Every finding on record at Father Baker Manor

Based on interview and record review conducted during a survey, the facility failed to ensure that residents were free of significant medication errors for one (1) (Resident #1) of three (3) residents reviewed for medication errors. Specifically, on 02/23/2026 Licensed Practical Nurse #1 pre-poured 20 residents' medications and administered medications to Resident #1 that were intended for Resident #2. Resident #1 later became difficult to arouse, developed hypotension (low blood pressure), bradycardia (heart beat fewer than 60 times per minute), and a lower respiratory rate which required the administration of Narcan (naloxone, medication used to reverse opioid overdoses). This resulted in, or had the likelihood of serious injury, serious harm, or death for Resident #1 that was Immediate Jeopardy and Substandard Quality of Care.The findings are: The policy titled Medication Administration dated 02/26/2026 documented the purpose was to ensure that all medications were administered accurately, appropriately, safely, and in a timely manner. All medication orders must include date, time, medication name, dose, frequency, and indication for the medication. The administration of medications procedure included to identify resident, compare medication label to the medication administration record, prepare/administer ordered medications to resident, and document administration of medications in the medication administration record. The policy titled Notification of a Significant Change in Condition dated 06/26/2015 documented the resident's medical provider will be notified promptly when the patient/resident experiences a significant change in condition. The licensed nurse should notify the medical provider of a change in the resident's condition that warrants notification. Resident #1 had diagnoses including Parkinson's disease (progressive movement disorder of the nervous system), dementia (progressive memory disorder), and anxiety. The Minimum Data Set (a resident assessment tool) dated 02/06/2026 documented that Resident #1 was cognitively intact and received medications including but not limited to antipsychotic (medication used to treat psychosis), antianxiety, antidepressant, and anticoagulant (medication used to prevent blood clots). The Comprehensive Care Plan revised 02/11/2026 documented Resident #1 had impaired cognitive function/impaired thought process related to dementia. Interventions documented for staff to administer medications per the provider's order, monitor for adverse reactions, effectiveness, and report as needed. The iQIES (internet Quality Improvement and Evaluation System) Complaint/Incident Investigation Report 2790253, received 02/26/2026 documented on 02/23/2026 Resident #1 was administered Resident #2 medications. Resident #1 was administered medications including but not limited to Ativan (medication used to treat anxiety) 0.5 milligrams, pregabalin (Lyrica, medication used to treat seizures and nerve pain) 300 milligrams,methadone (long-acting opioid medication used to treat pain) 7.5 milligrams, and oxycodone (opioid medication used to treat moderate to severe pain) 10 milligrams. The Progress Note completed by Licensed Practical Nurse #1 dated 02/23/2026 at 9:09 PM documented Resident #1 was given another resident's medication. The nursing supervisor, medical doctor and family were notified. Resident #1's vital signs remained stable. The Weights and Vitals Summary dated 02/24/2026 at 12:05 AM documented Resident #1's blood pressure was 90/52 (normal range 90-120/60-80) and they had a heart rate of 52 (normal 60-100 beats per minute). There was no documented evidence of corresponding nurse's notes, other vital signs documented or noted changes in the resident's mental status. There was no documented evidence that Medical Doctor #1 was notified. The Progress Note completed by Registered Nurse Supervisor #1 dated 02/27/2026 at 3:14 PM (late entry), documented on 02/23/2026, they were notified at 7:00 PM that a medication variance (discrepancy between a prescribed medication order and what is actually administered) had occurred with Resident #1. The resident remained at baseline with stable vital signs, and Medical Doctor #1 was updated at 7:20 PM with new orders to monitor the resident and vital signs every four (4) hours for 24 hours. The Progress Note completed by Licensed Practical Nurse #2 dated 02/24/2026 at 4:35 AM, documented Resident #1 was difficult to arouse, sternal rub (painful stimulus to test level of consciousness) with minimal effect, blood pressure 85/50, and extended period of time between respirations. A follow-up note dated 02/24/26 at 5:39 AM by Licensed Practical Nurse #2 documented a level 3 (non-urgent notification no return call necessary) voicemail was left for Medical Doctor #1. The Progress Note completed by Registered Nurse Supervisor #2 dated 02/24/2026 at 5:41 