated that the nurses are supposed to date the insulin vials when they are opened. She further stated that Lantus insulin is kept for 28 days after opening. 415.18(d)

Based on observation and staff interview, the facility did not ensure that infection control practices were maintained. Specifically, the nurse did not remove her gloves and wash her hands after a tube feeding observation. This was evident for 1 of 1 residents reviewed for Tube Feeding (Resident #116). This resulted in no actual harm with potential for more than minimal harm. The finding is: Resident #116 is a [AGE] year-old with [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had severely impaired cognition with long and short term memory problems. . On 5/8/12 at 5:13pm a tube feeding observation was conducted and the following was observed: The Licensed Practical Nurse (LPN) checked the feeding tube for placement, and aspirated the resident's stomach contents with a bulb syringe. Then the LPN went to the sink and filled a bag and container with water to be used to flush the feeding tube before and during the feeding. The LPN then continued to flush the feeding tube, set up the feed, and start the tube feeding. The LPN did not remove her gloves and wash her hands before touching the faucet and sink in a two- bedded room. On 5/8/12 at 5:41 pm the LPN was interviewed and stated that the should have removed her gloves and washed her hands after checking the residents feeding tube for placement and prior to touching the faucet and sink to prevent any cross contamination. 415.19(a)(1-3)

Based on record review and staff interviews, the facility did not ensure that the resident's medical record was accurate and completed as evidenced by: a licensed nurse not documenting on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. This was evident for 1 of 17 sampled residents. (Resident #13). This resulted in no actual harm with potential for more than minimal harm. The finding is: Resident #13 is a [AGE] year old female with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 dated 4/28/11 documented that resident is cognitively intact. The Physician Order's dated 6/15/11 documented "Tylenol 650 mg (milligrams) po (by mouth) 30 minutes prior to dressing change". The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"Tylenol 650 mg (milligrams) po (by mouth) 30 minutes prior to dressing change". The columns dated 6/24/11, 6/25/11, 6/27/11, 6/28/11, 6/29/11 and 7/1/11 had signature omissions. There was no documented evidence that the medication was administered on these dates. The Registered Nurse (RN) Supervisor was interviewed on 7/5/11 and approximately 3:30 PM and stated that the Medication Nurse is responsible for documenting all medication administered on the MAR. She further stated that this was not done. 415,22(a)(1-4)

Based on observation, record review and staff interviews, the facility did not ensure that residents receive the necessary care and services specifically: 1a) an Insulin Dependent resident who received 66 units of [MEDICATION NAME] and is fed 51 % of his nutrition via gastrostomy tube developed problems with the functioning of the gastrotomy tube for 33 hours, was not assessed by the Registered Nurse nor was the physician notified of the resident's condition. Subsequently, the resident had an episode of [DIAGNOSES REDACTED], lethargy and altered mental status and was admitted to the hospital; 1b) a resident on strict aspiration precaution was not supervised during meals 2) a resident who was experiencing pain to the back of his head did not receive pain medication in a timely manner (Resident #17). This was evident for 2 of 28 sampled residents. (Residents #14 and #17). This resulted in actual harm for resident #14 that is not Immediate Jeopardy and no actual harm with the potential for more than minimal harm for resident #17. The findings are: 1) Resident #14 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented that the resident's cognition was cognitively intact. This MDS also documents that the resident has a feeding tube (gastrostomy tube) and mechanically altered diet. The MDS further documented that the resident receives 51% of total calories via the tube feeding. The Comprehensive Care Plan dated 8/4/2010 documented that the resident has a swallowing problem and receives nutrition via a gastrostomy tube. The physician's orders [REDACTED].m; Automatic water flush:100cc Q (every) 2 hours via pump and total calories of 800 calories for 24 hours. The Physicians order dated 12/5/11 documented: "[MEDICATION NAME] 100-units/ml (milliliter)-66 units subcutaneously at bedtime." The enteral feeding monitoring form dated 12/17/10 documented that the resident receives 600 calories via "PO (by mouth) Diet Order/Supplements." The Certified Nursing Assistant Clinical Accountability and Assignments dated December, 2010 documented that the resident's nourishment intake and eating is via gastrostomy tube. The LPN (Licensed Practical Nurse) integrated progress notes dated 12/27/2010 at 6 a.m. documented "Peg (Percutaneous Endoscopic Gastrostomy) needs to be replaced, tube is too short-nsg (nursing) supervisor made aware. " The 24 hour report dated 12/27/10 documented under "Comments/Dept. Issues: (resident #14 room number) - PEG Needs to be replaced Tube is Short." There was no documented evidence that the resident was assessed by the RN (Registered Nurse) and the physician notified when the LPN observed that the gastrostomy tube was in need of replacement and short in length. Additionally, there was no documented evidence that the resident was assessed and monitored by the licensed nurses on the 7am -3pm or the 3pm - 11pm shifts after the documented problem with the gastrostomy tube on 12/27/10 at 6 a.m or that the physician was notified. The LPN progress note dated 12/28/2010 on the 11pm -7am shift documented "Observe GT (gastrostomy tube) peg unable to continue to connect to end of the peg. Seepage of tube feeds was a lot thur the night. Informed supervisor of same." There is no documented evidence that the resident was assessed by the Registered Nurse supervisor and the physician notified of the seepage of the gastrostomy tube on 12/27/10 and 12/28/10. