Every finding on record at Ellicott Center for Rehabilitation and Nursing

Based on interview and record review conducted during a Complaint investigation (Complaint #NY00356490) during a Standard survey completed on 2/13/2025, the facility did not ensure that each resident was free from significant medication errors for one (1) (Resident #202) of four (4) residents reviewed for insulin medications. Specifically, Resident #202 did not receive scheduled insulin doses or have their blood glucose (sugar) monitored per the provider orders. On 10/6/2024. the resident was found unresponsive, nonverbal with a blood glucose of 579 (normal 60 - 110) which resulted in hospitalization for diabetic ketoacidosis (a life-threatening complication of diabetes that occurs when the body does not have enough insulin). Additionally, a nurse inaccurately documented the resident was in the hospital on 10/6/2024 at the time of their scheduled insulin dose and blood glucose monitoring. This resulted in actual harm to Resident #202 that was not Immediate Jeopardy. The finding is: The policy titled Insulin Administration dated 1/2020, documented the type of insulin, dose requirements, and method of administration must be verified before administration to assure it corresponds with the physician's order, document the resident's blood sugar and insulin administration on the Medication Administration Record. The policy titled Blood Glucose Testing/Meter/Device dated 2/1/2024, documented to record the results of the resident's blood glucose test on the Medication Administration Record, follow appropriate interventions regarding blood glucose test results (sliding scale insulin, oral medications etc.), and notify healthcare provider of abnormal test results or refusals. The policy titled Medication Administration Review dated 8/2019, documented licensed nurses must ensure that prior to the end of their shift all medications administered/refused/or held must be properly documented on the Medication Administration Record. Nurse will follow up and document appropriately on medications that were administered but not documented. Resident #202 had diagnoses including diabetes (a chronic condition where the body's immune system mistakenly attacks and destroys insulin producing cells in the pancreas and the body cannot make insulin needed for regulating blood glucose levels), end stage renal disease (kidney failure), and anxiety. The Minimum Data Set (resident assessment tool) dated 10/6/2024 (not yet completed), documented the resident's memory was intact and they were independent in making decision regarding tasks of daily life. Review of the hospital Discharge Summary, when the resident first arrived at that facility, dated 10/3/2024 at 11:18 AM, documented Resident #202 had a discharge diagnosis of diabetic ketoacidosis with coma (prolonged state of unconsciousness in which a person is unresponsive to their surroundings and cannot be awakened) associated with type 1 diabetes. The Admission/Readmission Evaluation dated 10/3/2024 at 6:46 PM, documented Resident #202's cognition was intact, and they needed set up assistance with eating and partial to moderate assistance with bathing, dressing, and transfers. The Order Recap Report (recap of physician orders) dated 2/12/2025, documented the following orders with a start date of 10/5/2024: Humalog insulin (rapid acting insulin) 4 units subcutaneously (beneath the skin) with meals; Humalog insulin per sliding scale (dose of insulin based on blood glucose level) 0-200 give 0 units, 201-250 give 2 units, 251-300 give 4 units, 301-350 give 6 units, 351-400 give 8 units subcutaneously before meals; Lantus insulin (long acting insulin) 12 units subcutaneously every morning and at bedtime. Review of the Medication Administration Record dated 10/1/2024 to 10/31/2024, revealed on 10/5/2024 the 5:30 PM entry for blood glucose monitoring with sliding scale, the 6:00PM entry for Humalog insulin 4 units subcutaneous, and the 9:00PM entry for Lantus insulin were blank. On 10/6/2024, the 7:30 AM entry for blood glucose monitoring with sliding scale, the 8:00AM entry for Humalog insulin, and the 9:00 AM entry for Lantus insulin were initialed by Licensed Practical Nurse Unit Manger #5 and documented a code of 6 (along with all other medications scheduled for that morning). According to the chart (on the medication record), code 6 meant the resident was hospitalized , and medications were not given. There was no documented evidence the provider was notified of the medication omissions. There was no documented evidence the resident's blood glucose was checked after 12:00 PM on 10/5/2024. Review of Resident #202's nurse Progress Notes revealed the following: -10/5/2024 at 2:00 PM, Licensed Practical Nurse Unit Manager #5 documented they spoke with the resident's family member regarding their insulin regime. Licensed Practical Nurse Unit Manager #5 spoke with the provider and new orders were given for Lantus 12 units in the morning and at bedtime; and Humalog 4 units with meals along with the sliding scale. -10/6/2024 at 3:22 PM, Registered Nurse Supervisor #1 documented the resident was sent out to the hospital at approximately 11:00 AM due to a nonverbal episode with weakness, slight facial droop and a blood sugar of 579. -10/6/2024 at 10:15 PM, a call was placed to the hospital to follow up on the resident's status and they were admitted with a diagnosis of diabetic ketoacidosis. There was no documented evidence the provider was notified of the medication omissions from 10/5/2024 and the morning of 10/6/2024. The EMS Patient Care Report (ambulance record) dated 10/6/2024, documented at 10:23 AM the resident was lying in bed, unable to follow commands. The family reported they thought the facility did not give the prescribed insulin and their blood glucose level was high. Family reported the resident's baseline was alert and oriented. The resident was responsive to painful stimuli and their blood glucose level was documented as high. Review of the daily staffing sheet dated 10/6/2024 for 7:00 AM-3:00 PM shift documented on the City View Unit Licensed Practical Nurse Unit Manager #5 was scheduled and the other scheduled nurse called off. During an interview on 2/12/2025 at 12:18 PM, the Director of Nursing reviewed the daily staffing sheet and stated on 10/6/2024, it would have been Registered Nurse Supervisor #1 who was on City View covering the unit until the Licensed Practical Nurse Unit Manager #5 arrived. During an interview on 2/12/2025 at 1:33 PM, the Licensed Practical Nurse Unit Manager #5 stated they remembered the ambulance was already at the facility when they arrived on the unit that morning (10/6/2024) and Resident #202 was either on their way out or already out of the facility. Licensed Practical Nurse Unit Manager #5 reviewed Resident #202's Medication Administration Record and stated the 6 code meant the resident was hospitalized . They stated medications could be given an hour before or up to an hour after the time they were ordered, but blood glucose checks and insulin should be given at the time they were ordered. They stated that was the day they came in to relieve someone. Licensed Practical Nurse Unit Manager #5 stated they documented in the earlier medications (morning) a code 6 because the resident was going to the hospital when they arrived. Licensed Practical Nurse Unit Manager #5 stated they should have had the person who they relieved document in the Medication Administration Record. They stated Registered Nurse Supervisor #1 documented the resident's blood glucose level, but they did not know what time they obtained it. During a telephone interview on 2/12/2025 at 2:12 PM, Registered Nurse Supervisor #1 stated they were not on a medication cart that day (10/6/2024). They worked as a supervisor and was all over the building, probably hanging IV (intravenous) medications. The nurse for the City View Unit did not show up and they did not jump on a cart because that was their license on the line. They stated there was a nurse, the unit manager, scheduled on the unit that day, but they did not arrive until 10:00 AM when they should have been there at 7:00 AM. Registered Nurse Supervisor #1 stated they did not think the night shift nurse stayed over and there was nobody giving the residents morning medications. They weren't sure who called them about Resident #202, it might have been an aide or maybe the family member who found the resident and said they weren't acting like themselves. Registered Nurse Supervisor #1 stated the resident was nonverbal, not very responsive, they took their blood sugar, and it was 579 around 10:00 AM or 10:30 AM. Registered Nurse Supervisor #1 stated the resident's lack of getting their insulin that morning contributed to the resident's high blood glucose and hospitalization . During an interview on 2/13/2025 at 9:36 AM, Licensed Practical Nurse Unit Manager #5 stated it would be a medication error if someone didn't get their insulin as ordered. They stated when they got to the unit on 10/6/2024, Registered Nurse Supervisor #1 gave them the keys to the medication carts but did not know if they had passed any of the medication, that's probably why everything was red in the electronic Medication Administration Record, which meant medications were late. During an interview on 2/13/2025 at 10:29 AM, in the presence of the Director of Clinical Operations, the Director of Nursing reviewed Resident #202's electronic medical record and stated the last time the blood glucose was documented as completed was on 10/5/2024 at noon and it was 98. They stated it did not look like the resident was administered the Humalog or Lantus on 10/5/2024 and on 10/6/2024; there was the code 6 documented. The Director of Nursing stated that Licensed Practical Nurse Unit Manager #5 signed out the morning medications. The Director of Nursing stated they should not have signed off on the 7:30AM and 9:00AM scheduled medications if they came into work after 10:00 AM, unless they got an order from the provider to give the medications late. The Director of Nursing stated Registered Nurse Supervisor #1 should have been on the medication cart. They stated the facility had a liberalized medication schedule, but not for insulins. If the resident did not get their insulin or blood glucose checked, they would consider it an error. The Director of Nursing stated there was no record of the blood glucose being checked or the insulin given, and this could have contributed to their high blood glucose level and that Insulin was an important and a significant medication. The Director of Nursing stated they did not receive a call from the supervisor on this date to report low staffing levels. They or the Assistant Director of Nursing were available when staffing concerns arose and would have expected the supervisor to call them if there were issues. They expected the supervisor to pull staff from floors to accommodate, and if need be, to get on a medication cart themselves and get the medications administered. The Director of Nursing stated they did not know if this was harmful for the resident, but it was an untoward event. During a telephone interview on 2/13/2025 at 11:32 AM, Physician Assistant #1 stated they were familiar with the resident, and the resident was a brittle diabetic. They expected the nurses to give medications per medical orders and lack of insulin contributed to the resident's high blood glucose level. The lack of the blood glucose monitoring and lack of insulin could have been harmful for the resident, and they would consider this a significant medication error. During a telephone interview on 2/13/2025 at 12:50 PM, the Consultant Pharmacist stated, to administer a sliding scale insulin, staff would need to take a blood glucose level. Upon review of the Medication Administration Record, the Pharmacy Consultant stated Resident #202 was not administered Lantus insulin on 10/5/2024 or 10/6/2024 and no Humalog insulin on 10/6/2024. They stated the last blood glucose was checked on 10/5/2024 at midday. The Consultant Pharmacist stated, the resident not receiving the insulin doses contributed to high blood glucose and that insulin was a significant medication that was potentially dangerous. Staff would need to do all the monitoring that goes along with use of this medication. This resident does not make their own insulin, so they required it from an outside source. During an interview on 2/13/2025 at 1:20 PM, the Administrator stated they expected nurses to follow provider's orders. During a telephone interview on 2/13/2025 at 2:12 PM, the Medical Director stated they expected nurses to administer medication as ordered, and Resident #202's insulin and blood glucose check should have been completed. Not receiving the insulin contributed without a doubt to the resident's elevated blood sugar and without a doubt they could have been harmed by this. It was important for the facility to monitor the resident because of their medical history. 10NYCRR 415.12(m)(2)

Based on observation, interviews, and record review conducted during Complaint investigations (Complaint #s NY00359253 and NY00368473) during the Standard survey completed on 2/13/25, the facility did not ensure that food and drink was palatable, attractive and at a safe and appetizing temperature for three (Cityview, Skyview, and Harborview units) of four test trays. Specifically, food was served during meals at suboptimal temperatures and was not palatable. Residents #3, #55, #63, #65, #96, #104, and #203 were involved. The findings are: The facility policy and procedure titled Food Temperature Policy last reviewed 3/23, documented food sent to remote kitchens for distribution (such as meals, snacks, nourishments, oral supplement) will be transported and delivered to maintain temperatures at or below 41 degrees Fahrenheit for cold foods and at or above 140 degrees Fahrenheit for hot foods. All employees are responsible to notify their supervisor of any food item that does not meet the regulated safe acceptable service ranges (at or below 41 degrees Fahrenheit or above 135 degrees Fahrenheit). The Menu Planning and Food Service Committee-Meeting Attendance minutes dated 1/15/25 documented 16 residents were in attendance and that residents complained of cold food at times. A noted concern was that food carts sit at nurse station prior to pass. The Centers Health Care Food Safety attachment to the facility policy and procedure titled Food from Outside revised 7/12/23 documented the responsibility for food safety begins with decisions on purchasing and ends when food is safely served, or when potentially unsafe food is discarded. For holding hot foods that they were to be served immediately or held at or above 135 degrees Fahrenheit. During an interview on 2/6/25 at 10:31 AM, Resident #104 stated the food was lousy and was not served hot enough. During an interview on 2/6/25 at 3:53 PM, Resident #3 stated hot foods were often cold once they arrive on the unit and food was frequently overcooked or undercooked and inedible. During an interview on 2/6/25 at 3:04 PM, Resident #203 stated the food usually wasn't that good, was served lukewarm, and staff said they couldn't reheat it. During an interview on 2/7/25 at 8:58 AM, Resident #96 stated the food was bleh and only decent once in a while. They stated they were served fish on 2/6/25 and it was deep fried and too hard for them to chew. During a lunch meal tray line observation on 2/10/25, the temperatures of food items taken on the steam table in the main kitchen at 11:36 AM were taken by the cook prior to the start of tray line and were as follows: Chicken tenders measured 186 degrees Fahrenheit Ground chicken tenders measured 172 degrees Fahrenheit Pureed baked chicken measured 188 degrees Fahrenheit Sweet potato fries measured 196 degrees Fahrenheit Corn measured 189 degrees Fahrenheit Mashed potatoes measured 198 degrees Fahrenheit Pureed broccoli measured 198 degrees Fahrenheit Gravy measured 180 degrees Fahrenheit Coffee measured 180 degrees Fahrenheit Tray line commenced immediately after temperatures were taken. Plates were taken from a plate warmer, and insulators were used under and on top of plates, as they were placed on trays. Cold drinks and desserts had been removed from temporary storage in the walk-in freezer and were held on trays without ice. Coffee was pre-poured into commercial food service coffee mugs and held on trays. All drinks and desserts were covered with individual plastic disposable covers. The test tray for the Cityview unit left the kitchen in an insulated cart at 11:57 AM. The test tray for the Skyview unit left the kitchen in a closed metal cart at 12:17 PM. The test tray for the Harborview unit left the kitchen at 12:27 PM on top of an insulated cart in a plastic clam shell container, as the kitchen had run out of insulators and was waiting for some more to the brought from the dish room. All resident meals served from the steam tables from 12:26 PM to 12:30 PM were sent out in plastic disposable clam shell containers. As of 12:32 PM, resident meals once again were served on plates with top and bottom insulators. During an interview on 2/10/25 at 12:35 PM, Registered Dietician/Food Service Director #1 stated the facility had just received new insulators and plates that day and a cart with unopened boxes of insulators and plates was observed in the dietary supervisor's office. a.During an observation of a lunch meal tray on 2/10/25 on the Cityview unit, all trays were passed at 12:04 PM and the food temperatures on the pureed texture test tray were taken at 12:10 PM, when the Diet Technician #1 arrived on the unit and used the facility's dial thermometer. The temperatures and taste were as follows: Pureed baked chicken: no gravy, tasted cold, dry and unpalatable. The temperature was 91 degrees Fahrenheit. Mashed potatoes: no gravy, tasted cold, dry and unpalatable. The temperature was 96 degrees Fahrenheit. Pureed broccoli: tasted cold and unpalatable. The temperature was 95 degrees Fahrenheit. During an interview on 2/10/25 at 12:15 PM, Diet Technician #1 stated they thought the food tasted good and was hot enough. They stated when they did test trays, they did not test for a specific temperature but for a good taste. They did not know what the safe temperature range for food should be. During an interview on 2/10/25 at 12:18 PM, resident #65 stated their lunch was not good. They did not get any chicken, and their broccoli and rice were cold. They also stated their coffee was cold, which happened every day, for every meal, and they have complained to staff. b. During an observation of a lunch meal tray on 2/10/25 on the Skyview Unit, the second meal cart arrived on the unit at 12:07 PM, all trays were passed at 12:19 PM, and the food temperatures on the test tray were taken at 12:20 PM using Diet Technician #1's dial thermometer as follows: Chicken tenders measured at 85 degrees Fahrenheit; were cool to the taste. Sweet Potato Fries measured at 83 degrees Fahrenheit; and were cool, soft and limp without any crispiness and unpalatable. Corn measured at 81 degrees Fahrenheit; and was cool, bland, dry and chewy and unpalatable. During an interview at the time of the test tray, Diet Technician #1 stated they did not judge a test tray based on the temperature while serving because they go by the palatability. They stated if the tray was palatable then the temperature of the food did not matter. They felt the chicken tasted delicious, the sweet potato fries were fine and that corn was corn. During an interview on 2/10/25 at 12:37 PM, Resident #55 stated their lunch tray was a little on the dry side and was cold. When they received their tray, they thought their Sweet Potato Fries were burnt French Fries at first, the corn was bland, and they preferred their food warmer. c. During an observation of a lunch meal tray on 2/10/25 on the Harborview unit the first meal tray cart arrived at 12:12 PM and staff started passing the trays. The second cart with the test tray arrived at 12:31 PM and staff started passing the trays while continuing to pass trays from the first cart. All trays were passed at 12:41 PM, and the food temperatures on the test tray were taken at 12:42 PM with Diet Technician #1 using the facility's dial thermometer. The temperatures and taste were as follows: Corn measured 75 degrees Fahrenheit, tasted cold, chewy and was not palatable. Sweet potato fries measured 72 degrees Fahrenheit, were cold, not crispy and not palatable. Chicken tenders measured 105 degrees Fahrenheit, tasted lukewarm and not palatable. Diet Technician #1 stated they didn't have a specific temperature range that food should be served at, it was based on palatability. Diet Technician #1 tasted the corn, sweet potato fries, and chicken tenders and stated they thought the corn and chicken tenders were palatable but would like the sweet potato fries to be warmer. During an interview on 2/10/25 at 12:53 PM, Resident #63 had their lunch tray in their room and stated it was cold. They stated it was like that every day. During an interview on 2/10/25 at 1:01 PM, Registered Dietician/Food Service Director #1 stated foods needed to be served palatable to taste, they expected hot foods to reach the residents at 135-140 degrees Fahrenheit, and cold foods should be 45 degrees Fahrenheit or below. During an interview on 2/13/25 at 9:37 AM, the Director of Nursing stated 80 degrees Fahrenheit and below was too cold for hot foods to be served at and bacteria could grow at such temperatures. During an interview on 2/13/25 at 9:40 AM, the Administrator stated warm foods should be served at temperatures per preference and if food was supposed to be held at 140 degrees Fahrenheit to start, temperatures in the 70s, 80s and 90s at time of service were not good. There could be issues with food safety and residents could get sick. During an interview on 2/13/25 at 9:57 AM, the Director of Clinical Operations stated they were acting as the facility's Infection Preventionist, and safe warm food temperatures were 140 degrees Fahrenheit or above, food temperatures below that were a comfort issue for residents. If food was cooked to the required temperature in the kitchen and hit the benchmark and trays were passed timely, there should not be an issue with illness. 10NYCRR 415.14(d)(1)(2)

Based on observation, interview, and record review conducted during the Standard survey completed on 2/13/2025, the facility did not provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable, and homelike environment; and did not maintain comfortable temperature levels between 71 degrees Fahrenheit to 81 degrees Fahrenheit for two (Harbor View and City View units) of four units. Specifically, air temperatures were below 71 degrees Fahrenheit in resident rooms and shared resident areas on the Harbor View unit. In addition, shower chairs and the shower floor were observed with dried brown debris on them on the City View and Harbor View units. The findings are: The policy titled Home Like Environment, created 9/19/2022, documented residents were provided with a safe, clean, comfortable, and homelike environment and encouraged to use their own personal belongings to the extent possible. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. Characterized by cleanliness and order, comfortable yet adequate lighting, inviting colors and decor, personalized furniture and room arrangements, pleasant neutral scents, plants and flowers when appropriate, comfortable temperatures and noise levels. 1.The policy titled Temperature - Room, last revised 8/2019, documented comfortable and safe temperature levels were when the ambient temperature would be in relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk of hypothermia, respiratory ailments, and colds. The temperature in the facility rooms would be maintained at a temperature range of between 71 degrees to 81 degrees Fahrenheit. Temperatures would be measured as needed when there is a complaint about air temperature. Concerns would be reported to the supervisor and then to maintenance for review and further actions as necessary. Observations of the Harbor View unit and temperatures obtained using the surveyor's stem type thermometer revealed the following: -On 2/06/25 at 8:49 AM, Licensed Practical Nurse #7 was at their medication cart, wearing a winter hat. -On 2/6/25 at 9:44 AM, the air temperature in the hallway outside of Resident room [ROOM NUMBER] was 68.5 degrees Fahrenheit and felt cold; at 9:45 AM, the air temperature inside Resident room [ROOM NUMBER] was 67.8 degrees Fahrenheit, the window was closed, and the shade was down. The resident stated they felt cold and had three blankets on. -On 2/6/25 at 10:10 AM, Resident room [ROOM NUMBER] the air temperature was 67.2 degrees Fahrenheit and felt cold. The resident was in the room and was not interviewable. -On 2/7/25 at 8:23 AM, the hallway air temperature near Resident room [ROOM NUMBER] was 67.7 degrees Fahrenheit. Licensed Practical Nurse #7 stated they were not cold today, but yesterday they wore their winter hat because they were cold. -On 2/7/25 at 9:17 AM, The air temperature was 68.3 degrees Fahrenheit in the hallway near Resident room [ROOM NUMBER]. Resident #108 was self-propelling their wheelchair in the hallway near room [ROOM NUMBER], they were wearing a jacket and stated it was freezing in the building someone turn on the heat. -On 2/7/25 at 9:19 AM, the common area adjacent to the nurse's station air temperature was 69 degrees Fahrenheit. There were two residents in the area, one was wearing a hooded sweatshirt with the hood pulled up over their head. -On 2/7/25 at 9:22 AM, the common area diagonal from the nurse's station air temperature was 67.4 degrees Fahrenheit. There were three residents seated in the area. -On 2/7/25 at 10:40 AM, Licensed Practical Nurse #11 stated it was cold in the facility every day. The air temperature in the center of the common area was 66.7 degrees Fahrenheit and Resident #108 was wrapped in a blanket covering their nose and mouth. They stated their nose was freezing. There were four other residents seated in the area. -On 2/7/25 at 12:10 PM, the air temperature in Resident room [ROOM NUMBER] was 67.5 degrees Fahrenheit using the facility's infrared thermometer pointed at an interior wall. During an interview at the time of the observation, the Assistant Maintenance Director stated the thermostat in this room controlled the baseboard heat, and it was set to 70 degrees Fahrenheit. The Maintenance Director stated a floor mat was covering the baseboard, and they moved the floor mat and stated it might have affected the air temperatures. - On 2/7/25 at 12:15 PM the air temperature in the common area across from the nurse's station was 69.6 degrees Fahrenheit with both the Surveyor's stem-type thermometer and the facility's infrared thermometer. The Assistant Maintenance Director stated the heat in that area came from the rooftop air handling unit and PTAC units (packaged terminal air conditioner, a self-contained heating and cooling unit that's mounted through a wall). Five residents were in the common area and both PTAC units were off. The Maintenance Director turned on one of the PTAC units in the Lounge. At 12:30 PM, the air temperature in the common area had reached 70.1 degrees Fahrenheit with the Surveyor's stem-type thermometer. -On 2/11/25 at 11:28 AM, the air temperature in the hallway outside Resident room [ROOM NUMBER] was 69.1 degrees Fahrenheit; at 11:30 AM the air temperature inside Resident room [ROOM NUMBER] was 67.7. degrees Fahrenheit. At 11:33 AM, Licensed Practical Nurse #7 stated the rooms at the end of the hallway were always cold and they have told maintenance about it, supposedly they ordered a part, and it was fixed. They stated they were cold, and they moved around, so they could only imagine what it was like for the residents. The thermostat on the wall in Resident room [ROOM NUMBER] was observed set at 65 degrees Fahrenheit and was encased in a clear plastic locked box. -On 2/11/25 at 11:39 AM, Certified Nurse Aid #6 stated Resident room [ROOM NUMBER] was cold, and the air seeped in through the large window. They gave the resident extra blankets when they were cold. During an observation and interview on 2/11/25 at 11:47 AM, the air temperature of Resident room [ROOM NUMBER] was taken with the Maintenance Director using their infrared thermometer aimed at an interior wall with a result of 68.5 degrees Fahrenheit. At 11:49 AM, Resident room [ROOM NUMBER] was 68.1 degrees Fahrenheit. The Maintenance Director stated they liked to see resident rooms between 71 and 72 degrees Fahrenheit, and not lower than 71 degrees. They observed the thermostat in room [ROOM NUMBER] and said it was at 65 degrees right now. They stated the Assistant Maintenance Director took daily temperatures of rooms and that they could turn up the thermostat in room [ROOM NUMBER]. During an observation and interview on 2/11/25 at 11:53 AM, the Assistant Maintenance Director stated they checked air temperatures daily, they stated there were not any entries for cold room temperatures on the maintenance logbook on the Harbor View unit and the air handlers on that side of the building have been in working order. They stated they took an air temperature in room [ROOM NUMBER] around 7:00 AM that day and it was 74.1 degrees Fahrenheit using their infrared thermometer. At 11:59 AM, the Assistant Maintenance Director went into room [ROOM NUMBER], unlocked the thermostat and stated they were turning it up. The resident was lying in bed at this time. They took an air temperature of the room with their infrared thermometer and got 68.2 degrees Fahrenheit when they aimed it at an interior wall. They stated the temperatures should be between 71 to 72 degrees Fahrenheit but liked it at 74 degrees Fahrenheit. They stated the end rooms were always slightly colder. During an interview on 2/11/25 at 1:32 PM, Resident #77 stated it could be warmer in the facility, the windows were drafty and old. The resident was wearing a winter hat. During an interview on 2/11/25 at 8:39 AM, Registered Nurse Unit Manager #7 stated when the unit felt cold, they would call the maintenance staff to let them know so they could adjust the heat. They were the ones who controlled it. They stated they would get residents extra blankets if they were cold until it got warmer. During an interview on 2/11/25 at 12:19 PM, Licensed Practical Nurse #9 stated they noticed the cold air temperatures and that the resident in room [ROOM NUMBER] probably had five blankets on them. The building was very cold at night. During an observation on 2/12/25 at 9:20 AM, Resident room [ROOM NUMBER] was 66.7 degrees Fahrenheit, the resident stated they were cold and was wearing three blankets. Certified Nurse Aide #9 stated it was freezing in the room. During an interview on 2/13/25 at 12:04 PM with the Director of Clinical Operations present, the Director of Nursing stated someone had mentioned a resident was complaining of colder temperatures. The temperature range should be 71 degrees to 81 degrees Fahrenheit. They stated for a temperature of 67 degrees Fahrenheit and below staff would need to pass out extra blankets. 2.The policy titled Cleaning/Disinfecting Resident Care Items and Equipment, last revised 11/2018, documented reusable resident care items and equipment should be cleaned and disinfected according to current CDC (Center for Disease Control) recommendations for disinfection of healthcare facilities and the OSHA (Occupational Safety and Health Administration) Bloodborne Pathogens Standard. Shared resident care items are items and equipment that can be used in the care of multiple residents. These reusable items should be cleaned/disinfected between each resident and use. Items/equipment visibly contaminated with blood and/or other potentially infectious materials should be promptly cleansed and decontaminated following Occupational Safety and Health Administration guidelines. The policy titled Environmental Services Cleaning of Shower Room, last revised 5/2018, documented the facility provided a safe and sanitary environment to prevent the development and transmission of disease and infection. Sweep and mop tile floor according to floor cleaning procedure. During an observation on 2/6/2025 at 9:33 AM the shower room on City view was soiled with dried brown fecal matter (approximately 6 x 2 inches) in the right corner of the shower stall floor. There were 2 smaller chunks of brown fecal matter under the shower chair. This was the only usable shower stall; the other stall was full of equipment. During an observation on 2/7/2025 at 9:09 AM the shower room floor remained soiled with dried brown debris and under the shower chair. The shower chair was soiled with dried brown fecal matter smeared on the seat. This was the only usable shower stall; the other stall was full of equipment. During an observation and interview on 2/7/2025 at 10:33 AM, Certified Nurse Aide #10 stated the dried brown debris on the shower room floor and shower chair on Harbor View was feces and it needed to be cleaned. Certified Nurse Aide #10 stated whoever gave the shower last was responsible for cleaning the shower chair and housekeeping was responsible for mopping the floors. They should ensure the shower stalls and chairs are cleansed for infection control reasons, they don't want to spread germs because the chairs are used for multiple residents. During an interview on 2/13/2025 at 10:53 AM, Certified Nurse Aide #10 stated the dried brown debris on the shower chair and floor did not present a homelike environment. They wouldn't want their house to look like that, that's gross. During an observation and interview on 2/7/2025 at 10:37 AM, Licensed Practical Nurse Unit Manager #5 stated the dried brown debris on the shower chair on City View was feces. They stated they believed the dried brown debris area on the shower stall floor was dirty or stained but could not say for sure what it was. The Certified Nurse Aide who gave a shower last was responsible for cleaning the shower chair, then housekeeping followed up with cleaning the shower stall. Licensed Practical Nurse Unit Manager #5 stated the Certified Nurse Aides should use the disinfecting wipes provided to them to clean the shower equipment before and after each use. It was important for infection control reasons. During an interview on 2/13/2025 at 10:50 AM, Licensed Practical Nurse Unit Manager #5 stated dried feces on shower chairs and floors was not conducive to a homelike environment. During an observation and interview on 2/7/2025 at 10:41 AM, Housekeeping Aide #1 stated the dried brown debris on the shower chair and dried brown debris smear on the shower floor on Harbor View was probably feces. Certified Nurse Aides were responsible for cleaning up any linens and bodily fluids and housekeeping was responsible for cleaning shower stalls and floors. During an observation on 2/13/2025 at 8:00 AM the shower chair seat in Harbor View shower room was completely covered in smeared dried brown debris (feces) (approximately 6 x 12 inches). During an observation and interview on 2/13/2025 at 8:01 AM, Certified Nurse Aide #9 stated the dried brown debris smear across the shower chair in Harbor View shower room was probably feces and that presented a risk for cross contamination. They stated the Certified Nurse Aide who gave a shower last responsible for cleaning the shower chair after. During an observation and interview on 2/13/2025 at 8:07 AM, Registered Nurse Unit Manager #7 stated the dried brown debris on the shower chair in Harbor View shower room could be feces. It was an infection control issue and could cause cross contamination. Certified Nurse Aides are responsible for cleaning up before and after they gave a shower, and housekeeping cleaned the shower stalls. During an interview on 2/13/2025 at 9:15 AM, the Director of Nursing stated shower rooms and shower chairs should be cleaned before and after every shower. Housekeepers are responsible for cleaning shower stalls and whoever gave the shower was responsible for cleaning the chair. During a follow up interview at 2/13/2025 at 11:08 AM, the Director of Nursing stated the dried brown debris on the shower chairs and/or floor did not present a homelike environment. They would not want their house to look like that. During an interview on 2/13/2025 at 11:44 AM, the Director of Clinical Operations/ Interim Infection Preventionist stated they expected staff to clean all equipment before and after each use, including shower chairs. The dried brown debris on shower chairs and/or floor put residents at risk for the spread of pathogens and did not present as homelike. During an interview on 2/13/2025 at 12:27 PM, the Administrator stated they expected staff to clean equipment prior to and after each use. They would not want another resident using equipment that was soiled with feces, it is an infection control issue and could cause cross contamination. Housekeeping cleansed and sanitized shower stalls but did not touch urine or feces. The Administrator stated they would not want dried brown debris in their home or to sit on it, it was not homelike. 10 NYCRR 415.5(h)(4)

Based on observation, interview and record review conducted during Complaint investigations (Complaint #s NY00362643 and NY00369017) during the Standard survey completed on 2/13/25, the facility did not ensure that residents who were unable to carry out activities of daily living, received the necessary services to maintain good grooming and personal hygiene for two (Residents #39 and #96) of 9 residents reviewed. Specifically, Resident #39 was not gotten out of bed on multiple days and had an unkempt beard. Resident #96 had a moderate amount of long chin hair and jagged dirty fingernails. The findings are: The policy titled Activities of Daily Living Care and Support dated 3/13/24 documented care and support will be provided for residents who were unable to carry out activities of daily living independently in accordance with the resident's assessed needs, personal preferences, and individualized plan of care that includes assistance with hygiene (grooming) and mobility (transfers). Nail care should be provided as needed and facial hair will be groomed per resident's preference. 1. Resident #39 had diagnoses including osteomyelitis (infection in bone), gastrostomy (an opening into the stomach wall that allows feeding tube insertion), and atrial fibrillation (irregular heart rate). The Minimum Data Set (a resident assessment tool) dated 11/19/24 documented the resident had moderate cognitive impairment, and for transfers and personal hygiene the resident was dependent on staff to complete all the activity. The undated comprehensive care plan identified as current by the Director of Nursing, documented the resident had difficulty communicating due to garbled speech, interventions included to anticipate the resident's needs. The resident required assistance with activities of daily living and interventions included for bed to chair transfers two staff were to use a mechanical lift and for personal hygiene the resident was dependent on one staff. The Kardex Report (a guide used by staff to provide care) dated 2/10/25 documented Resident #39 required two people using a mechanical lift to be transferred from their bed to a chair and required one person to complete all personal hygiene tasks (the resident could not use their own strength for any part of the activity). Adaptive equipment included a wheelchair. During an observation and interview on 2/6/25 at 9:03 AM, Resident #39 was lying in bed, watching television. They had a long, unkempt beard on their face. The resident stated they would like their beard shaved because it can get itchy at times, and nobody ever asked them if they wanted it shaved. Resident #39 stated when they had asked staff about being shaved, staff would say they looked cute with their beard. Resident #39 stated they never got out of bed because of their feeding tube and that staff never shaved them. The resident stated they would like to be out of bed sometimes. There was no wheelchair or Geri chair (a medical reclining chair) in the resident's room or outside their room in the hallway. Further observations of Resident #39 revealed the following: -On 2/7/25 at 10:43 AM, the resident was lying in bed, sleeping. -On 2/10/25 at 8:11 AM, the resident was lying in bed, watching television. Their beard was unkempt and had not been trimmed or shaved. -On 2/10/25 at 2:50 PM, the resident was lying in bed and was not observed to be out of bed on this date. During an observation of morning care and wound care on 2/11/25 from 9:58 AM to 11:20 AM; Certified Nurse Aide #6 and Certified Nurse Aide #7 provided incontinence care. At 10:26 AM, Certified Nurse Aide #6 stated they were finished providing care for the resident. At 10:28 AM, Licensed Practical Nurse #7 started the resident's wound treatments and completed them at 11:20 AM. None of the staff offered to get the resident up out of their bed or to shave them. During an interview on 2/11/25 at 12:06 PM, Certified Nurse Aide #8 (assigned to Resident #39) stated that they didn't usually work on this unit, and they fed the resident this morning. They stated that Certified Nurse Aide #6 was supposed to wash up and provide a bed bath for Resident #39 that morning. During an interview on 2/11/25 at 12:09 PM, Certified Nurse Aide #6 stated they were asked to provide incontinent care to Resident #39 this morning. They were not told to provide morning care, the assigned aide (Certified Nurse Aide #8) was supposed to do that part of care. They stated the resident didn't usually get out of bed and they weren't sure why. During further interview on 2/11/25 at 1:57 PM, Certified Nurse Aide #6 stated there was a certified nurse aide who worked weekends, and they usually shaved the residents, they stated right now Resident #39's beard was decent, but residents have to ask to be shaved and be vocal about what they want. During an observation interview on 2/12/25 at 9:42 AM, Registered Nurse Unit Manager #7 was standing outside of Resident #39's room, the resident was awake, lying in bed. The Registered Nurse Unit Manager #7 stated Certified Nurse Aides were supposed to offer shaving to the residents, usually done on shower days. They stated the resident was in bed mostly because of their pressure sore and they never asked if the resident wanted to get out of bed. They stated the resident was on a different unit prior being on this unit and that therapy were the ones that provided chairs to residents. At 9:47 AM, Resident #39 stated they would like to get out of bed. During an interview on 2/12/25 at 9:48 AM, Certified Nurse Aide #9 stated the resident never got up out of bed and they weren't exactly sure why but probably because they had a sore. They stated they never asked the resident if they wanted to get up and they didn't have a chair that's why they didn't ask the resident. Certified Nurse Aide #9 stated the resident was on a different unit, then went out to the hospital and when they came back, they were on this unit. The resident would probably say yes if staff asked if they wanted to get up. During an interview on 2/13/25 at 12:25 PM, Licensed Practical Nurse #7 stated the resident didn't have a chair, at one point therapy said they were looking for one, but they had tossed out some equipment. They stated the resident's friend used to shave them but hadn't been in to visit for a while. During an interview on 2/13/25 at 8:39 AM, the Registered Nurse Unit Manager #7 stated that the resident should be offered a shave, and that the resident didn't like the razors. They stated the activity director came over and shaved the resident with an electric razor and that it worked better for the resident. During an interview on 2/13/25 at 12:04 PM with the Director of Clinical Services present, the Director of Nursing stated unit managers were supposed to make sure staff were providing activities of daily living to residents. The Director of Nursing stated the staff should have offered Resident #39 to be out of bed and they liked everyone to be out of bed everyday unless it was contraindicated, but this resident could be up for several hours daily. The Director of Nursing stated a lot of the time this resident is scruffy because they don't like the razors here. 2. Resident #96 had diagnoses that included fracture of orbital (eye socket) floor, major depressive disorder, and osteoarthritis (chronic degenerative bone disease; breakdown of cartilage and other tissues within the joint). The Minimum Data Set, dated dated dated [DATE], documented Resident #96 was cognitively intact, understands, and was understood. The Minimum Data Set documented that Resident #96 required a partial/moderate assist of one staff member for personal hygiene. The Kardex with a printout date of 2/13/25 documented Resident #96 received their showers Saturdays during the 7:00 AM - 3:00 PM shift and Wednesday during the 3:00 PM- 11:00 PM shift. Additionally, the Kardex documented to prevent the resident from scratching and keep hands and body parts from excessive moisture, keep fingernails short. The comprehensive care plan dated 2/30/24 documented Resident #96 required assist with self-care and mobility related to impaired balance. Resident #96 required supervision or verbal cues or touching assist of one staff member with self-care and personal hygiene and required a substantial assist of one staff member for showering/bathing Review of nursing progress notes dated 10/1/24 to 2/13/25 revealed no documented evidence that Resident #96 refused shaving or nail care. During an observation and interview on 2/7/25 at 8:03 AM, Resident #96 was sitting on the side of their bed eating breakfast. They stated they could not see well because they were legally blind. Resident #96's fingernails were long, slightly jagged, and dirty with brown debris. The resident also had 0.5 to 1-inch white whiskers on their face and chin. During an observation and interview on 2/7/25 at 8:56 AM, Resident #96 pulled at the whiskers on their chin and stated they were bothered by them. They stated staff rush and tell them they do not have time to shave them when providing care. During an observation and interview on 2/11/25 at 8:01 AM, Resident #96 was sitting on the side of their bed eating scrambled eggs with their fingers of their right hand. The brown debris remained under their fingernails and the whiskers remained on their face and chin. During an observation and interview on 2/11/25 at 9:13 AM, Certified Nurse Aide #5 performed morning care for Resident #96 by washing, rinsing, and drying the resident's face, neck, underneath their breasts and armpits, peri area and buttocks. Resident #96 was dressed and was gotten out of bed. Certified Nurse Aide #5 exited the room to obtain foot pedals. At 9:37 AM Resident #96 stated their nails were long and had brown debris under them and they needed to be cleaned and cut. They were bothered by them, and it was hard to manipulate food with them being that long. Certified Nurse Aide #5 reentered with foot pedals, placed them on Resident #96's wheelchair then offered to brush Resident #96's teeth. They did not wash nor offer to clean Resident #96's hands and nails or assist with removal of their chin hair. During an interview on 2/11/25 at 9:52 AM, Certified Nurse Aide #5 stated they did not shave or offer to shave Resident #96, and they should have. They said it was important to keep the residents looking good and for dignity reasons. They should have offered even if they refuse or have refused because shaving is included in morning care. All Certified Nurse Aides were responsible for shaving their residents whenever, not just on shower days. Certified Nurse Aide #5 stated they did not offer to wash Resident #96's hands during morning care or perform nail care and they should have. They noticed there was some brown debris under the nails but forgot to do them. Certified Nurse Aide #5 stated Resident #96 eats with their hands often so it is important to clean the hands and under the nails for infection control reasons. They stated nails should be kept short and filed to avoid residents scratching themselves, germs can get inside of scratches. During an interview on 2/11/25 at 9:58 AM, Licensed Practical Nurse #6 stated shaving and nail care should always be offered to residents. It was important for infection control and dignity reasons. Certified Nurse Aides were responsible for shaving and providing nail care to residents and nurses were responsible for ensuring aides were offering and providing them. During an interview on 2/11/25 at 10:31 AM, Licensed Practical Nurse Unit Manager #5 stated Certified Nurse Aide #5 should have offered to wash Resident #96's hands, provide nail care, and shave them during morning care. It was important for infection control and dignity reasons. They stated nurses and team leaders were responsible for ensuring certified nurse aides were completing their assignments. During an interview on 2/12/25 at 2:08 PM, the Director of Nursing stated morning care for the dependent resident consisted of a basic bed bath; wash face, arm pits, incontinent care, oral care, hair, dressed, nail care if warranted and shaving if wanted. Residents should be offered to be shaved, for dignity reasons. The Director of Nursing stated they would have expected Certified Nurse Aide #5 to have offered to shave Resident #96 during morning care and wash hands and provide nail care if they noticed they needed to be done. Resident #96 should have had their nails soaked and cleaned properly. It was an infection control issue, especially if they eat with their hands. They stated the Unit Manager was responsible for ensuring nail care and shaving was being provided to the residents on the unit. During an interview on 2/13/25 at 9:23 AM, the Nurse Educator stated Certified Nurse Aide #5 should have offered to shave and provide nail care to Resident #96 when performing morning care. They stated it was important for dignity reasons to at least offer to shave residents. Not offering or providing nail care was an infection control issue, especially if Resident #96 eats with their hand. Certified Nurse Aides should review the residents care plan prior to providing care to know what level of assistance the resident requires. 10 NYCRR 415.12(a)(3)