AM, documented resident lethargic, responsive to verbal and tactile stimuli, blood pressure 85/50, pulse (heart rate) 50, respirations 10 (normal 12-20 breaths per minute) with resident pausing for periods of time between each breath then taking heavy breaths. The Acute Visit Provider Note completed by the Medical Doctor #1 dated 02/24/2026 documented they met with Resident #1 at approximately 10:00 AM on 02/24/2024 for an acute visit secondary to a medication error. The note documented Resident #1's vital signs; respiration rate 10, heart rate 64, blood pressure 156/55. The note further documented Resident #1 was sleeping and not following commands. Medical Doctor #1 documented they ordered Narcan to be administered. Additionally, the note documented Medical Doctor #1 evaluated Resident #1 again at 2:00 PM on 02/24/2026 and the resident was awake but tired, conversant, and recalled being told the previous night of receiving the wrong medication. During a telephone interview on 03/05/2026 at 9:51 AM, Licensed Practical Nurse #1 stated at the beginning of their shift (2:00 PM), they had pre-poured all medications to be administered during their shift on 02/23/2026, except for narcotic medications. They placed the medications in plastic medication cups and wrote the residents names on the sides of the cups. They stated they misidentified the pregabalin (medication that treats nerve pain) as it looked exactly like a medication that Resident #1 was to receive, administered all the medications in the cup to Resident #1, immediately realized their error, and notified Registered Nurse Supervisor #1. Licensed Practical Nurse #1 stated they should not have pre-poured medications because they could be administered to the wrong resident and could cause adverse reactions. During a telephone interview on 03/05/2026 at 10:31 AM, Registered Nurse Supervisor #1 stated Licensed Practical Nurse #1 had reported the medication error on 02/23/2026 at approximately 7:00 PM. The supervisor stated they notified Medical Doctor #1 and Resident #1 remained stable throughout the shift which ended at 10:00 PM. During a telephone interview on 03/05/2026 at 10:46 AM, the Pharmacy Consultant stated they expected nurses to follow the six (6) rights of medication administration (right patient, right medication, right dosage, right route, right time, and right documentation) and not pre-pour medications secondary to the risk of administering medications incorrectly. They further stated the medications Resident #1 received in error could cause dizziness, lethargy, and decreased respirations. During an interview on 03/05/2026 at 10:57 AM, the Director of Nursing stated the facility's investigation revealed Licensed Practical Nurse #1 had pre-poured the medications to be administered during their shift and they had erroneously administered Resident #2's medications to Resident #1. The Director of Nursing stated they expected nursing staff to follow the facility policy for medication administration and to follow the six (6) rights of medication administration. During an interview on 03/05/2026 at 11:18 AM, Medical Doctor #1 stated the medications Resident #1 received in error were heavy duty medications that could cause lethargy, decreased blood pressure, decreased respirations, and altered mental status. Additionally, they stated the nurses should not pre-pour medications. During a telephone interview on 03/05/2026 at 11:27 AM, the Medical Director stated nursing staff should follow the rights of medication administration to ensure residents receive the correct medications. During an interview on 03/05/2026 at 12:56 PM, the Administrator stated they expected staff to follow the facility policy and medication administration rights to prevent medication errors. Medications should be prepared and administered to one (1) resident at a time. During a follow-up telephone interview on 03/02/2026 at 2:05 PM, Medical Doctor #1 stated they did not give vital sign parameters to the nursing staff when they ordered to monitor Resident #1's vital signs on 02/23/2026, but thought facility would notify them of any abnormal vital signs. They further stated they would have ordered the Narcan sooner for Resident #1, had they been made aware of the change in Resident #1's vital signs, increased lethargy and abnormal respiratory rhythm. During a telephone interview on 03/06/2026 at 8:08 AM, Licensed Practical Nurse #2 stated on the night shift of 02/24/2026, Resident #1 was difficult to arouse, they performed a sternal rub, and Resident #1 responded minimally. Additionally, they stated they notified Medical Doctor #1 via voicemail level three (3), non-urgent notification and in retrospect, they should have notified via a level one (1) (urgent - return call within 15 minutes) or level two (2) (routine - return call within two hours). The facility Administrator was informed of the Immediate Jeopardy at F 760 on 03/05/2026 at 4:13 PM and the facility submitted an approved plan to remove the immediacy on 03/05/2026. The Survey team determined through observation, interview, and record review the immediacy was removed on 03/06/2026 at 12:00 PM prior to exit based on the following corrective actions taken by the facility: - Resident #1 was monitored and there was no ill effect after the administration of Narcan.