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. There is no documented evidence of monitoring the resident's condition on the 7am to 3pm shift on 12/28/10. The LPN integrated progress notes dated 12/28/2010 at 4 p.m. documented "Around 3 p.m., Resident found to be lethargic, with altered mental status, skin cold and clammy, responsive to tactile stimuli. v/s (vital signs) T (temp) 97.6, P (pulse) 62, R (respirations) 14, BP (blood pressure) 128/66, BS (blood sugar) 31 mg/dl (milligrams/deciliter). Nsg (nursing) supervisor and Dr. (name of doctor) made aware, order to give [MEDICATION NAME] x 1 dose stat (immediately) and transfer resident to (name of hospital) for evaluation and treatment. [MEDICATION NAME] 1mg/ml (milligram/milliliter) given IM (intramuscular) to LT (left) deltoid and tolerated well. BS (blood sugar) at 3:20 p.m. 68mg/dl. Resident left unit via stretcher with 2 (two) EMS (emergency medical service) from (name of ambulance company), PEG to be replaced at the hospital ... " The nurses' progress note dated 1/3/11 at 3:30pm documented "...admitted res. (resident) from ...Hospital via stretcher ...c (with) primary dx (diagnosis) of [DIAGNOSES REDACTED]..." The nutritional assessment dated [DATE] documented "Readmit from hospital ...Dx (diagnosis) [DIAGNOSES REDACTED] 2 (secondary) PEG dislodgment. PEG replaced 12/29/10 ..." The (1st floor)7-3 unit Registered Nurse Supervisor (RNS) was interviewed on 4/18/11 at 2:10 p.m. The RNS stated that the nurses should have informed the doctor immediately when the residents tube began to show signs of malfunction to determine if the doctor wanted the resident to be transferred to the hospital. The RNS further stated that the residents intake should have been assessed to ensure that it was adequate since the resident was receiving Insulin. The RNS also stated that if the doctor had been informed that the residents tube was malfunctioning, the doctor could have made an informed decision regarding orders to hold or reduce the amount of Insulin to be administered and the RN should have assessed the resident, documented her findings in the nurses notes and informed the doctor. An interview was conducted on 4/19/11 at 2:30 p.m.,with the LPN on duty 12/27/10 at 6 a.m. and 12/28/10 at 4 p.m. The LPN stated that he did not know if the resident's tube had retracted "on the inside" but that only "3- 4 (three to four) inches of the tube was visible on the "outside of his body." The LPN further stated that he had "noticed" that the residents tube "was short" on 12/26/10 at 8 p.m. but had been able to connect the tube to the feeding. The LPN stated that he notified the RNS on 12/27/10 when the tube had retracted further, and was informed by the RNS (Registered Nurse Supervisor) to endorse the residents condition to the charge nurse on the oncoming 7-3 shift. The Director of Nursing (DNS) was interviewed on 4/19/11 at 3:30 p.m., and stated that the RN supervisors were expected to assess the residents as needed, address whatever problems that arise and inform the doctors accordingly. The DNS stated that there was no documentation that the RN checked the resident on 12/27/10, and that this was unacceptable. The RNS (on duty 12/28/10 on the 7-3 shift) was interviewed on 4/19/11 at 3:45 p.m. The RNS stated that she attended the "morning report" on 12/28/10 and did not report to the interdisciplinary team about the length of the resident's tube. The RNS further stated that she checked the resident and "saw the tube short" and asked the nurses to generate a G.I. ([MEDICATION NAME]) consultation, but did not go back to check the resident or call the doctor. The RNS also stated that " I should have ... called the doctor about the "short tube." The RNS (on duty 12/27/10 on the 3-11 shift) was interviewed on 4/19/11 at 4:15 p.m. and stated that he did not read the nurses' notes or follow-up on the problem with the resident's gastrostomy tube . The unit Physician was interviewed on 4/20/11 at 5:15 p.m. The physician stated that she remembered being notified when the resident was transferred to the hospital but did not recall being informed about the tube malfunction prior to the resident being found unresponsive and with low blood sugar. The physician further stated that from the initiation of the p.o. (per oral) diet that the resident needed to be maintained on strict aspiration precautions to prevent choking and/or pneumonia, and that entailed close supervision. The RNS (on duty 12/28/10 on the 11-7 shift) was interviewed on 4/20/11 at 5:30 p.m. The RNS stated that when she checked the resident the leakage was only minimal, and informed the LPN that the resident did not need to be sent out to the hospital. The RNS further stated that her assessment should have been documented in the residents medical record including a review of the prior nurses notes. The RNS also stated that if she had reviewed the residents chart she would have known about the problem with the resident's tube that had been documented in the previous nurses notes, and would have informed the doctor because "this resident is a diabetic and that would have been alarming" since the "resident