Based on observations, interviews, and record reviews conducted during a Compliant investigation (#NY00359451) during the Standard survey completed on 2/12/25, the facility did not ensure that residents who are fed by enteral means (by way of the intestine to deliver part or all of a person's caloric requirements) received the appropriate treatment and services to prevent possible complications for two (2) (Resident #147 and Resident #39) of two (2) residents reviewed for feeding tubes. Specifically, the facility did not provide the tube feed formula as ordered by the physician. In addition, the nursing staff inaccurately documented the formula was administered as ordered. The findings are: The facility policy and procedure titled Enteral Feedings last reviewed 2/23 documented it was the policy of the facility to provide enteral nutrition therapy to residents unable to obtain nutrition orally, when such therapy was ordered by the physician and not clinically contraindicated. The procedure included instructions to verify the physician's order, review the resident's care plan and to provide for any special needs of the resident, to ensure the equipment and devices were working properly. It also instructed to document date and time of procedure, type and amount of enteral feeding, name and title of the individual performing the procedure, if resident refused the procedure and reason(s) why and interventions taken, and the signature and title of the person recording the data. The facility policy and procedure titled Physician Orders last revised 2/20 documented enteral nutrition therapy orders would include the following components: formula, amount, route, flow rate, pump/gravity/bolus use; flushes: amount, frequency and type. The facility policy and procedure titled Medication Administration Review last revised 8/19 documented licensed nurses (Registered Nurses, Licensed Practical Nurses) must ensure that prior to the end of their shift all medications/treatments administered/refused/held, etc., were properly documented on the Medication Administration Record. 1. Resident #39 had diagnoses including osteomyelitis (infection in bone), gastrostomy (an opening into the stomach wall that allows feeding tube insertion), and atrial fibrillation (irregular heart rate). The Minimum Data Set (a resident assessment tool) dated 11/19/24 documented the resident had moderate cognitive impairment, had a feeding tube and received greater than 51% (percent) of their total calories through the feeding tube. The undated comprehensive care plan identified as current by the Director of Nursing, documented Resident #39 had a risk for altered nutrition related to dysphagia (difficulty swallowing), alternate feeding as primary nutritional source. Interventions included to provide feeding and flushes as ordered, monitor for tolerance. The Clinical Physician Orders dated 2/12/25 documented an order for FS Peptamen 1.5 via enteral tube at a rate of 80 milliliters per hour to begin at 2:00 PM for a total volume of 1600 milliliters to be delivered over 24 hours. May use FS Pivot 1.5 if Peptamen 1.5 was not available started on 12/23/24. An order for full nectar thickened liquid diet for oral gratification was ordered on 11/13/24. Observations of Resident #39 revealed the following: -on 2/6/25 at 9:13 AM, the resident was lying in bed, watching TV with a tube feeding Pivot 1.5, running at 80 milliliters per hour. The resident stated they were not on the tube feeding 24 hours per day, more like 20 hours per day. -on 2/7/25 at 8:23 AM, the resident was in bed; their tube feeding was not running. At 9:15 AM, the enteral feed was not running and Licensed Practical Nurse #7 stated that the enteral feed was hung at 2:00 PM every day and it wasn't usually running when they arrived for their shift. They stated that yesterday they hung it at 2:00 PM and it was done infusing earlier and they would hang a new bottle at 2:00 PM. -on 2/10/25 at 8:11 AM, the resident was in bed, their enteral feed was not running. The resident said it was running at night and staff took it down that morning. At 8:28 AM, Licensed Practical Nurse #7 stated the resident's feed was already done when they arrived for their shift that morning, they worked yesterday and hung it up at 2:00 PM. At 2:37 PM, the tube feed was not running. At 2:44 PM, the Licensed Practical Nurse #7 state they were going to hang the enteral feeding because they got busy earlier. The Licensed Practical Nurse #7 removed a bottle of Pivot 1.5 (33.8 fluid ounces/1500calories per 1000 milliliters) from a box in the resident's room and labeled it with the date, time and their initials. There were 6 bottles left in the box (that could hold 8 bottles) located on top of the resident's dresser in their room. At 2:50 PM, the nurse loaded the enteral feeding pump and primed the tubing, programmed the pump to 80 milliliters per hour to infuse 1600 milliliters with 240 milliliter flush every 4 hours. -on 2/11/25 at 7:21 AM, the resident was in bed, not hooked up to their tube feeding. The tube feeding pole was in their bathroom with a full bottle of Pivot 1.5 hanging dated 2/11/25. There were 5 bottles of Pivot 1.5 left in the box on top of the resident's dresser. During continuous observation from 9:58 AM until 11:20 AM, the resident's enteral feed was not running. During a telephone interview on 2/11/25 at 7:39 AM, Licensed Practical Nurse #8 stated they usually worked the 3:00 PM to 11:00 PM shift, but the night before they worked a double shift until 7:00 AM that morning (2/11/25). The resident's enteral feed was usually running when they arrived for their shift and it was set up for automatic flushes, they usually don't have to disconnect it on the 3:00 PM-11:00 PM shift. They stated the prior night they took the enteral feed down around 3:00 AM or 4:00 AM as the bottle had infused. They stated the rate was 80 milliliters per hour and the time it came down, depended on the time it was started. They did not know how much feed the bottle held and had unhooked it after the bottle infused. They didn't hang another bottle; they did get another bottle ready for the day shift to hang. They stated the resident had tolerated the feed and flushes and had no emesis. The Licensed Practical Nurse #8 stated if only one bottle (about 1000 milliliters) was infused then the resident wasn't getting enough and wasn't getting the amount ordered. During a telephone interview on 2/11/25 at 12:19 PM, Licensed Practical Nurse #9 stated the resident's tube feeding was usually running when they arrived for their shifts (full time 11:00 PM-7:00 AM), the resident got scheduled medications during their shift, so they flushed the feeding tube at those times. They stated the enteral feed usually ended around 6:00 AM or 6:30 AM, and they never had to hang another bottle. They thought the problem was how the order was written and that it was supposed to run over 20 hours, and 4 hours was for care, but the resident didn't get 4 hours of care in a 24-hour period, so they reached their maximum amount before their shift ended, so they took it all down. The Licensed Practical Nurse #9 state they didn't have to change the bottle, when the bottle was done, the resident was done. They stated they didn't know how much solution was in the bottle and they thought the resident was supposed to get 1200 milliliters (but they weren't sure at this time and didn't have the record to review). They stated a bottle had 1200 or 1400 milliliters in it. When the surveyor informed them that the bottle had 1000 milliliters, the Licensed Practical Nurse #9 stated that bottles were always overfilled and the amount in the bottle was always over the top line. They stated they wouldn't take it down if it had a lot more to go. They stated they could tell how much was infused if they looked at the pump, but sometimes the pump might not be cleared, and it might say that 3000 milliliters was infused. During an interview on 2/12/25 at 8:12 AM, the Registered Dietician #1 stated Resident #39 was on Peptamen 1.5 and could be substituted with Pivot 1.5, due to a shortage of tube feedings it depended on what was available from their 3rd party provider. The resident's feeding should be running at 80 milliliters per hour for a total volume of 1600 milliliters. It is infused over 24 hours, but it was meeting the resident's needs in 20 or 22 hours, because they would need to stop it to provide care. The bottles are 1000 milliliters, so the resident would need 1 whole bottle and 2/3rds of another bottle. They stated if nursing was not hanging another bottle, then the resident was not getting the feeding according to the provider's order. The resident should be observed to be hooked up to the feeding 24 hours per day. The resident's estimated needs based on their assessment the end of December were 2280-2660 calories at 30-35 calories per kilogram of body weight and protein needs were 114-152 based on 1.5-2 grams per kilogram of body weight for wound healing purposes. The formula is 1.5 calories per milliliter, so if the resident was getting 1000 milliliters, they were getting 1500 calories per day, and it was not meeting their needs. The resident hasn't had any recent weight loss, their weight went up 0.8 pounds since January. The Registered Dietician #1 stated nurses should know how much volume was in the enteral feed bottle and the order was clear for 1600 milliliters, it's like a medication and they needed to follow the amount ordered. During an interview on 2/13/24 at 12:21 PM, Licensed Practical Nurse #7 stated the order for the tube feeding was confusing, they would have to do the math, and they figured it would infuse for 20 out of 24 hours, they had questioned it before, but it was not cleared up. There was a button on the pump that has a history, but if nobody cleared it, it would be over the amount that was supposed to be infused. Prior to this current enteral feed, they were on a different formula at a different rate. During an interview on 2/13/25 at 12:04 PM with the Director of Clinical Operations present, the Director of Nursing stated they expected nurses to follow the order for tube feedings and it would take multiple bottles to meet Resident #39's needs. The Director of Nursing stated the Registered Dietician #1 usually put all the orders in for tube feedings. The Director of Clinical Operations stated someone checked the pump the other day to see how much was infused and it was over 1600 milliliters. They stated they didn't like the way the order was written and thought the order was confusing for the nurses. They stated the nurses weren't aware of how much formula was in the bottles and if the nurses were unsure of the order, they could have clarified it with Registered Dietician #1 or the Director of Nursing. 2. Resident #147 had diagnoses including Parkinson's Disease (a disorder of the central nervous system that affects movement, often including tremors), dysphagia, and gastrostomy (an opening into the stomach wall that allows feeding tube insertion, and a way to deliver part or all of a person's caloric requirements). The Minimum Data Set, dated dated dated [DATE] documented Resident #147 had moderate cognitive impairment, had a feeding tube and received greater than 51% of their total daily calories through the feeding tube. The undated comprehensive care plan identified as current by the Director of Nursing, documented Resident #147 had the potential for altered nutrition related to their diagnoses of Parkinson's Disease, dysphagia, and dementia, required a modified diet for oral gratification with alternate feeding (enteral feeding via tube) as primary nutrition. The Clinical Physician Orders dated 2/10/25 documented and order for Nutren 2.0 via enteral tube at a rate of 45 milliliters per hour to begin at 7:00 PM for a total volume of 1000 milliliters to be delivered over 24 hours. May use TwoCal HN if Nutren 2.0 unavailable started on 12/30/24. An order for honey thick/moderately thick consistency liquids and regular diet puree texture for foods was ordered 12/19/24. An order to change the enteral feeding setup (tubing, Piston Syringe, Graduated cylinder) every 24 hours was ordered on 11/24/24, and on order for a gastrostomy-tube check for placement before administration was ordered on 11/24/24. Review of the Medication Administration Record for February 2025 for Resident #147 documented for the evening shift to stop the enteral feeding at total volume of 1000 milliliters/document volume infused, flush per order and re-start feeding at 45 milliliters per hour. The documentation only included space for initials and a checkmark, there was no documentation of volume infused. The order was dated 12/30/24. Observations of Resident #147 revealed the following: -on 2/10/25 at 9:06 AM, Resident #147 was observed sitting in their wheelchair with the feeding tube attached and running. The formula bag was dated 2/9/25 and timed 8:00 PM. The enteral feeding pump was set to 45 milliliters per hour and there were 400 milliliters left in the bag of formula. The formula was Nutren 2.0 and held 1000 milliliters when full. -on 2/11/25 at 10:20 AM, Resident #147 was in observed in bed. Their enteral feed was not hooked up, the formula bag was observed on the pole and was dated 2/9/25 at 8:00 PM and was empty. Resident #147 stated the enteral feed had not been connected to their gastrostomy tube since the day before. Licensed Practical Nurse Unit Manager #1, stated a fresh formula bag should have been hung and started during the evening shift on 2/10/25 and this bag was empty and appeared to be from the day prior. Licensed Practical Nurse Unit Manager #1 checked the Medication Administration Record and stated that Licensed Practical Nurse #2 completed the Medication Administration Record for both the evening shift and the overnight shift into 2/11/25. On the Morning on 2/11/25, Licensed Practical Nurse #3 documented the enteral feed check on the Medication Administration Record. Licensed Practical Nurse #1 stated it was a concern that a fresh formula bag was not started on 2/10/25 at the ordered time of 7:00 PM because the resident needed the nutrition it provided and should receive the formula as ordered. During an interview on 2/11/25 at 11:08 AM, Director of Nursing #1 stated it was clear the enteral feed had not been hung and started as ordered on 2/10/25 and the formula and flush bags should be hung every day on the evening shift and both bags should be initialed and dated by the nurse who hung them. During a telephone interview on 2/11/15 at 11:43 AM, Licensed Practical Nurse #2 stated they did not remember hanging a bag of formula for Resident #147 during the evening shift on 2/10/25. They stated they did not remember how much formula was in the bag that was on the pole, and they did not check the formula bag for a date and time that it was hung. They stated they also worked the night shift and administered a thyroid medication to Resident #147 via bolus at about 6:00 AM and again stated they did not check how full the formula bag was, at that time. During an interview on 2/13/25 at 9:07 AM, Licensed Practical Nurse #3 stated they worked the 7:00 AM to 3:00 PM shift on 2/11/25 and went home sick at 10:00 AM. They checked the electronic Medication Administration Record and stated they had checked Resident #147's enteral formula bag at 7:21 AM on 2/11/25. They stated they remembered there was very little formula in the bag, so they turned the machine off and unhooked it. They stated they did not tell anyone that the formula bag for Resident #147 was almost empty, and that they had turned it off. When asked to calculate for how long the formula should be running at a rate of 45 milliliters up to a volume of 1000 milliliters, they stated it should be running for 22 hours and that would allow for medication administration and required flushes to be performed. During an interview on 2/11/25 at 11:15 AM, Registered Dietician #1 stated they were the person who calculated how much formula each resident required and someone missing their enteral feed was a concern as they would not be receiving the nutrition their body required. NYCRR 415.12(g)(2)

Based on observation, interview and record review conducted during the Standard survey, completed on 2/13/25, the facility did not ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with the physician's orders, and the comprehensive person-centered care plan for one (Resident #16) of one resident reviewed for peripherally inserted central catheter (PICC- a long, thin tube that is inserted through a vein in an arm and passed through to the larger veins near the heart) use. Specifically, Resident #16 was readmitted to the facility with a peripherally inserted central catheter in their left upper arm (PICC). There was a lack of physician orders and assessments, for monitoring arm circumference, external length, dressing changes and flushes for the peripherally inserted central catheter. Additionally, the comprehensive care plan was not developed to include the peripherally inserted central catheter. The finding is: The policy titled PICC (peripherally inserted central catheter) line dressing Change, last revised 1/2022, documented the PICC catheter insertion site is a potential entry site for bacteria that could produce a catheter-related infection, and sites should be assessed at least daily. The assessment of the site is to include the absence or presence of erythema, drainage, or swelling, induration, skin temperature at site, or complaint of tenderness at the site or along the vein tract. The dressing should be changed at least every 7 days, or sooner if the dressing is wet, soiled or loose. The policy titled Physician Orders, last revised 2/2020, documented the licensed nurse receiving orders is required to transcribe the order to the EMAR (electronic medical records) containing all required information. 1. Resident #16 had diagnoses including type II diabetes, end stage renal disease (severe kidney disease) requiring hemodialysis (medical procedure that filters waste, and excess fluid from the blood when the kidneys are no longer able to do so), and a history of Methicillin resistant staphylococcus aureus (common antibiotic-resistant bacteria) and carrier of Carbapenem-resistant Acinetobacter baumannii (bacteria resistant to many antibiotics). The Minimum Data Set (a resident assessment tool), dated 11/20/24, documented Resident #16 was cognitively intact, always understood and understands. The assessment documented they had intravenous access and intravenous medications. Resident #16's admission/readmission assessment dated [DATE], documented they had a peripherally inserted central catheter present upon readmission from the hospital. Resident #16's physician order listing report dated 2/11/25, revealed there were no orders for a peripherally inserted central catheter that included the use, monitoring, flushes, care and dressing changes. In addition, there were no orders for intravenous medications. Resident #16's care plan report, last revised 1/10/25, revealed there were no interventions for a peripherally inserted central catheter. During an observation and interview on 2/11/25 at 11:35 AM, Resident #16 was in their room in their wheelchair. There was a single lumen (tube) peripherally inserted central catheter in their left bicep. The dressing was dated 1/7/25 with illegible initials. The dressing was lifted at the base and soiled with brown debris. Resident #16 stated the catheter was placed at the hospital, and no one at the facility had addressed it since they had been back. During an observation and interview on 2/11/25 at 11:39 AM, Registered Nurse #2 observed the peripherally inserted central catheter in Resident #16's left arm. They stated they did not know the resident had it because the resident always wore long sleeves. Registered Nurse #2 stated the soiled dressing and lack of attention to the peripherally inserted central catheter put the resident at risk for infection. During an observation and interview on 2/11/25 at 12:01 PM, Licensed Practical Nurse #1 Unit Manager observed the peripherally inserted central catheter in Resident #16's left arm. They stated they did not know the resident had it, there were no orders for it, and it was not on their care plan. Licensed Practical Nurse #1 Unit Manager stated the dressing was soiled and lifting, and it was an infection risk. Licensed Practical Nurse #1 Unit Manager #1 stated the registered nurse that completed the admission assessment should have added the orders and updated the care plan for the peripherally inserted central catheter. They said it was very important to have orders so the staff would know how to care for it. During an interview on 2/12/25 at 9:37 AM, Physician's Assistant #1 stated they did not know Resident #16 had a peripherally inserted central catheter until they were notified on 2/11/25. They stated they expected the admitting nurse to add orders for any devices a resident was admitted with because the provider was not usually present when the resident was admitted . They stated it was very important for a resident with a peripherally inserted central catheter to have orders for monitoring placement, dressing changes, assessment and flushes. Physician's Assistant #1 stated that accessing a peripherally inserted central catheter after such a long time would put the resident at risk for a possible infection, a possible blot clot becoming dislodged and the possibility that the catheter had moved into the heart, which could lead to an arrythmia (an irregular heartbeat). During an interview on 2/12/25 at 11:47 AM, the Director of Nursing stated they expected the nurse that did the admission assessment for Resident #16 to enter the orders, and update the care plan, for the peripherally inserted central catheter. They stated the orders were important because it was how staff knew to take care of it. They stated peripherally inserted central catheters needed to be flushed every day, assessed regularly for infection and placement and the dressing should be changed at least weekly. The Director of Nursing stated, by not addressing the peripherally inserted central catheter, it put Resident #16 at risk for infection. 10 NYCRR 415.12 (k)(2)

Based on observation, interview and record review conducted during the Standard survey completed on 2/13/25, the facility did not ensure that residents who require dialysis, received services consistent with professional standards of practice for one (Resident #16) of one resident reviewed. Specifically, Resident #16 did not have ongoing monitoring upon leaving the facility and returning from hemodialysis (treatment that filters waste and excess fluid from the blood when the kidneys were unable to). There were no assessments of their access site and there was no communication between the dialysis center and the facility. Additionally, the wrong type of hemodialysis access device was listed on the resident's provider orders. The finding is: The policy titled Dialysis Management, last reviewed 5/2019, documented residents receiving hemodialysis treatments will be assessed and monitored to ensure quality of life and well-being. On admission the resident will be assessed for the type of access device and the site will be observed for function and signs of infection. The facility will establish open communication with the resident's dialysis center, utilizing a Dialysis Communication Book. The nurse will establish pre-dialysis vital signs (blood pressure, pulse, temperature, and respirations), advanced directives and any pertinent resident information. On return from the dialysis center the nurse will review the communication, specifically reviewing pre and post vital signs, treatment tolerance and any medications given, and any new orders for resident care. The nurse will evaluate the resident for mental status, pain, access site condition and response to treatment. Following the review the nurse will notify the provider as needed, and document in nurse's notes. The policy titled Dialysis Access Care, last reviewed 5/2019, documented the different types of access devices for hemodialysis. The policy documented, post dialysis to monitor the dressing, that was changed at the center, for excess bleeding. The nurse should document the location of the catheter, condition of the dressing (interventions if needed), if dialysis was done during shift, any part of report from dialysis nurse post-dialysis being given, and observations post-dialysis. Resident #16 had diagnoses including type II diabetes, end stage renal disease (severe kidney disease) requiring hemodialysis, and a history of methicillin resistant staphylococcus aureus (common antibiotic-resistant bacteria). The Minimum Data Set (a resident assessment tool), dated 11/20/24, documented the resident was cognitively intact, always understood and understands and did not receive hemodialysis at the time of the assessment. Resident #16's Order Listing Report printed 2/12/25, documented an order dated 1/10/25 for an AV (arterial-venous) fistula/AV Graft (dialysis access device, created by combining an artery and a vein), monitor for bruit (sound of pulse in an artery) and thrill (feeling of pulse in an artery) every shift and notify the medical provider for absence, monitor for bleeding, if noted apply pressure and notify the medical provider, and no blood pressure in the left arm. An order dated 1/13/25 documented the resident was to attend dialysis two times a week on Monday and Thursday. An order dated 2/3/25 documented to obtain a weight every day shift. The comprehensive care plan, initiated 1/10/25, documented Resident #16 had impaired renal function (without a catheter) related to end stage renal disease. The care plan did not include the care and monitoring of their dialysis device or the resident's dialysis schedule. Review of the Progress Notes dated 1/10/25 -2/11/25, revealed a nurse note dated 2/6/25 at 12:55 PM that Resident #16 was weighed in their wheelchair and would be leaving for dialysis soon. There were no other notes regarding information related to dialysis or assessment of the resident prior to or after they returned from dialysis and no documented communication with the dialysis center. Review of the nursing evaluations from 1/10/25- 2/11/25, revealed no pre/post dialysis evaluations in the electronic medical record for Resident #16. There were no other assessments regarding information related to dialysis or assessment of the resident prior to or after they returned from dialysis and no documented communication with the dialysis center. Review of the Treatment Administration Records from 1/10/25-2/11/25, revealed nurses documented that they monitored an AV (arterial-venous) fistula/graft for bruit, thrill and bleeding every shift. The resident did not have an AV (arterial-venous) fistula/graft. The Dialysis Communication Book labeled with Resident #16's name was located at the nurse's station on 2/11/25 at 10:15 AM. The book contained blank communication sheets, meant for communication between the facility and the dialysis center and a medication list. During an interview on 2/11/25 at 10:39 AM, Registered Nurse #2 stated that residents that go to dialysis were supposed to take a binder to the center with them and thought the unit manager dealt with that and any communication between the facility and the dialysis center. They stated that staff were supposed to take vital signs and give the resident the medications they may have missed when they returned to the facility. Registered Nurse #2 stated that Resident #16 did not usually come right back to the unit when they came back from dialysis because they stayed downstairs to smoke. They stated the dialysis center staff monitored the fistula in the residents left arm at dialysis. During an interview on 2/11/25 at 11:12 AM, Unit Manager Licensed Practical Nurse #1 stated that when a resident went to dialysis, the medication nurse should send an updated medication list, what medications they received, and a recent weight to the dialysis center with the resident. Then when the resident returned, they should review the communication from the dialysis center and monitor the resident's dialysis device for bleeding. There was a binder for that information that the resident should take with them to dialysis. There is an assessment the nurse was supposed to complete, in the electronic medical record, with the pre and post dialysis information. Unit Manager Licensed Practical Nurse #1 reviewed Resident #16's electronic medical record and stated they were unable to locate any assessments with pre and post dialysis data. They stated that it was important to monitor the resident and communicate with the dialysis center to be sure they were giving the resident the proper care. During an observation and interview on 2/11/25 at 11:35 AM, Resident #16 was in their wheelchair in their room. They revealed their left arm there was a PICC (peripherally inserted central catheter - a catheter that is inserted through a vein and advanced until the tip enters the central venous system) line present, and no evidence of an arterial-venous fistula. Resident #16 had a dressing covering a perma-cath (a long, flexible tube inserted into a vein for long term access to the bloodstream for dialysis) in their left upper chest. Registered Nurse #2 stated they must have misread the order for the AV (arterial-venous) fistula, and they were monitoring the perma-cath when they documented on the Treatment Administration Record. During an interview on 2/11/25 at 12:21 PM, Resident #16 stated they had never brought a communication binder with them to dialysis. They stated that the nurse at dialysis had asked them if they could bring a medication list, but they did not know how to get that information. During an interview on 2/12/25 at 9:37 AM, Physician's Assistant #1 stated communication between the facility and a resident's dialysis center was important because the dialysis center needed to know what medications the resident was on, and if there were any changes. They also need to know what medications the resident got prior to dialysis and what their vital signs were. It was particularly important if the resident had a low blood pressure prior to treatment, and then monitoring how much fluid the dialysis treatment removed and if they had any complications during treatment. They did not know if the facility was sending the communication sheets or completing their pre and post assessments. They did not realize there was an order to monitor an AV (arterial-venous) fistula but stated it should not be there because the resident did not have one. They had a perma-cath in their chest for dialysis. During a telephone interview on 2/12/25 at 11:29 AM, the dialysis center Registered Nurse #8 stated Resident #16 came to the dialysis center twice a week. They stated the facility did not send any information with the resident. Registered Nurse #8 stated it was important to have communication between the facility and the dialysis center because they should at least know the resident's advanced directives, medications they received that day, especially blood pressure medications, what their weights were, and the facility should know if they had any issues during dialysis. During an interview on 2/12/25 at 11:47 AM, the Director of Nursing stated they expected the nurses to give the resident their morning medications and complete the communication sheet prior to going to dialysis. The resident should take the communication binder with them to dialysis and the center should complete their portion for the nurse to review when they came back. They stated there was a pre and post dialysis template in the electronic medical record for the nurse to complete every time the resident went to dialysis. The Director of Nursing was unable to locate any documentation regarding dialysis for Resident #16. They also stated the nurses should not have been documenting on the AV (arterial-venous) fistula on the Treatment Administration Record, they should have told someone that the resident did not have a fistula. The Director of Nursing stated there was no education on dialysis access devices or the procedure for a resident going to dialysis. During an interview on 2/13/25 at 10:50 AM, the Administrator stated there should be communication between the facility and the dialysis center each time the resident went for their treatment. They stated they expected that one of the nurses would have spoken up that the resident did not have an AV (arterial-venous) fistula instead of documenting on something that wasn't there. 10 NYCRR 415.12

Based on observation, interview, and record review conducted during a Standard survey completed on 2/13/25, the facility did not ensure that all drugs and biologicals were securely stored in accordance with State and Federal Laws for one of one facility reviewed for medication storage. Specifically, there were two full boxes that contained discontinued prescription medications for 22 residents located in an unsecured first floor conference room. This involved Resident #'s 10, 21, 23, 31, 32, 34, 35, 51, 60, 69, 70, 79, 81, 85, 130, 133, 135, 502, 503, 504, 505, and 506. Additionally, there was one full box of discontinued prescription medications for 32 residents located on the second floor in a Nurse Manager's office that was open and unlocked. This involved Resident #'s 9, 10, 23, 29, 31, 41, 42, 55, 57, 79, 92, 97, 108, 111, 115, 128, 131, 139, 402, 403, 404, 405, 406, 407, 507, 508, 509, 510, 512, 513, 514, and 515. The findings are: The policy and procedure titled Medication Storage dated 1/2019, documented that medications will be stored in a manner that maintains the integrity of the product, ensures the safety of the residents, and is in accordance with the Department of health guidelines. With exception of Emergency Drug Kits, all medications will be stores in a locked cabinet, cart, or medication room that is accessible only to authorized personnel. During an observation on 2/11/25 at 8:18 AM, the unlocked first-floor conference room had two boxes of medications that were on the floor under a table and were easily visible. Box #1 was unlabeled and unsealed with the top flap of the box opened. Box #2 was labeled discontinued medications and was opened and not sealed. Both boxes contained multiple blister packs of prescription medications and bottles of stock medications that included but not limited to insulin pens, inhalers, antipsychotic (used to treat psychosis) injectable and pill form medications, antibiotics, antidepressants, anxiolytics (used to treat anxiety), anticonvulsants (used to treat seizures), diuretics, corticosteroids (used to treat inflammation), antihypertensives (used to treat high blood pressure) and vitamin supplements. There were no return receipts located in either box of medications. The Resident's involved included Resident #'s 10, 21, 23, 31, 32, 34, 35, 51, 60, 69, 70, 79, 81, 85, 130, 133, 135, 502, 503, 504, 505, and 506. During an interview on 2/11/25 at 9:28 AM, the Director of Nursing stated the boxes of medications located in the conference room were discontinued resident medications waiting to be sent back to the pharmacy. They stated that discontinued medications were to be kept in the medication rooms on the unit or would be placed in their office until they were picked up by pharmacy. The Director of Nursing stated they were unaware how long the boxes of medications had been in the conference room, and that the nursing supervisor may have placed them there because they did not have access to their office. The Director of Nursing stated that the conference room was not considered a medication storage room, and medications should not have been stored there because staff and residents could access the room. During a telephone interview on 2/11/25 at 9:59 AM, Pharmacist #1 stated the pharmacy made two deliveries a day to the facility and would pick up discontinued medications at that time. They stated they would expect the facility to keep discontinued medications locked up and secured to ensure they were not being taken by someone who should not have them and would not want the discontinued medications to be mixed up with the residents' active medications. During an observation and interview on 2/11/25 at 11:31 AM, on the second floor Riverview unit, the nurse managers office was door was open and a full box of medications was on the floor in the office, unsealed and visibly seen. Licensed Practical Nurse Manager #1 stated the box contained discontinued resident medications and that discontinued medications were kept in their office until they arranged a pickup time with the pharmacy. During an observation and interview on 2/11/25 at 3:37 PM, Licensed Practical Nurse Manager #1 revealed the box of prescription medications in their office contained 162 blister packs of resident prescription medications that included but not limited to psychotropic medication, antidepressants, antihypertensive, diuretics, and various prescribed resident inhalers (device to give medication that is inhaled through the nose or mouth). Licensed Practical Nurse Manager #1 stated that they would try to close their office door when they would leave the unit but that it was not always locked. They stated it was possible for residents to enter their office when the door was unlocked. Licensed Practical Nurse Manger #1 stated that they should have taken the discontinued medications down to the Director of Nursing. This involved Resident #'s 9, 10, 23, 29, 31, 41, 42, 55, 57, 79, 92, 97, 108, 111, 115, 128, 131, 139, 402, 403, 404, 405, 406, 407, 507, 508, 509, 510, 512, 513, 514, and 515. During an interview on 2/11/25 at 3:35 PM, Registered Nurse Manager #7 stated discontinued resident medications were boxed up and taken down to the conference room and placed under the table until the pharmacy picked up the medications. Registered Nurse Manager #7 stated the conference room was unlocked during the day and that staff had access to the conference room. They stated they were unsure what time the conference room was locked at night. During an interview on 2/12/25 at 3:13 PM, Licensed Practical Nurse #7, stated supervise on the evening shift (3:00 PM -11:00 PM) and would bring discontinued resident medications to the conference room or would place them in a crate behind the reception desk when they knew the pharmacy was expected. During an interview on 2/13/25 at 10:43 AM, the Administrator stated discontinued resident medications should not be kept in the conference room or out in the open. They stated they were not aware discontinued medications were being placed in the conference room and should not be. The conference room was not considered a secured location, and that residents, staff and visitors would have access to them. The Administrator stated they would expect discontinued resident medications to be kept locked and secured on the units until they were picked up by pharmacy. They stated they would consider the unit manager's office secured only if it was locked and not left opened. 10 NYCRR 415.18 (e) (1-4)

Based on observation, interview and record review conducted during a Standard survey completed 2/13/25, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and a comfortable environment, to help prevent the development and transmission of communicable diseases and infections for four (4) (Residents #39, #96, #119 and #139) of seven (7) residents observed for hands-on care. Specifically, Resident #39 was on Enhanced Barrier Precautions (interventions designed to reduce transmission of multi-drug-resistant organisms including gown and glove use during high contact resident care activities) and staff did not wear a gown during medication and parenteral feed administration through a percutaneous endoscopic gastrostomy tube (a method of delivering liquid nutrition fluids and medicine directly into the stomach), staff did not change gloves or wash their hands after providing fecal incontinence care, and prior to touching clean items; and soiled linens were placed directly on the floor without a barrier in place (#96); staff did not wear a gown while emptying a foley catheter (tube inserted into bladder to drain urine) urine drainage bag (#119); and for Resident #139 staff did not wear a gown while flushing a cholecystostomy tube (a thin tube inserted into the gallbladder to drain infected or blocked fluid). Additionally, Residents #119 and #139 did not have signage that indicated Enhanced Barrier Precautions were required. The findings are: The policy titled Enhanced Barrier Precautions dated 5/30/24, documented enhanced barrier precautions will be initiated and implemented for residents as applicable in accordance with Centers for Medicare & Medicaid Services and/or state regulations and/or in accordance with Centers for Disease Control and Prevention guidance to reduce the risks of transmission of Multiple Drug-Resistant Organisms. Enhanced Barrier Precautions is applicable for residents with any of the following: infection or colonization with a Multiple Drug-Resistant Organisms, wounds (any type of wound requiring a dressing) and/or indwelling medical devices (central line, urinary catheter, feeding tube, etc.) regardless of Multiple Drug-Resistant Organisms colonization status. Enhanced Barrier Precaution requires wearing disposable gloves and an isolation gown prior to high contact activity. High contact resident care activities include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use e.g. central line, urinary catheter, feeding tube, tracheostomy/ventilator and wound care - any skin opening requiring a dressing. Signage is placed on the door or just outside the resident's room to indicate Enhanced Barrier Precautions are in place. The facility's Enhanced Barrier Precautions education power point documented, enhanced barrier precautions are indicated for residents with any of the following: infection or colonization with a Multiple Drug-Resistant Organisms when contact precautions do not otherwise apply or a resident has a wound and/or an indwelling medical device even if the resident is not known to be infected or colonized with a Multiple Drug-Resistant Organisms. Review of the enhanced barrier precaution signage (a sign used by the facility that was supposed to be posted outside a resident's door to indicate they required enhanced barrier precautions) documented that providers and staff must wear gloves and a gown for the following high-contact resident care activities: device care or use: central line, urinary catheter, feeding tube, tracheostomy, and wound care (any skin opening requiring a dressing). The policy titled Hand Hygiene dated 5/30/24 documented, the facility adheres to recommendations by the Centers for Disease Control and Prevention (CDC) for the practice of hand hygiene in accordance with standard, enhanced barrier, and transmission-based precautions. Hand hygiene is performed as a minimum at these times; include before and after contact with a resident, after contact with blood, body fluids, visibly contaminated surfaces, after contact with objects or surfaces in the resident's room, after removing personal protective equipment (gloves, gown, facemask, eye protection). 1a. Resident #39 had diagnoses including osteomyelitis (infection in bone), gastrostomy (an opening into the stomach wall that allows feeding tube insertion), and atrial fibrillation (irregular heart rate). The Minimum Data Set (a resident assessment tool) dated 11/19/24 documented Resident #39 had moderate cognitive impairment, had a feeding tube and received greater than 51% (percent) of their total calories through the feeding tube, for personal hygiene and bathing the resident was dependent on staff to complete all the activity. The comprehensive care plan identified as current by the Director of Nursing, documented the resident had a risk for altered nutrition related to dysphagia, alternate feeding as primary nutritional source. Interventions included to provide feeding and flushes as ordered, monitor for tolerance. The resident had bladder and bowel incontinence, interventions included to check them every 2-4 hours to assist with toileting as needed and to provide incontinence care The Kardex Report (a guide used by staff to provide care) dated 2/10/25 documented Resident #39 was on Enhanced Barrier Precautions. Staff were to wear a gown and gloves when completing high contact activities at the bedside including device care. During an observation on 2/6/25 at 9:13 AM, Resident #39 was in bed in their room. There was a sign on the wall next to their doorway that indicated the resident was on Enhanced Barrier Precautions. There was personal protective equipment in the hallway across from the resident's doorway. During an observation on 2/10/25 at 8:28 AM, Licensed Practical Nurse #7 prepared medications to administer to Resident #39. At 8:38 AM, they entered the resident's room, donned (put on) gloves but did not wear a gown. The Licensed Practical Nurse #7 filled a container with water, used a syringe to draw up water, and accessed the resident's gastrostomy tube. They flushed the tube with water and administered all their medications with water flushes in between each medication. During an interview on 2/10/25 at 8:57 AM, Licensed Practical Nurse #7 stated the resident was on Enhanced Barrier Precautions because they were positive for clostridium difficile (bacteria in the bowel that may cause diarrhea) several months ago but was now asymptomatic. They stated when they did their wound treatments, they followed the Enhanced Barrier Precautions. During an observation on 2/10/25 at 2:50 PM, Licensed Practical Nurse #7 accessed Resident #39's gastrostomy tube wearing gloves and no gown. They flushed the tube with water and connected the tube feeding. During an interview on 2/13/25 at 11:44 AM, the Director of Clinical Operations/Interim Infection Preventionist stated when staff entered a room of a resident on Enhanced Barrier Precautions, they had to don (put on) gown and gloves, and if they felt there was a risk of splash then they could wear a face shield or mask). If staff did not wear personal protective equipment when providing care to a resident on Enhanced Barrier Precautions, they risked the spread of pathogens. The nurse not wearing the gown while administering meds and flushes via the gastrostomy tube put the resident and other residents at risk for the spread of organisms. They stated the nurse providing care was ultimately responsible for ensuring they wear the appropriate personal protective equipment, and they should take accountability. b. During an observation of Resident #39's morning care on 2/11/25 at 9:58 AM, Certified Nurse Aide #6 and Certified Nurse Aide #7 donned a gown and gloves. Certified Nurse Aide #6 unfastened the resident's incontinence brief and cleaned the resident's genitalia and groin. They turned the resident onto their right side and Certified Nurse Aide #6 cleaned the resident's buttocks and anal cleft. There was a moderate amount of feces cleaned off the resident. Without changing their gloves and washing their hands, the Certified Nurse Aide #6 applied a clean incontinence brief, changed the resident's gown and covered the resident with blankets, and used the bed remote to elevate the resident's head of bed. During an interview on 2/11/25 at 12:09 PM, Certified Nurse Aide #6 stated they usually changed their gloves after providing bowel incontinence care, but they forgot because they were being watched. They stated they did this, so they didn't get germs or their dirty gloves on any clean items. During an interview on 2/12/25 at 9:42 AM, the Registered Nurse Unit Manager #7 stated staff should change their gloves and wash their hands when soiled or after providing care for infection control purposes. 2. Resident #96 had diagnoses including fracture of orbital (eye socket) floor, major depressive disorder, and osteoarthritis (chronic degenerative bone disease; breakdown of cartilage and other tissues within the joint). The Minimum Data Set, dated dated dated [DATE], documented Resident #96 was cognitively intact, understands, and was understood. Resident #96 was frequently incontinent of bowel and bladder and was dependent on staff for toileting hygiene. The Kardex with a printout date of 2/13/25 documented Resident #96 was dependent and required a physical assist of one staff member for toileting hygiene. and required partial to substantial assist of one helper for dressing The comprehensive care plan dated 2/30/24, documented Resident #96 was at risk for pressure injury development related to impaired mobility and incontinence. Interventions included to minimize extended exposure of skin to moisture by providing frequent incontinence care and prompt removal of wet/damp clothing or sheets as needed, to turn and position every 2-4 hours as indicated. During an observation of incontinent care on 2/11/25 at 9:20 AM, Certified Nurse Aide #5 performed hand hygiene, applied gloves then performed morning care for Resident #96 by washing, rinsing, and drying the resident's face, neck, underneath their breasts and armpits. Certified Nurse Aide #5 then unfastened the tabs on Resident #96's incontinence brief, tucked it in between their legs and stated they were incontinent of urine. They cleansed their genitalia and perineal area (area between the anus and genitalia) with perineal cleansing spray (no rinse, was applied on to towel), folding the towel over in between each pass. Resident #96 was rolled onto their left side and a moderate amount of brown feces were observed in the crease of their buttock. Certified Nurse Aide #96 cleansed the left buttock, then right buttock, then cleansed the crease from front to back, folding the towel over in between each pass until the feces was removed. The soiled incontinence brief was tucked under the resident, they were rolled onto their right side, and the brief was removed. A new incontinence brief was applied, and resident was rolled onto their back. The brief tabs were fastened, and the soiled towel and incontinence brief were rolled into a ball and placed directly on the bed. There was no barrier in place. Certified Nurse Aide #5 did not remove their gloves or perform hand hygiene, then walked over to Resident #96's closet, grabbed the handle, opened the door and removed pants and a shirt. They put the pants on Resident #96 and secured the tie string of the pants. Grabbed the bed remote, lowered the bed down, and assisted Resident #96 into a sitting position on the side of their bed by grabbing one of Resident #96's hands with their soiled gloved hand. Certified Nurse Aide #5 then donned (put on) Resident #96's shirt, then shoes, grabbed their wheelchair and placed it next to the bed. Then placed the soiled incontinence brief and soiled linen rolled up in a ball directly onto the floor at the end of Resident #96's bed; there was no barrier in place. Certified Nurse Aide #5 assisted Resident #96 into their wheelchair, brushed their hair, and offered to have Resident #96 brush teeth but they stated they wanted to wait. Certified Nurse Aide #5 then removed their gloves and performed hand hygiene. Certified Nurse Aide #5 exited room to look for Resident #96's foot pedals, returned and stated therapy was getting new foot pedals. Placed clean gloves on and picked up soiled brief and linen from Resident #96's floor, exited the room, entered the soiled work room and discarded soiled linen and brief into proper receptacles. Returned to room with foot pedals and placed them on Resident #96's wheelchair and wheeled Resident #96 to the dining room. During an interview on 2/11/25 at 9:52 AM, Certified Nurse Aide #5 stated they did not remove their gloves or perform hand hygiene after performing incontinent care, and they should have. There were urine and feces present and they touched things in the room afterwards. It was important to remove gloves and perform hand hygiene after performing incontinent care because germs could be passed along. Certified Nurse Aide #5 stated they should not have placed the soiled incontinence brief and soiled linen on the bed or floor without a barrier because that was cross contamination. They stated these all were infection control issues. During an interview on 2/11/25 at 9:58 AM, Licensed Practical Nurse #6 stated glove changes and hand hygiene should be performed right after incontinent care, especially if feces were involved. They stated a barrier should always be placed for soiled linen and briefs. It was important to stop the spread of germs. These were basic infection control practices and were important for staff to follow. During an interview on 2/11/25 at 10:31 PM, Licensed Practical Nurse Unit Manager #5 stated glove changes and hand hygiene should always be performed right after incontinent care involving feces and a barrier should be placed for soiled items. During an interview on 2/12/25 at 2:08 PM, the Director of Nursing stated they expected staff to perform glove changes and hand hygiene prior to, frequently during, and following incontinent care, and directly after whenever feces was present. They expected some sort of barrier to be in place for soiled items. These issues were infection control nightmares. During an interview on 2/13/25 at 11:44 AM, the Director of Clinical Operations/ Interim Infection Preventionist stated they expected staff to have a barrier in place for soiled items, they should never be placed directly on the bed or floor to ensure there was no spread of blood borne pathogens or bacteria. They expected staff to perform glove changes immediately after incontinent care before touching anything else in the room, especially if feces were involved. Staff should wash their hands then provide further care to the resident. It was important to perform hand hygiene to stop the spread of pathogens. 3. Resident #119 had diagnoses including chronic kidney disease, diabetes mellitus type 2, and urinary tract infection. The Minimum Data Set, dated dated dated [DATE] documented Resident #119 had moderate cognitive impairment, and an indwelling urinary catheter. The comprehensive care plan dated 11/1/24 documented Resident #119 had an indwelling catheter related neurogenic bladder (a bladder dysfunction caused by nervous system conditions). Interventions include catheter/perineal care and Resident #119 was at risk for infection related to frequent urinary tract infections and chronic indwelling foley catheter. During an observation on 2/7/2025 at 9:11 AM, Nursing Supervisor Registered Nurse #5 was observed emptying Resident #119's foley catheter drainage bag wearing gloves and but not gown. There was no Enhanced Barrier Precaution signage on the resident's door. During an interview on 2/10/25 at 3:11 PM, Nursing Supervisor Registered Nurse #5 stated they emptied Resident #119's foley catheter bag on 2/7/25 and they were not wearing a gown because they didn't need to wear a gown unless they were flushing the catheter tubing. 4. Resident #139 had diagnoses including chronic cholecystitis (inflammation of gallbladder), depression and hypertension. The Minimum Data Set, dated dated dated [DATE] documented Resident #139 was cognitively intact. Resident #139's Kardex dated 12/18/24 documented enhanced barrier precautions, wear gown and gloves when providing high contact activities including, device care. The comprehensive care plan dated 2/7/25 documented Resident #139 was at risk for Multiple Drug-Resistant Organisms colonization/infections related to invasive devices cholecystostomy tube (C-tube), interventions included Enhanced Barrier Precautions dated 2/7/25. During an observation on 2/6/25 at 12:21 PM, Resident #139 had a cholecystostomy tube and there was no Enhanced Barrier Precaution signage on Resident #139's door and no personal protective equipment available outside the resident's room. During an observation on 2/10/25 at 11:38 AM, Enhanced Barrier Precaution signage was on Resident #139's door and Nursing Supervisor Registered Nurse #5 was observed to flush Resident #139's cholecystostomy tube without wearing a gown. During an interview on 2/10/25 at 11:41 AM, Nursing Supervisor Registered Nurse #5 stated they had not noticed the Enhanced Barrier Precaution signage on Resident #139's door or the personal protection bin outside Resident #139's door. They stated they did not know they were on Enhanced Barrier Precautions. Upon reading the enhanced barrier precaution sign Nursing Supervisor Registered Nurse #5 stated they should have been wearing a gown while flushing the cholecystostomy tube for infection control purposes. During an interview on 2/11/25 at 4:25 PM, Registered Nurse Educator #6 stated they educate all staff on policy and procedure of Enhanced Barrier Precautions. All residents with an open wound, an indwelling medical device or a diagnosis of multidrug-resistant organisms' staff should be wearing a gown and gloves and if suspected splash the staff should be wearing a face mask and face shield or goggles. They stated Enhanced Barrier Precautions was to protect the residents and staff while performing high-contact resident care activities. They stated they would have expected Nursing Supervisor Registered Nurse #5 to have worn a gown in addition to wearing the gloves while emptying the foley catheter drainage bag for Resident #119 and while flushing the cholecystostomy tube for Resident #139. During an interview on 2/13/25 at 10:38 AM, Unit Manager Licensed Practical Nurse #1 stated the Enhanced Barrier Precaution signage was posted outside Resident #119's door per the facility's policy after the observation of Nursing Supervisor Register Nurse #5 emptying the foley drainage bag on 2/7/25. They stated they were responsible to ensure the Enhanced Barrier Precaution signage and personal protective equipment set up was in place for residents on their unit. During an interview on 2/13/25 at 11:06 AM, the Director of Clinical Operations/Interim Infection Preventionist stated they would have expected Nursing Supervisor Registered Nurse #5 to have worn a gown in addition to wearing the gloves while emptying the foley catheter drainage bag for Resident #119 and while flushing the cholecystostomy tube for Resident #139. The Director of Clinical Operations stated they would have expected the Infection Control Preventionist and Director of Nursing to have ensured the Unit Managers were following the facility policy and procedures and had the Enhanced Barrier Precaution signage and personal protective equipment bins already in place for Resident #119. 10 NYCRR 415.19(a)(2) (b)(4)