- The facility reviewed the following policies: Opioid Overdose and the Use of Naloxone Sub-acute and Long-Term Care Facilities; Medication Administration; Medication Variance Reporting; and Notification of a Significant Change in Condition.- The facility revised the Medication Administration policy to include the six (6) rights of medication administration and added one patient/resident at a time. - Nursing staff responsible for medication administration were educated on Medication Administration, Medication Variance Reporting, Notification of a Significant Change in Condition, and the medical provider paging system which included levels of urgency to return the call (Level 1 = emergency, Level 2 = routine, Level 3 = notification). Any nursing staff on vacation, on leave of absence, or agency staff will be educated prior to medication administration.-Medication administration and medication cart audits were completed and will continue. 10 New York Code Rules Regulations 415.12(m)(2)

Based on observation, interview, and record review conducted during an Abbreviated survey (Complaint #NY00383408) the facility did not ensure that all alleged violations involving abuse are reported immediately but not later than 2-hours after the allegation is made if the events that cause the allegation involve abuse, to the Administrator of the facility and to other officials (including to the State Survey Agency) for one (1) (Residents #1) of three (3) residents reviewed for abuse. Specifically, an allegation that a Certified Nurse Aide slapped a resident was not reported to the Administrator in the required timeframe and resulted in delayed reporting to the New York State Department of Health. The finding is: The policy titled Identification, Prevention, Investigation and Reporting of Victims of Potential Abuse, Neglect, or Exploitation dated 9/26/24 documented it was the facilities policy to report any suspected or actual victim of abuse when identified. All alleged violations involving abuse or mistreatment are reported immediately, but not later than 2 hours after the allegation is made if the events that caused the allegation involved abuse, to the administrator of the facility and to other officials including the New York State Department of Health through established procedures. Resident #1 had diagnoses including dementia, anxiety, and type 2 diabetes. The Minimum Data Set (a resident assessment tool) dated 3/19/25 documented Resident #1 had severe cognitive impairment, had rejection of care behaviors, and required substantial/maximal assistance with bathing/showering. The comprehensive care plan dated 10/15/24 documented the resident had dementia with sundowning (a state of increased confusion and restlessness, usually in late afternoon or evening, experienced by people with dementia) interventions included to cue, reorient, and supervise as needed; the resident was a maximal assist for showers. Review of the New York State Department of Health Complaint Tracking System Complaint/Incident Investigation Report revealed the date/time of the alleged incident was 6/7/25 at 7:00 AM. The date/time the Administrator was first made aware of the incident was 6/11/25 at 9:45 AM. It was submitted by the facility on 6/11/25 at 11:47 AM. Review of the Resident/Patient Occurrence Report dated 6/11/25 revealed a potential altercation between a staff member and resident occurred on 6/7/25 between 6:45 AM-7:00 AM in the shower room. The staff member alleged they witnessed another staff member slap the resident across the face. During an observation on 6/17/25 at 9:23 AM, Resident #1 was seated in their chair. They were alert and oriented to self only. There were no bruises or injuries were noted to their face, neck, or hands. During an interview on 6/17/25 at 11:52 AM, the Registered Nurse #1 stated on 6/7/25 around 7:00 AM, Certified Nurse Aide #2 reported to them that they witnessed Certified Nurse Aide #1 slap Resident #1 across the face in the shower room. Registered Nurse #1 stated they thought there was a supervisor working that day, but they did not report this allegation to the supervisor and stated they knew they should have. They stated they got busy and had no other excuse as to why they didn't inform the supervisor. They stated an alleged slap was considered physical abuse. During an interview on 6/17/25 at 2:05 PM, Registered Nurse Supervisor #1 stated they worked on 6/7/25 from 7:00 AM to 10:00 PM. They stated nobody had reported any allegations of abuse to them. They also worked the next