is on Insulin and would have gone into [DIAGNOSES REDACTED] (low blood sugar)." Speech Therapy Dysphagia Evaluation dated 8/31/10 documented Oropharyngeal Dysphagia. Patient requesting p.o. (per oral) feeding-Pt (patient) goal: eat by mouth...Precautions: coughing. The comprehensive care plan for "IMPAIRED SWALLOW/DYSPHAGIA'' dated 1/5/11 documented "....Close supervision during meals...." The physician's orders [REDACTED]. The physician's orders [REDACTED]. Close supervision during p.o. (by mouth) intake." The resident was observed in his room, in bed on 4/19/2011 at 8:20 A.M. to 8:35 A.M., eating pureed hot cereal and pureed eggs. The resident was observed feeding himself the cereal, eggs and drinking from a milk carton. During the observation there was no staff present in the resident's room. The unit LPN (Licensed Practical Nurse) entered the resident's room at 8:35 A.M. and asked the resident "Are you finished yet." The resident had consumed 1/4th (one fourth) of the cereal, eggs and coffee (containing thickener). The LPN left the resident's room, leaving tray in front of the resident and the resident unsupervised. The resident then stated to the SA (State Agency) that he preferred to have his coffee with milk, and pointed to the cup of black coffee. The resident was also observed on 4/19/2011 at 10 A.M. drinking a "Health Shake" labelled "Pureed with honey thick- thickened to honey consistency" through a straw in the dining room unassisted. The unit Registered Nurse (RN) was interviewed on 4/19/11 at 9:00 a.m. The RN stated that the resident should be supervised at all meals to ensure that "he doesn't choke." The RN further stated he would make sure that the required supervision would consistently be provided. 2) Resident #17 is an [AGE] year old male with a history of [MEDICAL CONDITION] with [MEDICAL CONDITION], hypertension, benign prostate [MEDICAL CONDITIONS], right toe ulcer and [MEDICAL CONDITION]. The minimum data set of assessed reference date 2/3/2011 documented his BIMS score (brief interview for mental status) as a 15 out of a possible 15, with no limitations in cognition. The physician's orders [REDACTED]. Q8 (every 8) hours for pain or temperature above 100 F (Fahrenheit), orally, PRN (as needed). The medication administration records for April, 2011 were also reviewed and documented the same orders as stated above. The care plan for "Alteration in Comfort" dated 2/3/11 documented to monitor for signs and symptoms of pain, note site, frequency and intensity and refer to physician. It also documented to administer medication as ordered. On 4/20/11, at approximately 2:00PM, the resident was observed lying in bed, at the lowest position and complaining of pain to the back of his head. He stated that the registered nurse was made aware of his pain but did not offer him pain medication. He stated that he only received his regular medication. He further complained that the pain was so severe that he couldn't even get up to go downstairs to recreation. At this time, the registered nurse was immediately interviewed. The registered nurse stated that the resident complained of pain in the morning and was assessed as having a pain score of 8 out of a possible 10 in severity. He stated that he did not give any pain medication because the patient was on [MEDICATION NAME] 4x (four times) a day. He stated that he did not call the physician yet or give any pain medication. He added that he just reassessed the resident as having a 5/10 pain score with a reduction in blood pressure from 140/90 to 130/80. At 2:30PM, the registered nurse stated that he notified the physician of the resident's complaint and status. The physician ordered to give [MEDICATION NAME]. At 2:45PM, the registered nurse stated that the [MEDICATION NAME] was given and the resident was feeling better. He said that he should have called the physician earlier for interventions. He stated that the Tylenol order was for generalized pain, as per protocol and fever. The [MEDICATION NAME] was originally ordered for pain in the foot. He stated that I should have notified the physician earlier for pain management and to find out if he (the patient) could take something stronger. He stated that he was contemplating on elevated blood pressure and this was why he didn't give any pain medication. At 5:00PM, on 4/20/11, the involved registered nurse was again interviewed. He stated that he went to check the resident ' s blood pressure 3x. He stated that he asked the resident if he had pain all three times. The first time the resident ' s pain was 8/10 and severe. He said that the resident was reassessed at 10:45AM, a 2nd time and reported that he still had pain, but it was a little better. He stated that he didn't offer pain medication the 1st or 2nd time, until the 3rd time when the physician ordered to give the pain medication. At 5:20PM, on 4/20/11, the resident ' s certified nursing aide was interviewed. He stated that the resident's usual behavior is that he gets up, washes himself, dresses himself and goes down to recreation. He states that he observed the resident in bed this morning, at which time he did not complain of pain, but stayed in bed which was not his typical behavior. At 5:25PM, on 4/20/11, the Director of Nursing was interviewed. She stated that if any resident reports pain, a pain assessment is done and then the physician or nurse practitioner is notified. She stated that if a PRN (as needed) order for pain medication is in place, pain medication can be administered. She stated that the nurse should have administered the PRN (as needed) pain medication and notified the physician since the resident was still complaining of pain. 415.12