Based on record review and interview conducted during the Standard survey completed on 2/13/25, the facility did not complete and electronically submit encoded, accurate and complete Minimum Data Set (a resident assessment tool) assessments to the Centers for Medicare and Medicaid Services System within the required timeframe for 26 (Resident #4, #5 #6,#9, #14, #17, #18, #27, #28, #30, #47, #63, #66, #67, #78, #80, #82, #103, #109, #110, #118, #122, #125, #127, #132, #145) of 26 residents reviewed for resident assessments. Specifically, Resident #27, #80, #122, #127 and #145's Minimum Data Set assessments were not electronically submitted within 14 days after the assessment completion date. Additionally, Residents #4, #5, #6, #9, #14, #17, #18, #28, #30, #47, #63, #66, #67, #78, #82, #103, #109, #110, #118, #125, and #132 had Minimum Data Set assessments that were not completed within 14 days following their Assessment Reference Date (date of the Minimum Data Set) and had not been submitted. The findings include but are not limited to: The facility policy titled MDS (Minimum Date Set) Completion and Submission dated 10/2019, documented the facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. The Assessment Coordinator or designee shall be responsible for ensuring that resident assessments are submitted to the Centers for Medicare and Medicaid Services. The following timeframes will be observed by this facility: Annual MDS completion date: assessment reference date plus 14 calendar days; Transmission date: care plan completion date plus 14 calendar days. Quarterly MDS completion date: assessment reference date plus 14 calendar days; Transmission date: MDS completion date plus 14 calendar days. 1. Resident #14 was admitted to the facility with diagnoses that included chronic obstructive pulmonary disease (chronic lung disease), atrial fibrillation (irregular heart rate), and schizophrenia (a mental illness). The Quarterly Minimum Data Set, dated dated dated [DATE] was due to be completed by 12/31/24 and had remained incomplete as of 2/13/25, which was 44 days past the required completion date. 2. Resident #103 was admitted to the facility with diagnoses that included diabetes mellitus, chronic obstructive pulmonary disease, and hypertension (high blood pressure). The Annual Minimum Data Set, dated dated dated [DATE] was due to be completed by 12/30/24 and had remained incomplete as of 2/13/25, which was 43 days past the required completion date. 3. Resident #122 was admitted to the facility with diagnoses that included chronic obstructive pulmonary disease, cerebral infarction (stroke), and chronic pain syndrome. The Significant Change in Status Minimum Data Set, dated dated dated [DATE] was signed as complete on 1/12/25 and the care plan decision was completed on 1/19/25. The 12/29/24 Minimum Data Set was transmitted and accepted in the Centers for Medicare and Medicaid System on 2/11/25, which was 9 days past the required timeframe of 14 days after care plan completion. 4. Resident #145 was admitted to the facility with diagnoses that included anorexia (abnormal loss of appetite) and weakness. The Quarterly Minimum Data Set, dated dated dated [DATE] was signed as complete on 1/12/25. The 12/29/24 Minimum Data Set was transmitted and accepted in the Centers for Medicare and Medicaid System on 2/11/25, which was 16 days past the required timeframe of 14 days after completion. Review of the facility's Minimum Data Set in Progress List dated 2/13/25 provided by Registered Nurse #4 Minimum Data Set Coordinator, revealed 164 Minimum Data Set assessments with assessment reference dates from 12/6/24 -1/29/25 remained in progress and had not been completed within 14 days following their assessment reference date. During an interview on 2/13/25 at 9:03 AM, Registered Nurse #4 Minimum Data Set Coordinator stated that they were responsible to sign off the completed Minimum Data Set assessments after all departments had coded their sections and would submit the Minimum Data Set assessments to the Centers for Medicare and Medicaid Services once a week. Registered Nurse #4 Minimum Data Set Coordinator stated that they believed they had 2 weeks to complete the Minimum Data Set assessments from the assessment reference date and 2 weeks to submit the Minimum Data Set assessments after the completion date. They stated that they would look in the electronic medical record to determine when the assessments were due. Registered Nurse #4 Minimum Data Set Coordinator stated that they had some late submissions, they had been busy, and assessments were overlooked. Registered Nurse #4 Minimum Data Set Coordinator stated that they had several late Minimum Data Set assessments that remained in progress and that they had been waiting on other departments to complete their sections. They stated that there had been staffing changes in the social work department and that their Regional Director of Clinical Reimbursement and Administrator had been aware of all overdue Minimum Data Set assessments. During an interview on 2/13/25 at 10:37 AM, the Administrator stated that they had been aware of the multiple Minimum Data Set assessments that were in progress and had not been completed by the due date. They stated that the Minimum Data Set Coordinator and the Regional Director of Clinical Reimbursement communicated with them regarding late assessments. The Administrator stated that they fell behind due to staffing shortages in the social work department and that they had just hired a new Social Work Director. During an interview on 2/13/25 at 2:16 PM, the Regional Director of Clinical Reimbursement stated that they reviewed the Minimum Data Set in progress list daily in the electronic medical record and were aware of the overdue assessments. They stated that the assessments were not being completed timely due to staffing issues with the social work department and that they recently hired an additional Minimum Data Set Coordinator that needed to be trained. The Regional Director of Reimbursement stated that the Minimum Data Set assessments should be completed within 14 days of the assessment reference date and should be transmitted within 14 days of the completion date. They stated they would expect all Minimum Data Set assessments to be completed and transmitted within the required timeframe but had been difficult to complete due to staffing and that they do what they can. 10 NYCRR 415.11

Based on observation, interview, and record review during the Standard survey completed on 2/13/25, the facility did not operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes. Specifically, the facility was not in compliance with Section 915 of the 2020 Fire Code of New York State, which requires carbon monoxide detection in buildings with fuel-burning appliances and on-going preventative maintenance of carbon monoxide detectors. This affected three (first, second, and third floors) of three resident use floors in the front building. The finding is: The policy and procedure titled Carbon Monoxide (CO) Detector Policy, created 4/25/24, documented the facility shall install carbon monoxide detectors in quantities and locations as necessary to comply with applicable life safety code and any other local ordinance. The carbon monoxide detectors shall be inspected periodically for function but no less than annually. Observations during the building tour on 2/6/25 from 8:30 AM until 1:40 PM revealed fuel-burning appliances were located on the first floor of the front building and resident sleeping rooms were located on the second and third floors of the front building. Further observation revealed single-station battery-operated carbon monoxide detectors were located on the first, second, and third floors of the front building. The User's Guide for the carbon monoxide detectors documented to keep your alarm in good working order, you must test the alarm once a week by pressing the test/ reset button and vacuum the alarm cover once a month to remove accumulated dust. Review of the log titled Carbon Monoxide Detector Audit revealed entries were dated 11/21/23, 12/23, 1/1/24, 2/3/24, 3/5/24, and 8/24. Further review revealed the number of carbon monoxide detectors on the logs was inconsistent and ranged from four to six. During an interview on 2/7/25 at 2:55 PM, the Assistant Maintenance Director stated there were a total of seven carbon monoxide detectors in the facility and Maintenance Assistant #2 was checking them monthly until they left employment in August 2024. They stated they could not locate Carbon Monoxide Detector Audit logs for April, May, June, or July 2024. The Assistant Maintenance Director also stated they personally checked carbon monoxide detectors periodically, at least two times per week, but did not document their checks. During an interview on 2/12/25 at 10:34 AM, the Maintenance Director stated they based frequency of preventative maintenance on manufacturers' instructions, and in this case, the carbon monoxide detectors should be tested weekly and vacuumed monthly. They further stated they had been the Maintenance Director at this facility for less than two weeks. During an interview on 2/12/25 at 12:47 PM, the Administrator stated they expected testing of all equipment by maintenance staff to be documented. 42 CFR 483.70(b) 10NYCRR: 415.29(a)(2), 711.2(a)(1) 2020 Fire Code of New York State, Section 915: 915.3.1, 915.6

Based on observation, interview and record review conducted during an Onsite Post Survey Revisit #1 completed on 4/24/25, the facility did not ensure that in accordance with accepted professional standards and practices, they maintained medical records on each resident that were complete; accurately documented; readily accessible; and systematically organized for three (3) (Resident #2, #16 and #127) of eleven residents reviewed. Specifically, treatment orders for PICC line (peripherally inserted central catheter) dressing changes and measurements of their arm circumference were not documented as completed and the orders did not include external migration (displacement) measurements (#2). Additionally, Resident #16 and Resident #127 did not have physician orders to receive dialysis treatments and their dialysis binders (communication book) did not include updated orders. The findings are: The policy and procedure titled Documentation and Charting dated 1/20 documented all services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. All observations, medications, services performed, etc., must be documented in the clinical records. The facility utilizes an electronic health record for clinical documentation. The policy and procedure titled Dialysis Management dated 5/19 documented the nurse will obtain orders for monitoring of site and interventions as appropriated. Orders are to include hemodialysis center, location, contact number and scheduled days. 1. Review of Standard Survey Statement of Deficiencies (form 2567) issued by the New York State Department of Health with an exit date 2/13/25 revealed the facility was cited for the lack of physician orders and assessments for monitoring arm circumference, external length, dressing changes and flushes for the peripherally inserted central catheter. Per the facilities plan of corrections all residents were reviewed to ensure there was physician orders for documentation of site monitoring/care. Resident #2 was admitted to the facility with diagnoses osteomyelitis (infection in the bone) of the left foot and ankle, pressure ulcer of the left heel and chronic ulcer of the right lower leg. The Minimum Data Set (a resident assessment tool) dated 3/27/25 documented Resident #2 was cognitively intact, understands, and was understood. The assessment tool documented Resident #2 was on intravenous (IV) medications. Review of the medical providers orders active orders dated 3/27/25 to measure arm circumference (X) inches above insertion on admission and weekly and apply an transdermal intravenous (IV) dressing weekly on the day shift with a start date 3/26/25. Additionally, the orders with last review date of 4/3/25 did not include an order to measure their peripherally inserted central catheter length measured from insertion site to tip of hub (migration/displacement measurement) as per the plan of correction. The treatment administration record dated 4/1/25 - 4/30/25 documented Resident #2's arm circumference was to be measured above insertion site weekly on 4/3/25, 4/10/25 and 4/17/25. There was no documented evidence the resident's arm circumference measurement was completed, and the record was blank. The arm circumference did not indicate the inches above the insertion site to measure the arm circumference and an x was documented. In addition, the PICC line dressing (transdermal intravenous dressing) was to be changed weekly on 4/3/25, 4/10/25 and 4/17/25. There was no documented evidence the dressing change was completed, and the record was blank. During an observation on 4/23/25 at 11:01 AM, Resident #2 was in bed and had a PICC line (peripherally inserted central catheter) inserted in their right upper arm. The peripherally inserted central catheter dressing was intact but was not dated. During an interview at the time of the observation Resident #2 stated they had received (IV) intravenous medication but they thought the medication was completed. They stated staff had been changing the dressing to the intravenous (IV) site. During an interview on 4/24/25 at 1:40 PM, Registered Nurse Educator #1 stated for the past couple weeks they had been doing the weekly PICC line dressing changes, measuring arm circumferences, and measuring the lengths on all of the intravenously (IV) lines in the facility. They stated they were not necessarily responsible for completing those treatments but since they have been the Registered Nurse in the building, they had been doing them. Registered Nurse Educator #1 stated they had measured Resident #2's arm circumference weekly and changed the resident's PICC (peripherally inserted central catheter) line dressing weekly but had not signed off them off as completed in the electronic treatment record. They stated they had been multitasking and did not go back into the treatment record to sign them off as completed but they should have. Registered Nurse Educator #1 stated Resident #2's order for arm circumference just had an x to indicate the centimeters of Resident #2 arm circumference but there should have been the actual number in centimeters documented. During an interview on 4/24/25 at 2:00 PM, the Director of Nursing stated treatments should be documented as completed in the treatment record. They stated Resident #2 had an incomplete treatment administration record. The Director of Nursing stated they did not see an order for Resident #2 to have their peripherally inserted central catheter line length measured from insertion site to tip of hub. They stated they were responsible for the initial peripherally inserted central catheter orders for Resident #2 and must have omitted or unclicked the batch order for it. They stated that every resident should have had an order to measure the peripherally inserted central catheter length from insertion site to tip of hub per the facilities plan of corrections. During an interview on 4/24/25 at 2:56 PM, the Administrator stated their expectation would be that all treatments were completed as ordered and were signed off as given in the resident's medical record. If the treatments were not documented as completed it would be an incomplete record. 2a. Resident #16 had diagnoses that included end stage renal (kidney) disease with dependence on renal dialysis (process of purifying the blood of a person whose kidneys are not working normally), and diabetes mellitus. The Minimum Data Set, dated dated dated [DATE] documented Resident #16 was cognitively intact and received dialysis treatments The Comprehensive Care Plan initiated 11/20/24, documented Resident #16 had impaired renal function related to end stage renal (kidney) disease. The care plan did not include goals and interventions for renal dialysis. Review of the Visual/Bedside Kardex Report (guide used by staff to provide care) dated 4/24/25 revealed there was no documented evidence that Resident #16 received dialysis treatments. The Treatment Administration Record dated 4/1/25 - 4/30/25 documented the nurses monitored a Permacath/Central Catheter (flexible tube inserted into a large vein in the neck or chest) for signs of bleeding and placement every shift for dialysis. There was no documented evidence on the Treatment Administration Record that included the frequency and scheduled days of dialysis treatments. Review of the Order Listing Report (physician's orders) with date range 1/1/25 - 4/30/25 revealed there were no active orders in place for Resident #16 to receive dialysis treatments. During an interview on 4/23/25 at 11:52 PM, Licensed Practical Nurse #6 stated residents who received dialysis should have a physician's order in the electronic medical record that included their scheduled days, and it would sometimes be documented on the Medication Administration Record for them to sign off. They stated Resident #16 went to dialysis two times a week. During an interview on 4/24/25 at 1:52 PM, Licensed Practical Nurse Manager #3 stated that all residents who received dialysis should have a physician's order in the electronic medical record that included the frequency and time of their treatment. Licensed Practical Nurse Manager #3 reviewed Resident #16's physician orders in the electronic medical record and stated there was no current physician orders in place for them to receive dialysis. They stated Resident #16 had an order for their Permacath site to be monitored every shift and should have had a physician's order to receive dialysis treatment. b. Review of Standard Survey Statement of Deficiencies (form 2567) issued by the New York State Department of Health with an exit date 2/13/25 revealed the facility was cited lack of ongoing monitoring upon leaving the facility and returning from hemodialysis. Per the facilities plan of correction Resident #16's communication book was updated with current medication list and a full house review of all the residents receiving hemodialysis communication binders were to be reviewed. Review of Resident #16's dialysis communication binder on 4/24/25 at 12:29 PM revealed the Order Summary Report in Resident #16's binder reflected active orders as of 1/28/25 and did not include their correct type of dialysis site (Permacath -a flexible tube inserted into a large vein in the neck or chest), or current dialysis days. During an interview on 4/24/25 at 1:36 PM, Licensed Practical Nurse Manger #3 stated every resident would have their own dialysis binder that include a copy of their face sheet, physician orders, and dialysis communication forms. They stated the dialysis binders should be updated anytime there was a change to the resident' s physician orders. Licensed Practical Nurse Manager #3 stated they were responsible to update orders in the binders, this was important for the dialysis center to be aware of the resident's current physician orders. 3a. Resident #127 had diagnoses that included end stage renal (kidney) disease with dependence on renal dialysis, and diabetes mellitus. The Minimum Data Set, dated dated dated [DATE] documented that Resident #127 was cognitively intact and received dialysis treatments. The Comprehensive Care Plan initiated 8/1/24 documented Resident #127 needed hemodialysis related to end stage renal disease three times a week. Interventions included (but not limited to) monitor/document any signs of infection to access site; monitor Permacath site for bleeding and placement; and to encourage Resident #1 to go to their scheduled dialysis appointments. Review of the Visual/Bedside Kardex Report dated 4/24/25 revealed there was no documented evidence that Resident #127 received dialysis treatments. Review of the Treatment Administration Record dated 4/1/25 - 4/30/25 revealed nurses documented they monitored Resident #127's Permacath/Central Catheter for signs of bleeding and placement every shift for dialysis. There was no documented evidence on the Treatment Administration Record that included the frequency and scheduled days of dialysis treatments. The Order Listing Report (physicians orders) that included active, completed, and discontinued physician orders, revealed there was no active order in place from 3/18/25 - 4/24/25 for Resident #127 to receive dialysis treatments three times a week. During an interview on 4/24/25 at 12:05 PM, Licensed Practical Nurse #7 stated there should be an order in the electronic medical record documenting what days residents went to dialysis. Licensed Practical Nurse #7 stated Resident #127 received dialysis three times a week. During an interview on 4/24/25 at 1:53 PM, the Director of Nursing stated they would expect all residents who received dialysis to have a physician's order that included their specific days, frequency, dialysis center, and time of appointment. The Director of Nursing reviewed Resident #16 and Resident #127's physician's orders in the electronic medical record and stated there were no active orders for their dialysis treatments. They stated Resident #16 and Resident #127's order for dialysis had not been re-activated upon readmission to the facility and should have been. During an interview on 4/24/25 at 1:55 PM, the Director of Clinical Operations stated dialysis orders were expected to be obtained on admission/re-admission specifying treatment and frequency. They stated both Resident #16 and Resident #127 should have had a physician's order in place for their dialysis treatment. b. Review of Resident #127's dialysis communication binder on 4/24/25 at 9:14 AM revealed the Order Summary Report in Resident #127's binder reflected active orders as 1/28/25. During an interview on 4/24/25 at 1:53 PM, the Director of Nursing stated the dialysis binders would need to be updated if there was a change to the resident's schedule or when mediation changes occurred. The Director of Nursing stated the Order Summary Report dated 1/28/25 for Resident #16 and Resident #127 was not current had would have expected the Unit Managers to have updated both residents' dialysis binders with a current medication list. Further interview at 3:19 PM, the Director of Nursing stated all Unit Managers were educated regarding the plan of correction and were aware of what information needed to be included in each dialysis binder. They stated the Unit Managers were responsible to update each dialysis binder and that they were responsible to ensure the plan of correction was completed. The Director of Nursing stated a new medication list should have been printed and added to Resident #16 and Resident 127's dialysis binders on re-admission. NYCRR 10 415.22(a) (1-4)

Based on observation, interview and record review conducted during an Onsite Post Survey Revisit #1 completed on 4/24/25, the facility did not ensure that in accordance with accepted professional standards and practices, they maintained medical records on each resident that were complete; accurately documented; readily accessible; and systematically organized for three (3) (Resident #2, #16 and #127) of eleven residents reviewed. Specifically, treatment orders for PICC line (peripherally inserted central catheter) dressing changes and measurements of their arm circumference were not documented as completed and the orders did not include external migration (displacement) measurements (#2). Additionally, Resident #16 and Resident #127 did not have physician orders to receive dialysis treatments and their dialysis binders (communication book) did not include updated orders. The findings are: The policy and procedure titled Documentation and Charting dated 1/20 documented all services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. All observations, medications, services performed, etc., must be documented in the clinical records. The facility utilizes an electronic health record for clinical documentation. The policy and procedure titled Dialysis Management dated 5/19 documented the nurse will obtain orders for monitoring of site and interventions as appropriated. Orders are to include hemodialysis center, location, contact number and scheduled days. 1. Review of Standard Survey Statement of Deficiencies (form 2567) issued by the New York State Department of Health with an exit date 2/13/25 revealed the facility was cited for the lack of physician orders and assessments for monitoring arm circumference, external length, dressing changes and flushes for the peripherally inserted central catheter. Per the facilities plan of corrections all residents were reviewed to ensure there was physician orders for documentation of site monitoring/care. Resident #2 was admitted to the facility with diagnoses osteomyelitis (infection in the bone) of the left foot and ankle, pressure ulcer of the left heel and chronic ulcer of the right lower leg. The Minimum Data Set (a resident assessment tool) dated 3/27/25 documented Resident #2 was cognitively intact, understands, and was understood. The assessment tool documented Resident #2 was on intravenous (IV) medications. Review of the medical providers orders active orders dated 3/27/25 to measure arm circumference (X) inches above insertion on admission and weekly and apply an transdermal intravenous (IV) dressing weekly on the day shift with a start date 3/26/25. Additionally, the orders with last review date of 4/3/25 did not include an order to measure their peripherally inserted central catheter length measured from insertion site to tip of hub (migration/displacement measurement) as per the plan of correction. The treatment administration record dated 4/1/25 - 4/30/25 documented Resident #2's arm circumference was to be measured above insertion site weekly on 4/3/25, 4/10/25 and 4/17/25. There was no documented evidence the resident's arm circumference measurement was completed, and the record was blank. The arm circumference did not indicate the inches above the insertion site to measure the arm circumference and an x was documented. In addition, the PICC line dressing (transdermal intravenous dressing) was to be changed weekly on 4/3/25, 4/10/25 and 4/17/25. There was no documented evidence the dressing change was completed, and the record was blank. During an observation on 4/23/25 at 11:01 AM, Resident #2 was in bed and had a PICC line (peripherally inserted central catheter) inserted in their right upper arm. The peripherally inserted central catheter dressing was intact but was not dated. During an interview at the time of the observation Resident #2 stated they had received (IV) intravenous medication but they thought the medication was completed. They stated staff had been changing the dressing to the intravenous (IV) site. During an interview on 4/24/25 at 1:40 PM, Registered Nurse Educator #1 stated for the past couple weeks they had been doing the weekly PICC line dressing changes, measuring arm circumferences, and measuring the lengths on all of the intravenously (IV) lines in the facility. They stated they were not necessarily responsible for completing those treatments but since they have been the Registered Nurse in the building, they had been doing them. Registered Nurse Educator #1 stated they had measured Resident #2's arm circumference weekly and changed the resident's PICC (peripherally inserted central catheter) line dressing weekly but had not signed off them off as completed in the electronic treatment record. They stated they had been multitasking and did not go back into the treatment record to sign them off as completed but they should have. Registered Nurse Educator #1 stated Resident #2's order for arm circumference just had an x to indicate the centimeters of Resident #2 arm circumference but there should have been the actual number in centimeters documented. During an interview on 4/24/25 at 2:00 PM, the Director of Nursing stated treatments should be documented as completed in the treatment record. They stated Resident #2 had an incomplete treatment administration record. The Director of Nursing stated they did not see an order for Resident #2 to have their peripherally inserted central catheter line length measured from insertion site to tip of hub. They stated they were responsible for the initial peripherally inserted central catheter orders for Resident #2 and must have omitted or unclicked the batch order for it. They stated that every resident should have had an order to measure the peripherally inserted central catheter length from insertion site to tip of hub per the facilities plan of corrections. During an interview on 4/24/25 at 2:56 PM, the Administrator stated their expectation would be that all treatments were completed as ordered and were signed off as given in the resident's medical record. If the treatments were not documented as completed it would be an incomplete record. 2a. Resident #16 had diagnoses that included end stage renal (kidney) disease with dependence on renal dialysis (process of purifying the blood of a person whose kidneys are not working normally), and diabetes mellitus. The Minimum Data Set, dated [DATE] documented Resident #16 was cognitively intact and received dialysis treatments The Comprehensive Care Plan initiated 11/20/24, documented Resident #16 had impaired renal function related to end stage renal (kidney) disease. The care plan did not include goals and interventions for renal dialysis. Review of the Visual/Bedside [NAME] Report (guide used by staff to provide care) dated 4/24/25 revealed there was no documented evidence that Resident #16 received dialysis treatments. The Treatment Administration Record dated 4/1/25 - 4/30/25 documented the nurses monitored a Permacath/Central Catheter (flexible tube inserted into a large vein in the neck or chest) for signs of bleeding and placement every shift for dialysis. There was no documented evidence on the Treatment Administration Record that included the frequency and scheduled days of dialysis treatments. Review of the Order Listing Report (physician's orders) with date range 1/1/25 - 4/30/25 revealed there were no active orders in place for Resident #16 to receive dialysis treatments. During an interview on 4/23/25 at 11:52 PM, Licensed Practical Nurse #6 stated residents who received dialysis should have a physician's order in the electronic medical record that included their scheduled days, and it would sometimes be documented on the Medication Administration Record for them to sign off. They stated Resident #16 went to dialysis two times a week. During an interview on 4/24/25 at 1:52 PM, Licensed Practical Nurse Manager #3 stated that all residents who received dialysis should have a physician's order in the electronic medical record that included the frequency and time of their treatment. Licensed Practical Nurse Manager #3 reviewed Resident #16's physician orders in the electronic medical record and stated there was no current physician orders in place for them to receive dialysis. They stated Resident #16 had an order for their Permacath site to be monitored every shift and should have had a physician's order to receive dialysis treatment. b. Review of Standard Survey Statement of Deficiencies (form 2567) issued by the New York State Department of Health with an exit date 2/13/25 revealed the facility was cited lack of ongoing monitoring upon leaving the facility and returning from hemodialysis. Per the facilities plan of correction Resident #16's communication book was updated with current medication list and a full house review of all the residents receiving hemodialysis communication binders were to be reviewed. Review of Resident #16's dialysis communication binder on 4/24/25 at 12:29 PM revealed the Order Summary Report in Resident #16's binder reflected active orders as of 1/28/25 and did not include their correct type of dialysis site (Permacath -a flexible tube inserted into a large vein in the neck or chest), or current dialysis days. During an interview on 4/24/25 at 1:36 PM, Licensed Practical Nurse Manger #3 stated every resident would have their own dialysis binder that include a copy of their face sheet, physician orders, and dialysis communication forms. They stated the dialysis binders should be updated anytime there was a change to the resident' s physician orders. Licensed Practical Nurse Manager #3 stated they were responsible to update orders in the binders, this was important for the dialysis center to be aware of the resident's current physician orders. 3a. Resident #127 had diagnoses that included end stage renal (kidney) disease with dependence on renal dialysis, and diabetes mellitus. The Minimum Data Set, dated [DATE] documented that Resident #127 was cognitively intact and received dialysis treatments. The Comprehensive Care Plan initiated 8/1/24 documented Resident #127 needed hemodialysis related to end stage renal disease three times a week. Interventions included (but not limited to) monitor/document any signs of infection to access site; monitor Permacath site for bleeding and placement; and to encourage Resident #1 to go to their scheduled dialysis appointments. Review of the Visual/Bedside [NAME] Report dated 4/24/25 revealed there was no documented evidence that Resident #127 received dialysis treatments. Review of the Treatment Administration Record dated 4/1/25 - 4/30/25 revealed nurses documented they monitored Resident #127's Permacath/Central Catheter for signs of bleeding and placement every shift for dialysis. There was no documented evidence on the Treatment Administration Record that included the frequency and scheduled days of dialysis treatments. The Order Listing Report (physicians orders) that included active, completed, and discontinued physician orders, revealed there was no active order in place from 3/18/25 - 4/24/25 for Resident #127 to receive dialysis treatments three times a week. During an interview on 4/24/25 at 12:05 PM, Licensed Practical Nurse #7 stated there should be an order in the electronic medical record documenting what days residents went to dialysis. Licensed Practical Nurse #7 stated Resident #127 received dialysis three times a week. During an interview on 4/24/25 at 1:53 PM, the Director of Nursing stated they would expect all residents who received dialysis to have a physician's order that included their specific days, frequency, dialysis center, and time of appointment. The Director of Nursing reviewed Resident #16 and Resident #127's physician's orders in the electronic medical record and stated there were no active orders for their dialysis treatments. They stated Resident #16 and Resident #127's order for dialysis had not been re-activated upon readmission to the facility and should have been. During an interview on 4/24/25 at 1:55 PM, the Director of Clinical Operations stated dialysis orders were expected to be obtained on admission/re-admission specifying treatment and frequency. They stated both Resident #16 and Resident #127 should have had a physician's order in place for their dialysis treatment. b. Review of Resident #127's dialysis communication binder on 4/24/25 at 9:14 AM revealed the Order Summary Report in Resident #127's binder reflected active orders as 1/28/25. During an interview on 4/24/25 at 1:53 PM, the Director of Nursing stated the dialysis binders would need to be updated if there was a change to the resident's schedule or when mediation changes occurred. The Director of Nursing stated the Order Summary Report dated 1/28/25 for Resident #16 and Resident #127 was not current had would have expected the Unit Managers to have updated both residents' dialysis binders with a current medication list. Further interview at 3:19 PM, the Director of Nursing stated all Unit Managers were educated regarding the plan of correction and were aware of what information needed to be included in each dialysis binder. They stated the Unit Managers were responsible to update each dialysis binder and that they were responsible to ensure the plan of correction was completed. The Director of Nursing stated a new medication list should have been printed and added to Resident #16 and Resident 127's dialysis binders on re-admission. NYCRR 10 415.22(a) (1-4)

Based on observation, interview, and record review conducted during an Abbreviated (#NY00351834) survey completed on 2/7/25, the facility did not provide pharmaceutical services to meet the needs of each resident and the facility did not ensure that drug records were in order and that an account of all controlled drugs are maintained and periodically reconciled for four (River View, Harbor View, City View, and Sky View) of four units. Specifically, on 8/19/24, 93 narcotic (medication used to treat moderate to severe pain) medications were unaccounted for on the River View unit. Additionally, on 2/5/25 one narcotic reconciliation book with the keys to a medication cart and narcotic cupboard were left unattended in the River View medication room, and two narcotic reconciliation books with the keys to 2 medication carts and 2 narcotic cupboards were left unattended in the Sky View medication room. Licensed Practical Nurse #1 was observed to have completed a narcotic reconciliation by themselves without the presence of the nurse going off duty on City View. Furthermore, the controlled drug records for all the unit shift to shift counts were not consistently signed off as completed. The findings are: The facility policy titled Controlled Substance Management dated 8/22 documented the medication nurse is responsible for proper storage of controlled drugs in a double door, double locked, double keyed, steel, wall mounted, controlled drug cabinet during non-med pass times and in locked controlled drug compartment of medication cart during med pass times. Additionally, separate records shall be maintained on all controlled substances in the form of a declining inventory record. Such records shall be accurately maintained, and such records shall be reconciled by the incoming and outgoing nurse. Two nurses must count the remaining medication at each shift and any handoff of narcotic keys. 1. The facility Investigation Form dated 8/22/24 documented at approximately 7:15 AM on 8/19/24 Administrative staff were notified several narcotic blister packs were missing from the River View medication room. Licensed Practical Nurse #2 arrived for the day shift on 8/19/24, Licensed Practical Nurse #3 had left the facility prior to completing a narcotic reconciliation with the incoming nurse. Licensed Practical Nurse #2 completed the narcotic reconciliation alone and discovered 5 narcotic blister packs were missing. The following narcotic medications were missing: -Norco 10/325 mg (milligrams) 10 tablets. -Oxycontin 5 mg (milligrams) 7 tablets. -Percocet 5/325 mg (milligrams) 47 tablets. -Hydrocodone/Acetaminophen 7.5/325 mg (milligrams) 29 tablets. The facility investigation documented the keypad to access River View medication room was not functioning and staff were able to access the medication room via employee swipe badge thus bypassing the keypad. The River View maintenance log documented staff reported the lock on the narcotic cupboard was broken. The log notated a lock was ordered on 7/15/24. The statement signed and dated by maintenance on 2/5/25 documented the lock on the narcotic cupboard was repaired on 8/19/24, after the narcotics went missing. During an observation of the River View medication room on 2/5/25 at 6:34 AM, one narcotic reconciliation book was observed with the keys to a medication cart and narcotic cupboard placed inside the front cover of each book. During an observation of the Sky View medication room on 2/5/25 at 7:06 AM, two narcotic reconciliation books were observed sitting on the counter with two sets of keys to the medication carts and narcotic cupboards placed next to the narcotic books. During a telephone interview on 2/5/25 at 1:10 PM, Registered Nurse #1 stated they worked on the River View unit in August 2024 and the keypad access to the River View medication room was not functioning. Additionally, the lock on one of the narcotic cupboards affixed to the wall was broken. During a telephone interview on 2/6/25 at 6:09 AM, Licensed Practical Nurse #3 stated they worked on the River View unit 8/19/24 until 7:00 AM and instead of counting the narcotic medications with the oncoming nurse, they reconciled the narcotic medications alone. They stated the count was correct when they left the keys in the narcotic book and left the building. Additionally, they stated the locks on the narcotic cabinet were broken. During a telephone interview on 2/5/25 at 10:07 AM, the Registered Nurse Director of Nursing at the time of the incident stated there was a malfunction of the keypad on the River View medication room door on 8/19/24 and employees were able to utilize their badge to access the medication room. Additionally, no staff were able to state how long the keypad had been malfunctioning. Furthermore, they directed maintenance to repair the keypad and the narcotic cupboard lock. During a telephone interview on 2/5/25 at 10:18 AM, the consultant Pharmacist stated narcotics should be store appropriately based on all laws/regulations and double locked. Additionally, it was unacceptable to leave narcotic and medication cart keys in the medication room without reconciling the narcotics with the oncoming shift. 2a. During an observation/interview in the medication room on the City View unit on 2/5/25 at 7:00 AM, Licensed Practical Nurse #1 was observed performing a narcotic count reconciliation with no other nurse present. Licensed Practical Nurse #1 stated the narcotic and medication cart keys were left in the medication room with the narcotic reconciliation book by the nurse from the 11:00 PM - 7:00 AM shift. Additionally, Licensed Practical Nurse #1 stated they frequently count the narcotics alone. 2b. Review of the Shift Count (Narcotic Count Records) from 1/5/25-2/4/25 the following lacked documented evidence that narcotic reconciliation was completed by the oncoming and outgoing nurses: - River View A side cart had 68 shifts - River View B side cart had 55 shifts - Harbor View A side cart had 56 shifts - Harbor View B side cart had 35 shifts - City View A side cart had 40 shifts - City View B side cart had 46 shifts - Sky View A side cart had 77 shifts - Sky View B side cart had 48 shifts During an interview on 2/5/25 at 9:30 AM, the Director of Nursing stated narcotics should be reconciled by the outgoing and incoming nurse prior to the exchange of keys to ensure a correct narcotic count and prevent diversion. Additionally, it was unacceptable to leave the narcotic and medication cart keys in the medication room without performing the narcotic reconciliation with the outgoing and oncoming nurse. During a telephone interview on 2/5/25 at 10:18 AM, the consultant Pharmacist stated narcotics should be store appropriately based on all laws/regulations and it was unacceptable to leave narcotic and medication cart keys in the medication room without reconciling the narcotics with the oncoming shift. Additionally, narcotics should be reconciled every shift to ensure the narcotic count is accurate and to prevent diversion. 10 NYCRR 415.18(a)(b)(3)

Based on interview and record review conducted during an Abbreviated survey (Complaint #NY00359366), the facility did not ensure that all residents had the right to formulate advanced directives that would be honored for one (Resident #1) of six residents reviewed. Specifically, Cardiopulmonary Resuscitation (CPR) was implemented for Resident #1 who had a MOLST (Medical Orders for Life Sustaining Treatment) identifying the resident's wishes as Do Not Resuscitate (DNR). The finding is: The policy and procedure titled Advance Directive and State Specific Medical Orders for Life Sustaining Treatment-New York dated [DATE] documented residents have the right to formulate an advance directive and to request, refuse and discontinue treatments. An advance directive is a written statement of a person's wishes regarding medical treatment made to ensue those wishes are carried out should the person be unable to communicate them to a physician. New York State uses the Medical Orders for Life-sustaining Treatment. A physician order shall be obtained and entered into the electronic medical record following consent of the resident/representative. The policy and procedure titled Code Blue/CPR (Cardiopulmonary Resuscitation) dated [DATE] documented the facility will provide emergency cardiopulmonary resuscitation in accordance with the resident end of life determinations, example: Medical Orders for Life Sustaining Treatment (MOLST). The policy documented that cardiopulmonary resuscitation will be initiated upon recognition of cardiopulmonary arrest in accordance with the resident code status (full code). The policy and procedure titled Resident Identification dated [DATE] documented a resident identification system is used to assist facility personnel to accurately identify a resident. The facility had adopted a photo and/or wristband identification system to help assure that medication, treatment, and services are administered to the correct resident. Resident #1 had diagnoses that included malignant neoplasm of the brain, lung, and lymph nodes, chronic obstructive pulmonary disease (COPD), and hypertension (high blood pressure). The Minimum Data Set (a resident assessment tool) dated [DATE] documented Resident #1 was cognitively intact and was understood. The Medical Orders for Life Sustaining Treatment (MOLST) form dated [DATE] at 12:18 PM documented Resident #1's advanced directive status as DNR (do not resuscitate) and a DNI (do not intubate). An updated Medical Orders for Life Sustaining Treatment form dated [DATE] at 12:57 PM, documented Resident #1's advanced directive status as DNR (do not resuscitate) and a DNI (do not intubate). The form was updated to include not send to the resident to the hospital and was comfort measures only. The comprehensive care plan dated [DATE] documented Resident #1 had a Medical Orders for Life Sustaining Treatment (MOLST) form in place. The Medical Providers Orders dated [DATE] documented do not attempt resuscitation and do not intubate. A Progress Note completed by the Director of Social Work dated [DATE] at 12:14 PM, documented they spoke with Resident #1 and their Health Care Proxy (HCP) who wanted the Medical Orders for Life Sustaining Treatment form to reflect: do not attempt resuscitation, do not intubate with limited medical interventions. A Progress Noted dated [DATE] at 4:30 AM, the Director of Nursing documented on [DATE] at 4:00 AM Resident #1 was discovered unresponsive with no evidence of vital signs (heartbeat, respirations). Nurse was called to the room, the Medical Orders for Life Sustaining Treatment verified by the nurse and cardiopulmonary resuscitation was initiated. 911 (emergency medical service) was called and arrived at which time it was discovered that Resident #1 actually had a do not resuscitate status. The note documented the paramedics did not continue cardiopulmonary resuscitation and Resident #1 expired at 4:00 AM. The facility investigation dated [DATE] documented that on [DATE] at approximately 3:50 AM Resident #1 was found without vital signs and a code blue was called. Licensed Practical Nurse #1 had erroneously reviewed Resident #2's (roommate) Medical Orders for Life Sustaining Treatment form at time of event, not Resident #1's form. The conclusion of the investigation documented Licensed Practical Nurse #1 failed to confirm identity of resident prior to initiating cardiopulmonary resuscitation. During a telephone interview on [DATE] at 1:20 PM, Certified Nurse Aide #1 stated around 3:45 AM on [DATE] they went to go check on Resident #1. They stated Resident #1 looked like they were sleeping but did not wake to their voice. Certified Nurse Aide #1 stated they shook Resident #1's arm, they did not respond, and they noted Resident #1 was not breathing. Certified Nurse Aide #1 stated they notified Licensed Practical Nurse #1 that Resident #1 (using the resident's name) was not responding or breathing. Certified Nurse Aide #1 stated that Licensed Practical Nurse #1 preformed cardio-pulmonary resuscitation on Resident #1 until the paramedics arrived. Certified Nurse Aide #1 stated they were not aware Resident #1 had a do not resuscitate order until after the event was over. During an interview on [DATE] at 2:11 PM, the Assistant Director of Nursing stated the Certified Nurse Aides were not allowed to initiate cardio-pulmonary resuscitation and were educated that when they find a resident unresponsive, they were to immediately notify a nurse. The Assistant Director of Nursing stated that in general orientation all staff members were taught to identify a resident by looking at their picture in the electronic medical record. They stated based on the resident population the facility does not utilize name bands as identification because the residents do not want to wear them, remove them, or place them on other things. During an interview on [DATE] at 3:08 PM, Licensed Practical Nurse #1 stated around 3:50 AM on [DATE] they were alerted by Certified Nurse Aide #1 they had an unresponsive resident and thought they could be dead. Licensed Practical Nurse #1 stated they went to Resident #1's room to look at the resident. The resident had no pulse, no respirations, was gray in color, their body was cold and it had rigor (rigidity-when the body starts hardening after death). Licensed Practical Nurse #1 stated Certified Nurse Aide did not tell them the resident's name at the time but when they went into the room there was not another resident in the room. Licensed Practical Nurse #1 stated they went to the nurses desk and pulled the paper medical record for that room, assuming the room was not occupied with another resident. They stated the Medical Orders for Life-Sustaining Treatment form they looked at, indicated cardio-pulmonary resuscitation. Licensed Practical nurse #1 stated they called 911 on the way back to the room and began cardio-pulmonary resuscitation (CPR). Licensed Practical Nurse #2 arrived to assist, and they both performed chest compressions until the Emergency Medical Technicians arrived. Licensed Practical Nurse #1 stated the Emergency Medical Technicians did not perform cardio-pulmonary resuscitation on Resident #1 because they stated rigor had set in and they pronounced Resident #1 deceased . Licensed Practical Nurse #1 stated after they returned from a break, Licensed Practical Nurse #2 notified them that Resident #1 had a do not resuscitate order and CPR (cardiopulmonary resuscitation) should not have been initiated. Licensed Practical Nurse #1 stated in error they looked at the Medical Orders for Life-Sustaining Treatment form for Resident #2 (roommate) not Resident #1. They stated they went into code mode but should have taken a moment and verified the resident to their picture in the electronic medical record prior to starting cardio-pulmonary resuscitation as the facility trained them to do. During a telephone interview on [DATE] at 6:58 AM, Licensed Practical Nurse #2 stated on [DATE] around 3:45 AM they were alerted by a Certified Nurse Aide (unknown name) there was a code blue. They stated they got the crash cart (cart with emergency supplies) and when they arrived at Resident #1's room, Licensed Practical Nurse #1 was about to begin chest compressions to Resident #1. Licensed Practical Nurse #2 stated 911 was already called and they worked along with Licensed Practical Nurse #1 to provide chest compressions until the Emergency Medical Technicians arrived. Licensed Practical Nurse #2 stated they did not verify who the resident was, nor the residents advance directive orders prior to initiating CPR. Licensed Practical Nurse #2 stated after the event they had asked a Certified Nurse Aide (unknown name) how was the resident (using the name of Resident #2) during the beginning of the shift and the Certified Nurse Aide replied that was not Resident #2, that was Resident #1. Licensed Practical Nurse #2 stated at that time they checked the Medical Orders for Life-Sustaining Treatment form for Resident #1 and realized an error had been made. They immediately called the Director of Nursing. Licensed Practical Nurse #2 stated Resident #1's advance directive wishes were not honored. They stated they should have verified the Medical Orders for Life-Sustaining Treatment form against the EMR (electronic medical record) and with the resident's picture in the EMR (electronic medical record) prior to performing CPR (cardio-pulmonary resuscitation). During an interview on [DATE] at 10:20 AM, the Director of Social Work stated Resident #1 should not have received cardio-pulmonary resuscitation because that was not their wishes, and Resident #1 choices were not honored. During a telephone interview on [DATE] at 10:53 AM, the Medical Director stated they were aware Resident #1 had received cardio-pulmonary resuscitation in error on [DATE]. The Medical Director stated it was disrespectful to Resident #1 that they had cardio-pulmonary resuscitation initiated because their wishes were not honored. They stated Resident #1 was alert and made the decision not to be resuscitated and a human error occurred. An interview was conducted on [DATE] at 11:22 AM with the Director of Nursing and the Director of Clinical Operations was present. The Director of Nursing stated on [DATE] Resident #1 received cardio-pulmonary resuscitation in error when Licensed Practical Nurse #1 viewed the wrong resident's Medical Orders for Life-Sustaining Treatment form. They stated Licensed Practical Nurse #1 did not verify the picture in the electronic medical record prior to starting cardio-pulmonary resuscitation. They stated that Resident #1's wishes were not initially honored but ultimately were because no pulse or respiration were revived. The Director of Nursing stated prior to starting cardio-pulmonary resuscitation on a resident staff should have verified by confirming with the picture in the electronic medical with the physicians orders and the MOLST (medical orders for life sustaining treatment). The Director of Clinical Operations stated they agreed with what was stated by the Director of Nursing. Based on the following corrective actions it was determined the facility implemented corrective actions to correct the non-compliance. -Licensed Practical Nurse #1 was placed on administrative leave on [DATE]. They were reeducated on proper identification of residents prior to initiating cardiopulmonary resuscitation. -Licensed Practical Nurse #2 was given a training referral on verifying/confirm resident identity and Medical Orders for Life Sustaining Treatment prior to initiating cardiopulmonary resuscitation. -The Staff Educator and/or designee reeducated all licensed nurses on cardiopulmonary resuscitation management of events. Education included confirming identification prior to administering cardiopulmonary resuscitation. As off [DATE] 89% of licensed nurses were educated. As of [DATE] 100% of all nurses were re-educated. -A full house audit was completed of resident's photos in the electronic medical record. -A full house audit of all residents Medical Orders for Life Sustaining Treatment was completed to ensure they were available on nursing units. -Social Worker #1 completed an audit of all resident advance directive determination, Medical Orders for Life Sustaining Treatment, physician orders and do not resuscitate consent. -AD HOC PI (when necessary, Quality Assurance performance improvement) meeting was completed on [DATE] with the Medical Directors participation. 10 NYCRR 400.21