day, and no allegations of abuse were reported to them. They stated the floor nurse should have called them and reported the allegation, then they would have called the Director of Nursing or Administrator to inform them because they were required to report it. During an interview on 6/17/25 at 2:27 PM, the Director of Nursing stated Certified Nurse Aide #2 told the nurse on the floor (Registered Nurse #1) that they witnessed another Certified Nurse Aide #1 slap Resident #1. Registered Nurse #1 should have called the supervisor to report this, and the supervisor would have then called them or the Administrator at home. This was their policy for any allegation of abuse. The Director of Nursing stated they never got a call that weekend. The Director of Nursing stated the process broke down when Registered Nurse #1 did not report it to the Registered Nurse Supervisor #1. This incident should have been reported to Administration on Saturday (6/7/25) morning and was not reported to them until Wednesday (6/11/25), when Certified Nurse Aide #2 reported the incident to the Registered Nurse Unit Manager, who then reported it to the Administrator. During an interview on 6/17/25 at 3:03 PM, the Administrator stated a slap across the face would be considered abuse. They expected staff to report any allegation of abuse to them. They stated in this situation there was a 4-day delay in staff reporting the allegation to themselves, the Director of Nursing, or a supervisor. The Administrator stated if they knew about this allegation sooner, they would have reported it as required. 10NYCRR 415.4(b)(2)

Based on observation, record review, and interview conducted during an Abbreviated survey (Complaint #NY00383408), the facility did not have evidence that all alleged violations were thoroughly investigated and did not prevent further potential abuse or mistreatment while the investigation was in progress in response to all allegations of abuse for one (1) (Resident #1) of three (3) residents reviewed. Specifically, there was a delay in initiating an investigation when a staff member reported they witnessed physical abuse of Resident #1, and the accused staff continued working after the allegation was made. Additionally, the facility investigation did not include interviews or assessments of other residents who the accused cared for and statements from all staff involved. The finding is: The policy titled Identification, Prevention, Investigation and Reporting of Victims of Potential Abuse, Neglect, or Exploitation dated 9/26/24 documented all cases of suspected or actual abuse will be reported to the immediate supervisor/manager and an investigation will begin immediately. They would coordinate and facilitate interventions to prevent further abuse. The Occurrence Investigation Summary would be initiated and utilized as a resource; all documentation would be maintained in a confidential manner. The Director of Nursing or designee will coordinate the investigation and is responsible for maintaining and ensuring completion of all investigative documentation, including occurrence reports, assessments, statements, and other supporting documentation. Providers must be able to provide evidence that once an allegation of abuse was made, the investigation was commenced immediately regardless of the time of day or day of week the incident occurred. Resident #1 had diagnoses including dementia, anxiety, and type 2 diabetes. The Minimum Data Set (a resident assessment tool) dated 3/19/25 documented Resident #1 had severe cognitive impairment, had rejection of care behaviors, and required substantial/maximal assistance with bathing/showering. The comprehensive care plan dated 10/15/24 documented the resident had dementia with sundowning (a state of increased confusion and restlessness, usually in late afternoon or evening, experienced by people with dementia) interventions included to cue, reorient, and supervise as needed; the resident was a maximal assist for showers. Review of the Resident/Patient Occurrence Report dated 6/11/25, revealed a potential altercation between a staff member and resident occurred on 6/7/25 between 6:45 AM-7:00 AM in the shower room. The staff member alleged they witnessed another staff member slap Resident #1 across the face. The investigation file included written statements from staff dated 6/11/25 or later. There was no evidence the investigation was started immediately once the accusation was made. There was no statement provided by the accused Certified Nurse Aide #1 or that they were contacted for a statement. There was no evidence that other residents the accused cared for were assessed or interviewed to determine the potential for other victims. Review of Progress Notes dated 6/7/25-6/10/25 revealed there was no documentation that Resident #1 was assessed for any injuries. A Nurse Practitioner Progress Note dated 6/11/25, documented the resident was assessed for injuries due to a potential altercation with staff, and no injuries were noted. During an observation on 6/17/25 at 9:23 AM, Resident #1 was seated in their chair. They were alert and oriented to self only. There were no bruises or injuries noted to their face, neck, or hands. During a telephone interview on 6/17/25 at 10:13 AM, Certified Nurse Aide #1 stated a coworker had told them about the slap allegation and that they would never hit Resident #1. They worked with Resident #1 daily, and they were used to the resident and knew how to work with them and their behaviors. They stated Certified Nurse Aide #3 was in the shower room at the same time showering another resident. They remembered Certified Nurse Aide #2 walked into the shower room and left quickly. Nobody had asked them what happened or to provide a statement, they found out about the allegation after they were fired. They stated they finished their shift that day and worked the next day (Sunday) too. During an interview on 6/17/25 at 10:24 AM, Certified Nurse Aide #2 stated they were getting residents up for breakfast and was looking for another staff member to help them, so they went into the shower room because to ask if Certified Nurse Aide #3 knew where other staff were. When they walked into the shower room, they heard Resident #1 yelling which was their usual behavior. Both shower bay doors were open and Certified Nurse Aides #1 and #3 were giving showers. They stated as they walked to Certified Nurse Aide #3's shower bay and while walking by the other shower bay, they saw the smack. Certified Nurse Aide #2 stated they saw Certified Nurse Aide #1 hit Resident #1 on their face and neck with their open left hand. The resident moved back in the chair a little bit and said, ow was that necessary. They went over to Certified Nurse Aide #3 and asked where the other aide was to help them and left the shower room. They stated they did not intervene and did not tell Certified Nurse Aide #3 what they witnessed. When they left the shower room, they reported what they saw immediately to Registered Nurse #1. They stated nobody asked them to write a statement or anything. They stated when they returned to work after they worked the weekend, on either Tuesday or Wednesday, they told the Registered Nurse #2 Unit Manager about it. Certified Nurse Aide #2 stated they considered a slap physical abuse. During an interview on 6/17/25 at 11:30 AM, Certified Nurse Aide #3 stated they were in the shower room and Certified Nurse Aide #1 was in the other shower bay, giving Resident #1 a shower. They had the doors open for safety because Resident #1 could get worked up sometimes and they could help each other out if needed. They stated Certified Nurse Aide #2 came into the shower room briefly, asked them if they knew where another aide was and then left. Certified Nurse Aide #3 stated they heard Resident #1 say is that necessary and Certified Nurse Aide #1 stated what I'm washing your bottom. Certified Nurse Aide #3 stated they popped their head into Resident #1's shower bay and saw Certified Nurse Aide #1 kneeling down washing the resident's buttocks. A couple minutes after that, Registered Nurse #1 entered the shower room and asked them if they heard or saw anything out of the ordinary in the shower room. Certified Nurse Aide #3 told them no, then Registered Nurse #1 asked if Certified Nurse Aide #1 hit Resident #1. Certified Nurse Aide #3 stated absolutely not. Certified Nurse Aide #3 stated they could hear everything in that shower room, due to the acoustics, and they didn't hear any slapping noise, or a scuffle of any sort. The resident would have yelled out or fought back if they were hit. They stated during the shower, they heard Certified Nurse Aide #1 saying typical shower conversation like almost done, sit back, relax. Certified Nurse Aide #3 stated Certified Nurse Aide #2 didn't report anything to them when they were in the shower room, and nobody asked them to write a statement that day. They stated if they thought the resident was in an unsafe situation they were supposed to step in and make them safe and if you see something, say something. During an interview on 6/17/25 at 11:52 AM, the Registered Nurse #1 stated on 6/7/25 around 7:00 AM, Certified Nurse Aide #2 reported to them that they witnessed Certified Nurse Aide #1 slap Resident #1 across the face in the shower room. Registered Nurse #1 stated they went into the shower room and observed Resident #1 and Certified Nurse Aide #1 and didn't see anything out of the ordinary. The aide was still washing the resident in the shower and the resident had no red marks on their face and was calm. The Registered Nurse #1 stated they went over to Certified Nurse Aide #3, who was in the next shower bay showering another resident, and quietly asked if they heard or saw anything happen between Resident #1 and Certified Nurse Aide #1. The Certified Nurse Aide #3 responded