Based on observation, interview, and record review conducted during Complaint investigations (#NY00296344, #NY00320402 and #NY00297199) during the Standard survey completed on 10/4/23, the facility did not ensure sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for four (River View, Sky View, Harbor View, and City View) of four resident care units. Specifically, the facility did not have adequate nursing staff based on the facility's established minimum numbers of staff for each shift. Additionally, there was a lack of sufficient nursing staff to get residents out of bed, pass medications timely and according to physician orders, and not meeting resident care needs (showers). Resident #'s 1, 3, 8, 9, 11, 13, 19, 21, 23, 29, 37, 45, 49, 51, 52, 62, 73, 79, 80, 85, 98, 104, 107, 116, 118, 126, 142 and 401 were involved. The findings are: Refer to F677- Activities of Daily Living, scope and severity (S/S) =D Refer to F755- Pharmacy Services/Procedures/Pharmacist/Records 1. Review of the Facility Assessment Portfolio dated 9/26/23 documented the facility's bed capacity was 160 residents and census on assessment date was 145 residents. The facility assessment documented that all units were budgeted for 4 Certified Nursing Assistants (CNA) (except for 5 CNAs on the River View Unit) for day shift on each unit; 3 CNAs on the evening shift for each unit; and 2 CNAs for night shift on each unit. The facility assessment documented that each unit was budgeted for 2 medication nurses each shift, a unit manager, with an addition of Registered Nurse (RN) charge nurse for the evening and night shift on the River View unit. The facility was also budgeted for a RN Supervisor each shift. Review of a document provided by the Acting Administrator titled (Facility Name) Minimum Staffing Pattern dated 8/24/23 documented the day shift minimal staffing would be a total of 5 Licensed Practical Nurses (LPN) or RNs and 8 CNAs. The evening shift would have a minimum total of 4 LPNs or RNs and 8 CNAs. The night shift would have a minimum total of 3 LPNs or RNs and 4 CNAs. The minimum staffing pattern did not document/include the RN supervisor each shift. Review of the Daily Staffing Sheets on 7/16/23 and from 8/27/23 to 10/3/23 documented the facility did not meet their minimum number of staff: 7/16/23 3:00 PM - 11:00 PM shift - down one nurse and three CNAs 7/16/23 11:00 PM - 7:00 AM shift - down two nurses 8/27/23 3:00 PM - 11:00 PM shift - down two CNAs 8/28/23 7:00 AM - 3:00 PM shift - down one CNA 9/4/23 11:00 PM - 7:00 AM shift - down one nurse 9/11/23 7:00 AM - 3:00 PM down - one nurse 9/16/23 7:00 AM - 3:00 PM down - one nurse 10/1/23 7:00 AM - 3:00 PM shift - down one CNA During an interview on 9/29/23 at 2:04 PM, the Staffing Coordinator stated they used the (Facility Name) Minimum Staffing Pattern to staff the facility. The Staffing Coordinator stated they also needed a nursing supervisor per shift that was not included in the minimum staffing numbers. They stated they have been working the position for the past two weeks and they have not fallen below the minimum number of staff since they started. The Staffing coordinator stated that it was their goal to staff above the critical and if they did go below minimum it is because of staff call-offs. During an interview on 10/2/23 at 8:37 AM, the Assistant Director of Nursing (ADON) stated they received a couple calls yesterday from the day shift supervisor to help with getting more staff to come in. The ADON stated the evening shift supervisor, who worked 3:00 PM to 3:00 AM, also called to get more staff. The ADON stated they did not get a call from the night shift which was unusual. The ADON stated the DON was on call from 3:00 AM - 7:00 AM after the evening shift supervisor left at 3:00 AM. During a further interview on 10/3/23 at 4:40 PM, the ADON stated that on 7/16/23 the facility fell below the minimum staffing numbers. The ADON stated they did not know if any management came into the facility to assist. The ADON stated that if any management did come into assist, then it should have been documented. During an interview on 10/3/23 at 9:00 AM, the Director of Nursing (DON) stated the (Facility Name) Minimum Staffing Pattern was a guide of minimal number of staff needed in the facility. The DON stated in addition to the minimum staffing pattern a nursing supervisor was needed for each shift. The DON reviewed the daily staffing sheets dated 8/27/23, 8/28/23, 9/4/23, 9/11/23, 9/16/23, and 10/1/23 the DON stated the facility did not meet their minimum numbers. The DON stated when a shift fell below the minimum staffing number, the nursing supervisor was to call management into work. The DON stated they did not come into assist on the 11-7 shift. The DON stated there were open positions for an in-service coordinator and two-unit managers. The DON stated the importance of meeting the minimum staffing numbers was to provide adequate care to the residents. The DON stated that they did not feel the residents were receiving the services they should be such as treatments, incontinent care every 2-4 hours, getting out of bed, ADL care, and showers due to low staffing numbers. 2. Review of provided Resident Council minutes revealed on 3/15/23 and 9/13/23 customer service concerns were reported. Additionally, documented on the 9/13/23 the minutes were concerns regarding staffing shortages on the weekends and that the DON was in attendance by invitation of residents to help understand issues concerning staffing and care being provided by nursing staff. During an interview on 9/29/23 at 1:34 PM, Activities Director #1 stated the customer service concern in the resident council minutes (3/15 and 9/13) referred to staff not being courteous, having an attitude, not treating residents with respect. Activities Director #1 stated that they had seen this themselves and that customer service for residents had declined over the years. During a Resident Council meeting held on 9/27/23 at 1:41 PM with 15 residents participating revealed residents had concerns that involved long time wait times for the staff to answer call lights, and they often received their medications late particularly on the weekends. Residents also stated the facility had a lot of call-offs. It was also reported by the residents that they were told there was nothing the facility could do about short staffing, as there was a union involved. 3. Interviews with Residents, Ombudsman, Family Members and Staff: During an interview on 9/26/23 at 10:57 AM, Resident #126 stated medications were administered late, and the facility was often short staffed with only one nurse on the River View unit. During an interview on 9/26/23 at 10:57 AM, Resident #13 stated there was not enough staff and some days they were left in their urine for a long time During an interview on 9/26/23 at 11:47 AM, Resident #62 stated there were not enough CNAs and nurses. Sometimes they had to wait a while for incontinent care or had to remain in bed because there was not enough staff to get them out of bed. During a telephone interview on 9/26/23 at 1:37 PM, Resident #9's health care proxy stated that at times when they visit, they see residents that had fallen onto the floor, and they feel there was not enough nursing staff. During an interview on 9/26/23 at 2:08 PM, Resident #3 stated the staffing at the facility was horrible, especially on weekends. Sometimes there was only one CNA and one nurse for each floor. Sometimes there wasn't even a nurse, so a supervisor had to pass the medications which in turn then end up being late. Resident #3 stated they have talked to Administration several times about the poor staffing, and they just say they were trying their best. During an interview on 9/27/23 at 8:34 AM, Resident #107 stated medications were administered late, and the facility was often short staffed with only one nurse on the River View unit. During an interview on 9/27/23 at 8:47 AM, Resident #19 stated the facility needed to get more staff, sometimes they had to wait a long time for the staff to change their brief or to get assistance with eating. Resident #19 stated they feel rushed during meals. During an interview on 9/27/23 at 9:00 AM, Resident #142 stated the evening and night shifts were especially short staffed, they stated there were times when the call light was not answered for an entire shift. During an interview on 9/27/23 at 9:19 AM, Resident #104 stated they wait quite a few hours to get their brief changed after having a bowel movement, sometimes 6 - 7 hours due to the lack of staff. Additionally, Resident #104 stated they have not received a shower nor had their hair washed since May of 2023. During an interview on 9/27/23 at 10:20 AM, the Ombudsman stated the facility was short staffed, this results in the residents receiving their medications late or not at all. When there was only one nurse on the floor, they will only pass medications for one side, then residents have to wait for the nursing supervisor to pass the medications on the other side. The staff don't have time to give showers, they have to choose between passing meals or giving showers. The ombudsman also stated that the residents were not getting out of bed. During an interview on 9/28/23 at 12:05 PM, Resident #3 stated there was only one CNA on the 3:00 PM -11:00 PM shift last night (9/27). During an interview on 9/28/23 at 3:32 PM, Resident #401 stated there was only one CNA on the evening shift the prior night (9/27) and nobody changed their roommate all night until after breakfast that morning. During an interview on 9/28/23 at 4:28 PM, CNA #5 (City View Unit) stated they worked 16 hours as the only CNA on the 3:00 PM-11:00 PM and 11:00 PM - 7:00 AM shift yesterday (9/27/23). They worked with one LPN. CNA #5 stated they could not take care of the residents who were two assist, so they could not get care done. CNA #5 stated showers get done for only those residents were one assist. During an interview on 9/28/23 at 4:49 PM, LPN #4 stated they usually work the 7:00 AM - 3:00 PM shift on Harbor View or River View units, and about once a week they work as the only nurse. LPN #4 stated when they were the only nurse, they could not get the residents' medications passed on time, and they usually finish their morning medication pass around noon. They stated they cannot get their charting completed but try to document on the 24-hour report sheet. During an interview on 9/29/23 at 6:22 AM, CNA #1 stated they worked the 11:00 PM - 7:00 AM shift on the City View Unit and were the only CNA on the unit from 4:30 AM to 7:00 AM, because the other CNA had left. When they were the only CNA on the unit, they could only accomplish the bare minimum, which was to get one resident out of bed for dialysis. CNA #1 stated the situation was dreadful. CNA #1 stated they used to have a routine and get residents up in the morning, but with working shorthanded they stated that their responsibility during the night shift was to keep residents dry and ensure their needs were met. On this day (9/29), they required the assistance from the nurse supervisor, as the resident scheduled for dialysis required a 2-assist with a mechanical lift to get out of bed. During an interview on 10/2/23 at 8:35 AM, LPN #1 stated they had just worked the night shift (10/1) on the River View unit, and they were the only one working on the unit. They didn't have any CNAs working with them. RN Supervisor #2 tried calling people in, but nobody would. LPN #1 stated RN Supervisor #2 helped on the unit for a while and the residents who were sleeping, they left alone and that they changed some people. During a telephone interview on 10/2/23 at 8:54 AM, RN Supervisor #2 stated there was one nurse on the River View unit 11:00 PM (10/1/23) to 7:00 AM (10/2/23). RN Supervisor #2 stated they assisted as they were able until their end of shift at 3:00 AM, and when they left building, LPN #1 was alone on River View unit. Additionally, RN Supervisor #2 stated they notified the DON via text message on 10/2/23, between 11:30 PM and 12:00 AM, the facility was at a critical staffing level with four LPNs and three CNAs to staff the building on the 11:00 PM - 7:00 AM shift. During an interview on 10/2/23 at 9:12 AM, the DON stated they were notified via text message by RN Supervisor #2 on 10/1/23 at 11:44 PM of the critical staffing level in the facility. The DON stated that RN Supervisor #2 should not have left the building at 3:00 AM at the end of their shift, should have stayed, and LPN #1 should not have been left alone on the unit for those 4 hours. 4a. During an observation and interview on 9/29/23 at 11:55 AM, Resident #80 was in bed with their lunch tray on the overbed table. Resident #80 stated they were still in bed today because there were only two CNAs working on the unit, and they wanted to get out of bed to go get their money. During an interview on 9/29/23 at 11:57 AM, CNA #6 stated the nurse said Resident #80 could get up after lunch because they only had two aides on the unit today. CNA #6 stated it would have been hard to get the resident out of bed before lunch. 4b. During an interview on 9/29/23 at 7:27 AM, CNA #10 stated they normally work the 7:00 AM - 3:00 PM shift on Sky View. CNA #10 stated about three times a week they work with only with one more CNA on the unit, and they do their best to keep the residents safe, dry, and fed. CNA #10 stated they were only able to provide incontinent care twice a shift when they should be performing care three or four times a shift. CNA #10 stated that they cannot shower the residents and sometimes a two-assist resident remains in bed because of staffing. During an observation and interview on 9/29/23 at 7:39 AM, Resident #29's call light was ringing. Resident #29 stated they wanted to get out of bed and were waiting for CNA #10 to assist them. CNA #10 was observed to turn off Resident #29's call light at 7:45 AM and continued to assist a resident that was having behaviors. During a further observation and interview at 9:34 AM, Resident #29 was sitting in their wheelchair and stated that CNA #10 had just gotten them out of bed and they were angry they had to wait. Resident #29 stated they had to wait until after breakfast to get out of bed because the unit was short staffed. During an interview on 9/29/23 at 1:42 PM, CNA #10 stated they could not get Resident #29 out of bed before breakfast when they first asked because they were assisting another resident and because there was only one other CNA working with on the unit this morning (9/29). During an interview on 10/4/23 at 9:04 AM, the DON that a resident should be able to get out of bed at their request and that at times the residents cannot get out of bed because of low staffing. 5a. During a record review/observation on 9/28/23 at 9:26 AM, the Sky View team one medication cart computer had four residents that were highlighted in red in the EMAR. During an interview at this time, LPN #7 stated the red highlight was an alert that indicated that Residents #49, #116, #37 and #8 had late medications. LPN #7 stated the medications were late because they just arrived to work and were instructed to pass medications. 5b. During a record review/observation on 9/29/23 at 8:35 AM, the Sky View team two medication cart computer had four residents that were highlighted in red on their electronic medication administration record (EMAR). During an interview at this time LPN #5 stated the red highlight indicated that Residents #73, #62, #98 and #116 had late medical provider orders (ex. finger sticks). LPN #5 stated the medications were late because they were currently the only nurse on the unit and that they had not arrived at work until 8:20 AM. During an observation on 9/29/23 at 9:37 AM, LPN #5 was exiting Resident #73's room with an insulin syringe. LPN #5 stated that Resident #73's insulin was ordered for 7:30 AM prior to their breakfast. LPN #5 stated that Resident #73's insulin was given late because they did not arrive to work until 8:20 AM and they obtained fasting blood sugars for team two prior to starting their medication pass. During an interview on 10/4/23 at 9:04 AM, the DON stated they were aware that both nurses where late on 9/29/23 and would have expected the night nurse to perform the fasting blood sugars and to give the insulin. 5c. During a record review/observation on 10/2/23 at 11:23 AM, Sky View team one medication cart had 14 residents that were highlighted in red on their EMAR. During an interview at this time, LPN #1 stated the red highlight indicated that Residents #118, #116, #52, #45, #85, #9, #11, #49, #79, #21, #62, #23, #1 and #51 medications were late. LPN #1 stated the resident's medications were late because they had completed the medication pass on the City View and was not floated to the Sky View unit until 11:00 AM. During an interview on 10/4/23 at 9:04 AM, the DON stated they were not aware that there was no nurse passing medications to Sky View team 1 until 11:00 AM on 10/2/23. 5d. During an observation and interview on 10/3/23 at 8:43 AM, the River View A (team one) medication cart top drawer contained 8 souffle cups of pre-poured medications marked by resident room numbers. LPN #4 stated the medication pass on the River View unit was very heavy and they pre-pour medications to administer the medications as efficiently as they can to complete the medication administrations on time. During an interview on 10/03/23 at 10:47 AM, Nurse Practitioner (NP) #1, stated residents have reported to them that they did not receive their medications until noon or not at all on the weekends. NP #1 stated that it was their expectation that the residents get their medication on time or prioritize the medication pass if the nurses were running late. During an interview on 10/4/23 at 9:04 AM, the DON stated late medication administration was due to low staffing. The DON stated that if there was only one nurse on a unit for the day shift, it would be impossible for medications to be administered on time. During an interview on 10/4/23 at 10:22 AM, the Acting Administrator in the presence of Operation Support, stated they were aware that medications have been given late and their expectation was medications should be given on time. The Acting Administrator stated, probably staffing has had an effect on medications being administrated late. The Acting Administrator stated they were unaware if their staffing number were below minimum, but they added that facility could do much better with our staffing numbers. The Acting Administrator stated that they felt their residents were safe with the minimum staffing number because there was also a building supervisor in addition to the minimum number of staff. Operation's Support stated they agreed with the Acting Administer. 10 NYCRR 415.13(b)(1)

Based on observation, interview and record review conducted during the Standard survey completed on 10/4/23, the facility did not provide pharmaceutical services to meet the needs of each resident and the facility did not ensure that drug records were in order and that an account of all controlled drugs is maintained and periodically reconciled for four (River View, Harbor View, City View and Sky View) of four units. Specifically, on the Riverview Unit Licensed Practical Nurse (LPN) #4 was observed to have pre-poured resident medications and two narcotic reconciliation books with the keys to a medication cart and narcotic cupboard were left unattended in the medication room. Additionally, on the Sky View Unit LPN #7 was observed to have completed a narcotic reconciliation by themselves without the presence of the nurse going off duty. Furthermore, the controlled drug records for all the units shift to shift counts were not consistently signed off as completed. The findings are: The facility Policy and Procedure (P&P) titled Medication Administration dated 12/19 documented that medications may not be prepared in advance and must be administered within one hour of their prescribed time, unless otherwise specified. The facility P&P titled Controlled Substance Management dated 8/22 documented separate records shall be maintained on all controlled substances in the form of a declining inventory record. Such records shall be accurately maintained. The P&P documented that such records shall be reconciled by the incoming and outgoing nurse. Two nurses must count the remaining medication at each shift and any handoff of narcotic keys. 1) During an observation/interview on 10/3/23 at 8:43 AM, the River View A Medication Cart top drawer contained 8 souffle cups of pre-poured medications marked by room numbers. LPN #4 stated the medication pass on the Riverview unit was very heavy and they pre-pour medications to administer the medications as efficiently as they can to complete the medication administrations on time. LPN #4 stated they are not supposed to pre-pour medications, as it can cause a medication administration error. Additionally, LPN #4 stated they were unable to identify the medications nor the residents the pre-poured medications were to be administered to without observing the Medication Administration Records (MAR's) associated with the room numbers indicated on the souffle cups. During an interview on 10/3/23 at 8:53 AM, the Assistant Director of Nursing (ADON) stated medications are not to be pre-poured secondary to increased risk of medication administration errors. During an interview on 10/3/23 at 9:21 AM, the Director of Nursing (DON) stated it was not acceptable to pre-pour medications, medications should be administered to one resident at a time to decrease the risk of medication administration errors. During an interview on 10/3/23 at 10:58 AM, Nurse Practitioner (NP) #1 stated nurses should not pre-pour medications secondary to increased risk of medication errors. Medications should be administered to one resident at a time, after the medications are dispensed from the pharmacy packaging. During an observation of the River View Medication Room on 10/4/23 at 7:49 AM, two narcotic reconciliation books were observed with the keys to a medication cart and narcotic cupboard placed inside the front cover of each book. 2) During an observation/ interview in the medication room on the Sky View Unit on 9/28/23 at 9:26 AM, LPN #7 was observed performing a narcotic count reconciliation with no other nurse present for Team One medication cart. LPN #7 stated the narcotic keys were left in the narcotic book on top of the medication cart from the previous 11:00 PM- 7:00 AM shift. LPN #7 stated that the second 7:00 AM- 3:00 PM nurse on the unit refused to count and pass medications for the whole unit that morning. LPN #7 stated they were the corporate restoration nurse and just arrived at the facility and was directed to pass medications on the unit. LPN #7 stated they have observed in the past that nurses leave at the end of their shift not preforming narcotic reconciliation if the oncoming nurse was late. During an interview on 9/28/23 at 9:30 AM, LPN #4 stated they reconciled narcotics for the Sky View Unit Team Two with LPN #8 that morning. LPN #4 stated they refuse to take narcotic keys for both medication carts on any unit and did not reconcile narcotics for Team One. LPN #4 stated there was supposed to be a second nurse on the 7:00 AM- 3:00 PM shift and LPN #8 did not ask them to do narcotic reconciliation for Team One prior to them leaving. During an interview on 9/29/23 at 6:40 AM LPN #8 stated they did not perform a narcotic count reconciliation on 9/28/23 prior to them leaving their 11:00 PM-7:00 AM shift for Sky View Team One. LPN #8 stated that the second nurse was not on time, and they left the narcotic keys in the book and left the building because it was the end of their shift. LPN #8 stated they did not tell a supervisor that they did not reconcile their narcotics but should have. During an interview on 10/4/23 at 8:24 AM, LPN #1 stated when they pass the narcotic keys they do the count and then both nurses sign off at the back of the book. LPN #1 stated sometimes nurses just leave their keys and don't count with the oncoming shift. When the next nurse has arrived for their shift they have to count by themselves because nobody on the previous shift stayed until their relief arrived. LPN #1 stated this happens especially on the weekends. LPN #1 stated if their relief doesn't arrive, they give them 1.5 hours, then they call the supervisor to do the count and take the keys. LPN #1 stated the supervisors can't force staff to stay and even if a supervisor was on the unit, they would still leave. 3) Review of the Shift Count (Narcotic Count Records) from 9/8/23-9/29/23 the following lacked documented evidence that narcotic reconciliation was completed by the oncoming and outgoing nurses: -River View team one cart had 41 shifts -River View team two cart had 48 shifts -Harbor View team one cart had 28 shifts -Harbor View team two cart 36 shifts -City View team one cart 31 shifts -City View team two cart 26 shifts -Sky View team one cart had 38 shifts -Sky View team two cart had 32 shifts During an interview on 10/4/23 at 7:33 AM, the DON stated there were no nurses on the River View Unit, and the 11:00 PM - 7:00 AM nurse had left the facility prior to reconciling the narcotic count. The DON stated nursing staff are expected to remain in the facility until their relief arrives on the unit, and narcotics are to be reconciled between the off going and oncoming nurses. At 9:04 AM the DON stated that they were not aware on 9/28/23 that the narcotic keys were left in the book and the narcotics were not reconciled for Sky View Team One for the 7:00 AM- 3:00 PM shift. The DON stated that all narcotics need to be reconciled between two nurses at shift change because the count could be off and prevent diversion. During an interview on 10/4/23 at 9:58 AM, the Pharmacist Consultant stated that narcotic reconciliation occurs with the oncoming nurse and the nurse that is leaving. They stated that it is not proper practice to leave the narcotic keys in the narcotic book on top of the medication cart or for a nurse to leave without reconciling the narcotics because anyone can have access to the narcotic and there is a potential for diversion. 10 NYCRR 415.18(a)(b)(3)

Based on interview and record review conducted during a Complaint investigation (Complaint #NY00324268) during a Standard survey completed on 10/4/23 the facility did not ensure that it promoted and facilitated resident self-determination through the support of resident choice for two (Residents #93 and #398) of four residents reviewed for choices. Specifically, preferred number of showers were not provided in accordance with resident wishes per week. The findings are: The facility policy and procedure title ADL-Personal Hygiene with a revision date of 10/2019 documented the purpose is to direct the nursing staff to meet the residents needs per the plan of care and Kardex on a daily basis. Resident bath or showers will be scheduled per resident preference but at least weekly per the unit shower schedule and a bed bath will be provided on non- shower days. If the resident refused assistance with care needs, the reason(s) why and the intervention taken will be documented by the Licensed Nurse. 1. Resident #398 had diagnoses including cerebral vascular accident (CVA- stroke) with left sided hemiparesis (weakness of one side of the body) and cerebral palsy (CP-a disorder that prevents a person's movement, balance and posture). Review of the Minimum Data Set (MDS- a resident assessment tool) dated 9/13/23 revealed the resident was understood, understands and was cognitively intact. The MDS further documented the resident was an extensive assist for personal hygiene and it was very important how they chose between a tub bath, shower, or bed bath. Review of the Kardex (guide used by staff to provide care) dated 10/3/23 revealed under the section Bathing totally dependent x 2 staff. Shower/Bath (specify day/shift) was left blank. Review of the undated Unit Shower Schedule revealed Resident #398 was scheduled for two showers per week on Tuesdays and Fridays and that every resident on the unit was scheduled for two showers. Additional review of the shower schedule revealed that no residents were scheduled for more than two shower per week. Review of the Bathing Task documented in the electronic medical record (EMR) (certified nurse aide (CNA) documentation) from 9/11/23 through 10/3/23 documented the resident only receive one shower on 9/23/23. Review of the Progress Notes dated 9/6/23 through 10/3/23 revealed no documented evidence Resident #398 refused their showers. During an interview on 10/3/23 at 10:40 AM with Resident #398 stated their stay has not been good, staff do what they want to do and when they want to do it, they have not had a shower since they have been at the facility for a month and would like a shower every day or at a minimum of three times a week. Staff do not ask them if they want a shower, and they have never refused to have a shower. 2. Resident #93 had diagnoses including dementia, depression and anxiety. Review of the MDS dated [DATE] documented the resident was understood, understands and was cognitively intact. The MDS further documented the resident was an extensive assist for personal hygiene. The MDS dated [DATE] documented it was very important how they chose between a tub bath, shower, or bed bath. During an interview on 9/29/23 at 10:35 AM Resident #93 stated they do not get their showers every day like they prefer. Review of the Visual/ Bedside Kardex Report dated 10/4/23 documented under Bathing the resident was to receive a Shower on Monday, Wednesday, Friday on the 7am-3pm shift and Tuesday, Thursday and Saturday on the 3pm-11pm shift. Resident prefers daily showers. Review of the undated Assignment sheet documented Resident #93 prefers daily showers. Review of the Documentation Survey Report Sep-23 dated 10/4/23 revealed under Shower from 9/1/23 through 9/30/23 Resident #93 received nine showers out of twenty-six. Review of the Progress Notes dated 9/1/23 through 10/3/23 revealed no documented evidence Resident #93 refused their showers. During an interview on 10/3/23 at 10:54 AM CNA #3 stated the Unit Manager (UM) writes the showers on the assignment sheet, most residents get a shower 1-2 times per week but if they ask for more, they can have more showers. CNA #3 was unsure of Resident #93 or #398 shower schedule and stated it should be documented in the shower book at the nurse's station. If the resident refused, they would tell the nurse. During an interview on 10/3/23 at 11:42 AM Registered Nurse (RN) #1 UM stated the nursing supervisor on admission will ask the resident their shower preferences. Showers also go by room number two times per week; showers for the day get highlighted on the assignment sheet. RN UM #1 was unsure of the resident #398 preferences for a shower or why the resident had not had a shower since admission. During an interview on 10/03/23 at 12:16 PM the Assistant Director of Nursing (ADON) and with Regional Director of Clinical Services present stated the supervisor on admission discusses shower preference with residents. The resident's preference should be documented on the care plan and Kardex. The ADON stated residents should get their showers per their preference and they're not. During an interview on 10/4/23 at 12:08 PM the Regional Director of Clinical Services stated Resident #93 was care planned for a shower every day and was not getting it every day and should be. 415.5(b)(1)(3)

Based on interview and record review during a Standard survey completed on 10/4/23, the facility did not ensure that they immediately informed the resident's representative when there was a significant change in the resident's health, mental, or psychosocial status for two (Resident #s 27 and #54) of two residents reviewed. Specifically, there was no evidence Resident #54's Health Care Proxy/Responsible Party (HCP/RP) was informed that the resident was transferred to the hospital on 7/20/23 and staff did not contact Resident #27's alternate representative when they could not reach their primary representative to notify of an acute hip fracture. The findings are: The policy titled Notification of a Change in a Resident's Condition or Status dated 12/2016 documented unless otherwise instructed by the resident, a nurse will notify the resident's representative when the resident was involved in an accident or incident that resulted in an injury including injuries of unknown source and when it was necessary to transfer the resident to a hospital. 1. Resident #54 had diagnoses including traumatic brain injury, epilepsy, and cerebral infarction (a stroke). The Minimum Data Set (MDS, a resident assessment tool) dated 7/31/23 documented Resident #54 had moderately impaired cognition and required extensive assistance for eating. Review of nursing Progress Note dated 7/20/23 at 7:05 PM, written by Registered Nurse (RN) #3, documented the physician ordered the resident to be sent to the hospital due to abnormal labs due to gallstones. There was no documented evidence that the HCP/RP was notified. Review of the Facility 24 Hour Report dated 7/20/23 and 7/21/23 revealed no documented evidence that Resident #54's HCP/RP was notified of the transfer to the hospital. During a telephone interview on 9/27/23 at 11:20 AM, Resident #54's HCP/RP stated the resident had been in the hospital recently and the facility did not notify them of the transfer. They stated they found out from the hospital. During an interview on 10/4/23 at 7:52 AM, Licensed Practical Nurse (LPN) Unit Manager #2 stated the supervisor who sent the resident to the hospital was responsible for updating the resident's responsible party (RP/HCP) of the transfer, no matter what time of the day. The LPN UM #2 stated if they couldn't get to it, they should pass it on to the next shifts so someone could follow up. The LPN UM #2 stated they did not notify Resident #54's RP of the transfer to the hospital on 7/20/23. During an interview on 10/4/23 at 8:55 AM, the Director of Nursing (DON) stated the person who sent Resident #54 to the hospital should have notified the family and documented it in a progress note. 2. Resident #27 had diagnoses including nondisplaced fracture of the left femur, age-related osteoporosis (a condition where bones become weak and brittle) and dementia. The MDS dated [DATE], documented the resident was understood, usually understands, and had severely impaired cognitive skills. The comprehensive care plan (CCP) dated 7/26/23 documented that Resident #27 had an alteration in physical function related to a left hip fracture. The Care Plan Note dated 7/19/23 at 1:31 PM, the Director of Social Work documented that Resident #27 was a full code with no MOLST in place and the family member makes all decisions for them. The Radiology Report dated 7/25/23 documented an acute or recent impacted left femoral neck fracture with no change from the 7/24/23 report. The Physician Progress Note dated 7/25/23 at 1:42 PM, the Nurse Practitioner (NP) #1 documented that Resident #27 had an acute left femur fracture. NP #1 documented the resident would likely benefit from conservative management rather than surgical and the unit manager was to discuss with the HCP. A progress noted dated 7/27/23 at 1:08 PM, MD #1 documented that Resident #27 had an x-ray confirmed acute fracture of the left femoral head and a message was left for the emergency contact with no return call. MD #1 documented that due to Resident #27's cognitive impairment, frailty and other co-morbidities, conservative treatment was preferred to surgical and will await call back from the HCP. Review of the Progress notes revealed the following: -On 7/25/23 at 1:38 PM, LPN #6 documented they telephoned Resident #27's family member and left a message for them to return call to the facility to inform them about the fracture. -On 8/2/23 at 3:18 PM, LPN #6 documented they left a telephone message for Resident #27's family member to return call. -On 8/4/23 at 8:55 AM, LPN #10 documented they left a telephone message for Resident #27's emergency contact #2 to return call. There was no documentation from 7/25/23-8/3/23 that Resident #27's alternate representative was contacted when staff were unable to contact their primary representative. During an interview on 9/28/23 at 1:35 PM, the NP #1 stated that they consulted with MD #1, and they wanted to treat Resident #27 left femur fracture treated conservatively and the unit manager was to speak with the resident's family member. During further interview on 10/3/23 at 10:41 AM, NP #1 stated they would have expected the second representative to be contacted if the facility they were unable to get in contacted with Resident #27 first representative. During a telephone interview on 10/3/23 at 12:33 PM, LPN #6 stated they believe they attempted to get in contact with Resident #27's representative about their broken hip. LPN #6 stated they do not recall if they attempted to contact Resident #27's second representative. LPN #6 stated that they would have documented all attempts they made to contact Resident #27's representatives. During a telephone interview on 10/3/23 at 2:15 PM, MD #1 stated that they preferred to treat Resident #27 fracture femur by conversative measures due to their geriatric judgement. The MD #1 stated they wanted the facility to get in contact with the resident representative to make the decision and they would have expected the facility to update them (the MD #1) sooner that they were unable not get in contact with Resident #27's representative. During an interview on 10/4/23 at 9:22 AM, the DON stated they were unaware that the unit manger did not get in contact with the family member prior to 8/4/23 and they would have expected LPN #6 to call Resident #27's representatives every day. The DON stated that Resident #27's second family member was contacted when the resident was sent to the emergency room for evaluation of the hip fracture on 8/4/23 and they should have been contacted sooner. The DON stated that would have expected all attempts to contact the family members to be documented. During an interview on 10/4/23 at 10:22 AM, the Administrator stated their expected the resident's representatives would be contacted daily until one of the representatives were reached. The Administrator stated their expectation for that all attempts of representative notification be documented. 10NYCRR 415.3(f)(2)(ii)(d)

Based on observation, interview, and record review conducted during the Standard survey completed on 10/4/23, the facility did not provide a safe, clean, comfortable, and homelike environment for one unit (Riverview) of four resident units. Specifically, there were strong odors of cigarette smoke, ashes on the floor, and cigarette butts in the toilet and on the floor of the Riverview shower room. The policy and procedure (P&P) Smoking Program, revised 6/2019, documented the facility shall establish and maintain safe resident smoking practices. While the facility does promote a smoke free environment, those residents who wish to smoke will be provided with appropriate accommodations to safely do so. The undated P&P Homelike Environment documented residents are provided with a safe, clean, comfortable, and homelike environment. The findings are: During an observation on 9/26/23 at 11:30 AM, a strong cigarette smoke odor was detected in the Riverview unit shower room and there was a cigarette butt inside the bathtub. During an interview on 9/27/23 at 8:36 AM, Resident #107 stated the shower room smelled of stale cigarette smoke, cigarette butts, ashes were on the floor, and the shower room floor was slimy. During an observation on 9/27/23 at 8:54 AM, a strong cigarette smoke odor was detected in the Riverview unit shower room, and cigarette ashes were observed on the floor near the toilet. During an observation on 9/28/23 at 8:40 AM, a strong cigarette smoke odor was detected in the Riverview unit shower room, and cigarette ashes were observed on the floor near the sink. Additionally, a cigarette butt was observed on the floor next to the bathtub. During an interview on 9/29/23 at 11:58 AM, Riverview Housekeeper #1 stated they often smell cigarette smoke in the Riverview shower room but have never seen anyone smoking in the shower room. Additionally, there are often cigarette butts and cigarette ashes in the shower room that they clean. During an observation on 10/2/23 at 7:31 AM, a strong cigarette smoke odor was detected in the Riverview unit shower room, cigarette ashes were observed on the floor, and two cigarette butts were observed in the toilet. During an observation/interview on 10/2/23 at 11:39 AM, with the Maintenance Director, a strong cigarette smoke odor was detected in the Riverview shower room, cigarette ashes were observed on the floor, and three cigarette butts were observed in the toilet. The Maintenance Director stated the Riverview shower room smelled of cigarette smoke, and they were notified that residents were smoking in the Riverview unit shower room. During an interview on 10/3/23 at 7:33 AM, the Administrator stated they were aware someone was smoking in the Riverview unit shower room, and that put other residents' safety at risk. During an interview on 10/4/23 at 7:33 AM, the Director of Nursing (DON) stated they were aware a resident smoked in the Riverview unit shower room and smoking in the facility posed a safety risk to the residents on the unit and in the facility. 10NYCRR 415.5(h)(1)

Based on observation, interview, and record review conducted during a Complaint investigation (Complaint #NY 259) completed during the Standard survey on 2/24/20, the facility did not provide an environment as free from accident hazards as possible and devices to prevent accidents for two (Residents #15, 109) of seven residents reviewed. Specifically, the facility did not ensure the bariatric (heavy duty, larger) shower chair safely fit through the shower room doorway. Resident #109 sustained a leg laceration, was transferred to the hospital and required 18 sutures. Additionally, Resident #15 was not transferred with a mechanical lift (Hoyer) and did not have safety devices (Dycem, non-slip mat) in place as planned. This resulted in actual harm that is not immediate jeopardy for Resident #109 and resulted in the potential for harm for Resident #15 that is not immediate jeopardy. The findings are: The facility policy and procedure (P&P) titled Accident - Incidents dated 8/2019 documented if the resident has sustained any suspected or actual significant injury, is sent to the hospital or abuse is suspected, the supervisor/manager must notify the Administrator/Director of Nurses. The Supervisor/Manager will begin the investigation for root causes of the occurrence. The team will review the investigation and continue if necessary, discuss and determine from the investigation the root causes, make recommendations for additional intervention, education and conclude the investigation. 1. Resident #109 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS, a resident assessment tool) dated 1/9/20 documented the resident was cognitively intact, required an extensive assistance of one person for locomotion on the unit (how resident moves between locations in his/her room and adjacent corridor on same floor), and required two or more persons physical assist with part of bathing activity. The facility undated P&P titled Shower/Tub Bath documented to assist the resident into the bath chair, if applicable. Transport the resident to the bath area. After the bathing/showering task has been completed, take the resident back to his or her room. Be sure the resident's feet are not dragging on the floor. Review of the Visual/Bedside Kardex Report (guide used by staff to provide care) As of 2/24/2020 documented Resident #109 required a total mechanical lift with two staff members for transfers and extensive assist of two staff members for bathing. During an interview on 2/19/20 at 8:55 AM, Resident #109 stated they got a cut on their left thigh when they had received shower. Review of a facility Accident/Incident Report completed by the Registered Nurse (RN) Assistant Director of Nursing (ADON) dated 9/20/20 (sic) documented the resident (#109) was being brought back to room in shower chair when their left thigh accidentally came in contact with door jam on door in shower room. Staff were counseled on the need to take care in transferring resident (#109) with large size on shower chair. Review of a facility Investigation Form completed by the ADON dated 9/21/19 documented Resident #109 was being transported back to their room in shower chair after receiving their shower on 9/20/19. Due to their large body size, Resident #109's left leg sustained mechanical trauma when contacting the door jam on shower room door. The CNA (Certified Nursing Assistant) was able to demonstrate proper transfer technique. Resident #109 was immediately provided first aide and was transferred to the ER (emergency room ) for further evaluation. Resident #109 returned with sutures to their left lower extremity. Review of a Progress Notes completed by the ADON dated 9/21/19 documented Resident #109 returned fromER on ,[DATE] at 3:30 PM. The note documented to keep the dressing intact to the left lower extremity for two days, then remove and apply a DSD (dry sterile dressing) daily. Remove the sutures in 2 weeks (18). During an interview on 2/24/20 at 7:46 AM, RN #2 Unit Manager (UM) stated CNA #8 was pushing Resident #109 through the doorway of the shower room when the residents' leg hit the doorway causing a laceration, 12 cm (centimeters) x 3.5 cm. During an observation on 2/24/20 at 7:54 AM the ADON was only able to push the bariatric shower chair, without a resident, at an angle through the shower room doorway and stated, that's where the problem is, it (bariatric shower chair) doesn't fit through the door. During an interview on 2/24/20 at 8:17 AM, the Respiratory Therapist stated, I heard a lot of yelling, so I went down and provided first aid care in the doorway of the shower room. They (CNA's) couldn't get the chair out (the doorway). I had to figure out what angle to get the chair out the doorway. During an interview on 2/24/20 at 8:28 AM, the Assistant Director of Therapy stated, The chair (bariatric shower chair) doesn't fit through the doorway. During an interview on 2/24/20 at 8:45 AM, the Director of Maintenance the stated the width (w) of the shower room door was 33 (inches) and the dimensions of the bariatric shower chair were 33 5/8 (w), 27 1/2 d (depth), 39 3/4 h (height). During an observation on 2/24/20 at 8:45 AM, the Director of Maintenance was only able to push the bariatric shower chair, without a resident, at an angle through the shower room doorway. During an interview on 2/24/20 at 9:22 AM, CNA #5 stated she witnessed the three CNA's attempting to get Resident #109 out the shower room doorway with bariatric shower chair at an angle. The bariatric shower chair and the resident were stuck in the doorway. During an interview on 2/24/20 at 9:31 AM, Licensed Practical Nurse (LPN) #2 responsible for Resident #109 on 9/20/19 stated, the aides had the resident in shower chair and the resident sustained [REDACTED]. They (CNA's) weren't paying attention. They were shimmying and had the resident sideways. You can't put the bariatric shower chair straight through. During an interview on 2/24/20 at 10:17 AM, CNA #7 stated she was assisting Resident #109 with the shower, there were three of us trying to maneuver the chair with the resident out of the doorway. I don't remember but somehow her leg hit the doorway. In addition, she had not been educated on maneuvering the bariatric shower chair in and out of the shower room doorway. During an interview on 2/24/20 at 10:41 AM, the Attending Physician stated, Resident #109 sits on a bariatric shower chair, they (CNA's), hit the door frame causing a laceration. The Attending Physician then visualized the bariatric shower chair and shower room doorway stating, The door is not spacious enough for the bariatric chair. It doesn't fit through the door with a resident. There is no safe distance. Patient safety is first, they should have assessed if there was enough room before they took the resident out that way. During an interview on 2/24/20 at 1:04 PM, the Director of Nursing (DON) stated she was not aware of the dimensions of the shower room doorway. The DON was aware there were issues getting the bariatric shower chair in and out of the shower room doorway. We saw there were problems. We had to get Resident #109 in and out of shower room the best way we could. We should not have continued to use the bariatric shower chair due to the width of the shower chair and door frame. During an interview on 2/24/20 at 2:30 PM Resident #109 stated, I prefer to take showers, but I haven't since my leg got cut. I'm afraid I'll get cut again. 2. Resident #15 had [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident was cognitively intact. The MDS further documented the resident was non ambulatory and required extensive assist of two staff members to transfer. The P&P titled Assistive Devices and Equipment dated 7/2017 documented the facility provides, maintains, trains and supervises the use of assistive devices and equipment for residents. The P&P titled Safe Lifting and Movement of Residents dated 7/2017 documented to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents. Manual lifting of residents shall be eliminated when feasible. Staff responsible for direct care will be trained in the use of manual (gait/transfer belts) and mechanical lifting devices. Review of the comprehensive care plan (CCP) dated 12/16/19 revealed Resident #15 required extensive assist for bed mobility, transferred with a mechanical lift and was non ambulatory. In addition, Resident #15 had a history of [REDACTED]. Review of the undated Visual/Bedside Kardex Report revealed instructions for staff to place Dycem to the top of wheelchair cushion and the resident was a total mechanical lift for transfers. The Fall Risk Evaluation dated 8/17/19 documented the resident was at high risk for falls. During an observation on 2/24/20 at 9:20 AM CNA #1 & 2 positioned Resident #15's wheelchair parallel to the right side of the bed. CNA # 1 removed the right arm rest from the wheelchair. CNA #1 placed his forearm under Resident #15's right arm while CNA#2 placed her left forearm under Resident 15's left arm. CNA's #1 & 2 then grabbed the back of Resident #15's brief and lifted them into the bed. The CNA's did not use the mechanical lift to transfer Resident #15. Additionally, there was no Dycem on the wheelchair cushion as planned. During an interview on 2/24/20 at 9:24 AM, CNA #1 stated he did not use the lift because Resident #15 can be aggressive and refuse the lift. I always transfer Resident #15 with a two assist. Safety devices for this resident included a gym mat on the floor at the bedside. CNA #1 was unaware Dycem was to be in the wheelchair. If I read the care plan, I would have known but did not. Additionally, CNA #1 stated there were never enough slings on the unit for the mechanical lift. CNA #1 was unaware of unsafe transfer risks. During an interview on 2/24/20 at 9:40 AM, CNA #2 stated Resident #15 would strike out at staff when using the mechanical lift and transferred Resident #15 with two arm and arm assist. We all do it that way. The care plan should be reviewed prior to care and it was not. CNA #2 was not aware Resident #15's plan included the use of a lift or Dycem. During an interview on 2/24/20 at 9:45 AM, RN #1 Unit Manager stated Resident #15 would get aggressive when seeing the mechanical lift. RN #1 would expect CNA's to review the plan of care, attempt to use the lift, re approach at a later time during periods of agitation, and ensure all safety devices were in place. If Resident #15 was still resistive the expectation would be to notify therapy for suggestions and document the issue in the nurse's notes. We have a zero-lift policy, no one should be transferred unsafely. Dycem prevents Resident #15 from sliding out of the wheelchair. During an observation on 2/24/20 at 9:47 AM CNA's #1 & 2 used a mechanical lift and transferred Resident #15 from the bed to the wheelchair at this time Dycem was placed on the cushion as planned. Resident #15 was calm, pleasant and displayed no aggression towards the CNA's during the mechanical lift transfer. During interview on 2/24/20 at 10:55 AM, the DON stated, care plan violations are taken seriously. The expectation is to look at the care plan before providing care, If the transfer required a mechanical lift, the expectation would be to use the lift. The DON would expect the aides to approach Resident #15 later when resistant. Dycem provides a non-slip surface and is used to assist in prevention of falls and should have been in place if it was planned. During an interview on 2/24/20 at 12:14 PM, the Director of Rehab Services stated lateral transfers without gait belts are unsafe for Resident #15 and potentially could cause subluxation (partial dislocation) or dislocation of the shoulder when using an under-arm approach. If the care plan reads mechanical lift for transfers, I would expect them to use the lift to prevent potentially injuring the resident. Dycem is used to help prevent sliding out of the chair and she was unaware Resident #15 wasn't fond of the lift. 415.12 (h)(2)

Based on interview and record review conducted during an Abbreviated survey (Complaint #NY 819) completed on 5/11/17, the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. One (Resident #1) of three residents reviewed for quality of care had an issue with a delay in treatment with the Ophthalmologist (eye physician) following cataract surgery that resulted in endophthalmitis (severe inflammation) and left orbital [MEDICAL CONDITION] (infection of the soft tissues of the eye socket) requiring surgery to remove the contents of the inner eye resulting in loss of vision. This resulted in actual harm that is not immediate jeopardy. The finding is: 1. Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS- an assessment tool) dated 10/19/16 revealed the resident is cognitively intact and is understood. Review of an Eye Clinic Consult dated 10/10/16 revealed the resident, on that date, had a cataract surgery to the left eye with an intraocular lens implant. Review of the 24-Hour Report dated 10/28/16 completed by the Licensed Practical Nurses (LPNs) revealed the following; -Day shift left eye is inflamed and reddened, the Unit Manager and Nurse Practitioner (NP) were notified, new orders [MEDICATION NAME](antibiotic) eye drops. -Evening shift left eye is very red with yellow crusty drainage.[MEDICATION NAME] and all other drops as directed. -Night shift left eye swelling and redness persists. Complained of pain, [MEDICATION NAME] (narcotic pain medication) given with effect, antibiotic eye drops continued. Review of an LPN Progress Note dated 10/29/16 at 6:30 AM revealed the left eye remains red and swollen with yellow drainage, antibiotic eye drops continued, complained of pain, [MEDICATION NAME] administered with effect. Review of a Progress Note dated 10/30/16 at 2:04 AM revealed the resident complained of breakthrough pain between scheduled [MEDICATION NAME]. Tylenol given as needed. Medium amount of drainage noted to left eye lid with noticeable swelling and discoloration.[MEDICATION NAME] continue. Review of a Progress Note dated 10/31/16 at 12:54 AM revealed the resident was heard in her room vomiting. Resident stated that her stomach hurt and she had a lot of pain in the left eye related to the infection. Blood pressure (BP) was 204/100 (elevated) in right arm and repeat BP 178/102 (elevated), heart rate was 62 (average 80), temperature was 100.4 (normal 98.6) orally and 99.4 via the ear, oxygen saturation was 98% (normal 98-100%) on room air with no diaphoresis (sweating) noted. No observable weakness noted. The supervisor was contacted about the high BP. [MEDICATION NAME] was given for stomach upset and Tylenol as needed for pain and low grade fever. Ice chips were provided. Review of Registered Nurse (RN) #1's Progress Note dated 10/31/16 at 7:51 AM revealed the resident was seen due to staff nurse report of resident having an increased BP and emesis twice. Upon assessment, the resident was found to be in pain related to the left eye that is inflamed with scant purulent (pus) drainage and swelling. The resident offered subjective report of overall discomfort and a decrease in vision in the left eye. The NP was contacted regarding resident condition awaiting call back with new orders. Review of RN #1's Progress Note dated 10/31/16 at 1:17 PM revealed the resident was seen by the NP and an emergency appointment was made at the Eye Clinic regarding an apparent left eye infection, increased pain and discomfort. Review of an Eye Clinic Consult dated 10/31/16 revealed the resident was diagnosed with [REDACTED]. Instructions for care revealed [MEDICATION NAME] (antibiotic) 1.5 % one drop every other hour (alternate with [MEDICATION NAME] drops) left eye. [MEDICATION NAME] 2.0% one drop every other hour (alternate with [MEDICATION NAME]). Alternate drops hourly- an antibiotic should be given every hour day and night. [MEDICATION NAME] (medication to decrease the amount of fluid in the eye) 500 milligrams twice a day. Follow-up at the Eye Clinic on 11/1/16 at 10:00 AM. Review of a NP Acute Visit note dated 10/31/16 revealed the resident was seen for redness, pain and decrease in vision left eye following cataract removal on 10/10/16. The resident started with redness and puffiness to the left eye with slight drainage and was sent to the Eye Clinic for an emergency appointment. The resident received a [MEDICATION NAME] injection at the visit and was diagnosed with [REDACTED]. Resident also started on [MEDICATION NAME]. Review of an LPN Progress Note dated 11/1/16 at 6:22 AM revealed at 6:00 AM the resident's vital signs were stable. Left eye remained red and swollen with yellow bloody drainage. Resident stated she is unable to see out of the eye at that time. Eye drops were given. As needed Tylenol and scheduled [MEDICATION NAME] given for pain. Review of the Emergency Department (ED) Physician note dated 11/1/16 revealed the resident was sent to the ED from the Eye Clinic due to orbital [MEDICAL CONDITION] and endophthalmitis of the left eye and placed on intravenous (IV) antibiotics and antibiotic drops to the left eye. Review of an Infectious Disease Consult dated 11/15/16 revealed the resident went to surgery on 11/10/16 where evisceration (removal of the internal contents of the eye leaving the scleral shell and extraocular muscles intact) took place. Recommend to continue oral antibiotics for 4 weeks upon discharge. During an interview on 5/2/17 at approximately 10:00 AM, the NP stated that on 10/28/16 it was reported to her via phone by RN #1 that the resident had slight redness in the left eye. RN #1 did not report any swelling or drainage. The NP was aware the resident recently had cataract surgery on the left eye. The NP stated that she [MEDICATION NAME] drops on 10/28/16; she did not physically see the resident on 10/28/16. The NP stated that she saw the resident on Monday 10/31/16 and the left eye was worse with redness, pain and decreased vision and she made an immediate Eye Clinic appointment for 10/31/16. The resident returned from the Eye Clinic with orders for [MEDICATION NAME] and [MEDICATION NAME] eye drops with instructions to return to the Eye Clinic on 11/1/16. The NP stated that the resident was seen on 11/1/16 and sent directly to the ED from the Eye Clinic. During a telephone interview on 5/4/17 at approximately 12:00 PM, RN #1 (no longer employed at the facility) stated that he recalls the resident had cataract surgery in October 2016. He stated that he assessed the resident on Friday afternoon, 10/28/16 and she had slight redness to the left eye but no drainage, pain or discomfort. He notified the NP and received a new order for an antibiotic eye drop which was started. RN #1 stated that he was off the weekend and saw the resident again on Monday 10/31/16. On Monday morning, the resident's eye had deteriorated so he called the NP who arranged an emergency appointment at the Eye Clinic for that day. RN #1 stated that he does not recall what happened to the resident after that. During a telephone interview on 5/10/17 at approximately 3:00 PM the Ophthalmologist stated she performed the resident's left eye cataract surgery on 10/10/16. She stated that someone from the nursing home called the Eye Clinic on Friday 10/28/16 with concerns about the left eye being red and possibly infected. She stated that her Resident (a medical graduate engaged in specialized practice under the supervision of an attending physician) called the nursing home back and recommended the resident be seen at the Eye Clinic on 10/28/16 but the nurse who took the call said they would have their in-house physician handle it. The Ophthalmologist stated that by the time the resident was seen at the Eye Clinic on Monday 10/31/16 the eye was so far gone the resident required antibiotic injections into the eye and every hour topical antibiotic drops; the resident had a [DIAGNOSES REDACTED]. The Ophthalmologist stated the resident was seen at the Eye Clinic on 11/1/16 and sent directly to the ED. IV antibiotics were started at the hospital but the eye continued to worsen and the resident required an evisceration of the left eye. During surgery the infection was so bad that the bacteria had eaten a hole into the back wall of the eyeball and that normally during evisceration surgery a marble spacer is placed into the eye socket to hold the space but it could not be done because of the infection. They had to wait for the infection to improve and take the resident back to surgery a second time to place the spacer and that the resident no longer has sight in the left eye. The Ophthalmologist stated that the resident should have been seen at the Eye Clinic on 10/28/16 for any complication of eye surgery. The resident should have been seen by a specialist who has the proper eye instruments to visualize the condition behind the eye, things that cannot be seen with the naked eye. The Ophthalmologist stated that the delay in being seen by an eye specialist from Friday 10/28/16 - Monday 10/31/16 caused the resident's severe endophthalmitis and loss of vision in the eye. Review of a document entitled A recent post-operative patient, concerning the left eye dated 11/2/16 written by the Medical Resident and emailed to the Ophthalmologist revealed the Medical Resident's conversation with the facility staff member on 10/28/16 regarding Resident #1. The document revealed that on Friday 10/28/16 at approximately 2:45 PM the Medical Resident received a message (placed by RN #1) that the resident had a red eye that looked infected. On 10/28/16 at 3:15 PM the Medical Resident returned the call however, RN #1 was off duty so he spoke to another nurse. He told the nurse that he was informed that there was concern for a possible infection, and if that was so the patient should be taken to the ED. He was informed by the nurse that the facility had already taken care of it, that they had spoken to the facility physician who had already decided to treat [MEDICATION NAME] drops. The nurse expressed to the Medical Resident that the facility doctor and nurse did not feel that the patient needed to be examined emergently. The Medical Resident inquired about the resident's symptoms and severity including whether there was significant eye pain, decreased VA (visual acuity), purulent drainage, and floaters/flashing lights. The nurse informed him that the current symptoms of redness, pain and discharge were mild and that she did not think the patient was complaining about any of the symptoms he had specified. The Medical Resident documented that he instructed the nurse that the facility should call immediately or take the patient to the ED for new/worsening ocular symptoms including worsening eye pain and decreasing VA. The nurse expressed understanding. The Medical Resident documented that he messaged a hospital representative that the resident was not coming in because the facility physician wanted to [MEDICATION NAME]. He included in the message that he informed facility staff to call with worsening symptoms, and commented that facility staff did not seem that interested in speaking with him. 415.12 (m)(2)

Based on observation, interview and record review during the Extended Survey completed 11/6/15, it was determined that the facility was not administered in an effective and efficient manner that would enable each resident to attain or maintain the highest practicable physical, mental and psychosocial well-being. Specifically, concerns rising to the level of IMMEDIATE JEOPARDY to resident's health and safety included the facility's failure to have an effective system in place to ensure accurate medication order entry, transcription, and administration to all residents in the facility. Administration was unaware of multiple significant medication errors related to transcription, administration, and the unavailability of ordered medication. The Administrator was unaware of the lack of pharmacy safeguards and oversight in place for the delivery and administration of correct medications. This had the potential to affect all 155 residents residing in the facility and receiving medications at the time of survey. This resulted in widespread IMMEDIATE JEOPARDY TO RESIDENT HEALTH AND SAFETY that is actual harm for Resident #150. The findings are: Refer to F225 - Investigate/Report Allegations/Individuals, scope and severity (s/s) = J Refer to F309 - Provide Care/Services for Highest Well-Being, s/s=K Refer to F329 - Drug Regimen is Free from Unnecessary Drugs, s/s=K Refer to F333 - Residents are Free of Significant Medication Errors, s/s=K Refer to F425 - Pharmaceutical Services - Accurate Procedures, s/s=K Refer to F428 - Drug Regimen Review, Report Irregular, Act On, s/s=K Refer to F520 - QAA Committee - Members/Meet Quarterly/Plans, s/s=L 1. Interview with the Administrator on 10/28/15 at approximately 9:00 AM revealed the facility uses the Point Click Care (PCC) program for the electronic Medical Record System. The Administrator stated that the facility transitioned to an electronic Medication Administration Record [REDACTED]. Interview with the Director of Nursing Services (DNS) on 11/4/15 at 2:40 PM revealed there were no medication error reports for the past three months except for the medication errors that were just identified by the survey team. Interview with the DNS and the Administrator on 11/4/15 at 5:15 PM revealed the facility transitioned to the eMAR/ eTAR in March of 2015. They trained all the nurses at that time but there was no ongoing monitoring to ensure the accuracy of medication transcription and administration. Interview with the DNS on 11/6/15 at 7:50 AM revealed she was not aware of all the medication and transcription errors that had occurred until the survey team brought them to her attention. The DNS stated that she would have expected her staff to inform her of these issues. The DNS stated that she expected the dispensing pharmacy to have a system in place to avoid medication errors related to excessive dosing and questionable medication orders. During a later interview on 11/6/15 at approximately 8:22 AM, the DNS was asked what her expectations of her staff was, concerning missing medications or clarifying medication orders. The DNS stated she would expect her staff to contact the head nurse (unit manager) or the physician and then stated I don't have an answer for you. They're supposed to contact the pharmacy, the head nurse, the doctor to clarify the order. The deficiencies cited under F225, F309, F329, F333, F425, F428, and F520 and the potential serious impact they represent to the quality of care and the quality of life of facility residents, demonstrate a failure on the part of the Administrator to ensure effective management and operation of the facility. 2. Resident #150 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident was moderately cognitively impaired, usually understands, and was understood. Review of the undated Comprehensive Care Plan (CCP) revealed the resident has a potential for violence related to hallucinations and delusions manifested by agitation and aggressive behaviors. The CCP documented that the resident has impaired cognition and thought process, mood problems related to mental illness, and receives antidepressants, anti-anxiety, and antipsychotic medications. CCP interventions included reviewing new medications, dosage increases, recent discontinuations, omissions, drug interactions/ adverse reactions, errors, drug toxicity, and record possible causes of cognitive deficits. The CCP documented an intervention to administer medications as ordered, and monitor and document for side effects and effectiveness. Review of a Physician's Telephone Order dated 9/15/15 revealed orders for [MEDICATION NAME] (mood stabilizing drug used with psychiatric patients) 300 mg (milligrams) twice daily (BID), [MEDICATION NAME] (antipsychotic medication used to treat [MEDICAL CONDITION] disease) 0.5 mg once daily (QD), and [MEDICATION NAME] (mood stabilizing medication) 250 mg BID. Review of an Acute Visit Note, written by the NP (Nurse Practitioner), dated 9/22/15 revealed the patient has a history of [MEDICAL CONDITION] disorder and continues to display bizarre behaviors that remain uncontrolled, despite current behavior modifying medications. The NP documented staff reported that the resident was making sexually inappropriate statements towards male workers, difficult with hands-on care. Review of a Physician's Telephone Order, written by the NP, dated 9/22/15 revealed the following orders; - Increase [MEDICATION NAME] to 1 mg BID for behavior - Increase [MEDICATION NAME] to 500 mg BID for behavior - *[MEDICATION NAME] (antipsychotic medication) 2 mg intramuscular (IM) x (times) one now, then every 6 hours as needed (prn) x 72 hours for severe agitation. Review of an Acute Visit Note, written by the NP, dated 9/23/15 revealed the resident was seen to evaluate all psychoactive medications. The NP documented a plan to continue [MEDICATION NAME] 300 mg BID for [MEDICAL CONDITION] disorder. Spoke at length with Pharmacy (a Pharmacist) regarding transition from [MEDICATION NAME] to [MEDICATION NAME] (long acting [MEDICATION NAME]). Order written to discontinue [MEDICATION NAME] on Monday (9/28/15) and administer [MEDICATION NAME] 50 mg once every 28 days starting Monday. Review of a Physician's Telephone Order, written by the NP, dated 9/23/15 revealed the following: - [MEDICATION NAME] (long acting) 50 mg IM every 28 days - Discontinue [MEDICATION NAME] on Monday (9/28/15) Review of the electronic Medication Administration Record [REDACTED]. There was no documented evidence on the eMAR that 24 accuracy checks were done. Additional review of the eMAR dated September 2015 revealed that the resident continued to receive [MEDICATION NAME] 1 mg BID on 9/28/15 and 9/29/15 despite the order to discontinue the medication. The eMAR documented that the [MEDICATION NAME] was held (not given) on 9/30/15 at 9:00 AM. Review of a Nursing Progress Note dated 9/30/15 at 10:00 AM revealed the [MEDICATION NAME] was held because the resident was lethargic. Further review of Nursing Progress Notes dated 9/23/15, 9/25/15 and 9/28/15 revealed the Pharmacy system had identified and reported a possible drug interaction between the [MEDICATION NAME] and [MEDICATION NAME] that may produce unexpected effects (severe neurotoxicity- damage to the brain). Additional review of Nursing Progress Notes revealed the following: - 9/29/15 at 10:00 PM - The resident slept in the wheelchair all shift, refused dinner but medications given, temperature 102.4 degrees (normal 98.6 ), Tylenol given, and recheck of temperature 99 ° degrees. - 9/30/15 at 6:38 AM - Refused to wake up. - 9/30/15 at 10:00 AM - Medications held due to lethargy. - 9/30/15 at 3:00 PM - Resident very lethargic this shift, heart rate (HR) 136 (average 80), respirations 24 (normal 12 to 20), temperature 100.8 degrees, medications were held due to lethargy, and intake of foods and fluid poor this shift. HR down to 98 and temperature retake was 100.3° (degrees Fahrenheit (F), and the resident remains lethargic. - 9/30/15 at 8:00 PM - The resident as asleep all shift, respirations are normal, temperature 99.9 degrees, given Tylenol, and recheck 98.5° F. Aroused with difficulty, no swallowing motions noted, dinner held, crushed meds in applesauce, able to suck water with straw 100 milliliters (ml) intake. There was no documented evidence that the physician or NP were notified of the change in the resident's condition on 9/29/15 or 9/30/15. Review of an untimed Physician's Telephone Order, written by the NP, dated 10/1/15 revealed orders to obtain STAT (immediate) bloodwork that included a CBC with diff (complete blood count with differential), CMP (complete metabolic profile - blood chemistry studies), a [MEDICATION NAME] level, a urinalysis, urine culture and sensitivity, and a chest x-ray. The orders directed to start [MEDICATION NAME] (antibiotic) one gram IM daily and start Clysis (fluid administered subcutaneously into the abdomen) fluids with normal saline (NS). Review of a Laboratory Report dated 10/1/15 revealed Critical BUN and Na called to RN Supervisor at facility on 10/1/15 at 4:42 PM. Further review of nursing Progress Notes revealed the following: - 10/1/15 AM - AM medications refused. - 10/1/15 at 3:00 PM - Resident lethargic this shift, HR 130, temperature 101.3° F, respirations 26. - 10/1/15 at 7:21 PM - NP updated on STAT blood work results; [MEDICATION NAME] level 1.58 (normal 0.60 - 1.60), Blood Urea Nitrogen (BUN - blood test to determine kidney function and hydration status) 129 (normal 5 to 27), Sodium Level (Na) 159 (normal 133 to 147). Order to send to the emergency room for treatment and evaluation. - 10/1/15 at 10:00 PM - Difficult to arouse, labored breathing, blood pressure 144/118 (normal), HR of 131, temperature 102.7° F, respirations 16, difficulty to arouse for meds (medications), no swallowing motions noted, all meds held, call to transfer resident to hospital. - 10/2/15 at 8:08 AM - The resident was admitted to the hospital ICU (intensive care unit) with altered mental status and [MEDICAL CONDITION] (elevated sodium level in the blood). During an interview on 11/3/15 at 11:08 AM, the NP stated that the resident had [DIAGNOSES REDACTED]. The NP spoke with the family and the family had requested a medication that was longer acting. That is why the [MEDICATION NAME] 2 mg prn was changed to the [MEDICATION NAME] 50 mg to be administered every 28 days. The plan was to wean the resident from the [MEDICATION NAME]. The NP stated that she was not concerned with the potential Black Box Warnings (potential for severe interactions) nor did she have concerns related to the potential for an elevating BUN and Na, with only receiving a couple of doses of [MEDICATION NAME]. The NP was asked if she was aware that the [MEDICATION NAME] 50 mg was documented as being administered on 9/24/15, 9/26/15, 9/29/15 and the [MEDICATION NAME] was not discontinued as ordered. The NP stated no and suggested that the surveyor discuss the medication concerns with the Unit Manager. The NP further stated I write the order, the nurses take care of the rest. During an interview on 11/3/15 at 11:16 AM, the Licensed Practical Nurse (LPN #11) Unit Manager stated she realized that the [MEDICATION NAME] 50 was not given as ordered and she questioned her nurses. The nurses said that they gave the regular [MEDICATION NAME], a medication error report was completed regarding the [MEDICATION NAME], and the nurses were spoken to. LPN #11 stated that she had to enter the order for [MEDICATION NAME] 50 mg IM q 28 days into the computer two extra times because once you sign that you gave the [MEDICATION NAME], the system does not allow for you to make a correction that it was signed out in error. During an interview on 11/3/15 at 11:29 AM, LPN #12 stated that she was told she gave the wrong [MEDICATION NAME] on 9/24/15 by her Charge Nurse. LPN #12 stated that there was only one vial of [MEDICATION NAME] in the cart to give. During a telephone interview on 11/3/15 at approximately 11:35 AM, the pharmacist stated that the Pharmacy dispensed [MEDICATION NAME] 50 mg a couple of times. Three times to be exact on 9/23/15, 9/25/15, and 9/28/15. Review of the Pharmacy delivery sheet confirmed that [MEDICATION NAME] 50 mg was delivered to the facility on three occasions for Resident #150. During a telephone interview on 11/3/15 at 2:24 PM, the NP stated I honestly can't answer what would happen if the resident received an extra 100 mg of [MEDICATION NAME]. I would have to do some research and confer with the MD. My intention was to wean off the [MEDICATION NAME] and start [MEDICATION NAME]. On 10/1/15, I did not know what was going on with the resident; I acted appropriately and sent her out to the ER. During an interview on 11/3/15 at 3:31 PM, the Medical Director stated That is a lot of [MEDICATION NAME]. Certainly there would be the potential for harm, but I cannot say with 100 percent (%) certainty. We would be concerned with cardiac arrhythmias (loss of normal heart rhythm) and kidney injury with these types of medications. Given the resident's comorbidities (the presence of one or more diseases) and the [MEDICATION NAME] level on the high side of normal, if the resident got an additional dose of [MEDICATION NAME], of course with two additional doses along with the other medications - [MEDICATION NAME] - the greater the potential. During an interview on 11/3/15 at approximately 4:25 PM, the Director of Nursing Services (DNS) and the Administrator stated that the Pharmacy had no record of any [MEDICATION NAME] 50 mg being returned to the Pharmacy. During an interview on 11/3/15 at approximately 4:15 PM, LPN #4 stated that the resident was combative on 9/26/15, up and down out of the chair, and needed [MEDICATION NAME]. LPN #4 stated there was one vial of [MEDICATION NAME] in the medication cart and that is what she gave. LPN #4 stated that she checked the vial against the eMAR, it matched so that is what she gave. LPN #4 stated she did not know if it was 2 mg or 50 mg [MEDICATION NAME]. LPN #4 stated she found out about the error yesterday (11/2/15) from her Charge Nurse and was educated. During a telephone Interview on 11/4/15 at 10:10 AM, the Pharmacy Consultant stated he was not familiar with Resident #150, he did not review her medications, and he was not aware of any medication errors. The Pharmacy Consultant stated that adverse reactions would include sedation, [MEDICAL CONDITION](fast heart beat), and respiratory issues. The Pharmacist stated that when [MEDICATION NAME] is administered with the [MEDICATION NAME] ([MEDICATION NAME] is a funny drug he said) and you have a resident with multiple comorbidities and is on multiple drugs, the concern would also be increased levels of [MEDICATION NAME] and kidney damage. Review of the FDA (US Food and Drug Administration) prescribing information for [MEDICATION NAME] 50 mg revealed the medication is indicated for the treatment of [REDACTED]. [DIAGNOSES REDACTED] (NMS) has been reported in association with antipsychotic drugs. Clinical manifestations of NMS include high fever, muscle rigidity, altered mental status, irregular pulse or blood pressure, [MEDICAL CONDITION] may also include elevated creatinine (blood test to determine kidney function) and acute renal (kidney) failure. During an additional interview on 11/5/15 at 8:30 AM, the DNS stated she was first made aware of the [MEDICATION NAME] error on 11/2/15. Neither the LPN #11 Unit Manager or the Registered Nurse (RN #9) who assists on the unit, reported the error to her when it happened in September 2015. A medication error report was started on 11/2/15. During an interview on 11/6/15 at 8:52 AM, RN #9 stated she was aware that there was a [MEDICATION NAME] error but was not aware of the magnitude of the medication error until 11/2/15. In addition, she was not aware that a medication error report was not completed until 11/2/15. 415.26

Based on observation, interview, and record review conducted during the Extended Survey completed 11/6/15, the facility failed to ensure that the Quality Assessment and Assurance (QAA) committee effectively identified and corrected quality deficiencies with potential to cause serious harm to residents and did not develop and implement appropriate plans of action. The facility QAA committee failed to ensure an effective system for accurate medication order entry, transcription, and administration for all residents in the facility. The QAA committee failed to ensure there were safeguards in place to ensure the accurate acquiring receiving, and dispensing of medications to the facility and safe medication administration to residents. The QAA committee did not ensure that ongoing audits were conducted to verify accurate and safe implementation of the electronic Medication Administration Record [REDACTED]. This resulted in widespread IMMEDIATE JEOPARDY TO RESIDENT HEALTH AND SAFETY with actual harm. The findings are: Refer to F225 - Investigate/Report Allegations/Individuals, Scope and Severity (s/s) = J Refer to F309 - Provide Care/Service for Highest Well-Being, s/s=K Refer to F329 - Drug Regimen is Free from Unnecessary Drugs, s/s=K Refer to F333 - Residents are Free of Significant Medication Errors, s/s=K Refer to F425 - Pharmaceutical Services - Accurate Procedures, RPH, s/s=K Refer to F428 - Drug Regimen Review, Report Irregular, Act On, s/s=K 1. Interview with the Administrator on 10/28/15 at approximately 9:00 AM revealed the facility uses the Point Click Care System (PCC) for their electronic Medical Record System. The Administrator stated that the facility transitioned to the electronic Medication Administration Record [REDACTED]. Interview with the Director of Nursing Services (DNS) on 11/4/15 at 2:40 PM revealed there were no medication error reports completed during the past three months except for the medication errors identified by the survey team during the Extended survey. Interview with the DNS and the Administrator on 11/4/15 at 5:15 PM revealed the facility transitioned to the eMAR/eTAR in March of 2015. The Administrator stated that they trained all the nurses at that time but they had not done any ongoing monitoring of the eMAR system to ensure the accuracy of medication transcription and administration. During an interview on 11/4/15 at approximately 11:15 AM, the Administrator stated I'm not going to say we don't have a problem with pharmacy. We use three back up pharmacies. Interview with the DNS on 11/6/15 at 7:50 AM revealed she was not aware of all the medication and transcription errors that had occurred until the survey team brought them to her attention. The DNS stated that she would have expected her staff to inform her of these issues. She also expected the dispensing pharmacy to have a system in place to avoid the medication errors related to excessive dosing and questionable medication orders. During an interview on 11/6/15 at approximately 8:22 AM, the DNS was asked what her expectations of her staff were concerning missing medications or clarifying orders. The DNS stated I don't have an answer for you. They're supposed to contact the pharmacy, the head nurse (unit manager), and the doctor to clarify the order. Interview with the Consultant Pharmacist on 10/30/15 at approximately 9:00 AM revealed that since facility switched to the electronic medical record and the eMAR, there have been issues with order entry and duplicate orders. Resident #150 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident was moderately cognitively impaired, usually understands, and was understood. Review of the undated Comprehensive Care Plan (CCP) revealed the resident has a potential for violence related to hallucinations and delusions manifested by agitation and aggressive behaviors. The CCP documented that the resident has impaired cognition and thought process, mood problems related to mental illness, and receives antidepressants, anti-anxiety, and antipsychotic medications. CCP interventions included reviewing new medications, dosage increases, recent discontinuations, omissions, drug interactions/ adverse reactions, errors, drug toxicity, and record possible causes of cognitive deficits. The CCP documented an intervention to administer medications as ordered, and monitor and document for side effects and effectiveness. Review of a Physician's Telephone Order dated 9/15/15 revealed orders for [MEDICATION NAME] (mood stabilizing drug used with psychiatric patients) 300 mg (milligrams) twice daily (BID), [MEDICATION NAME] (antipsychotic medication used to treat [MEDICAL CONDITION] disease) 0.5 mg once daily (QD), and [MEDICATION NAME] (mood stabilizing medication) 250 mg BID. Review of an Acute Visit Note, written by the NP (Nurse Practitioner), dated 9/22/15 revealed the patient has a history of [MEDICAL CONDITION] disorder and continues to display bizarre behaviors that remain uncontrolled, despite current behavior modifying medications. The NP documented staff reported that the resident was making sexually inappropriate statements towards male workers, difficult with hands-on care. Review of a Physician's Telephone Order, written by the NP, dated 9/22/15 revealed the following orders; - Increase [MEDICATION NAME] to 1 mg BID for behavior - Increase [MEDICATION NAME] to 500 mg BID for behavior - *[MEDICATION NAME] (antipsychotic medication) 2 mg intramuscular (IM) x (times) one now, then every 6 hours as needed (prn) x 72 hours for severe agitation. Review of an Acute Visit Note, written by the NP, dated 9/23/15 revealed the resident was seen to evaluate all psychoactive medications. The NP documented a plan to continue [MEDICATION NAME] 300 mg BID for [MEDICAL CONDITION] disorder. Spoke at length with Pharmacy (a Pharmacist) regarding transition from [MEDICATION NAME] to [MEDICATION NAME] (long acting [MEDICATION NAME]). Order written to discontinue [MEDICATION NAME] on Monday (9/28/15) and administer [MEDICATION NAME] 50 mg once every 28 days starting Monday. Review of a Physician's Telephone Order, written by the NP, dated 9/23/15 revealed the following: - [MEDICATION NAME] (long acting) 50 mg IM every 28 days - Discontinue [MEDICATION NAME] on Monday (9/28/15) Review of the electronic Medication Administration Record [REDACTED]. There was no documented evidence on the eMAR that 24 accuracy checks were done. Additional review of the eMAR dated September 2015 revealed that the resident continued to receive [MEDICATION NAME] 1 mg BID on 9/28/15 and 9/29/15 despite the order to discontinue the medication. The eMAR documented that the [MEDICATION NAME] was held (not given) on 9/30/15 at 9:00 AM. Review of a Nursing Progress Note dated 9/30/15 at 10:00 AM revealed the [MEDICATION NAME] was held because the resident was lethargic. Further review of Nursing Progress Notes dated 9/23/15, 9/25/15 and 9/28/15 revealed the Pharmacy system had identified and reported a possible drug interaction between the [MEDICATION NAME] and [MEDICATION NAME] that may produce unexpected effects (severe neurotoxicity- damage to the brain). Additional review of Nursing Progress Notes revealed the following: - 9/29/15 at 10:00 PM - The resident slept in the wheelchair all shift, refused dinner but medications given, temperature 102.4 degrees (normal 98.6 ), Tylenol given, and recheck of temperature 99 ° degrees. - 9/30/15 at 6:38 AM - Refused to wake up. - 9/30/15 at 10:00 AM - Medications held due to lethargy. - 9/30/15 at 3:00 PM - Resident very lethargic this shift, heart rate (HR) 136 (average 80), respirations 24 (normal 12 to 20), temperature 100.8 degrees, medications were held due to lethargy, and intake of foods and fluid poor this shift. HR down to 98 and temperature retake was 100.3° (degrees Fahrenheit (F), and the resident remains lethargic. - 9/30/15 at 8:00 PM - The resident as asleep all shift, respirations are normal, temperature 99.9 degrees, given Tylenol, and recheck 98.5° F. Aroused with difficulty, no swallowing motions noted, dinner held, crushed meds in applesauce, able to suck water with straw 100 milliliters (ml) intake. There was no documented evidence that the physician or NP were notified of the change in the resident's condition on 9/29/15 or 9/30/15. Review of an untimed Physician's Telephone Order, written by the NP, dated 10/1/15 revealed orders to obtain STAT (immediate) bloodwork that included a CBC with diff (complete blood count with differential), CMP (complete metabolic profile - blood chemistry studies), a [MEDICATION NAME] level, a urinalysis, urine culture and sensitivity, and a chest x-ray. The orders directed to start [MEDICATION NAME] (antibiotic) one gram IM daily and start Clysis (fluid administered subcutaneously into the abdomen) fluids with normal saline (NS). Review of a Laboratory Report dated 10/1/15 revealed Critical BUN and Na called to RN Supervisor at facility on 10/1/15 at 4:42 PM. Further review of nursing Progress Notes revealed the following: - 10/1/15 AM - AM medications refused. - 10/1/15 at 3:00 PM - Resident lethargic this shift, HR 130, temperature 101.3° F, respirations 26. - 10/1/15 at 7:21 PM - NP updated on STAT blood work results; [MEDICATION NAME] level 1.58 (normal 0.60 - 1.60), Blood Urea Nitrogen (BUN - blood test to determine kidney function and hydration status) 129 (normal 5 to 27), Sodium Level (Na) 159 (normal 133 to 147). Order to send to the emergency room for treatment and evaluation. - 10/1/15 at 10:00 PM - Difficult to arouse, labored breathing, blood pressure 144/118 (normal), HR of 131, temperature 102.7° F, respirations 16, difficulty to arouse for meds (medications), no swallowing motions noted, all meds held, call to transfer resident to hospital. - 10/2/15 at 8:08 AM - The resident was admitted to the hospital ICU (intensive care unit) with altered mental status and [MEDICAL CONDITION] (elevated sodium level in the blood). During an interview on 11/3/15 at 11:08 AM, the NP stated that the resident had [DIAGNOSES REDACTED]. The NP spoke with the family and the family had requested a medication that was longer acting. That is why the [MEDICATION NAME] 2 mg prn was changed to the [MEDICATION NAME] 50 mg to be administered every 28 days. The plan was to wean the resident from the [MEDICATION NAME]. The NP stated that she was not concerned with the potential Black Box Warnings (potential for severe interactions) nor did she have concerns related to the potential for an elevating BUN and Na, with only receiving a couple of doses of [MEDICATION NAME]. The NP was asked if she was aware that the [MEDICATION NAME] 50 mg was documented as being administered on 9/24/15, 9/26/15, 9/29/15 and the [MEDICATION NAME] was not discontinued as ordered. The NP stated no and suggested that the surveyor discuss the medication concerns with the Unit Manager. The NP further stated I write the order, the nurses take care of the rest. During an interview on 11/3/15 at 11:16 AM, the Licensed Practical Nurse (LPN #11) Unit Manager stated she realized that the [MEDICATION NAME] 50 was not given as ordered and she questioned her nurses. The nurses said that they gave the regular [MEDICATION NAME], a medication error report was completed regarding the [MEDICATION NAME], and the nurses were spoken to. LPN #11 stated that she had to enter the order for [MEDICATION NAME] 50 mg IM q 28 days into the computer two extra times because once you sign that you gave the [MEDICATION NAME], the system does not allow for you to make a correction that it was signed out in error. During an interview on 11/3/15 at 11:29 AM, LPN #12 stated that she was told she gave the wrong [MEDICATION NAME] on 9/24/15 by her Charge Nurse. LPN #12 stated that there was only one vial of [MEDICATION NAME] in the cart to give. During a telephone interview on 11/3/15 at approximately 11:35 AM, the pharmacist stated that the Pharmacy dispensed [MEDICATION NAME] 50 mg a couple of times. Three times to be exact on 9/23/15, 9/25/15, and 9/28/15. Review of the Pharmacy delivery sheet confirmed that [MEDICATION NAME] 50 mg was delivered to the facility on three occasions for Resident #150. During a telephone interview on 11/3/15 at 2:24 PM, the NP stated I honestly can't answer what would happen if the resident received an extra 100 mg of [MEDICATION NAME]. I would have to do some research and confer with the MD. My intention was to wean off the [MEDICATION NAME] and start [MEDICATION NAME]. On 10/1/15, I did not know what was going on with the resident; I acted appropriately and sent her out to the ER. During an interview on 11/3/15 at 3:31 PM, the Medical Director stated That is a lot of [MEDICATION NAME]. Certainly there would be the potential for harm, but I cannot say with 100 percent (%) certainty. We would be concerned with cardiac arrhythmias (loss of normal heart rhythm) and kidney injury with these types of medications. Given the resident's comorbidities (the presence of one or more diseases) and the [MEDICATION NAME] level on the high side of normal, if the resident got an additional dose of [MEDICATION NAME], of course with two additional doses along with the other medications - [MEDICATION NAME] - the greater the potential. During an interview on 11/3/15 at approximately 4:25 PM, the Director of Nursing Services (DNS) and the Administrator stated that the Pharmacy had no record of any [MEDICATION NAME] 50 mg being returned to the Pharmacy. During an interview on 11/3/15 at approximately 4:15 PM, LPN #4 stated that the resident was combative on 9/26/15, up and down out of the chair, and needed [MEDICATION NAME]. LPN #4 stated there was one vial of [MEDICATION NAME] in the medication cart and that is what she gave. LPN #4 stated that she checked the vial against the eMAR, it matched so that is what she gave. LPN #4 stated she did not know if it was 2 mg or 50 mg [MEDICATION NAME]. LPN #4 stated she found out about the error yesterday (11/2/15) from her Charge Nurse and was educated. During a telephone Interview on 11/4/15 at 10:10 AM, the Pharmacy Consultant stated he was not familiar with Resident #150, he did not review her medications, and he was not aware of any medication errors. The Pharmacy Consultant stated that adverse reactions would include sedation, [MEDICAL CONDITION](fast heart beat), and respiratory issues. The Pharmacist stated that when [MEDICATION NAME] is administered with the [MEDICATION NAME] ([MEDICATION NAME] is a funny drug he said) and you have a resident with multiple comorbidities and is on multiple drugs, the concern would also be increased levels of [MEDICATION NAME] and kidney damage. Review of the FDA (US Food and Drug Administration) prescribing information for [MEDICATION NAME] 50 mg revealed the medication is indicated for the treatment of [REDACTED]. [DIAGNOSES REDACTED] (NMS) has been reported in association with antipsychotic drugs. Clinical manifestations of NMS include high fever, muscle rigidity, altered mental status, irregular pulse or blood pressure, [MEDICAL CONDITION] may also include elevated creatinine (blood test to determine kidney function) and acute renal (kidney) failure. During an additional interview on 11/5/15 at 8:30 AM, the DNS stated she was first made aware of the [MEDICATION NAME] error on 11/2/15. Neither the LPN #11 Unit Manager or the Registered Nurse (RN #9) who assists on the unit, reported the error to her when it happened in September 2015. A medication error report was started on 11/2/15. During an interview on 11/6/15 at 8:52 AM, RN #9 stated she was aware that there was a [MEDICATION NAME] error but was not aware of the magnitude of the medication error until 11/2/15. In addition, she was not aware that a medication error report was not completed until 11/2/15. 415.27(c)(2)(3)(v)

Based on record review and staff interview conducted during a Complaint investigation (Complaint #NY 504) during the Extended survey completed on 11/6/15, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Six (Residents #87,89,110,150,193,206) of 35 residents reviewed for quality of care had issues involving the lack of an assessment by a registered professional nurse (RN) of a resident with a change in condition (#150), lack of a timely RN assessment of a resident with an injury (#150), lack of ongoing monitoring of a AV (arteriovenous fistula - a surgically created connection or passageway between an artery and a vein) fistula [MEDICAL TREATMENT] site (#87), and bloodwork and stool specimens that were not obtained per physician order [REDACTED]. This resulted in a pattern of IMMEDIATE JEOPARDY and SUBSTANDARD QUALITY OF CARE TO RESIDENT HEALTH AND SAFETY that is actual harm for Resident #150. The findings are: 1. Resident #150 has [DIAGNOSES REDACTED]. Review of the Minimum Date Set (MDS - a resident assessment tool) dated 9/15/15 revealed the resident was moderately cognitively impaired, usually understands, and was understood. Review of the undated Comprehensive Care Plan (CCP) (identified as current by the Licensed Practical Nurse (LPN #11) Unit Manager) revealed the resident has a potential for violence related to hallucinations and delusions manifested by agitation and aggressive behaviors. The CCP documented that the resident has impaired cognition, thought process, and mood problems related to mental illness and receives antidepressants, anti-anxiety, and antipsychotic medications. CCP interventions include reviewing new medications, dosage increases, recent discontinuations, omissions, drug interactions/ adverse reactions, errors, drug toxicity, and record possible causes of cognitive deficits. The CCP documented an intervention to administer medications as ordered, and monitor and document for side effects and effectiveness. Review of a Physician's Telephone Order dated 9/15/15 revealed orders for [MEDICATION NAME] (mood stabilizing drug used with psychiatric patients) 300 mg twice daily (BID), [MEDICATION NAME] (antipsychotic medication used to treat [MEDICAL CONDITION] disease) 0.5 mg once daily (QD), and [MEDICATION NAME] (mood stabilizing medication) 250 mg BID. Review of a Physician's Telephone Order, written by the NP (Nurse Practitioner), dated 9/22/15 revealed the following orders; - Increase [MEDICATION NAME] to 1 mg BID for behavior - Increase [MEDICATION NAME] to 500 mg BID for behavior - *[MEDICATION NAME] (antipsychotic medication) 2 mg intramuscular (IM) x (times) one now, then every 6 hours as needed (prn) x 72 hours for severe agitation. Review of a Physician's Telephone Order, written by the NP, dated 9/23/15 revealed the following: - [MEDICATION NAME] (long acting antipsychotic medication) 50 mg IM every 28 days - Discontinue [MEDICATION NAME] on Monday (9/28/15) Review of the electronic medical record (eMAR) dated September 2015 revealed that the [MEDICATION NAME] 50 mg IM was transcribed onto the eMAR three separate times and the resident received [MEDICATION NAME] 50 mg IM on 9/24/15, 9/26/15 and 9/29/15 instead of once every 28 days. There was no documented evidence on the eMAR that 24 accuracy checks were done. Review of nursing Progress Notes dated 9/24/15 to 9/29/15 revealed no documented evidence that a Registered Nurse (RN) assessed the resident following the repeated administration of [MEDICATION NAME]. During an interview on 11/3/15 at approximately 4:05 PM, RN #9 stated she is the Wound Nurse in the facility, but she helps the LPN Unit Manager as needed. RN #9 stated that she was aware of the initial [MEDICATION NAME] medication error. RN #9 stated that she did not assess the resident, the resident should have been assessed by an RN after receiving the additional doses of [MEDICATION NAME] 50 mg and the resident should have been monitored. Review of the eMAR dated September 2015 revealed that the resident continued to receive [MEDICATION NAME] 1 mg BID on 9/28/15 and 9/29/15 despite the order to discontinue the medication. The eMAR documented that the [MEDICATION NAME] was held (not given) on 9/30/15 at 9:00 AM. Nursing Progress Notes dated 9/23/15, 9/25/15 and 9/28/15 revealed the pharmacy system had identified and reported a possible drug interaction between the [MEDICATION NAME] and [MEDICATION NAME] that may produce unexpected effects (severe neurotoxicity- damage to the brain). Additional review of nursing Progress Notes revealed the following: - 9/29/15 at 10:10 PM - Licensed Practical Nurse (LPN #4) documented that the resident slept in the wheelchair all shift, refused dinner but medications given, temperature 102.4 degrees (normal 98.6 ), Tylenol given, and recheck of temperature 99 ° degrees. - 9/30/15 at 6:38 AM - LPN #18 documented that the resident refused to wake up. - 9/30/15 at 10:00 AM -LPN #12 documented that medications (including [MEDICATION NAME]) were held due to lethargy. - 9/30/15 at 3:00 PM - LPN #12 documented that the resident was very lethargic this shift, heart rate (HR) 136 (average 80), respirations 24 (normal 12 to 20), temperature 100.8 degrees, medications were held due to lethargy, and intake of foods and fluid poor this shift. HR down to 98 and temperature retake was 100.3 degrees, and the resident remains lethargic. - 9/30/15 at 8:00 PM - LPN #4 documented that the resident was asleep all shift, respirations are normal, temperature 99.9 degrees, given Tylenol, and recheck 98.5 degrees. Aroused with difficulty, no swallowing motions noted, dinner held, crushed meds in applesauce, able to suck water with straw 100 milliliters (ml) intake. Further review of the nursing Progress Notes dated 9/29/15 and 9/30/15 revealed no documented evidence that an RN assessed the resident. Nursing Progress Notes dated 10/1/15 at 11:21 AM, 11:22 AM, and 11:23 AM revealed medications were refused. Review of an untimed Physician's Telephone Order, written by the NP, dated 10/1/15 revealed orders to obtain STAT (immediate) bloodwork that included a CBC with diff (complete blood count with differential), CMP (complete metabolic profile - blood chemistry studies), a [MEDICATION NAME] level, a urinalysis, urine culture and sensitivity, and a STAT chest x-ray. The orders directed to start [MEDICATION NAME] (antibiotic) one gram IM daily and start Clysis (fluid administered subcutaneously into the abdomen) fluids with normal saline (NS). Review of a Laboratory Report dated 10/1/15 revealed Critical BUN (blood urea nitrogen - blood test to determine kidney function and hydration status) and Na (Sodium) called to Registered Nurse (RN) Supervisor at facility on 10/1/15 at 4:42 PM . Further review of nursing Progress Notes revealed the following: - 10/1/15 at 3:00 PM - LPN #12 documented that the resident was lethargic this shift, HR 130, temperature 101.3 °degrees, respirations 26. - 10/1/15 at 7:21 PM - LPN #11 documented that the NP was updated on STAT blood work results; [MEDICATION NAME] level 1.58 (normal 0.60 - 1.60), Blood Urea Nitrogen (BUN) 129 (normal 5 to 27), Sodium Level 159 (normal 133 to 147). Order to send to the emergency room for treatment and evaluation. - 10/1/15 at 10:00 PM - LPN #4 documented that the resident was difficult to arouse, labored breathing, blood pressure 144/118 (elevated), HR of 131, temperature 102.7 degrees, respirations 16, difficulty to arouse for meds, no swallowing motions noted, all meds held, call to transfer resident to hospital. The resident remained in the facility 2 1/2 hours after the order was received to transfer the resident to the hospital and 5 hours after critical laboratory results were called to the facility. - 10/2/15 at 8:08 AM - The resident was admitted to the hospital ICU (intensive care unit) with altered mental status and [MEDICAL CONDITION] (elevated sodium level in the blood). During an interview on 11/6/15 at 8:52 AM, RN #9 stated she was aware that there was a [MEDICATION NAME] error but was not aware of the magnitude of the medication error until 11/2/15. In addition, she was not aware that a medication error report was not completed until 11/2/15. During a telephone interview on 11/4/15 at approximately 7:10 AM, the Physician stated he was not going to argue the point that there should have been an RN assessment. In summary there were significant medication errors on 9/24/15, 9/26/15, 9/28/15 and 9/29/15 without a documented RN assessment. The resident had changes in condition that included increased lethargy; poor oral intake; elevated temperature, heart rate, and respiratory rate; and difficulty swallowing beginning on 9/29/15 without an RN assessment. b.) Review of a nursing Progress Note, written by LPN #7, dated 9/27/15 at 10:42 PM revealed the resident was noted to have reddish/ purple bruise on her lower chin. Review of a nursing Progress Note, written by the LPN (#11) Unit Manager, dated 9/30/15 at 8:47 AM revealed this writer noted resident had area under her chin. RN Supervisor updated, data collected. An RN Assessment Progress Note, written by RN #9, dated 9/30/15 at 8:48 AM documented noted area 3 cm (centimeter) x 3cm x 0 cm under chin that is bruised. Resident has a history of banging her chin as an acting out behavior when she doesn't get what she wants. Redirection does not prevent the behavior at this time. She is currently on 1:1 (one to one) for behaviors. Review of an Accident and Incident Report (A&I) dated 9:30/15 at 8:47 AM revealed the resident had an ecchymotic (purplish patch caused by blood under the skin) area on the bottom of the skin. The A&I Report was initiated on 9/30/15. During an interview on 11/3/15 at 10:19 AM, the LPN (#11) Unit Manager stated that the 11:00 PM to 7:00 AM nurse, LPN #7, should have notified the RN Supervisor and an A&I Report should have been completed when the bruise was noted. The LPN (#11) Unit Manager stated that she had personally witnessed the resident bang her chin on the table when she did not get her way. Interview with the Administrator on 11/6/15 at approximately 4:15 PM revealed there was no additional information available. 2. Resident #206 has [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed that the resident is cognitively intact, understood, and understands. Review of a Medication Review Report dated 9/12/15 revealed an order for [REDACTED]. Review of a Physician's Telephone Order dated 9/14/15 revealed orders to obtain a CBC (complete blood count), CMP (comprehensive metabolic panel), HgbA1C (glycated hemoglobin to test the average plasma glucose concentration over prolonged periods of time), and a PT/INR ([MEDICATION NAME] time and international normalized ratio a test to measure how fast blood clots) every Monday, Wednesday, and Friday; an ACTH Stimulation Test (adrenocorticotropic hormone that is injected into a person to stimulate the adrenal glands to release a hormone called [MEDICATION NAME]); and a Serum [MEDICATION NAME] to be obtained 30 minutes and 60 minutes after the ACTH stimulation test. Review of a nursing Progress Note dated 9/20/15 at 3:05 PM revealed that Resident #206 had a nose bleed at 2:00 PM which was stopped by applying pressure and tilting the resident's head backwards. A nursing Progress Note dated 9/20/15 at 10:30 PM documented that the resident had another nose bleed. The Nursing Supervisor was notified and the nose bleed was stopped by applying ice to the bridge of the nose. There was no documentation that the Physician was notified. Review of the chronological medical record from 9/14/15 to 10/6/15 revealed that there were no laboratory results for the CBC, CMP, HgbA1C, ACTH Stimulation Test, or Serum [MEDICATION NAME] ordered on [DATE]. In addition, there were no laboratory results for PT/INRs from 9/14/15 to 9/28/15. Review of nursing Progress Notes dated 9/14/15 to 10/6/15 revealed there was no documentation that the resident refused the blood draws or that staff was not able to obtain blood samples from the resident. Review of the medical record revealed a Routine Coagulation (the process by which blood clots) laboratory report dated 9/29/15 documented a PT of 42.3 (reference range 11.0 to 15.0) and an INR of 4.54 (therapeutic range 2.0 to 3.0). Additional review of the laboratory report revealed a handwritten notation to Hold [MEDICATION NAME]. Review of a Routine Coagulation laboratory report dated 9/30/15 revealed a PT of 41.6 and an INR of 4.45. A handwritten notation on the report documented Continue to hold. Interview with the DNS on 11/6/15 at approximately 8:22 AM revealed that she expects her staff to obtain labs as ordered by the physician and if the resident refuses or the staff could not draw blood from the resident, she would expect there to be a notation in the nursing notes. Review of the policy and procedure entitled Lab and Diagnostic Test Results: Physician Role and Follow Up dated 4/2013 revealed staff will process test requisitions and arrange for tests. 3. Resident #193 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is cognitively intact, understands, and is understood. Review of a Medication Review Report dated 8/3/15 revealed current Laboratory Orders, initiated 9/17/14, included the following laboratory (lab) tests to be done every three months: - CBC - BUN (blood urea nitrogen - blood test to determine kidney function and hydration status), - Creatinine (blood test to determine kidney function) - ESR (erythrocyte sedimentation rate- a test to measure inflammation) - CRP (C-reactive protein - a test for inflammation) every 3 months Review of the paper chart and electronic medical record (EMR) from April 2015 to current revealed the following laboratory tests were obtained as follows: 4/10/15- CBC, BUN, ESR, and CRP 5/8/15- CBC, BUN, creatinine 6/24/15- CBC, BUN, creatinine 10/28/15- BUN, creatinine Review of the Phlebotomy (needle puncture of the vein to obtain a blood specimen) Collection Logs from May 2015 to current revealed no evidence that an ESR and CRP level were drawn since 4/10/15. During an interview on 10/30/15 at 2:06 PM, the RN (#8) Unit Manager stated that the nurse who obtains a lab order is to transcribe the order into the electronic medical record, sign off the transcription of the order, and write the order in the Phlebotomy Collection Log. The RN Nurse Manager stated that lab personnel will sign off each lab request after the bloodwork is drawn. The RN Unit Manager stated that she did not know that the ESR or CRP were not obtained every three months as ordered by the physician. 4. Resident #89 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is cognitively intact. Review of a Physician's Telephone Order dated 10/27/15 revealed an order to obtain a stool specimen for [MEDICAL CONDITION] ([MEDICAL CONDITION] - bacteria in the intestine that may cause diarrhea). Review of the medical record and the electronic medical record (EMR) on 11/5/15 revealed no documented evidence that the stool for [MEDICAL CONDITION] was obtained or documentation explaining why it was not completed. Interview with the DNS on 11/6/15 at 7:50 AM revealed she couldn't find any results to show that the laboratory (lab) test was done. During an interview on 11/6/15 at approximately 8:22 AM, the DNS stated that she expects her staff to obtain labs as ordered by the physician and if the resident refused or the staff could not draw blood from the resident, she would expect there to be a notation in the nursing notes. 5. Resident #110 has a [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan (CCP) dated 1/8/15 (identified as current by RN #4) revealed the resident was identified with the potential for altered nutrition, hydration, and hematological status (relating to the blood). CCP interventions include obtaining and monitoring lab/diagnostic work as ordered and follow up as indicated. Review of a Medication Review Report dated 9/4/15 and signed by the Physician on 9/4/15 revealed an active order to obtain a BMP (basic metabolic profile-basic blood chemistries) every (Q) week times (x) 2 weeks. Review of the entire medical record revealed no documented evidence of the BMP laboratory results. During an interview on 11/5/15 at 11:26, the RN (#4) Unit Manager stated that even though the signed orders in the chart are considered to be the most current, she believes that the BMP Q week x two weeks is an old order, and not technically a new order. The RN Unit Manger stated that the BMP order was not discontinued and it was missed by the nurses and the doctor as well. 6. Resident #87 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 5/16/15 revealed the resident is cognitively intact, understands, and is understood. Review of an Acute Visit Note, written by the Nurse Practitioner (NP), dated 5/8/15 revealed the resident receives [MEDICAL TREATMENT] three times per week and the resident has a RUE (right upper extremity) AV shunt with a positive bruit (sound of blood flow) and thrill ( a buzzing vibration felt by palpation). Review of a Physician's Telephone Order, signed by the NP, dated 5/8/15 revealed orders for [MEDICAL TREATMENT] every Monday, Wednesday, and Friday for [MEDICAL CONDITION]. Further review of the orders revealed no documented evidence of an order pertaining to the care of the [MEDICAL TREATMENT] (AV shunt). Review of physician's orders [REDACTED]. Review of the undated Resident Care Plan revealed no documented evidence of an individualized care plan to address the care and monitoring of the resident's AV shunt. Review of the Medication Administration Record [REDACTED]. Review of the Treatment Administration Record (TAR) dated 5/1/15 through 5/31/15 there was no entry on the TAR to document that the bruit and thrill were monitored or that the AV shunt was monitored for bleeding and/or signs and symptoms of infection. Review of the entire medical record, including nursing Progress Notes dated 5/12/15 to 5/21/15 revealed there was no documented evidence that the condition of the AV shunt was monitored by nursing staff except for four Progress Notes written by LPN #15, on 5/8/15, 5/9/15, 5/10/15, and 5/11/15 which documented positive bruit/ thrill. Review of Acute Visit Notes, written by the NP, dated 5/19/15 and 5/20/15 revealed Right upper extremity AV shunt, positive bruit and thrill. Interview with the Registered Nurse (RN) Administrator of the [MEDICAL TREATMENT] Center on 10/30/15 at approximately 10:23 AM revealed the facility should remove bandages from the access site four hours after [MEDICAL TREATMENT], monitor the access site for anything unusual including bleeding or infection, and notify the MD (medical doctor) of anything unusual. The RN stated that the facility nurses should monitor bruit and thrill according to the facility policy. Interview with the Assistant Director of Nursing Services (ADNS) on 11/6/15 at approximately 7:57 AM revealed that nursing staff should be checking bruit and thrill every shift and documenting that in the MAR, TAR, or in a narrative note. In addition, the pressure dressing applied at [MEDICAL TREATMENT] should be removed when the resident returns to the facility and the [MEDICAL TREATMENT] site should be monitored for bleeding and infection. Review of a facility policy entitled [MEDICAL TREATMENT] Care dated 10/2014 revealed nursing staff are to observe the shunt for signs and symptoms of infection/ inflammation, observe the shunt for thrill and bruit every shift, and report any abnormal findings to the physician and/or [MEDICAL TREATMENT]. Interview with the Director of Nursing Services (DNS) on 10/29/15 at approximately 9:15 AM revealed she could not say whether or not the [MEDICAL TREATMENT] site was monitored because there was no documented evidence regarding the provision of care and services for the resident with [MEDICAL CONDITION], receiving [MEDICAL TREATMENT]. 415.12

Based on observation, interview and record review conducted during the Extended survey completed on 11/6/15, it was determined that the facility failed to ensure that each resident's drug regimen is free from unnecessary medications. Six (Residents #11, 79, 130, 146,150, 206) of 17 residents reviewed for unnecessary medications had issues involving the lack of monitoring therapeutic drug levels (#11, 206), apical pulse (heart rate) (#79), and blood sugars (#130, 206) as ordered by the physician, the lack of an adequate indication for the use of [MEDICATION NAME] (antipsychotic medication used to treat [MEDICAL CONDITION]) (#150), and the lack of an attempt of a gradual dose reduction (GDR) of [MEDICATION NAME] (mood stabilizing medication) or document clinical rationales for not attempting a GDR (#146). This resulted in a pattern of IMMEDIATE JEOPARDY AND SUBSTANDARD QUALITY OF CARE TO RESIDENT HEALTH AND SAFETY with no actual harm. The findings are: 1. Resident #150 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (Minimum Data Set - a resident assessment tool) dated 9/15/15 revealed the resident was moderately cognitively impaired, usually understands, and was understood. Review of the undated Comprehensive Care Plan (CCP) revealed the resident has a potential for violence related to hallucinations and delusions manifested by agitation and aggressive behaviors. The CCP documented that the resident has impaired cognition, thought process, and mood problems related to mental illness and receives antidepressants, anti-anxiety, and antipsychotic medications. CCP interventions included reviewing new medications, dosage increases, recent discontinuations, omissions, drug interactions/ adverse reactions, errors, drug toxicity, and record possible causes of cognitive deficits. The CCP documented an intervention to administer medications as ordered, and monitor and document for side effects and effectiveness. Review of the History and Physical (H&P) dated 9/15/15 revealed the resident called out intermittently and had no hallucinations, delusions, anxiety, or agitation at the time. Review of an Acute Visit Note, written by the NP (Nurse Practitioner), dated 9/22/15 revealed the patient has a history of [MEDICAL CONDITION] disorder and continues to display bizarre behaviors that remain uncontrolled, despite current behavior modifying medications. The NP documented staff reported that the resident was making sexually inappropriate statements towards male workers, difficult with hands-on care. Review of a Physician's Telephone Order, written by the NP, dated 9/22/15 revealed the following orders; - Increase [MEDICATION NAME] to 1 mg BID for behavior - Increase [MEDICATION NAME] to 500 mg BID for behavior - *[MEDICATION NAME] (antipsychotic medication) 2 mg intramuscular (IM) x (times) one now, then every 6 hours as needed (prn) x 72 hours for severe agitation. The prn [MEDICATION NAME] order did not include specific circumstances/indications for the use of the medication. Review of an Acute Visit Note, written by the NP, dated 9/23/15 revealed the patient was seen the morning of 9/23/15, reclining in a Geri-chair. The NP documented that earlier that morning, the patient attempted to wash the floor with her own feces, refused hands on care, and [MEDICATION NAME] was administered with relief of symptoms. Review of nursing Progress Notes dated 9/16/15 through 10/1/15 revealed the following: - 9/16/15 - The resident was noted with periods of restless. - 9/17/15 and 9/18/15 - The resident made multiple attempts to self- transfer herself out of bed and the wheel chair. - 9/18 /15 - The resident can be resistive to care, no behavior issues, is adjusting. - 9/19/15 - Aggressive with staff and resistive with care. - 9/20 /15 - In quiet mode. - 9/21/15 - Pleasant, cooperative with all aspects of care. - 9/22/15 at 7:05 AM - No behavior issues. - 9/22/15 at 11:34 AM - Attempted to hit and spit at staff, throwing feces at staff, order to give [MEDICATION NAME] 2 mg IM times one dose now. - 9/23/15 - Extremely agitated, attempting to climb out of chair and yelling she wants the police. [MEDICATION NAME] given due to extreme combative behavior, one to one with no effect. There was no description of the combative behavior. - 9/24/15 - Increased agitation noted, prn [MEDICATION NAME] administered with some effect. During an interview on 11/3/15 at approximately 11:08 AM, the NP stated that the resident was having some agitation and that other behavior modifying interventions were ineffective. The NP stated that the prn [MEDICATION NAME] was to be used for severe agitation and for compliance reasons, the prn [MEDICATION NAME] was for only 72 hours. 2. Resident #206 has [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed that the resident is cognitively intact, understands, and is understood. Review of a Medication Review Report (renewal order sheet) dated 9/12/15 revealed orders for [MEDICATION NAME] (diabetes medication) 500 mg twice a day for diabetes mellitus and [MEDICATION NAME] ([MEDICATION NAME] - a blood thinning medication) 2.5 mg at bedtime on Sunday, Monday, Wednesday, Thursday, and Saturday and [MEDICATION NAME] 5 mg at bedtime on Tuesday and Friday for [MEDICAL CONDITION] ([MEDICAL CONDITION] - a blood clot in a deep vein). Additional review of the Medication Review Report dated 9/12/15 revealed active orders for the following laboratory tests: - Finger sticks (sample of blood to determine blood glucose level) every day before meals and at bedtime and notify the physician if the finger sticks are less than 60 (low blood sugar - [DIAGNOSES REDACTED]) or greater than 200 (high blood sugar - [MEDICAL CONDITION]). - PT/ INR ([MEDICATION NAME] and international normalized ratio - blood tests to determine the clotting time of blood) every Monday, Wednesday, and Friday. Review of a Physician's Telephone Order dated 9/14/15 revealed orders to administer 10 mg of [MEDICATION NAME] (oral corticosteroid) in the morning and 5 mg of [MEDICATION NAME] in the evening after a Serum [MEDICATION NAME] blood test (test to measure the amount of [MEDICATION NAME] in the blood) was done. Review of the electronic Medication Administration Records (eMARs) dated 9/11/15 to 10/6/15 revealed that the resident received the [MEDICATION NAME] and [MEDICATION NAME] as ordered by the physician. Additional review of the eMARs revealed the order for [MEDICATION NAME] 10 mg and 5 mg was not transcribed on the eMAR. a.) Further review of the eMARS dated 9/11/15 to 10/6/15 revealed that [MEDICATION NAME] 10 mg at 5:00 PM and [MEDICATION NAME] 5 mg at 5:00 PM were transcribed on the eMARs. The eMARs documented that [MEDICATION NAME] 5 mg was administered daily at 9:00 AM from 9/15/15 to 10/6/15. On 9/17/15, 9/19/15, 9/20/15, 9/24/15, 9/27/15, 9/28/15, 9/29/15, and 9/30/15 there was a notation of 9 on the eMAR indicating to check nursing notes. Review of nursing Progress Notes, written by three different nurses, dated 9/17/15, 9/19/15, 9/20/15, 9/24/15, 9/27/15, and 9/29/15 revealed that [MEDICATION NAME] 5 mg was not available or were on order. A nursing Progress Note dated 9/30/15 documented that the [MEDICATION NAME] 5 mg order needed to be clarified by the physician. The eMARs dated 9/11/15 to 10/6/15 documented that [MEDICATION NAME] 10 mg was administered daily at 5:00 PM from 9/15/15 to 10/6/15. Review of the Omnicell automated medication dispensing cabinet Transactions by Patient revealed that nursing staff removed doses of [MEDICATION NAME] 25 mg on 9/15/15, 9/18/15, 9/20/15, and twice on 9/26/15. There were no Physician's Order to administer [MEDICATION NAME] 5 mg, 10 mg, or 25 mg in the resident's medical record. Interview with a Representative from the dispensing pharmacy on 11/4/15 at approximately 11:06 AM revealed that the pharmacy never received an order for [REDACTED]. b.) Review of the electronic Treatment Record (eTAR) and eMAR dated 9/12/15 to 9/29/15 revealed no documented evidence that the finger sticks before meals and at bedtime, ordered to monitor the resident's blood sugar levels, were done. Interview with a Registered Nurse (RN #9) on 11/5/15 at approximately 3:35 PM revealed that blood glucose levels would be entered in the Vitals section in the electronic medical record, under the parameters tab, and then the blood glucose levels would transfer to the eMAR. RN #9 stated that there was a glitch in the electronic medical record system and if the blood sugar parameters, for example less than 60 or greater than 200, were not entered, they would not transfer. Interview with the Director of Nursing Services (DNS) on 11/6/15 at approximately 8:22 AM revealed that she expects her staff to obtain labs or finger sticks as ordered by the physician, and if the resident refused or the staff could not draw blood from the resident, she would expect there to be a notation in the nursing notes. c.) Review of the chronological medical record from 9/14/15 to 9/28/15 revealed there were no PT/INR results in the resident's record. Review of a Routine Coagulation (the process by which blood clots) laboratory report dated 9/29/15 revealed the PT level was 42.3 (reference range 11.0 to 15.0) and the INR result was 4.54 (therapeutic level 2.0 to 3.0). Additional review of the laboratory report revealed a handwritten notation to Hold [MEDICATION NAME]. Review of a Routine Coagulation laboratory report dated 9/30/15 revealed a PT of 41.6 and an INR of 4.45. A handwritten notation on the report documented Continue to hold. Interview with the DNS on 11/6/15 at approximately 8:22 AM revealed her expectation is that the PT/INRs should be done as ordered. When a lab order is put into the computer, a lab slip is filled out and put into the lab book. 3. Resident #11 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has severely impaired cognition and has had verbal behavioral symptoms directed toward others during the past seven days. Review of a Physician's Order dated 10/2/14 revealed the resident was started on [MEDICATION NAME] Acid ([MEDICATION NAME]) 125 mg every morning and at bedtime. Review of the electronic Medication Administration Records (eMARs) dated 10/2014 to 11/2015 revealed the resident received the [MEDICATION NAME] Acid ([MEDICATION NAME]) 125 milligrams (mg) twice daily. Review of laboratory results located in the medical record revealed no documented evidence that a [MEDICATION NAME] Acid level was obtained since the resident started the medication in 10/2014. During an interview on 11/2/15 at 10:20 AM, the Registered Nurse (RN #4) Unit Manager stated she didn't see a [MEDICATION NAME]/[MEDICATION NAME] Acid level in the chart and it's odd that the pharmacist didn't catch that one wasn't done, usually they are done about every six months. During the interview, the Nurse Practitioner (NP) entered the room and the RN head nurse asked her to order the [MEDICATION NAME] Acid level for the resident. The NP stated the [MEDICATION NAME] Acid level should be done yearly. 4. Resident #79 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is cognitively intact, understood, and understands. Review of the Medication Review Report dated 10/30/15 revealed an active physician order for [REDACTED]. Order date 2/17/15. Review of the eMAR dated 10/2015 revealed the resident received [MEDICATION NAME] daily and there was no documentation that the apical pulse was checked prior to administration from 10/1/15 through 10/31/15 as ordered by the physician. The apical rate boxes on the eMAR were filled in with x's. Interview with RN #4 on 11/5/15 at approximately 1:55 PM revealed the nurses are expected to document the apical rate on the eMAR. The eMAR system sometimes does not allow us to do that, so I tell the nurses to document the apical rate in the nursing Progress Notes or on the Monthly Vital Sign record. An x on the eMAR indicates that a task was not complete. I honestly don't know why there are x's for the whole month of October. Review of the Monthly Vital Sign Log dated October 2015 and Nursing Progress Notes dated 10/2/15 to 10/30/15 revealed no evidence that apical rates were monitored for Resident #79. Interview with a Licensed Practical Nurse (LPN #17) on 11/5/15 at approximately 2:01 PM revealed Yes, you should document the apical rate on the eMAR prior to the administration the [MEDICATION NAME]. 5. Resident #130 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is cognitively intact. Review of a Medication Review Report dated 9/1/15 through 11/30/15 revealed an active order for [MEDICATION NAME] HCL (diabetic medication) 500 mg tablet by mouth (po) two times a day for DM and to obtain fingersticks q am (every morning) and q hs (every bedtime) two times a day every Monday and Wednesday for DM. The orders directed to call (the physician) if the blood glucose if less than 60 or greater than 400. Review of the eMARs dated 9/1/15 through 11/5/15 revealed no documented evidence that the fingerstick blood glucose levels were completed two times per day on Mondays and Wednesdays and there were no results of the glucose levels. Review of nursing Progress Notes dated 9/1/15 through 11/6/15 revealed documentation that the resident's fingerstick blood glucose levels were 37 (normal blood glucose 60 to 100) and 132 upon returning from therapy on 10/27/15 at 3:00 PM and 177 on 10/28/15 in the AM. Interview with the DNS on 11/6/15 at 8:50 AM revealed there was no documentation of the actual glucose levels. The LPN (#12) Medication Nurse, who was present during the interview, stated there wasn't anywhere to document the actual glucose number on the eMAR and that she documented them in the electronic nursing Progress Notes. However, the DON stated that when she looked for the results in the electronic Medical Record Progress Notes, there was limited, if any documentation of the glucose levels. The DNS stated that she was not aware of this situation and would have thought that the LPN would notify her supervisor about the problem. The DNS stated that no one told her there was no spot on the eMAR for the finger stick results or had asked what they should be doing about it. 6. Resident #146 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is severely cognitively impaired, sometimes understands, and is understood. Review of the CCP dated 10/12/15 revealed that the resident receives [MEDICATION NAME] for behavior management. The CCP documented that the resident has a history of seeking/stealing food and eating non-food items. CCP interventions include a plan to discuss the GDR of medication with the MD (medical doctor) when appropriate. Review of the Medication Review Report dated 1/13/15 revealed an order to increase the resident's [MEDICATION NAME] to 750 mg every 12 hours for behavior disturbance. Additional review of the Medication Review Report revealed [MEDICATION NAME] 500 mg every 12 hours was started 7/10/14. Review of the MARs and eMARS dated 1/2015 to 11/2015 revealed the resident received [MEDICATION NAME] 750 mg every 12 hours as ordered by the physician. Review of a Behavior Note dated 8/4/15 revealed resident noted taking food or drink from other residents in lounge or unattended food. Review of a Team Care Plan Meeting note dated 10/12/15 revealed the resident remains wandering on the unit in search of food. Is provided with one to one, redirection. These interventions are effective . Review of nursing Progress Notes dated 8/4/15 through 10/29/15 revealed no documented evidence that the resident was wandering or seeking food. Intermittent observations from 10/28/15 to 11/6/15, between the hours of 8:00 AM and 3:45 PM, revealed the resident was sitting in a wheelchair in the dining room or in bed in his room. There were no observations of the resident wandering or seeking food. Review of the medical record, including Physician's Orders, MARs, eMARs, and Physician and nursing Progress Notes, dated 11/2014 to 11/2015 revealed no documented evidence that a [MEDICATION NAME] GDR was attempted for Resident #146. Review of Progress Notes, written by the NP, dated 5/17/15 through 10/13/15 revealed staff reported no concerns and the resident's overall mood was good. There was no documented clinical rationale for not attempting a GDR of the [MEDICATION NAME]. Review of the monthly Medication Review Regime (MRR), completed by the Consultant Pharmacist dated 1/2015 through 11/2015 revealed no recommendations for a GDR of the [MEDICATION NAME]. During an interview on 11/3/15 at 9:15 AM, the Social Worker (SW #1) stated that the resident has a history of wandering and seeking out food. SW #1 stated that the last documented Behavior Note was completed on 8/4/15. SW #1 stated that she thought the last time that the resident was discussed in BMARC (behavior management assessment review committee) was in July 2015. SW #1 stated she was not sure if a GDR of the [MEDICATION NAME] was attempted and she did not know if there was documented evidence from the physician that a GDR of the [MEDICATION NAME] would be clinically contraindicated. During a telephone interview on 11/3/15 at 10:53 AM, the Consultant Pharmacist stated that he does not keep records of GDR's. The Consultant Pharmacist stated that every resident gets discussed as a team at the monthly BMARC meetings and the Social Worker documents the meetings. The Consultant Pharmacist stated to be honest, I cannot recall the specifics as to why he did not recommend a GDR for this resident. 415.12(l)(1)(2)(i)(b)(c)

Based on observation, interview, and record review conducted during a Complaint investigation (Complaint #NY 070) during the Extended survey completed on [DATE], the facility failed to ensure that residents are free from any significant medication errors. Seven (Resident's #90, 93, 125, 150, 189, 205, 206) of 35 residents reviewed for medications had issues involving the incorrect transcription of medication orders; repeated administration of an incorrect medication (Resident #206); administration of the wrong doses and/or frequency of blood pressure medication, a mood stabilizing medication, and an antipsychotic medication (Resident's #90, 93, 150, 189), omitted doses of insulin (Resident #205) and an oral corticosteroid (Resident #206) , and delay initiating new medications, including a diuretic (medication that promotes the excretion of urine)(Resident #189), a nonsteroidal anti-[MEDICAL CONDITION] medication, and an antibiotic (Resident #125). This resulted in a pattern of IMMEDIATE JEOPARDY and SUBSTANDARD QUALITY OF CARE TO RESIDENT HEALTH AND SAFETY that is actual harm for Resident #150. The findings are: 1. Resident #150 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident was moderately cognitively impaired, usually understands, and was understood. Review of the undated Comprehensive Care Plan (CCP) revealed the resident has a potential for violence related to hallucinations and delusions manifested by agitation and aggressive behaviors. The CCP documented that the resident has impaired cognition and thought process, mood problems related to mental illness, and receives antidepressants, anti-anxiety, and antipsychotic medications. CCP interventions included reviewing new medications, dosage increases, recent discontinuations, omissions, drug interactions/ adverse reactions, errors, drug toxicity, and record possible causes of cognitive deficits. The CCP documented an intervention to administer medications as ordered, and monitor and document for side effects and effectiveness. Review of a Physician's Telephone Order dated [DATE] revealed orders for [MEDICATION NAME] (mood stabilizing drug used with psychiatric patients) 300 mg (milligrams) twice daily (BID), [MEDICATION NAME] (antipsychotic medication used to treat [MEDICAL CONDITION] disease) 0.5 mg once daily (QD), and [MEDICATION NAME] (mood stabilizing medication) 250 mg BID. Review of an Acute Visit Note, written by the NP (Nurse Practitioner), dated [DATE] revealed the patient has a history of [MEDICAL CONDITION] disorder and continues to display bizarre behaviors that remain uncontrolled, despite current behavior modifying medications. The NP documented staff reported that the resident was making sexually inappropriate statements towards male workers, difficult with hands-on care. Review of a Physician's Telephone Order, written by the NP, dated [DATE] revealed the following orders; - Increase [MEDICATION NAME] to 1 mg BID for behavior - Increase [MEDICATION NAME] to 500 mg BID for behavior - *[MEDICATION NAME] (antipsychotic medication) 2 mg intramuscular (IM) x (times) one now, then every 6 hours as needed (prn) x 72 hours for severe agitation. Review of an Acute Visit Note, written by the NP, dated [DATE] revealed the resident was seen to evaluate all psychoactive medications. The NP documented a plan to continue [MEDICATION NAME] 300 mg BID for [MEDICAL CONDITION] disorder. Spoke at length with Pharmacy (a Pharmacist) regarding transition from [MEDICATION NAME] to [MEDICATION NAME] (long acting [MEDICATION NAME]). Order written to discontinue [MEDICATION NAME] on Monday ([DATE]) and administer [MEDICATION NAME] 50 mg once every 28 days starting Monday. Review of a Physician's Telephone Order, written by the NP, dated [DATE] revealed the following: - [MEDICATION NAME] (long acting) 50 mg IM every 28 days - Discontinue [MEDICATION NAME] on Monday ([DATE]) Review of the electronic Medication Administration Record (eMAR) dated [DATE] revealed that the [MEDICATION NAME] 50 mg IM was transcribed onto the eMAR three separate times and the resident received [MEDICATION NAME] 50 mg IM on [DATE], [DATE] and [DATE] instead of once every 28 days. There was no documented evidence on the eMAR that 24 accuracy checks were done. Additional review of the eMAR dated [DATE] revealed that the resident continued to receive [MEDICATION NAME] 1 mg BID on [DATE] and [DATE] despite the order to discontinue the medication. The eMAR documented that the [MEDICATION NAME] was held (not given) on [DATE] at 9:00 AM. Review of a Nursing Progress Note dated [DATE] at 10:00 AM revealed the [MEDICATION NAME] was held because the resident was lethargic. Further review of Nursing Progress Notes dated [DATE], [DATE] and [DATE] revealed the Pharmacy system had identified and reported a possible drug interaction between the [MEDICATION NAME] and [MEDICATION NAME] that may produce unexpected effects (severe neurotoxicity- damage to the brain). Additional review of Nursing Progress Notes revealed the following: - [DATE] at 10:00 PM - The resident slept in the wheelchair all shift, refused dinner but medications given, temperature 102.4 degrees (normal 98.6 ), Tylenol given, and recheck of temperature 99 ° degrees. - [DATE] at 6:38 AM - Refused to wake up. - [DATE] at 10:00 AM - Medications held due to lethargy. - [DATE] at 3:00 PM - Resident very lethargic this shift, heart rate (HR) 136 (average 80), respirations 24 (normal 12 to 20), temperature 100.8 degrees, medications were held due to lethargy, and intake of foods and fluid poor this shift. HR down to 98 and temperature retake was 100.3° (degrees Fahrenheit (F), and the resident remains lethargic. - [DATE] at 8:00 PM - The resident as asleep all shift, respirations are normal, temperature 99.9 degrees, given Tylenol, and recheck 98.5° F. Aroused with difficulty, no swallowing motions noted, dinner held, crushed meds in applesauce, able to suck water with straw 100 milliliters (ml) intake. There was no documeted evidence that the physician or NP were notified of the change in the resident's condition on [DATE] or [DATE]. Review of an untimed Physician's Telephone Order, written by the NP, dated [DATE] revealed orders to obtain STAT (immediate) bloodwork that included a CBC with diff (complete blood count with differential), CMP (complete metabolic profile - blood chemistry studies), a [MEDICATION NAME] level, a urinalysis, urine culture and sensitivity, and a chest x-ray. The orders directed to start [MEDICATION NAME] (antibiotic) one gram IM daily and start Clysis (fluid administered subcutaneously into the abdomen) fluids with normal saline (NS). Review of a Laboratory Report dated [DATE] revealed Critical BUN and Na called to RN Supervisor at facility on [DATE] at 4:42 PM. Further review of nursing Progress Notes revealed the following: - [DATE] AM - AM medications refused. - [DATE] at 3:00 PM - Resident lethargic this shift, HR 130, temperature 101.3° F, respirations 26. - [DATE] at 7:21 PM - NP updated on STAT blood work results; [MEDICATION NAME] level 1.58 (normal 0.60 - 1.60), Blood Urea Nitrogen (BUN - blood test to determine kidney function and hydration status) 129 (normal 5 to 27), Sodium Level (Na) 159 (normal 133 to 147). Order to send to the emergency room for treatment and evaluation. - [DATE] at 10:00 PM - Difficult to arouse, labored breathing, blood pressure ,[DATE] (normal), HR of 131, temperature 102.7° F, respirations 16, difficulty to arouse for meds (medications), no swallowing motions noted, all meds held, call to transfer resident to hospital. - [DATE] at 8:08 AM - The resident was admitted to the hospital ICU (intensive care unit) with altered mental status and [MEDICAL CONDITION] (elevated sodium level in the blood). During an interview on [DATE] at 11:08 AM, the NP stated that the resident had [DIAGNOSES REDACTED]. The NP spoke with the family and the family had requested a medication that was longer acting. That is why the [MEDICATION NAME] 2 mg prn was changed to the [MEDICATION NAME] 50 mg to be administered every 28 days. The plan was to wean the resident from the [MEDICATION NAME]. The NP stated that she was not concerned with the potential Black Box Warnings (potential for severe interactions) nor did she have concerns related to the potential for an elevating BUN and Na, with only receiving a couple of doses of [MEDICATION NAME]. The NP was asked if she was aware that the [MEDICATION NAME] 50 mg was documented as being administered on [DATE], [DATE], [DATE] and the [MEDICATION NAME] was not discontinued as ordered. The NP stated no and suggested that the surveyor discuss the medication concerns with the Unit Manager. The NP further stated I write the order, the nurses take care of the rest. During an interview on [DATE] at 11:16 AM, the Licensed Practical Nurse (LPN #11) Unit Manager stated she realized that the [MEDICATION NAME] 50 was not given as ordered and she questioned her nurses. The nurses said that they gave the regular [MEDICATION NAME], a medication error report was completed regarding the [MEDICATION NAME], and the nurses were spoken to. LPN #11 stated that she had to enter the order for [MEDICATION NAME] 50 mg IM q 28 days into the computer two extra times because once you sign that you gave the [MEDICATION NAME], the system does not allow for you to make a correction that it was signed out in error. During an interview on [DATE] at 11:29 AM, LPN #12 stated that she was told she gave the wrong [MEDICATION NAME] on [DATE] by her Charge Nurse. LPN #12 stated that there was only one vial of [MEDICATION NAME] in the cart to give. During a telephone interview on [DATE] at approximately 11:35 AM, the pharmacist stated that the Pharmacy dispensed [MEDICATION NAME] 50 mg a couple of times. Three times to be exact on [DATE], [DATE], and [DATE]. Review of the Pharmacy delivery sheet confirmed that [MEDICATION NAME] 50 mg was delivered to the facility on three occasions for Resident #150. During a telephone interview on [DATE] at 2:24 PM, the NP stated I honestly can't answer what would happen if the resident received an extra 100 mg of [MEDICATION NAME]. I would have to do some research and confer with the MD. My intention was to wean off the [MEDICATION NAME] and start [MEDICATION NAME]. On [DATE], I did not know what was going on with the resident; I acted appropriately and sent her out to the ER. During an interview on [DATE] at 3:31 PM, the Medical Director stated That is a lot of [MEDICATION NAME]. Certainly there would be the potential for harm, but I cannot say with 100 percent (%) certainty. We would be concerned with cardia arrhythmias (loss of normal heart rhythm) and kidney injury with these types of medications. Given the resident's comorbidities (the presence of one or more diseases) and the [MEDICATION NAME] level on the high side of normal, if the resident got an additional dose of [MEDICATION NAME], of course with two additional doses along with the other medications - [MEDICATION NAME] - the greater the potential. During an interview on [DATE] at approximately 4:25 PM, the Director of Nursing Services (DNS) and the Administrator stated that the Pharmacy had no record of any [MEDICATION NAME] 50 mg being returned to the Pharmacy. During an interview on [DATE] at approximately 4:15 PM, LPN #4 stated that the resident was combative on [DATE], up and down out of the chair, and needed [MEDICATION NAME]. LPN #4 stated there was one vial of [MEDICATION NAME] in the medication cart and that is what she gave. LPN #4 stated that she checked the vial against the eMAR, it matched so that is what she gave. LPN #4 stated she did not know if it was 2 mg or 50 mg [MEDICATION NAME]. LPN #4 stated she found out about the error yesterday ([DATE]) from her Charge Nurse and was educated. During a telephone Interview on [DATE] at 10:10 AM, the Pharmacy Consultant stated he was not familiar with Resident #150, he did not review her medications, and he was not aware of any medication errors. The Pharmacy Consultant stated that adverse reactions would include sedation, [MEDICAL CONDITION](fast heart beat), and respiratory issues. The Pharmacist stated that when [MEDICATION NAME] is administered with the [MEDICATION NAME] ([MEDICATION NAME] is a funny drug he said) and you have a resident with multiple comorbidities and is on multiple drugs, the concern would also be increased levels of [MEDICATION NAME] and kidney damage. Review of the FDA (US Food and Drug Administration) prescribing information for [MEDICATION NAME] 50 mg revealed the medication is indicated for the treatment of [REDACTED]. [DIAGNOSES REDACTED] (NMS) has been reported in association with antipsychotic drugs. Clinical manifestations of NMS include high fever, muscle rigidity, altered mental status, irregular pulse or blood pressure, [MEDICAL CONDITION] may also include elevated creatinine (blood test to determine kidney function) and acute renal (kidney) failure. During an additional interview on [DATE] at 8:30 AM, the DNS stated she was first made aware of the [MEDICATION NAME] error on [DATE]. Neither the LPN #11 Unit Manager or the Registered Nurse (RN #9) who assists on the unit, reported the error to her when it happened in [DATE]. A medication error report was started on [DATE]. During an interview on [DATE] at 8:52 AM, RN #9 stated she was aware that there was a [MEDICATION NAME] error but was not aware of the magnitude of the medication error until [DATE]. In addition, she was not aware that a medication error report was not completed until [DATE]. 2. Resident #189 had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated [DATE] revealed that the resident was cognitively intact, understood others, and was understood. a.) Review of an Acute Visit Note, written by the NP (Nurse Practitioner), dated [DATE] revealed the resident had increased [MEDICAL CONDITION] (swelling caused by excess fluid accumulation) in both lower extremities and the NP documented a plan to start [MEDICATION NAME] (diuretic - medication that promotes the excretion of urine) 80 mg QD (every day) for one week and then reduce to 40 mg (milligrams) daily. Review of a Physician/ Prescriber Telephone Order, signed by the FNP (Family Nurse Practitioner), dated [DATE] revealed the following medication orders: - K-Dur (potassium chloride) 20 meq (milliequivalent) po (by mouth) QD (every day) - [MEDICATION NAME] 80 mg po QD x (times) 1 week, Give first dose now, then decrease to 40 mg po QD [MEDICAL CONDITION]. Review of the Medication Administration Record (MAR) dated [DATE] through [DATE] revealed the medications ordered on [DATE] were not transcribed onto the ,[DATE] MAR and K-Dur 20 meq and [MEDICATION NAME] 80 mg were not administered to the resident at any time during February 2015. Review of the MAR dated [DATE] through [DATE] revealed documentation that [MEDICATION NAME] 80 mg po QD for [MEDICAL CONDITION] was documented as administered daily from [DATE] through [DATE]. Further review of the MAR dated [DATE] through [DATE] revealed Potassimin 20 mcg (microgram - a unit of mass or weight equal to one millionth of a gram) was documented as administered to the resident daily from [DATE] to [DATE]. Review of the electronic MARs (eMARs) dated ,[DATE] to ,[DATE] revealed that [MEDICATION NAME] 80 mg po QD was documented as administered daily from [DATE] through [DATE], except [DATE] (coded not available). There was no documented evidence on the eMAR that 24 hours accuracy checks were done. Additional review of the eMARs revealed the following: - ,[DATE] - Potassimin 20 mcg was documented as administered to the resident [DATE] through [DATE]. - ,[DATE] - Potassimin 20 mcg was documented as not administered on 10 of 30 days (coded as not available) in [DATE]. ,[DATE] - Potassimin 20 mcg was documented as not administered on 18 of 30 days (coded as not available or on order). b.) Interview with the Administrator on [DATE] at approximately 9:00 AM revealed that the facility utilizes the Point Click Care System (PCC) Electronic Medical Record System. The Administrator stated that the facility transitioned to an Electronic Medication Administration Record (eMAR) and electronic Treatment Administration Record (eTAR) in March of 2015. Interview with the Dispensing Pharmacist on [DATE] at 8:45 AM revealed that the facility's electronic MAR integrated with the dispensing Pharmacy in mid-March of 2015. The Pharmacist stated that once a medication order is input into Point Click Care (PCC) by the nurse in the facility, it automatically transfers to the dispensing Pharmacy, and the Pharmacy dispenses the medication. The facility does not fax the original order to the Pharmacy for review. The only time the medication orders are faxed to the Pharmacy, is when the facility receives a computer prompt from the Pharmacy that the orders are too long (over approximately 142 characters). During the interview, the Dispensing Pharmacist stated that when the [MEDICATION NAME] and K-Dur were originally ordered for Resident #189 on [DATE], the nurses were responsible to fax the orders to the Pharmacy and no faxed orders for [MEDICATION NAME] or K-Dur were received. The Pharmacy first became aware of the [MEDICATION NAME] order on [DATE] and became aware of the K-Dur order on [DATE]. Interview with the Consultant Pharmacist on [DATE] at 9:00 AM revealed that when eMAR system first went live in [DATE], there were a lot of problems with the entry of orders; a lot of duplicate orders. Interview with the Director of Nursing Services (DNS) on [DATE] at 9:55 AM revealed when a medication order is received, the nurse enters the order electronically into PCC and then prints out the order sheet for the prescriber to sign. The DNS stated that the orders cross over directly to Pharmacy and there is no double check done. The nurses entering the medication orders into PCC choose the times that the medications are administered. Further interview with the DNS on [DATE] at 10:48 AM revealed that the 11:00 PM to 7:00 AM (,[DATE]) shift nurses are supposed to check all of the charts for new orders and then are to check the eMARs. They are to pull up the eMAR, make sure the orders are in, and are right. This is to be done on a daily basis. The DNS stated that she discovered that the accuracy checks were not in place once the survey team started questioning the accuracy checks. The DNS stated that no audits were done on the charts that did not have accuracy checks. Interview with an ,[DATE] shift Registered Nurse (RN) Supervisor on [DATE] at approximately 1:15 PM revealed that the ,[DATE] nurses are to check the charts on a daily basis to make sure the medication orders are up to date in the eMAR. They check the orders for that day to see if there is a discrepancy. The RN Supervisor stated that there is no sign off for this check and that checks for the monthly changeover of eMARS is not being done at this time. c.) Interview with the FNP on [DATE] at approximately 2:45 PM revealed the FNP expected the resident to start on 80 mg of [MEDICATION NAME] on [DATE] when the order was written. The intention was for the resident to receive 80 mg of [MEDICATION NAME] for one week and then decrease the [MEDICATION NAME] to 40 mg daily. The FNP was not aware that the resident continued to receive 80 mg of [MEDICATION NAME] daily or that there was a five day delay initiating the [MEDICATION NAME]. Review of the Medication Review Report (renewal order sheet), signed by the MD (Medical Doctor), on [DATE] included the following: - [MEDICATION NAME] 80 mg orally one time a day for [MEDICAL CONDITION] (order date [DATE], start date [DATE]) - Potassimin tablet Give 20 mcg by mouth one time a day for supplement (order date [DATE], start date [DATE]) Further review of the Medication Review Report signed by the MD on [DATE] revealed there was no signature or initials of nursing staff to indicate that the accuracy of the medication orders was verified. Interview with the Medical Director on [DATE] at approximately 12:30 PM revealed the intent of the [DATE] order was for the resident to start on K-Dur 20 meq, not Potassimin 20 mcg, and [MEDICATION NAME] 80 mg was ordered to start, when the order was written, for one week and then decreased to 40 mg daily. Review of a Nursing Progress Note dated [DATE] at 11:45 PM revealed that the resident was found unresponsive without viable vital signs (blood pressure, temperature, pulse, respirations) and CPR (cardiopulmonary resuscitation) was started. Review of a Certificate of Death revealed the resident expired on [DATE] at 12:00 AM and the immediate cause of death was cardiopulmonary arrest. 3. Resident #90 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is cognitively intact, understands, and is understood. Review of the Comprehensive Care Plan (CCP) dated [DATE] revealed an identified problem of [MEDICAL CONDITION] related to [MEDICAL CONDITION], HTN, and a history of [MEDICAL CONDITION] infarction (MI - [MEDICAL CONDITION]). CCP interventions included administering meds (medications) as ordered. Review of a Medication Review Report dated and signed by the physician [DATE] revealed medication orders to increase [MEDICATION NAME] (heart medication) to 6.25 mg by mouth (po) BID for [MEDICAL CONDITION] and [MEDICATION NAME] (heart medication) 50 mg po QD for HTN. Review of the eMARs dated [DATE] and [DATE] revealed documentation that the [MEDICATION NAME] 6.25 mg continued to be administered once a day from [DATE] through [DATE], which was not in accordance with the [DATE] physician's orders [REDACTED]. The [MEDICATION NAME] 50 mg was administered QD as ordered. There was no documented evidence on the eMAR that 24 hour accuracy checks were done. Review of a Monthly Medication Report dated [DATE] revealed handwritten notes by the NP to discontinue (d/c) the [MEDICATION NAME] and to change the [MEDICATION NAME] to 25 mg po BID. Additional review of the Physician's Telephone Orders revealed an order written [REDACTED]. Review of the eMAR dated [DATE] revealed there was a duplication of the [MEDICATION NAME] orders. The [MEDICATION NAME] was transcribed to be given as both 50 mg po QD (from 7:00 AM to 10:00 AM) and 25 mg BID (at 9:00 AM and 5:00 PM). The eMAR documented that the resident received an additional 25 mg of [MEDICATION NAME] daily from [DATE] through [DATE]. There was no documentation on the [DATE] eMAR that 24 hour accuracy checks were done. During an interview on [DATE] at 12:45 PM, the DNS stated the nurse should have accurately transcribed the [DATE] order to increase the [MEDICATION NAME] to BID. In addition, the [DATE] order for [MEDICATION NAME] 25 mg po BID superseded the original [DATE] order for [MEDICATION NAME] 50 mg po daily. The nurse transcribing the order on [DATE] should have discontinued the original order for [MEDICATION NAME] 50 mg daily. LPN #11 who transcribed the order from [DATE] was not available for interview. 4. Resident #93 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has severely impaired cognitive skills for daily decision making, sometimes understands, and is usually understood. Review of the Medication Review Report, signed by the FNP on [DATE], included the following medication orders: - [MEDICATION NAME] Sodium ([MEDICATION NAME] - mood stabilizer) tablet Delayed Release 125 mg Give 1 tablet by mouth at bedtime for mood (order date [DATE], start date [DATE]) - [MEDICATION NAME] Sodium Tablet Delayed Release 250 mg. Give 1 tablet by mouth one time a day for behavior (order date [DATE], start date [DATE]) Review of the eMAR dated [DATE] through [DATE] revealed the following: - [MEDICATION NAME] Sodium Delayed Release 125 mg, give 1 tablet by mouth at bedtime for mood. The eMAR documented that [MEDICATION NAME] Sodium 125 mg was administered from [DATE] through [DATE] at 9:00 PM daily - [MEDICATION NAME] Sodium Delayed Release 250 mg, give 1 tablet by mouth one time a day for behavior. The eMAR documented that [MEDICATION NAME] Sodium 250 mg was administered from [DATE] through [DATE] (Resident refused medication [DATE]) at ,[DATE] (7:00 AM to 10:00 AM - liberalized administration times) - [MEDICATION NAME] ([MEDICATION NAME] Sodium) Tablet Delayed Release 125 mg, give 1 tablet by mouth two times a day related to senile dementia. The eMAR documented that [MEDICATION NAME] 125 mg BID was administered from [DATE] through [DATE] (Resident refused medication [DATE]) at ,[DATE] and from [DATE] through [DATE] at 4:00 PM to 6:00 PM (,[DATE]). - The eMAR documented that the resident received a total daily dose of 525 mg of [MEDICATION NAME] from [DATE] to [DATE], instead of a daily total dose of 375 mg as ordered by the NP on [DATE] Review of the eMAR dated [DATE] through [DATE] revealed the following: - [MEDICATION NAME] Sodium Delayed Release 125 mg, give 1 tablet by mouth at bedtime for mood. The eMAR documented that [MEDICATION NAME] Sodium 125 mg was administered from [DATE] through [DATE] at 9:00 PM. - [MEDICATION NAME] Sodium Delayed Release 250 mg, give 1 tablet by mouth one time a day for behavior. The eMAR documented that [MEDICATION NAME] Sodium 250 mg was administered from [DATE] through [DATE] at ,[DATE]. - [MEDICATION NAME] Tablet Delayed Release 125 mg, give 1 tablet by mouth two times a day related to senile dementia. The eMAR documented that [MEDICATION NAME] 125 mg BID was administered from [DATE] through [DATE] at ,[DATE] and from [DATE] through [DATE] at ,[DATE]. - The eMAR documented that the resident received a total daily dose of 525 mg of [MEDICATION NAME] from [DATE] through [DATE], instead of a daily total dose of 375 mg as ordered by the NP on [DATE] Additional review of the eMARS dated ,[DATE] and ,[DATE] revealed no documented evidence that 24 hour accuracy checks were done. Review of the entire (electronic and hard copy) Medical Record dated [DATE] through [DATE] revealed no documented evidence of additional orders for [MEDICATION NAME] or [MEDICATION NAME] Sodium. Review of a Physician/ Prescriber Telephone Order, signed by the FNP, dated [DATE] revealed an order to change to [MEDICATION NAME] liquid 125 mg po at 9:00 AM, 1:00 PM, and 5:00 PM and 250 mg po qHS (at bedtime). (525 mg total daily dose) During an interview on [DATE] at approximately 1:51 PM, the MD stated There was no order to increase the [MEDICATION NAME] (to 525 mg daily) until the FNP came in and changed the order on [DATE]. 5. Resident #125 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is cognitively intact. Review of the medical record face sheet revealed the resident was admitted to the facility on [DATE] and discharged [DATE]. a.) Review of a Physician's Telephone Order dated [DATE] revealed an order for [REDACTED]. Review of the eMAR dated [DATE] through [DATE] revealed the [MEDICATION NAME] order was entered into the electronic medical record (EMR) on [DATE] and was first administered on [DATE] at 2:00 PM. The [MEDICATION NAME] was also administered on [DATE] at 7:00 PM and was unavailable on [DATE] for the 9:00 AM and 2:00 PM scheduled doses. The [MEDICATION NAME] was documented as administered on ,[DATE] at 7:00 PM and the last dose was administered on [DATE] at 9:00 AM prior to the resident's discharge. The administration of [MEDICATION NAME] 800 mg TID was delayed five days and was administered for four of 12 scheduled doses. b.) Review of a Physician's Telephone Order dated [DATE] revealed an order for [REDACTED]. Review of the eMAR dated [DATE] through [DATE] revealed the [MEDICATION NAME] order was entered into the EMR on [DATE] and was first administered on [DATE] at 9:00 AM. Review of a Medication Administration Progress Note in the EMR revealed an entry dated [DATE] at 5:48 PM that the [MEDICATION NAME] was on order. Additional review of the ,[DATE] eMAR revealed the [MEDICATION NAME] was unavailable for administration on [DATE]. The administration of the [MEDICATION NAME] 875 mg was delayed five days and was administered for three of 14 scheduled doses. Interview with the DON on [DATE] at 7:50 AM revealed she was not aware of these medication errors and there were no medication error reports for the omitted doses. Review of a facility Policy entitled Physician Orders/ Visits dated ,[DATE] revealed the purpose of the policy is to maintain consistency and accuracy when obtaining and transcribing orders. The licensed nurse is responsible for confirming orders with the Physician and transcribing the orders. Calling the Pharmacy and ordering prescribed medications/ treatments and completion of the Pharmacy order sheet. Telephone orders are used between 30/ 60/ 90 day orders. When the nurse receives a Telephone Order the Physician is to sign the order during next rounds per New York State Health Code. The white copy goes in the Physician folder to be signed and a copy of the order is to be in the resident's Medical Record. The Head Nurse/ Charge Nurse is responsible for reviewing the computerized Pharmacy order to prior orders to assure that: - All previous discontinued orders are also discontinued on current sheets - Any new orders are still current and written on new order sheets. 6. Resident #205 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has severe cognitive impairment, sometimes understands, is sometimes understood, and received insulin medication during the seven days prior to the completion of the MDS. Review of a Medication Review Report dated [DATE] revealed active orders to administer [MEDICATION NAME] (long acting) insulin 8 units subcutaneously (injection beneath the skin) in the morning for diabetes mellitus and [MEDICATION NAME] R (regular - fast acting) insulin subcutaneously with fingersticks (sample of blood to determine blood glucose levels) four times a day before meals and at bedtime, according to Sliding Scale (the administration of insulin based on blood glucose levels) as follows: - For a blood glucose of ,[DATE] = 2 units of [MEDICATION NAME] R insulin - ,[DATE] = 4 units - ,[DATE]= 6 units - ,[DATE]= 8 units - ,[DATE]= 10 units - greater than 450 - Call MD During an observation on [DATE] at approximately 7:50 AM, LPN #14 obtained a fingerstick of 341 (normal ,[DATE] mg/dl) from Resident #205. During an interview during the medication observation at approximately 7:55 AM on [DATE], LPN #14 stated she did not have Regular insulin and [MEDICATION NAME] for the resident. The LPN stated she would have to check the Omni system (storage for extra medications). During a continual observation on [DATE], from approximately 7:50 AM until 10:05 AM Resident #205 was observed in the dining room and consumed approximately 75% of the breakfast meal. The resident was not administered insulin. Interview with the Assistant Director of Nursing Services (ADNS) on [DATE] at approximately 10:08 AM revealed the resident should have received insulin coverage as ordered. The ADNS stated that if the medications are not available the nurse should go to the Omnicell, or check the floor stock. The ADNS stated that the LPN should have informed me that insulins were not available. The ADNS stated the resident should have received 6 units of [MEDICATION NAME] R and 8 units of [MEDICATION NAME] in the morning, I will notify the Physician. Review of Nursing Progress Notes dated [DATE] revealed the NP was notified that the resident did not receive AM medications and no new orders were received. 7. Resident #206 has [DIAGNOSES REDACTED].

Based on interview and record review during the Extended Survey completed on 11/6/15, the facility failed to provide pharmaceutical services, including procedures that assure accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident. Two (Residents #150, 189) of 35 residents reviewed for pharmaceutical services had issues involving the lack of accurate medication order entry, transcription, and administration with the lack of safeguards in place to identify and prevent errors. Specifically, the pharmacy dispensed multiple (three) doses of an antipsychotic medication ordered to be administered once every 28 days, in a five day period without clarifying the physician's orders [REDACTED].#150). In addition, the facility failed to ensure the accurate transcription, dispensing, and administration of physician ordered medications (#189). This resulted in a pattern of IMMEDIATE JEOPARDY TO RESIDENT HEALTH AND SAFETY that is actual harm for Resident #150. The findings are: 1. Resident #150 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 9/15/15 revealed the resident was moderately cognitively impaired, usually understands, and was understood. Review of the undated Comprehensive Care Plan (CCP) revealed the resident has a potential for violence related to hallucinations and delusions manifested by agitation and aggressive behaviors. The CCP documented that the resident has impaired cognition and thought process, mood problems related to mental illness, and receives antidepressants, anti-anxiety, and antipsychotic medications. CCP interventions included reviewing new medications, dosage increases, recent discontinuations, omissions, drug interactions/ adverse reactions, errors, drug toxicity, and record possible causes of cognitive deficits. The CCP documented an intervention to administer medications as ordered, and monitor and document for side effects and effectiveness. Review of a Physician's Telephone Order dated 9/15/15 revealed orders for Lithium (mood stabilizing drug used with psychiatric patients) 300 mg (milligrams) twice daily (BID), Risperdal (antipsychotic medication used to treat bipolar disease) 0.5 mg once daily (QD), and Depakote (mood stabilizing medication) 250 mg BID. Review of an Acute Visit Note, written by the Nurse Practitioner (NP), dated 9/22/15 revealed the patient has a history of bipolar disorder and continues to display bizarre behaviors that remain uncontrolled, despite current behavior modifying medications. The NP documented staff reported that the resident was making sexually inappropriate statements towards male workers, difficult with hands-on care. Review of a Physician's Telephone Order, written by the NP, dated 9/22/15 revealed the following orders; - Increase Risperdal to 1 mg BID for behavior - Increase Depakote to 500 mg BID for behavior - *Haldol (antipsychotic medication) 2 mg intramuscular (IM) x (times) one now, then every 6 hours as needed (prn) x 72 hours for severe agitation. Review of an Acute Visit Note, written by the NP, dated 9/23/15 revealed the resident was seen to evaluate all psychoactive medications. The NP documented a plan to continue Lithium 300 mg BID for bipolar disorder. Spoke at length with Pharmacy (a Pharmacist) regarding transition from Risperdal to Haldol Decanoate (long acting Haldol). Order written to discontinue Risperdal on Monday (9/28/15) and administer Haldol Decanoate 50 mg once every 28 days starting Monday. Review of a Physician's Telephone Order, written by the NP, dated 9/23/15 revealed the following: - Haldol Decanoate 50 mg IM every 28 days - Discontinue Risperdal on Monday (9/28/15) Review of the electronic Medication Administration Record (eMAR) dated September 2015 revealed that the Haldol Decanoate 50 mg IM was transcribed onto the eMAR three separate times and the resident received Haldol Decanoate 50 mg IM on 9/24/15, 9/26/15 and 9/29/15 instead of once every 28 days. There was no documented evidence on the eMAR that 24 accuracy checks were done. Additional review of the eMAR dated September 2015 revealed that the resident continued to receive Risperdal 1 mg BID on 9/28/15 and 9/29/15 despite the order to discontinue the medication. The eMAR documented that the Risperdol was held (not given) on 9/30/15 at 9:00 AM. Review of a Nursing Progress Note dated 9/30/15 at 10:00 AM revealed the Risperdal was held because the resident was lethargic. Further review of Nursing Progress Notes dated 9/23/15, 9/25/15 and 9/28/15 revealed the Pharmacy system had identified and reported a possible drug interaction between the Lithium Carbonate and Haldol Decanoate that may produce unexpected effects (severe neurotoxicity- damage to the brain). Additional review of Nursing Progress Notes revealed the following: - 9/29/15 at 10:00 PM - The resident slept in the wheelchair all shift, refused dinner but medications given, temperature (temp)102.4 (normal 98.6 degrees Fahrenheit (F), Tylenol given, and recheck of temp 99 degrees. - 9/30/15 at 6:38 AM - Refused to wake up. - 9/30/15 at 10:00 AM - Medications held due to lethargy. - 9/30/15 at 3:00 PM - Resident very lethargic this shift, heart rate (HR) 136 (average 80), respirations 24 (normal 12 to 20), temp 100.8 F, medications were held due to lethargy, and intake of foods and fluid poor this shift. HR down to 98 and temperature retake was 100.3 F, and the resident remains lethargic. - 9/30/15 at 8:00 PM - The resident is asleep all shift, respirations are normal, temp 99.9 F, given Tylenol, and recheck 98.5 F. Aroused with difficulty, no swallowing motions noted, dinner held, crushed meds in applesauce, able to suck water with straw 100 milliliters (ml) intake. There was no documeted evidence that the Physician or NP were notified of the change in the resident's condition on 9/29/15 or 9/30/15. Review of an untimed Physician's Telephone Order, written by the NP, dated 10/1/15 revealed orders to obtain STAT (immediate) bloodwork that included a CBC with diff (complete blood count with differential), CMP (complete metabolic profile - blood chemistry studies), a Lithium level, a urinalysis, urine culture and sensitivity, and a chest x-ray. The orders directed to start Ceftriaxone (antibiotic) one gram IM daily and start Clysis (fluid administered subcutaneously into the abdomen) fluids with normal saline (NS). Review of a Laboratory Report dated 10/1/15 revealed Critical BUN (blood urea nitrogen-blood test to determine kidney function and hydration status) and Na (sodium) called to Registered Nurrse (RN) Supervisor at facility on 10/1/15 at 4:42 PM. Further review of nursing Progress Notes revealed the following: - 10/1/15 AM - AM medications refused. - 10/1/15 at 3:00 PM - Resident lethargic this shift, HR 130, temp 101.3 F, respirations 26. - 10/1/15 at 7:21 PM - NP updated on STAT blood work results; Lithium level 1.58 (normal 0.60 - 1.60), BUN - 129 (normal 5 to 27), Na 159 (normal 133 to 147). Order to send to the emergency room for treatment and evaluation. - 10/1/15 at 10:00 PM - Difficult to arouse, labored breathing, blood pressure 144/118 (normal), HR of 131, temp 102.7 F, respirations 16, difficulty to arouse for meds (medications), no swallowing motions noted, all meds held, call to transfer resident to hospital. - 10/2/15 at 8:08 AM - The resident was admitted to the hospital ICU (intensive care unit) with altered mental status and hypernatremia (elevated Na level in the blood). During an interview on 11/3/15 at 11:08 AM, the NP stated that the resident had [DIAGNOSES REDACTED]. The NP spoke with the family and the family had requested a medication that was longer acting. That is why the Haldol Lactate 2 mg prn was changed to the Haldol Decanoate 50 mg to be administered every 28 days. The plan was to wean the resident from the Risperdal. The NP stated that she was not concerned with the potential Black Box Warnings (potential for severe interactions) nor did she have concerns related to the potential for an elevating BUN and Na, with only receiving a couple of doses of Haldol. The NP was asked if she was aware that the Haldol Decanoate 50 mg was documented as being administered on 9/24/15, 9/26/15, 9/29/15 and the Risperdal was not discontinued as ordered. The NP stated no and suggested that the surveyor discuss the medication concerns with the Unit Manager. The NP further stated I write the order, the nurses take care of the rest. During an interview on 11/3/15 at 11:16 AM Licensed Practical Nurse (LPN #11) Unit Manager stated she had to enter the order for Haldol Decanoate 50 mg IM q (every) 28 days into the computer two extra times because once you sign that you gave the Haldol, the system does not allow for you to make a correction that it was signed out in error. During a telephone interview on 11/3/15 at approximately 11:35 AM, the Dispensing Pharmacist (#1) stated that the Pharmacy dispensed Haldol Decanoate 50 mg a couple of times. Three times to be exact on 9/23/15, 9/25/15, and 9/28/15. Review of the Pharmacy delivery sheet confirmed that Haldol Decanoate 50 mg was delivered to the facility on three occasions for Resident #150. During a telephone interview on 11/3/15 at 2:30 PM, the Dispensing Pharmacist (#2) stated that when an order gets put into the computer system, it comes across as a brand new order and the medication gets filled and sent. Pharmacist #2 stated the pharmacy does not have an automatic check or alert to indicate that a medication was just filled and sent. During an interview on 11/3/15 at approximately 4:25 PM, the Director of Nursing Services (DNS) and the Administrator stated that the Pharmacy had no record of any Haldol Decanoate 50 mg being returned to the Pharmacy. During a telephone Interview on 11/4/15 at 10:10 AM, the Pharmacy Consultant stated he was not familiar with Resident #150, he did not review her medications, and he was not aware of any medication errors. The Pharmacy Consultant stated that adverse reactions would include sedation, tachycardia (fast heart beat), and respiratory issues. The Pharmacist stated that when Haldol is administered with the Lithium (lithium is a funny drug he said) and you have a resident with multiple comorbidities and is on multiple drugs, the concern would also be increased levels of Lithium and kidney damage. In summary, there were no safeguards in place by the dispensing pharmacy to prevent the duplication of medication orders filled and delivered to the facility, and subsequently administered to the residents. 2. Resident #189 had [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident was cognitively intact, understood others, and was understood. Review of an Acute Visit Note, written by the NP (Nurse Practitioner), dated 2/24/15 revealed the resident had increased edema (swelling caused by excess fluid accumulation) in both lower extremities and the NP documented a plan to start Lasix (diuretic - medication that promotes the excretion of urine) 80 mg QD (every day) for one week and then reduce to 40 mg daily. Review of a Physician/ Prescriber Telephone Order, signed by the FNP (Family Nurse Practitioner), dated 2/24/215 revealed the following medication orders: - K-Dur (potassium chloride) 20 meq (milliequivalent) po (by mouth) QD (every day) - Lasix 80 mg po QD x (times) 1 week, Give first dose now, then decrease to 40 mg po QD edema. Review of the electronic Medication Administration Record (eMAR) dated 2/1/15 through 2/28/15 revealed the medications ordered on [DATE] were not transcribed onto the 2/2015 eMAR and K-Dur 20 meq and Lasix 80 mg were not administered to the resident at any time during February 2015. Review of the eMAR dated 3/1/15 through 3/31/15 revealed documentation that Lasix 80 mg po QD for edema was documented as administered daily from 3/1/15 through 3/9/15. Further review of the eMAR dated 3/1/15 through 3/31/15 revealed Potassimin 20 mcg (microgram - a unit of mass or weight equal to one millionth of a gram) was documented as administered to the resident daily from 3/1/15 to 3/8/15. Review of the eMARs dated 3/2015 to 5/2015 revealed that Lasix 80 mg po QD was documented as administered daily from 3/10/15 through 5/31/15, except 5/26/15 (coded not available). There was no documented evidence on the eMAR that 24 hours accuracy checks were done. Additional review of the eMARs revealed the following: - 3/2015 - Potassimin 20 mcg was documented as administered to the resident 3/10/15 through 3/31/15. - 4/2015 - Potassimin 20 mcg was documented as not administered on 10 of 30 days (coded as not available) in April 2015. 5/2015 - Potassimin 20 mcg was documented as not administered on 18 of 30 days (coded as not available or on order). Interview with the FNP on 11/2/15 at approximately 2:45 PM revealed the FNP expected the resident to start on 80 mg of Lasix on 2/24/15 when the order was written. The intention was for the resident to receive 80 mg of Lasix for one week and then decrease the Lasix to 40 mg daily. The FNP was not aware that the resident continued to receive 80 mg of Lasix daily or that there was a five day delay initiating the Lasix. Review of the Medication Review Report (renewal order sheet), signed by the MD (Medical Doctor), on 4/9/15 included the following: - Lasix 80 mg orally one time a day for edema (order date 2/24/15, start date 2/25/15) - Potassimin tablet Give 20 mcg by mouth one time a day for supplement (order date 2/24/15, start date 2/25/15) Further review of the Medication Review Report signed by the physician on 4/9/15 revealed there was no signature or initials of nursing staff to indicate that the accuracy of the medication orders was verified. Interview with the Medical Director on 10/29/15 at approximately 12:30 PM revealed the intent of the 2/24/15 order was for the resident to start on K-Dur 20 meq, not Potassimin 20 mcg, and Lasix 80 mg was ordered to start, when the order was written, for one week and then decreased to 40 mg daily. Interview with the Director of Nursing Services (DNS) on 10/30/15 at approximately 9:55 AM revealed A phone order is transcribed (by nursing staff) into Point Click Care (PCC - a computer software program) and a sheet is printed from PCC for the physician to sign. If it is a handwritten phone order, the same process is followed. There is no double check on the orders; anytime it (the order) goes in the computer, it is automatically sent to pharmacy. The nurses choose the (medication) administration times. Interview with the Consultant Pharmacist on 10/30/15 at approximately 9:00 AM revealed There is no such medication as Potassimin 20 mcg. It is my assumption that is a typo. The mcg should be meq. If the order in PCC matched the blister pack, I would not expect a nurse to question that. The c (in mcg) can look like an e (in meq). Probably should have caught that typo, so it is your call whether it should have been caught or something. I do not think a nurse would catch it. I am not a nurse. Review of the Omnicell (medication dispensing system) Transactions by Patient report dated 2/1/15 through 10/28/15 revealed the following medication transactions: - 3/4/15 at 9:00 AM - 2 TAB (tablets) Potassium Chloride ER (extended release) (K-Dur) 10 meq Tab - 3/7/15 at 11:17 AM - 1 TAB Potassium Chloride ER 20 meq Tab - 3/19/15 at 8:47 AM - 1 TAB Potassium Chloride ER 20 meq Tab In addition, the following transactions were included in the report: - 2/24/15 at 10:26 AM - 4 TAB Furosemide (Lasix) 20 mg Tab - 3/4/15 at 9:01 AM - 4 TAB Furosemide 20 mg Tab - 3/6/15 at 9:10 AM - 1 TAB Furosemide 20 mg Tab - 3/17/15 at 8:18 AM - 4 TAB Furosemide 20 mg Tab - 3/19/15 at 8:46 AM - 2 TAB Furosemide 20 mg Tab Interview with the Dispensing Pharmacist on 10/29/15 at approximately 9:22 AM revealed On 4/28/15, the facility attempted to reorder the Potassium. We did not have an order on file, so we called the facility and the staff member we spoke with stated the resident did not have a physician's orders [REDACTED]. There were no previous transactions prior to the 5/27/15 date except in Omnicell. Interview with the Dispensing Pharmacist on 10/30/15 at approximately 8:45 AM revealed At the time the original order was written on 2/24/15, the pharmacy was not integrated with the PCC system. The nurse would have been responsible to fax the new order to the pharmacy. No faxes came in for that particular resident during that time frame. The Lasix was not dispensed from the pharmacy until 4/28/15 when the pharmacy first received the Lasix order. I do not know where the medication came from that the nurses were signing for; it was not dispensed from this pharmacy. Review of a facility policy and procedure entitled Electronic Health Record Medication dated 2/2015 revealed the following: Policy Interpretation and Implementation: - All drugs and biological orders shall be written/entered, dated and signed by the person lawfully authorized to give such an order. - Telephone orders must be recorded immediately in the resident's eMAR by the person receiving the order and must include the date and time of the order. Medication Pass: - Nurse will review eMAR. - Nurse will pour appropriate medication. Transcribing Orders: - Nursing will transcribe written orders into eMAR. - All orders are noted by nurse receiving order. - If placing medication/treatment order in eMAR platform - ensure right medication, dose and route. If medication has duration, place start and stop date. 415.18(a)

Based on observation, interview, and record review during a complaint investigation (Complaint #NY 070) during the Extended survey completed on 11/6/15, it was determined that the Licensed Pharmacist failed to report drug regimen irregularities to the attending Physician. Four (Residents #93 ,146, 189, 206) of 17 residents reviewed for monthly medication regimen reviews (MRR) had issues involving the lack of the Consultant Pharmacist's identification of transcription errors and medication discrepancies resulting in significant medication errors. The Consultant Pharmacist did not identify or report incorrect and/or inaccurate transcription and subsequent administration or omission of diuretic medications (used to promote the excretion of urine) (#189, 206), oral steroids (#206), mood stabilizing medications (#93), and supplements (#189 resulting in significant medication errors. In addition, the Consultant Pharmacist did not recommend a gradual dose reduction (GDR) of a mood stabilizing drug (Depakote) that was used for an excessive duration (#146). This resulted in a pattern of IMMEDIATE JEOPARDY TO RESIDENT HEALTH AND SAFETY with no actual harm. The findings are: 1. Resident #189 had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 5/11/15 revealed that the resident was cognitively intact, understood others, and was understood. Review of an Acute Visit Note, written by the FNP (Family Nurse Practitioner), dated 2/24/15 revealed the resident had increased edema (swelling caused by excess fluid accumulation) in both lower extremities and the NP documented a plan to start Lasix (diuretic - medication that promotes the excretion of urine) 80 mg (milligrams) QD (every day) for one week and then reduce to 40 mg daily. Review of a Physician/ Prescriber Telephone Order, signed by the FNP, dated 2/24/215 revealed the following medication orders: - K-Dur (potassium chloride) 20 meq (milliequivalent) po (by mouth) QD - Lasix 80 mg po QD x (times) 1 week, Give first dose now, then decrease to 40 mg po QD edema. Review of the electronic Medication Administration Record (eMAR) dated 2/1/15 through 2/28/15 revealed the medications ordered on [DATE] were not transcribed onto the 2/2015 MAR and K-Dur 20 meq and Lasix 80 mg were not administered to the resident at any time during February 2015. Review of the eMAR dated 3/1/15 through 3/31/15 revealed documentation that Lasix 80 mg po QD for edema was documented as administered daily from 3/1/15 through 3/9/15. Further review of the eMAR dated 3/1/15 through 3/31/15 revealed Potassimin 20 mcg (microgram - a unit of mass or weight equal to one millionth of a gram) was documented as administered to the resident daily from 3/1/15 to 3/8/15. Review of the electronic eMARs dated 3/2015 to 5/2015 revealed that Lasix 80 mg po QD was documented as administered daily from 3/10/15 through 5/31/15, except 5/26/15 (coded not available). There was no documented evidence on the eMAR that 24 hours accuracy checks were done. Additional review of the eMARs revealed the following: - 3/2015 - Potassimin 20 mcg was documented as administered to the resident 3/10/15 through 3/31/15. - 4/2015 - Potassimin 20 mcg was documented as not administered on 10 of 30 days (coded as not available) in April 2015. 5/2015 - Potassimin 20 mcg was documented as not administered on 18 of 30 days (coded as not available or on order). Interview with the FNP on 11/2/15 at approximately 2:45 PM revealed the FNP expected the resident to start on 80 mg of Lasix on 2/24/15 when the order was written. The intention was for the resident to receive 80 mg of Lasix for one week and then decrease the Lasix to 40 mg daily. The FNP was not aware that the resident continued to receive 80 mg of Lasix daily or that there was a five day delay initiating the Lasix. Review of the Medication Review Report (renewal order sheet), signed by the MD (Medical Doctor), on 4/9/15 included the following: - Lasix 80 mg orally one time a day for edema (order date 2/24/15, start date 2/25/15) - Potassimin tablet Give 20 mcg by mouth one time a day for supplement (order date 2/24/15, start date 2/25/15) Further review of the Medication Review Report signed by the MD on 4/9/15 revealed there was no signature or initials of nursing staff to indicate that the accuracy of the medication orders was verified. Interview with the Medical Director on 10/29/15 at approximately 12:30 PM revealed the intent of the 2/24/15 order was for the resident to start on K-Dur 20 meq, not Potassimin 20 mcg, and Lasix 80 mg was ordered to start, when the order was written, for one week and then decreased to 40 mg daily. Review of the Riverview Unit MRR (Medication Regimen Review) report revealed that the Consultant Pharmacist reviewed Resident #189 on 3/7/15, 4/4/15, and 5/9/15 and no medication irregularities were identified regarding Lasix or K-Dur. Interview with the Consultant Pharmacist on 10/30/15 at approximately 9:00 AM revealed There is no such medication as Potassimin 20 mcg. It is my assumption that is a typo. The 'mcg' should be 'meq'. The c (in mcg) can look like an e (in meq). I probably should have caught that typo. The Lasix order should have definitely been caught on the MRR. There have been a lot of problems with order entry and duplicate orders. Whenever I identify an issue, I communicate it to the facility. 2. Resident #206 has [DIAGNOSES REDACTED]. Review of the admission MDS dated [DATE] revealed that the resident is cognitively intact, understands, and is understood. Review of a Physician's Telephone Order dated 9/14/15 revealed an order to administer 10 mg of Hydrocortisone (an oral corticosteroid to treat adrenocortical insufficiency) in the morning and 5 milligrams of Hydrocortisone in the evening after a serum cortisol blood test was done. Review of the eMARs dated 9/11/15 to 10/6/15 revealed that Hydrocortisone 10 mg and 5 mg were not documented on the eMAR. Additional review of the eMARs revealed that Hydrochlorothiazide (a diuretic medication that reduces the amount of sodium absorbed by the kidneys and is used to treat high blood pressure) 10 mg and Hydrochlorothiazide 5 mg were transcribed to be administered on the eMAR, instead of the Hydrocortisone. There was no documented evidence on the eMARS that 24 accuracy checks were done. Additional review of the eMARs dated 9/11/15 to 10/6/15 revealed documentation that Hydrochlorothiazide 5 mg was transcribed to be administered from 9/15/15 to 10/6/15. On 9/17/15, 9/19/15, 9/20/15, 9/24/15, 9/27/15, 9/28/15, 9/29/15, and 9/30/15 there were notations coded 9 which indicated to check the nursing notes. Review of Medication Administration Progress Notes dated 9/17/15, 9/19/15, 9/20/15, 9/24/15, 9/27/15, and 9/29/15 revealed documentation written by three different nurses that Hydrochlorothiazide 5 mg was not available or on order. The Medication Administration Progress Note dated 9/30/15 revealed that the order needed to be clarified by the physician. The eMARs dated 9/11/15 to 10/6/15 documented that Hydrochlorothiazide was administered 10 mg daily from 9/15/15 to 10/6/15. Review of the Omnicell automated medication dispensing cabinet Transactions by Patient report provided by the dispensing Pharmacy on 11/4/15 at approximately 11:37 AM revealed that nursing staff removed doses of Hydrochlorothiazide 25 mg on 9/15/15, 9/18/15, 9/20/15, and twice on 9/26/15. Review of physician's orders [REDACTED]. [REDACTED]. Review of the Riverview Unit monthly MRR report, completed by the Consultant Pharmacist, revealed Resident #206 was reviewed on 10/4/15 and the Pharmacist documented Medication Regimen Reviewed - No Irregularities Noted. Interview with the Consultant Pharmacist on 10/30/15 at approximately 9:30 AM revealed that he routinely checks the eMAR, physician's orders [REDACTED]. 3. Resident #93 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has severely impaired cognitive skills for daily decision making, sometimes understands, and is usually understood. Review of the Medication Review Report, signed by the FNP on 8/4/15, revealed the following medication orders: - Divalproex Sodium (Depakote - mood stabilizer) tablet Delayed Release 125 mg Give 1 tablet by mouth at bedtime for mood (order date 8/3/15, start date 8/3/15) - Divalproex Sodium Tablet Delayed Release 250 mg. Give 1 tablet by mouth one time a day for behavior (order date 8/3/15, start date 8/4/15) Review of the eMAR dated 8/1/15 through 8/31/15 revealed the following: - Divalproex Sodium Delayed Release 125 mg, give 1 tablet by mouth at bedtime for mood. The eMAR documented that Divalproex Sodium 125 mg was administered from 8/3/15 through 8/31/15 at 9:00 PM daily - Divalproex Sodium Delayed Release 250 mg, give 1 tablet by mouth one time a day for behavior. The eMAR documented that Divalproex Sodium 250 mg was administered from 8/4/15 through 8/31/15 (Resident refused medication 8/13/15) at 7-10 (7:00 AM to 10:00 AM - liberalized administration times) - Depakote (Divalproex Sodium) Tablet Delayed Release 125 mg, give 1 tablet by mouth two times a day related to senile dementia. The eMAR documented that Depakote 125 mg BID was administered from 8/9/15 through 8/31/15 (Resident refused medication 8/13/15) at 7-10 and from 8/8/15 through 8/31/15 at 4:00 PM to 6:00 PM (4-6). - The eMAR documented that the resident received a total daily dose of 525 mg of Depakote from 8/8/15 to 8/31/15, instead of a daily total dose of 375 mg as ordered by the NP on 8/14/15 Review of the eMAR dated 9/1/15 through 9/30/15 revealed the following: - Divalproex Sodium Delayed Release 125 mg, give 1 tablet by mouth at bedtime for mood. The eMAR documented that Divalproex Sodium 125 mg was administered from 9/1/15 through 9/7/15 at 9:00 PM. - Divalproex Sodium Delayed Release 250 mg, give 1 tablet by mouth one time a day for behavior. The eMAR documented that Divalproex Sodium 250 mg was administered from 9/1/15 through 9/8/15 at 7-10. - Depakote Tablet Delayed Release 125 mg, give 1 tablet by mouth two times a day related to senile dementia. The eMAR documented that Depakote 125 mg BID was administered from 9/1/15 through 9/8/15 at 7-10 and from 9/1/15 through 9/7/15 at 4-6. - The eMAR documented that the resident received a total daily dose of 525 mg of Depakote from 9/1/15 through 9/7/15, instead of a daily total dose of 375 mg as ordered by the NP on 8/14/15 Review of the entire (electronic and hard copy) Medical Record dated 8/4/15 through 9/7/15 revealed no documented evidence of additional orders for Depakote or Divalproex Sodium. Review of a Physician/ Prescriber Telephone Order, signed by the FNP, dated 9/8/15 revealed an order to change to Depakote liquid 125 mg po at 9:00 AM, 1:00 PM, and 5:00 PM and 250 mg po qHS (at bedtime). (525 mg total daily dose). During an interview on 11/5/15 at approximately 1:51 PM, the MD stated There was no order to increase the Depakote (to 525 mg daily) until the FNP came in and changed the order on 9/8/15. Review of the monthly MRR for Resident #93 dated September 2015 revealed Medication Regimen Reviewed - No Irregularities Noted was signed by the Consultant Registered Pharmacist on 9/5/15. Interview with the Consultant Pharmacist on 10/30/15 at approximately 9:00 AM revealed the Pharmacist does the monthly MRR onsite by comparing the physician's orders [REDACTED]. The interview revealed that since the facility switched to the EMR and the eMAR, there have been issues with order entry and duplicate orders. The Consultant Pharmacist stated that when these issues are identified, the Pharmacist communicates the issues to the pharmacy. The Consultant Pharmacist was unable to comment as to why the Depakote irregularity was not identified. 4. Resident#146 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is severely cognitively impaired, sometimes understands, and is understood. Review of the Comprehensive Care Plan (CCP) dated 10/12/15 revealed that the resident receives Depakote for behavior management. The CCP documented that the resident has a history of seeking/stealing food and eating non-food items. CCP interventions include a plan to discuss the GDR of medication with the MD (medical doctor) when appropriate. Review of the Medication Review Report dated 1/13/15 revealed an order to increase the resident's Depakote to 750 mg every 12 hours for behavior disturbance. Additional review of the Medication Review Report revealed Depakote 500 mg every 12 hours was started 7/10/14. Review of the MARs and eMARS dated 1/2015 to 11/2015 revealed the resident received Depakote 750 mg every 12 hours as ordered by the physician. Review of a Behavior Note dated 8/4/15 revealed resident noted taking food or drink from other residents in lounge or unattended food. Review of a Team Care Plan Meeting note dated 10/12/15 revealed the resident remains wandering on the unit in search of food. Is provided with one to one, redirection. These interventions are effective. Review of nursing Progress Notes dated 8/4/15 through 10/29/15 revealed no documented evidence that the resident was wandering or seeking food Intermittent observations from 10/28/15 to 11/6/15, between the hours of 8:00 AM and 3:45 PM, revealed the resident was sitting in a wheelchair in the dining room or in bed in his room. There were no observations of the resident wandering or seeking food. Review of the medical record, including physician's orders [REDACTED].#146. Review of Progress Notes, written by the NP, dated 5/17/15 through 10/13/15 revealed staff reported no concerns and the resident's overall mood was good. There was no documented clinical rationale for not attempting a GDR of the Depakote. Review of the Monthly MRR, completed by the Consultant Pharmacist dated 1/2015 through 11/2015 revealed no recommendations for a GDR of the Depakote. During an interview on 11/3/15 at 9:15 AM, the Social Worker (SW #1) stated that the resident has a history of wandering and seeking out food. SW #1 stated that the last documented Behavior Note was completed on 8/4/15. SW #1 stated that she thought the last time that the resident was discussed in BMARC (behavior management assessment review committee) was in July 2015. SW #1 stated she was not sure if a GDR of the Depakote was attempted and she did not know if there was documented evidence from the physician that a GDR of the Depakote would be clinically contraindicated. During a telephone interview on 11/3/15 at 10:53 AM, the Consultant Pharmacist stated that he does not keep records of GDR's. The Consultant Pharmacist stated that every resident gets discussed as a team at the monthly BMARC meetings and the Social Worker documents the meetings. The Consultant Pharmacist stated to be honest, I cannot recall the specifics as to why he did not recommend a GDR for this resident. Review of an undated policy entitled Organization of Pharmacy Services revealed the Consultant is responsible for evaluating medication orders, monitoring medication administration, evaluating response to medication therapy, and communicating observations and recommendations. 415.18(c)(2)

Based on interview and record review conducted during the Extended survey completed on 11/6/15, the facility failed to ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, are thoroughly investigated. Two (Residents #138, 150) of two residents reviewed for the investigation of identified medication errors lacked medication error reports or a thorough investigation into the errors. Resident #138 received duplicate doses of Aspirin and Resident #150 was received duplicate doses of an antipsychotic medication. The facility did not ensure that each identified medication error was followed-up and investigated thoroughly. This resulted in IMMEDIATE JEOPARDY and SUBSTANDARD QUALITY OF CARE TO RESIDENT HEALTH AND SAFETY with no actual harm. The findings are: 1. Resident #150 has [DIAGNOSES REDACTED]. Review of the Minimum Date Set (MDS - a resident assessment tool) dated 9/15/15 revealed the resident was moderately cognitively impaired, usually understands, and was understood. Review of the undated Comprehensive Care Plan (CCP) (identified as current by the Licensed Practical Nurse (LPN #11) Unit Manager) revealed the resident has impaired cognition, thought process, and mood problems related to mental illness and receives antidepressants, anti-anxiety, and antipsychotic medications. CCP interventions included reviewing new medications, dosage increases, recent discontinuations, omissions, drug interactions/ adverse reactions, errors, drug toxicity, and record possible causes of cognitive deficits. The CCP documented an intervention to administer medications as ordered, and monitor and document for side effects and effectiveness. Review of a Physician's Telephone Order dated 9/15/15 revealed orders for [MEDICATION NAME] (mood stabilizing drug used with psychiatric patients) 300 milligrams (mg) twice daily (BID), [MEDICATION NAME] (antipsychotic medication used to treat [MEDICAL CONDITION] disease) 0.5 mg once daily (QD), and [MEDICATION NAME] (mood stabilizing medication) 250 mg BID. Review of an Acute Visit Note, written by the Nurse Practitioner (NP), dated 9/22/15 revealed the patient has a history of [MEDICAL CONDITION] disorder and continues to display bizarre behaviors that remain uncontrolled, despite current behavior modifying medications. The NP documented staff reported that the resident was making sexually inappropriate statements towards male workers, difficult with hands-on care. Review of a Physician's Telephone Order, written by the NP, dated 9/22/15 revealed the following orders; - Increase [MEDICATION NAME] to 1 mg BID for behavior - Increase [MEDICATION NAME] to 500 mg BID for behavior - *[MEDICATION NAME] (antipsychotic medication) 2 mg intramuscular (IM) x (times) one now , then every 6 hours as needed (prn) x 72 hours for severe agitation. Review of an Acute Visit Note, written by the NP, dated 9/23/15 revealed the resident was seen to evaluate all psychoactive medications. The NP documented a plan to continue [MEDICATION NAME] 300 mg BID for [MEDICAL CONDITION] disorder. Spoke at length with pharmacy regarding transition from [MEDICATION NAME] to [MEDICATION NAME] (long acting [MEDICATION NAME]). Order written to discontinue [MEDICATION NAME] Monday (9/28/15) and administer [MEDICATION NAME] 50 mg once every 28 days starting Monday. Review of a Physician's Telephone Order, written by the NP, dated 9/23/15 revealed the following: - [MEDICATION NAME] (long acting [MEDICATION NAME]) 50 mg IM every 28 days - Discontinue [MEDICATION NAME] on Monday (9/28/15) Review of the electroninc Medication Administration Record [REDACTED]. Additional review of the eMAR dated September 2015 revealed that the resident continued to receive [MEDICATION NAME] 1 mg BID on 9/28/15 and 9/29/15 despite the order to discontinue the medication. The eMAR documented that the [MEDICATION NAME] was held (not given) on 9/30/15 at 9:00 AM. Review of a nursing Progress Note dated 9/30/15 at 10:00 AM revealed the [MEDICATION NAME] was held because the resident was lethargic. During an interview on 11/3/15 at 11:08 AM, the NP stated that the [MEDICATION NAME] 2 mg prn for agitation was changed to [MEDICATION NAME] 50 mg to be administered every 28 days. The NP stated that the plan was to wean the resident from the [MEDICATION NAME]. The NP was asked if she was aware that the [MEDICATION NAME] 50 mg was documented as administered on 9/24/15, 9/26/15, and 9/29/15 and that the [MEDICATION NAME] was not discontinued as ordered. The NP stated No and suggested that the surveyor discuss this issue with the Unit Manager. The NP further stated I write the order, the nurses take care of the rest. During an interview on 11/3/15 at 11:16 AM, the LPN (#11) Unit Manager stated she realized that the [MEDICATION NAME] was not given as ordered and she questioned her nurses. The LPN Unit Manager stated that the medication nurses said that they gave the regular [MEDICATION NAME], a medication error report was completed, and the nurses were spoken to. The LPN Unit Manager stated that she had to enter the order for [MEDICATION NAME] 50 mg IM q 28 days into the computer two extra times because once you sign that you gave the [MEDICATION NAME], the system does not allow for you to make a correction that it was signed out in error. During the interview, the medication error report was requested and none was produced. During an interview on 11/3/15 at 11:29 AM, LPN #12 stated that she was told she gave the wrong [MEDICATION NAME] on 9/24/15 by her Charge Nurse. LPN #12 stated that there was only one vial of [MEDICATION NAME] in the cart to give. During a telephone interview on 11/3/15 approximately 11:35 AM, the pharmacist stated that the pharmacy dispensed [MEDICATION NAME] 50 mg a couple of times. Three times to be exact on 9/23/15, 9/25/15, and 9/28/15. Review of the pharmacy delivery sheet confirmed that the [MEDICATION NAME] 50 mg was delivered to the facility on three occasions for Resident #150. During a telephone interview on 11/3/15 at 2:24 PM, the NP stated I honestly can't answer what would happen if the resident received an extra 100 mg of [MEDICATION NAME]. I would have to do some research and confer with the Medical Director. My intention was to wean off the [MEDICATION NAME] and start [MEDICATION NAME]. On 10/1/15 I did not know what was going on with the resident; I acted appropriately and sent her out to the ER. During an interview on 11/3/15 at 3:31 PM, the Medical Director stated That is a lot of [MEDICATION NAME]. Certainly there would be the potential for harm, but I cannot say with 100 percent (%) certainty. We would be concerned with cardiac arrhythmias (loss of normal heart rhythm) and kidney injury with these types of medications. Given the resident's comorbidities (the presence of one or more diseases) and the [MEDICATION NAME] level on the high side of normal, if the resident got an additional dose of [MEDICATION NAME], of course with two additional doses along with the other medications - [MEDICATION NAME] - the greater the potential. The Medical Director stated that he would have expected an investigation to have been started sooner into the matter. During an interview on 11/3/15 at approximately 4:25 PM, the Director of Nursing Services (DNS) and the Administrator stated that the pharmacy had no record of any [MEDICATION NAME] 50 mg being returned to the pharmacy. During an interview on 11/3/15 at approximately 4: 15 PM, LPN #4 stated that the resident was combative on 9/26/15, up and down out of the chair, and needed [MEDICATION NAME]. LPN #4 stated there was one vial of [MEDICATION NAME] in the medication cart and that is what she gave. LPN #4 stated that she checked the vial against the eMAR, it matched so that is what she gave. LPN #4 stated she did not know if it was 2 mg or 50 mg [MEDICATION NAME]. LPN #4 stated she found out about the error yesterday (11/2/15) from her charge nurse and was educated. During an additional interview on 11/5/15 at 8:30 AM, the DNS stated she was first made aware of the [MEDICATION NAME] error on 11/2/15. Neither the LPN (#11) Unit Manager or the Registered Nurse (RN #9) who assists on the unit, reported the error to her when it happened in September 2015. A medication error report was started on 11/2/15. During an interview on 11/6/15 at 8:52 AM, RN #9 stated she was aware that there was a [MEDICATION NAME] error but was not aware of the magnitude of the medication error until 11/2/15. In addition, the RN stated that she was not aware that a medication error report was not completed at the time of the errors. Review of a document entitled Medication Error Form dated 11/2/15 revealed the errors occurred on 9/24/15 and 9/26/15. There were no signatures or statements from LPN #4 or LPN #12, who documented that they administered the [MEDICATION NAME] 50 mg. 2. Resident # 138 has [DIAGNOSES REDACTED]. Review of an Order Summery Report, with an order date range from 7/1/15 through 7/31/15, revealed there were duplicate active physician's orders [REDACTED]. Review of the eMARS dated 7/2015 and 8/2015 revealed documentation that the resident received a doubled dose of the Aspirin (162 mg) on 13 of 23 days in 7/2015 and 10 of 17 days in 8/2015. Review of a Medication Administration Progress Notes dated 7/10/15 at 8:53 AM revealed Aspirin table 81 mg, give one tablet one time a day for [MEDICATION NAME] ([MEDICATION NAME]). Order in computer x2. Medication Administration Progress Notes dated 7/23/15, 7/24/15, 8/5/15, 8/6/15, 8/10/15, and 8/12/15 documented Aspirin tablet 81 mg, give one tablet one time a day for [MEDICATION NAME]. Duplicate. Review of Dental Orders and Progress Notes dated 8/3/15 revealed the resident complained of bleeding gums. The Dental Progress Note documented there was no evidence of bleeding gums, tissues WNL (within normal limits). Review of a nursing Progress Note dated 8/5/15 at 3:19 PM revealed the resident's gums were bleeding and warm water rinse slows down bleeding. Interview with the DNS on 11/4/15 at approximately 2:40 PM revealed there was no medication error report for the Aspirin for Resident #138. Interview with the Assistant Director of Nursing Services on 11/6/15 at approximately 8:45 AM revealed there would be a concern if a resident were to receive two doses of Aspirin daily. 415.4(b)(2)(3)

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED 8/8/11. Based on observation, record review, and staff and resident interview, the facility did not ensure a resident having pressure sores received necessary treatment and services to promote healing and prevent new sores from developing. Three (Residents # 149,156, 214) of three residents reviewed for pressure ulcers had issues. Resident #149 developed a painful pressure ulcer that was not addressed by the facility for approximately 5 days. This resulted in actual harm that is not immediate jeopardy. Resident # 156 developed a new unstageable pressure ulcer that was documented incorrectly and lacked a Registered Nurse (RN) assessment. In addition there was a three day delay in notifying the physician resulting in a delay in treatment. An incorrect and incomplete treatment was observed being provided to the resident's pressure ulcers. Resident #214 was admitted with a pressure ulcer and had no further assessment of the pressure ulcer. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy for Residents #156 and 214. The findings are: 1. Resident #149 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set ((MDS) dated [DATE] revealed the resident's cognition is moderately impaired. Review of the Comprehensive Care Plan (CCP) dated 4/26/12 does not indicate an individualized plan for prevention of pressure ulcers. Review of the Care Guide dated 11/1/11 includes moisturizing lotion to skin with care, observe feet for evidence of problems, and observe skin for dryness. Review of a Physician order [REDACTED]. When observed on 5/21/12 at 9:52 AM during personal care, CNA #3 provided the resident with a basin of water and the resident washed her upper body. CNA #3 then assisted the resident to lie down in bed and the resident informed the CNA that her buttock hurt and would he put something on it. CNA #3 turned the resident onto her right side and washed, rinsed and dried the resident's back. The resident stated "be careful when you wash my butt it hurts". The resident also stated the "washcloths are rough because they do not use fabric softener" and stated "when some people wash her they scrub back and forth and it hurts her". At 9:56 AM CNA #3 stated he needed more washcloths, left the resident's room and returned with them. The resident again stated "be careful when you wash my butt because it hurts". Observation of the resident's buttocks at this time revealed two areas on the inner aspect of the left buttock and one area on the inner aspect of the right buttock approximately 1 centimeter (cm) round with white slough (soft, moist, dead tissue that may be white, yellow, tan or green) and a Stage 2 pressure ulcer on the coccyx (tailbone) that is approximately 1 cm length by 1/2 cm width. After CNA #3 cleansed the resident's buttock and rectal area, he stated "they" use white barrier cream but he applies A&D ointment because that is what the resident likes. CNA #3 then assisted the resident to lay on her back and he cleansed the peri (perineal - area between anus and genitalia) area. At 10:11 AM CNA #3 left the room and returned at 10:14 AM with linen and washed and rinsed the resident's legs. At 10:26 AM the resident asked to have cream on her buttock because it hurts. At 10:26 AM CNA #3 applied A&D ointment to the areas on the resident's buttock but not the coccyx. During an interview on 5/21/12 at 4:44 PM, the Licensed Practical Nurse (LPN) Head Nurse stated the resident had skin issues in the past that were red areas. She stated the resident does not have any skin issues now and stated "Please tell me she does not have an open area". When interviewed on 5/21/12 at 5:03 PM, the LPN Head Nurse stated CNA #3 did not tell her that the resident had any open areas. When interviewed on 5/21/12 at 5:07 PM, the resident stated "My rear end hurts and I cannot see back there to know what's causing it". When observed on 5/21/12 at 5:08 PM, the Harbour View Registered Nurse (RN) Manager measured the open area on the coccyx and stated the resident has a Stage 2 open area measuring 0.5 cm L (length) x 0.6 cm W (width) on the coccyx. One area on the left upper buttock measuring 0.1 cm L X 0.4 cm W and one area on left lower buttock measuring 0.9 cm L X 0.5 cm W and one area on the right buttock measuring 1.3 cm L and 1.0 cm W (white slough areas) that are unstageable. When interviewed on 5/21/12 at 5:20 PM, the LPN Head Nurse stated the barrier cream that should have been put on the resident is periguard. When interviewed on 5/21/12 at 5:23 PM, the Harbour View RN Manager stated there is an order for [REDACTED]. During an interview on 5/21/12 at 5:26 PM, the LPN Head Nurse stated "when the CNA found the skin issue he absolutely should have told me about it". Review of the Skin/ Shower Worksheet dated 5/6/12, 5/20/12 and 5/27/12 revealed no documented evidence that a skin assessment was done by the Unit Nurse, Nurse Manager or Supervisor and the 5/13/12 skin assessment is signed by the CNA and Unit Nurse but not by the Nurse Manager / Supervisor that the resident refused. When interviewed on 5/21/12 at 5:35 PM, the evening shift LPN #4 stated when he got report today it was not reported to him that the resident had any open areas or other skin issues. He stated he was not aware of the resident having any open areas and explained he does skin checks on the resident. The LPN stated if the resident refuses the skin check he does not report it to the supervisor or anyone else. During an interview on 5/21/12 at 5:44 PM, the LPN Head Nurse revealed the Weekly Skin/ Shower Worksheet dated 5/6/12, 5/20/12 and 5/27/12 are not signed that a skin assessment was done. She further explained even if the resident refused the bath the nurse could still do the skin check. When interviewed on 05/21/12 at 6:24 PM, the LPN Head Nurse stated CNA #3 who cared for the resident today was contacted and the CNA indicated he told the day shift LPN that the resident had an open area. The LPN Head Nurse further stated the CNA could not have told the day shift LPN because he did not work today. She further explained if the CNA informed the day shift LPN about the resident skin issues it might have been over the weekend but there is nothing documented about it in the resident's medical record. The Director of Nursing (DON) was interviewed on 5/21/12 at 6:45 PM and stated the initial assessment of skin is done by the RN on duty. When a new pressure area is identified a Wound Alert (communication sheet) is started by the nurse. The DON stated she had not received a Wound Alert on this resident. During an interview on 5/22/12 at 9:13 AM, CNA #3 stated he told the day shift LPN about a week ago that the resident "had issues on her bottom" and said he does not know if the day shift LPN looked at it. He further explained he does not do treatments and did not know that there was an order for [REDACTED]. When interviewed on 5/22/12 at 9:53 AM the day shift LPN stated he was not aware of any skin issues on the buttocks until today. He stated "previously" he was putting the periguard in a cup and giving it to the CNA to put on the resident. The LPN said he signs the Treatment Record that the periguard was applied but did not check the resident's buttock. When interviewed on 5/22/12 at 10:02 AM, the Nurse Practitioner (NP) stated that the staff member that finds the pressure ulcer should let the Nurse "Team Leader" (Medication/ Treatment Nurse) know and they would inform the LPN Head Nurse and she would notify her (NP) and then we would look at it together (and order a treatment). The NP stated that the resident would then be seen on Weekly Skin Rounds and she would change the treatment if the pressure ulcer was not healing. She stated she expects to be notified when skin issues are found. The NP stated she was notified yesterday that the resident had a skin issue and she was not surprised because she knows the resident has fragile skin. When interviewed on 5/22/12 at 11:20 AM, the resident stated she has had the sore on her buttock a couple of days maybe as long as 5 days. She stated she had a CNA look at it. The resident stated she has never had sores before and the cream they are using now helps. 2. Resident #156 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is cognitively intact for daily decision making, understands and is understood. The resident is identified with one Stage 2 upon admission and 2 unstagable pressure ulcers. The largest pressure ulcer measures 7.1 centimeters (cm) (L) x 6.1 cm (W). Interview with the Registered Nurse (RN) Unit Manager (UM) on 5/15/12 at approximately 2:30 PM revealed the resident was admitted on [DATE] with a Stage 2 on the left buttock and one unstagable pressure ulcer to the left heel and one unstageable pressure ulcer to the resident's right heel. The RN UM also stated the resident has an unstagable pressure ulcer located on his coccyx (tailbone) that he developed since admission to the facility. Review of the Braden Scale (used to assess the resident's level of risk for pressure sore development, the rating scale ranges from a score of 6 to 23 - a lower score indicating greater risk for pressure sore development) dated 3/30/12 and 5/9/12 revealed the resident scored 15. Review of the Nursing Admission assessment dated [DATE] revealed the resident was admitted with the following pressure ulcers: - Stage 2 located on the right heel that measured 6.0 centimeters (cm) (L) x 7.0 cm (W) - Stage 2 located on the left heel that measured 4.1 cm (L) x 10 cm (W) - Stage 2 located on the left buttock that measured 3.0 cm (L) x 1.2 cm (W) Further review of the Nursing Admission assessment dated [DATE] revealed it was signed by Licensed Practical Nurse (LPN) #1 and countersigned by the RN UM. The RN UM stated she countersigned the LPN's documentation that she also assessed the resident's skin upon admission. Review of the Skin Care Records dated 4/4/12 to 5/16/12 revealed the following: - 4/4/12 the Stage 2 located on the resident's right heel measured 7.0 cm (L) x 6.0 cm (W) x < .01 cm (D). It was measured weekly. On 5/16/12 the area was unstageable and measured 7 cm (L) x 4 cm (W) x "unknown" (D) - 4/4/12 the Stage 2 located on the resident's left heel measured 10 cm (L) x 4.1 cm (W) x <.01 cm (D). It was measured weekly. On 5/16/12 the area was identified as unstageable and measured 8 cm (L) x 6 cm (W) x "unknown" (D) - 4/4/12 the Stage 2 located on the left buttock measured 3 cm (L) x 1.2 cm (W) x <0.1 cm (D). It was measured weekly. On 5/16/12 the Stage 2 pressure ulcer measured 1.2 cm (L) x 1 cm (W) x < 0.1 cm (D) Review of the Nursing Progress Note dated 4/27/12 revealed an unstageable pressure ulcer located on the resident's coccyx was identified by an LPN and documented that it was "a quarter in size". On 5/2/12 the unstageable pressure ulcer measured 4.5 cm (L) x 4 cm (W) x "unknown" (D). On 5/16/12 the unstageable coccyx pressure ulcer measured 6.1 cm (L) x 4.1 cm (W) x "unknown" (D). There was a lack of an RN assessment including measurements of the new unstageable pressure ulcer located on the resident's coccyx. Review of the Nursing Progress Note dated 4/27/12 at 10:00 PM revealed LPN #2 documented the "treatment to sacral area done, open area wound bed pink and clean. Above the opening is a quarter sized blackened area". The Nursing Progress Note documentation was signed by LPN #2. The RN UM also signed the Nursing Progress Note but did not include the date when she signed the note. On 5/18/12 the Director of Nursing (DON) was asked to provide any pressure ulcer assessment documentation including measurements by an RN on 4/27/12 when the unstageable pressure ulcer located on the coccyx (tailbone) was first identified by the LPN. Interview and review of the Nursing Progress Note dated 4/27/12 and review of the resident's medical record with the RN UM on 5/18/12 at 9:30 AM revealed the RN UM stated the resident's unstageable pressure ulcer located on the resident's coccyx was first identified on 4/27/12 by LPN #2 and she countersigned the note that she also assessed the resident's new unstageable coccyx pressure ulcer at that time. Review of the Nursing Progress Note dated 4/27/12 with the RN UM revealed the RN UM stated the LPN incorrectly documented that the treatment was provided to the "sacral area" when the treatment was actually provided to the Stage 2 pressure ulcer located on the resident's left buttock. The RN UM was also asked since she did not date her countersignature, when did she actually countersign the LPN's Nursing Progress Note? The RN UM said she countersigned the LPN's note on Monday, 4/30/12 and obtained a Physician order [REDACTED]. The RN UM said the LPN "always notifies her of residents' issues this way" and stated the LPN was on vacation and was unavailable for interview. The RN UM also stated the resident's pressure ulcer treatment is provided on the 3:00 PM to 11:00 PM shift. Review of the 24-hour shift report dated 4/27/12 revealed no documented evidence of the new, unstageable pressure ulcer located on the resident's coccyx. Review of the Physician order [REDACTED]. - Cleanse right heel with normal saline, apply Santyl (sterile ointment used to remove dead skin tissue) ointment, cover with DermaLevin (waterproof, adhesive foam dressing) dressing and wrap with Kerlix (type of gauze bandage) every day. - Cleanse left heel with normal saline, apply Santyl ointment, cover with DermaLevin dressing and wrap with Kerlix every day. - Cleanse left buttock with normal saline, apply Xeroform (sterile non-adherent gauze dressing) gauze, and cover with DermaLevin dressing every day. Review of the physician's orders [REDACTED]. Review of physician's orders [REDACTED]. Review of the Treatment Administration Records (TARs) dated 4/12 and 5/12 revealed the nurses documented that the treatments were done as ordered. Observation on 5/18/12 at 3:30 PM revealed LPN #3 washed her hands for 15 seconds and put on gloves. The CNA also washed her hands, put on gloves and held the resident's right leg during the treatment on the resident's right heel. The LPN removed the old dressing dated 5/17/12 from the right heel and there was a moderate amount of bloody and green drainage present. The LPN cleansed the open area with normal saline, a 4x4 gauze pad by using circular motions from inside the open area to the outside and surrounding skin area and back inside the open area of the unstageable pressure ulcer on the left heel. This motion was repeated with the same side of the same 4x4. The LPN had the CNA place the resident's right heel onto the bed. The LPN incorrectly cleansed the resident's right heel unstageable pressure ulcer and also placed the resident's open heel ulcer directly onto the bed without a barrier. After several minutes, the LPN picked up the resident's right heel and placed it onto an incontinence pad. The LPN placed Santyl ointment onto a tongue depressor, applied to the right heel, applied a 4x4 gauze pad and an ABD pad. The LPN was observed to place the tongue depressor on an open package of gauze pads on the over-the-bedside table. The LPN was observed to remove the ABD pad, 4x4 gauze pads and stated she needed to apply more Santyl ointment because it had to be "nickel thick". The LPN reapplied more Santyl ointment with the same used tongue blade and placed the DermaLevin dressing over the unstageable pressure ulcer on the right heel. During the same observation, the LPN was observed to remove her gloves and open the canister of "Soft'n Clean" wipes and used the wipes on her hands. The LPN then put on gloves, wrapped the resident's right heel in Kerlix and taped it in place. The LPN was then observed to remove her gloves and wash her hands. The LPN was then observed to put on gloves and remove the old dressing from the resident's left heel. A moderate amount of bloody drainage was observed in the old dressing and was also oozing from the left heel. The LPN was observed to cleanse the open area on the resident's left heel with normal saline on a 4x4 gauze pad by using circular motions from inside the open area to the outside and surrounding skin and back inside the open area of the unstageable pressure ulcer on the left heel. This motion was repeated with the same side of the same 4x4. The LPN removed her gloves and used the "Soft'n Clean" wipes on her hands. The LPN put Santyl ointment onto a tongue blade, then put gloves on, applied the Santyl on the tongue blade to the open area on the left heel, removed her gloves, removed the roll of "Soft'n Clean" wipes, unrolled the wipes into her hands, removed several wipes and returned the rest of the roll to the canister. The LPN put gloves on, applied the DermaLevin dressing, and wrapped the left heel with Kerlix. At 4:05 PM the LPN was observed to remove her gloves and wash her hands. When the LPN stated she was going to do the treatment to the resident's "bottom", the resident turned onto his right side. The LPN was observed to put on gloves and remove the old dressing from the resident's unstageable coccyx pressure ulcer. There was bright red, bloody drainage present, approximately the size of a dime, observed on the old dressing. The LPN stated she forgot the dressing, covered the resident, removed her gloves and left the room without washing her hands. The LPN went to the treatment cart, removed the DermaLevin dressing and returned to the resident's room. Without washing her hands, the LPN put on gloves, poured normal saline onto several 4x4 gauze pads, and was observed to "pat" around the open area of the pressure ulcer on the coccyx then up and down through the open area on the coccyx towards the resident's right buttock, down towards the anal opening and then back up through the open pressure ulcer on the right buttock and continued up through the open area on the resident's coccyx. This motion was repeated four times with the same side of the same 4x4. The LPN was observed to change her gloves and without washing her hands applied one dressing over both open areas (right buttock and coccyx). The LPN did not apply the Santyl ointment to the "left" buttock. The surveyor did not observe any open areas/pressure ulcer on the resident's left buttock but there was an open area on the resident's right buttock. The LPN was observed to remove her gloves and wash her hands. The LPN stated that this concludes the pressure ulcer treatments "to all areas". On 5/18/12 at 4:45 PM, the surveyor reviewed the Treatment Administration Record with the LPN. When the LPN was questioned why she did not apply Santyl ointment to the Stage 2 pressure ulcer, the LPN replied that there was no order to apply the ointment. After reviewing the 3 pages of the TAR with the LPN, the LPN stated she did not look at the 3rd page of treatments and missed the order to apply the Santyl ointment to the Stage 2 pressure ulcer on the resident's buttock. Review of the Comprehensive Care Plan (CCP) with a print date of 5/17/12 revealed the resident is able to make needs known, is always understood and always understands, the resident has pressure ulcer development on bilateral heels and left buttock upon admission. In addition, the resident has an in-house pressure ulcer to the coccyx related to immobility and the resident is non-compliant with turning and positioning in bed. During an interview and discussion with the RN UM on 5/21/12 at 4:00 PM, the RN UM stated she must be "dyslexic" because she mixed up the resident's right and left buttock. The Stage 2 pressure ulcer identified as located on the resident's left buttock was actually on the resident's right buttock and had been all along since his admission. The RN UM stated that the Stage 2 pressure ulcer on the resident's right buttock was miss-identified on the Admission Nursing Evaluation dated 3/30/12, the physician's orders [REDACTED]. Interview with the Administrator and the Director of Nursing (DON) on 5/21/12 at approximately 4:30 PM revealed there was no documentation of an RN assessment of the newly identified unstageable pressure ulcer located on the resident's coccyx. The LPN should have cleaned the pressure ulcers from clean to dirty areas and not the way LPN #3 cleansed the ulcers. In addition, the DON stated the nurse that took off the physician's orders [REDACTED]. Interview with the DON on 5/21/12 at 12:00 PM revealed there was no other documentation of an RN assessment including measurements for the resident's pressure ulcer area on the coccyx. A further interview with the DON on 5/21/12 at 6:30 PM revealed the RN NM or LPN accompanies the Assistant Director of Nursing (ADON) or herself (DON) on the weekly skin rounds on known pressure ulcers. The facility has weekly skin meetings to review Skin Care Records and the DON, ADON and the Nurse Managers attend. The DON further stated the nurse that identifies new areas is to make out a "Wound Alert" sheet which gets sent to her. The DON stated she doesn't think that directions on how to stage the residents' open areas are in the P&P but directions are available in the algorithm in the front of the skin books. The DON also stated no Wound Alert Sheet was initiated for Resident #156 regarding the unstageable pressure ulcer on the resident's coccyx area documented by the LPN on 4/27/12. In summary, there was lack of an RN assessment including measurements of a new unstageable coccyx pressure ulcer at the time of identification. There was a 3 day delay in notification of a new unstageable pressure ulcer on the resident's coccyx area which lead to a three day delay in obtaining treatment for [REDACTED]. 3. Resident #214 has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident was admitted to the facility on [DATE] with a Stage 1 pressure ulcer, is at risk to develop a pressure ulcer, and has one or more unhealed pressure ulcer(s) at Stage 1 or higher. The resident is identified as having one Stage 2 pressure ulcer that was present upon admission. Review of the Transfer Summary from the hospital dated 4/20/12 revealed the resident had a Stage 2 decubitus (pressure ulcer) in the sacrum area at the time of admission on 4/16/12. Review of the information sent with the resident from her recent hospitalization (from 4/16/12 to 4/20/12) revealed the nurse at the hospital documented on 4/19/12 that the resident had a Stage 2 pressure ulcer located on the left sacrum (area above tailbone on right and left buttocks). Review of the Admission Nursing Evaluation dated 4/20/12 revealed the form lacked a signature of the person or title of the one who completed the form along with a date when the form was completed. The un-named evaluator documented the resident had a Stage 2 pressure ulcer on her left buttock. Review of the undated Braden Scale for this resident revealed the resident has a score of 16. Review of the Nursing Progress Note dated 4/20/12 written by an Licensed Practical Nurse (LPN) at 11:05 PM revealed the resident had a Stage 2 pressure ulcer on her left buttock. Further review of the Nursing Progress Notes dated 4/20/12 through 5/22/12 revealed no further documentation of the Stage 2 pressure ulcer located on the resident's left buttock. On 5/15/12 at approximately 11:00 AM the Skin Care Records and the Skin/ Shower Worksheets of the nurses' weekly skin assessment dated from 4/20/12 through 5/15/12 were requested from the LPN Head Nurse. The LPN HN requested the Skin Care records from the ADON and stated the unit cannot find the Skin/Shower Worksheets of the nurses ' weekly skin assessment dated in April. Review of the Skin/ Shower Worksheets for 5/12 revealed the following: - 5/1/12 and 5/15/12 - form signed by CNA - 5/8/12 - form initialed refused by Unit Nurse - 5/22/12 - form unsigned On 5/15/12 at approximately 11:30 AM the Assistant Director of Nursing (ADON) reviewed the Admission Nursing Evaluation dated 4/20/12 with the surveyor. The ADON stated she "looked at the resident when she was admitted and the area was not a Stage 2 pressure ulcer but only scar tissue". The resident refused observation of personal care on 5/18/12. When interviewed on 5/21/12 at 6:15 PM, the LPN who documented that the resident was admitted with a Stage 2 on the left buttock on the Admission Nursing Evaluation dated 4/20/12 revealed the resident did have an open area on her left buttock when she was admitted . The LPN stated she did not sign and date the form and did not indicate the size of the pressure ulcer in her nurse's note. The LPN said she did not remember if she told anyone about the area. During an interview with the DON on 5/21/12 at 6:30 PM, the DON stated there was no "Wound Alert" sheet initiated for this resident and there was no Skin Care Record for this resident with the initiation date of 4/20/12. During an interview with the ADON on 5/23/12 at approximately 11:00 AM, the ADON stated that she did not see the hospital's Stage 2 pressure ulcer information that was sent with the resident. The ADON stated she did assess the resident and the resident did not have any open pressure ulcers, only scar tissue. The ADON stated she did not assess the resident until 4/24/12, four days after the resident was admitted . Review of the facility's policy entitled pressure Ulcer Documentation dated 3/2012 revealed the policy of the facility is to maintain a written data sheet recording status and treatment of [REDACTED]. Care Plan and MDS 3.0 and pressure ulcers are to be recorded on the 24-hour report form. In summary, there was a lack of an RN involvement in the resident's admission evaluation and a lack of an on-going assessment including measurements of a stage 2 pressure ulcer. 415.12(c)(2)

Based on observation, record review and staff interview conducted during a Partial Extended survey (complaint # NY 370) completed on 9/27/11, the facility did not ensure that the residents' environment remained as free of accident hazards as possible; and each resident receives adequate supervision and assistance devices to prevent accidents. For one (Resident #1) of five resident reviewed the facility failed to ensure that Resident #1, who was identified at risk for unsafe wandering was adequately supervised to prevent elopement. Specifically, Resident #1 had a history of [REDACTED]. Following an elopement on 7/3/11, the facility did not implement a plan to prevent visitors from allowing residents to leave the building through the front door entrance. Interventions were not revised following the resident's repeated attempts to leave the building. Fifteen minute checks were not done as planned and facility staff did not respond to the front door alarm when the resident left the building. A computerized alarm, located on the nursing unit was turned off and there was no attempt to investigate the cause of the alarm or locate the resident. In addition, during an interview on 9/21/11 at approximately 3:30 PM, the Administrator stated there were four additional residents in the Traveler's Club that were ambulatory wanderers and wore a ROAM Alert bracelet who were at risk for elopement. This resulted in no actual harm with potential for serious harm that is IMMEDIATE JEOPARDY AND SUBSTANDARD QUALITY OF CARE TO RESIDENT HEALTH AND SAFETY. The finding is: 1. Resident #1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Additional review of the MDS revealed the resident was independent for ambulation and transfers. Review of the most recent Care Planning Report dated 8/3/11 revealed the resident was identified at risk for elopement, had made "past attempts to abscond from facilities" and was on the Travelers Club (process to identify confused residents who are at high risk for elopement, by posting photos at various locations in the facility). Care plan approaches were to have a ROAM Alert (ROAM Alert - bracelet device worn by residents to detect wandering) in place, and to have a picture on the Travelers Club. Review of an undated document entitled "Traveler Club System" revealed the following: - When a confused resident is at high risk for leaving the facility/eloping they are evaluated by Social Work and placement on the Travelers Club is determined. - The resident's picture will be placed on the Travelers Club and posted on the units and by the elevators. - Each unit has a beeper that will beep when a resident of the Travelers Club is near an exit. It is the responsibility of the nurse on the unit to carry the beeper with them at all times during the shift and respond to the alert to ensure resident safety. The Nursing Supervisor also has a beeper of their own to carry with them at all times. -As an added temporary measure the receptionist will track each alarm on a tracking sheet to ensure all residents that trigger the alarm are checked on immediately. -Harbor View Unit has the main computer system and each nurse on this unit is responsible for checking the system when alarming and respond immediately. When you receive notice that the resident is safe and still in the building the alarm then can be accepted/cleared. The sound must be kept at an audible tone to ensure the residents safety. Review of an undated facility Offsite Investigation Report revealed Resident #1 was found outside of the facility in front of the building by a dietary employee on 7/3/11 at approximately 7:35 PM. Staff did not witness the resident leave the facility. The facility Investigation documented that review of the visitor's log revealed it was likely that a visitor unlocked the front Main Entrance door and let the resident out of the facility. During an interview on 9/21/11 at approximately 2:00 PM, the DON stated that after the resident was found outside of the building on 7/3/11, staff were required to attend a mandatory inservice on the "Travelers Club System". The DON stated that a new addition to the Travelers Club System, after the incident on 7/3/11, was that the receptionist was responsible for tracking each time the front door alarmed on a tracking sheet to ensure that all residents who triggered the alarm are checked immediately. The DON stated that after the elopement incident involving Resident #1 on 7/3/11, 15 minute checks were initiated as a nursing judgment. The DON explained that the 15 minute checks were not ordered by the Physician and were not documented on the care plan. The DON stated that "the nurses use their judgment; if a resident's behaviors escalate, they do 15 minute checks". The DON stated that the facility's corrective actions following the 7/3/11 elopement focused on educating staff but no action was taken at that time to ensure visitors did not let residents out of the building. Review of facility "Progress Notes" (Interdisciplinary Notes) written by Nursing and Social Work (SW) staff dated 7/27/11 to 9/14/11 revealed the following: - 7/27/11 (untimed) - LPN #3 documented that Resident #1 walked out the patio door. Staff witnessed the event and returned the resident to the building. - 8/6/11 - 2:30 PM - LPN #4 documented the resident attempted to leave the facility out of the side door. The LPN documented that staff stopped the resident from eloping and brought her back into the building. - 8/8/11 (7:00 PM to 3:00 PM shift) - LPN #4 documented that every 15 minute checks were done. - 8/9/11 - The Social Worker (SW) documented that the resident continued on 15 minute checks per nursing. - 8/16/11 at 5:00 PM - LPN #4 documented that the resident attempted to leave from the side door of the building, staff responded within seconds and re-directed the resident into the building. - 8/23/11 - The SW documented that the resident was very agitated, expressed several times that she wanted to leave and that she had her jacket. The SW documented that she notified the Nursing Supervisor that the resident was to be placed on 15 minutes checks due to the resident's statements. - 9/14/11 (untimed) - LPN #5 documented that the resident made several attempts to leave the facility. The LPN documented that the resident was re-directed with little to no effect. Review of Progress Notes between 8/23/11 and 8/31/11 revealed the resident's location was checked every 15 minutes for her whereabouts. Review of a facility document entitled 15 Minute Checks, between 9/13/11 and 9/16/11 revealed the resident's location was checked every 15 minutes, the last time being 8:30 PM on 9/16/11. Review of "24 Hour Nursing Reports" dated 9/1/11 through 9/16/11 revealed that Resident #1 was to be on 15 minute checks and was to be monitored for attempts to elope. Additional review of the Care Planning Report dated 8/3/11 revealed no documented evidence of an approach for every 15 minute checks. Review of the "Care Guide", used by the CNAs to provide care, dated 8/3/11 revealed there was no plan to check the resident every 15 minutes. In addition, there is no documented evidence that the Physician was notified of the resident's persistent effort to leave the facility. Review of a resident Accident and Incident (A&I) report dated 9/17/11 revealed the resident was reported missing from the facility on 9/16/11 at 10:45 PM. The report documented that the facility protocol was initiated to attempt to find the resident. The Administrator stated during interview on 9/20/11 at approximately 9:00 AM that Resident #1 was at risk for elopement and wore a ROAM Alert bracelet. The Administrator stated that the facility's surveillance camera revealed that on 9/16/11 at approximately 8:07 PM Resident #1 was let out of the front door of the building by a visitor. The Administrator stated that a receptionist works in the front door reception area from 8:00 AM to 8:00 PM daily. Observation of the surveillance video on 9/20/11 at approximately 10:00 AM revealed on 9/16/11 shortly after 8:00 PM, a visitor exited the front door of the building by placing his entire palm over the keypad. During the interview on 9/20/11 at 9:00 AM, the Administrator stated that visitors were aware that they could unlock the front door by placing their palm over the keypad. The video showed that the resident was watching the visitor leave, while she was standing in the foyer near the front entrance of the building. The resident walked up to the keypad, placed her palm on the keypad and attempted to open the front door. The visitor was still standing in the vestibule outside the front door at the time, and opened the door for the resident who then left the facility. The resident was wearing street clothes at the time of the elopement. During the interview on 9/20/11 at 9:00 AM, the Administrator stated that the ROAM Alert alarm sounded at the facility's front door and at a computer terminal located on the 1st floor Harbour View Unit, when the resident exited but the alarm was turned off. The Administrator stated that she conducted staff interviews and she was unable to determine who turned the alarm off. The Administrator stated that the police found the resident wandering the streets and brought her to a family member's house based on an address that the resident provided to police. The Administrator stated that the resident's family brought the resident to the emergency room (ER) to be evaluated. The Administrator stated that the facility did not know where the resident was until the facility received a telephone call from the ER Physician shortly after midnight on 9/17/11 requesting the resident's medication information. Review of the facility polity entitled Resident Elopement Policy with a revision date of 9/10 and undated facility document entitled Travelers Club System revealed the facility does not have a process that includes notifying the police when a resident has eloped from the facility. During an interview on 9/20/11 at approximately 12:00 PM, the Administrator explained that when a resident wearing a ROAM Alert bracelet sets off the front door alarm, a computer stationed on the Harbor View Unit (the unit the resident lived on) alarms. The Administrator further explained that the computer screen displays the name of the resident that is setting off the alarm, and displays a building diagram of the location of the resident where the alarm is being set off. The Administrator stated that the computer continues to alarm until a staff member "accepts" (turns off) the alarm on the computer. The Administrator also explained that when a resident sets off a ROAM Alert alarm, the beepers carried by the Registered Nurse (RN) Supervisor and Licensed Practical Nurses (LPNs) on each unit alarm and display the name of the resident that is setting off the alarm. Review of a "ROAM Alert Wander Protection System: Activity Log" (the log that tracks the alarms activated on the computer maintained on the Harbor View Unit) revealed that on 9/16/11 at 8:07 PM, Resident #1 set off the alarm at the main entrance. The log documented that on 9/16/11 at 8:09 AM there was a "duplicate alarm" (indicating that the alarm continued to sound) set off by Resident #1 at the main entrance. The log indicated that the alarm for Resident #1 was "accepted" (turned off) by staff on 9/16/11 at 8:58 PM. The Administrator stated during an interview on 9/21/11 at 3:00 PM that the computer has no mechanism to identify which staff member "accepted" (turned off) the alarm. The Administrator further stated that after investigation of the incident, no staff member accepted responsibility for "accepting" (turning off) the alarm on the Harbor View Unit computer. During a telephone interview on 9/21/11 at approximately 1:00 PM, a Registered Nurse (RN) Supervisor stated he worked as the facility Supervisor for the evening shift on 9/16/11. The RN Supervisor stated that he spent most of his time on two of the facility units other than the Harbor View Unit during the evening shift due to new admissions on those units. The RN Supervisor stated that he was told by a certified nurse aide (CNA #2) at "approximately 10:00 PM" that Resident #1 was missing. He stated facility staff immediately initiated a search for the resident inside and outside of the building. The RN Supervisor stated that his beeper did not alarm during his shift indicating that a resident had set off an alarm. The RN Supervisor stated that when he checked his beeper after the resident was reported missing, the beeper displayed the resident's name and the beeper indicated it had a low battery. The RN Supervisor stated that the low battery could be why the beeper did not alarm when Resident #1 set off the ROAM Alert alarm. He stated that at the beginning of his shift his beeper did not indicate that the battery was low. During an interview on 9/21/11 at approximately 1:00 PM, the Director of Nursing (DON) stated there was no system in place in the facility to change the beeper batteries on a regular basis. The DON stated that the beeper "chirps" when the battery is low and it is up to the individual nurse to change the battery when it is low. The DON further stated that all beeper batteries were changed after the elopement of Resident #1 on 9/16/11. During a telephone interview on 9/21/11 at approximately 3:00 PM, LPN #1 stated that she worked on the Harbor View Unit on 9/16/11 during the evening shift. LPN #1 stated that she was carrying her beeper during the shift and it did not alarm and Resident #1's name did not appear on the beeper. LPN #1 stated that the last time she thought she saw Resident #1 was at 9:30 PM at the Harbor View Unit Nurses' Station. She stated that the resident was on every 15 minute checks for which log sheets are maintained. LPN #1 stated that she did not "accept" (turn off) any alarm on the computer regarding Resident #1. The LPN further stated that "it's possible that the computer could alarm for 45 minutes without staff noticing it when they are busy caring for residents". Review of a "15 minute checks" log sheet dated 9/16/11 revealed documentation that Resident #1 was checked every 15 minutes during the 3:00 PM to 11:00 PM shift from 3:00 PM to 8:30 PM on 9/16/11. The log documented that Resident #1 was at the nurse's station from 7:15 PM through 8:30 PM on 9/16/11. LPN #2 stated during a telephone interview on 9/21/11 at approximately 12:00 PM that he is an Agency Nurse and worked the evening shift on the Harbor View Unit on 9/16/11. He stated that this was the first time he worked at the facility. LPN #2 stated that there was a beeper on his medication cart during the shift but he didn't know what it was for, nor did he hear it alarm during the shift. LPN #2 stated he learned that a resident had possibly eloped at approximately 10:40 PM. LPN #2 stated that after the resident was reported missing, he was assigned to drive around the area of the nursing home with a color photo of the resident and look for the resident. LPN # 2 stated that he never touched the computer as he did not know how it worked. LPN #2 stated that LPN #1 mentioned to him that the Resident #1 was on 15 minute checks however he did not do any checks because he was assigned to the other hall on the unit. During a telephone interview on 9/21/11 at approximately 11:00 AM, CNA #1 stated that she worked the evening shift on the Harbor View Unit on 9/16/11 and that she was assigned to Resident #1. CNA #1 stated that the last time she saw Resident #1 on 9/16/11, the resident was seated near the Nurses' Station between 7:00 PM and 8:00 PM. CNA #1 stated that she was not aware that Resident #1 was on every 15 minute checks. She further stated that she learned Resident #1 was missing from the facility at approximately 10:45 PM. CNA #1 stated that she searched for Resident #1 on the units then searched outside in a car with another CNA. CNA #1 stated that she never touched the computer at the Nurses' Station. During a telephone interview on 9/21/11 at approximately 11:00 AM, CNA #2 stated that she worked the evening shift on the Harbor View Unit on 9/16/11. CNA #2 stated that she was not assigned to Resident #1 but last saw her in the dining room between 7:00 PM and 7:30 PM. CNA #2 explained that she went to look for her assigned resident in Resident #1's room between 10:30 PM and 10:45 PM and noticed that Resident #1 was not in her room. CNA #2 stated that she immediately informed LPN #1 and staff initiated a search for the resident. CNA#2 stated she never touched the computer at the Nurses' Station. In summary, the facility did not take action to ensure that visitors were educated not to let residents out of the facility following Resident #1's elopement attempt on 7/3/11. Resident #1 made attempts to elope on 7/27/11, 8/6/11, 8/16/11 and 9/14/11. In addition, the resident expressed to the Social Worker on 8/23/11 that she wanted to leave. Review of the Care Planning Report dated 8/3/11 revealed there were two interventions documented: to have the "ROAM" alert in place and a picture on the Travelers Club. The care plan was not revised/updated to include new interventions after the resident's repeated elopement attempts. On 9/16/11, per review of the "24 Hour Nursing Reports", the resident was to be on 15 minute checks. The resident was not properly supervised as a review of the log sheets revealed there were no 15 minutes checks documented after 8:30 PM on 9/16/11. (The resident in fact left the facility at 8:07 PM). In addition, the systems the facility had in place to prevent elopement failed to prevent Resident #1 from exiting the facility. Harbor View Unit staff did not respond to the computer alarm when it alarmed on 9/16/11 at 8:07 PM. An unknown individual "accepted" (turned off) the computer alarm on 9/16/11 at 8:58 PM and did not attempt to locate the resident or inform supervisory staff that the resident set off the alarm at the front entrance. According to interviews with nursing staff, the beepers carried by the RN Supervisor and the LPNs on the unit did not alarm as they were supposed to when the resident set off the alarm on 9/16/11 at 8:07 PM. The resident was gone from the facility for approximately 2 hours and 45 minutes before staff realized she was missing. Interview with the Administrator on 9/20/11 at approximately 3:00 PM and observation on 9/20/11 between the hours of 1:00 PM and 4:00 PM revealed the facility completed an investigation and corrected the elopement prevention systems to remove the Immediate Jeopardy as follows: - A staff member was posted at the front entrance until a new key pad was put in 9/16/11 through 9/17/11 - 9/16/11 - Batteries were replaced in all beepers to ensure they were functioning - 9/16/11 - Staff were immediately re-educated regarding the facility's ROAM Alert System - Visual checks were immediately done on all residents to ensure they were in the building, care plans were accurate and bracelets were on as appropriate (9/16/11 and 9/17/11) - 9/16/11 - It was confirmed that the Harbour View Unit computer was functioning appropriately - 9/16/11 - All current wanderers remained on every 15 minute checks In addition, the following measures were implemented: - The Alarm System contractor was in the facility to assess the installation of a new upgraded system - A mailing was sent to all families regarding the importance of being aware of their surroundings and other residents. The mailing was completed to all family members 9/27/11. The letter will also be part of the admission packet for all new admissions - The installation of a new alarm will begin 9/29/11 with anticipated completion by 10/7/11 - Additional key pads will be installed once delivered, tentative delivery date for key pads is 9/29/11 - A stronger automatic closure was installed to strengthen the closing mechanism of the front door -The dietary and employee entrance door lock assemblies will be tied into the ROAM Alert System, to alert staff facility wide of any unauthorized exit from that door. Key pads will be fully integrated with the doors and the ROAM Alert system. - View only screens will be placed at each nurse's station and at the front entrance door. Staff will be able to view the location of the door that was triggered and respond to the location viewed from the view-only screen. The alarm can only be acknowledged from the location the door was opened. An announcement will be made over head from the paging system. - The ROAM Alert server will be in a locked area with limited access. - All the exits out of the building will be tied into the ROAM Alert system. 415.12(h)(1)(2)