they heard the resident say something like was that necessary and that they went over to check on Resident #1 and Certified Nurse Aide #1. Registered Nurse #1 stated they told Certified Nurse Aide #3 what was reported to them and the aide stated no, nothing like that happened. The Registered Nurse #1 stated if they thought the slap happened, they would have told Certified Nurse Aide #1 to leave and they would have taken over the resident's care. The Registered Nurse #1 stated they did not document their assessment of the resident and did not start and accident/incident report. They stated they should have documented their assessment and got staff statements because that was usually part of an incident for any falls, bruises, or skin tears. They had never been in this situation before and did what they were supposed to do, but did not write it down anywhere. The Registered Nurse #1 stated they did not ask Certified Nurse Aide #1 their side of the story and they should have asked, but they had it in their head they were going to notify the supervisor to handle it, but they never did that because they got busy. They stated an alleged slap was considered physical abuse. During an interview on 6/17/25 at 2:05 PM, Registered Nurse Supervisor #1 stated they worked on 6/7/25 from 7:00 AM to 10:00 PM. They stated nobody reported any allegations of abuse to them. They stated a slap would be considered abuse, they would have had to get statements from everyone, and an accident/incident report should have been done, especially if it was reported it was witnessed. They stated they would have asked the Director of Nursing if anything should have been done with the accused Certified Nurse Aide (like sending them home). During an interview on 6/17/25 at 2:55 PM, the Registered Nurse #2 Unit Manager stated on Wednesday (6/11/25) when Certified Nurse Aide #2 arrived to work they reported they witnessed Certified Nurse Aide #1 slap Resident #1 across the face when they went into the shower room to ask another aide something. The Certified Nurse Aide #2 stated they did not hear any slap sound but heard the resident say, was that necessary and Certified Nurse Aide #2 did not think the nurse did anything about it when they reported it to them on Saturday (6/7/25). They had Certified Nurse Aide #2 write a statement immediately and then they took the statement to the Administrator and reported it. The Registered Nurse #2 Unit Manager stated they assessed the resident and asked them some questions, monitored for any bruising or complaints of pain. They noticed no difference in the resident's demeanor. During an interview on 6/17/25 at 2:27 PM, the Director of Nursing stated there was an allegation that a resident was slapped on 6/7/25 around 7:00 AM and they considered a slap physical abuse. They stated the guidance they would have given to the supervisor would have been to assess the resident and to send the accused Certified Nurse Aide home during the investigation. To put someone on leave was protection for both the staff and the resident during the investigation stage. The Director of Nursing stated they took over the investigation after the Administrator reported it to the Department of Health. They stated they did not talk to any other residents the Certified Nurse Aide #1 cared for and whether that should be part of an investigation depended on the situation. In this situation they did not because by the time they found out about the allegation, the Certified Nurse Aide #1 no longer worked at the facility. If the supervisor had known about the allegation and reported it to them, they would have told them to go ask other residents. The Director of Nursing stated the Certified Nurse Aide #1 finished their shifts on Saturday, Sunday and worked Monday morning. They were terminated on Monday (6/9/25) afternoon for an unrelated issue. When they were aware of the allegation on Wednesday (6/11/25), the resident was assessed, interviewed, and their family and provider were notified. The Director of Nursing stated they did not talk to or get a statement from Certified Nurse Aide #1 because they were termed, and they do not usually talk to staff after that. The Director of Nursing stated it was hard to do a thorough investigation after the fact, and it should have been a conversation they had with the accused after the incident occurred. The Director of Nursing stated the Registered Nurse #1 did not document any kind of assessment of Resident #1 on 6/7/25 in the electronic medical record and anything the nurses did for the residents should be documented in the electronic medical record. During an interview on 6/17/25 at 3:03 PM, the Administrator stated Registered Nurse #2 Unit Manager reported to them on Wednesday (6/11/25) that Certified Nurse Aide #2 reported they witnessed Certified Nurse Aide #1 slap a resident. They immediately started an investigation, had the Unit Manager assess the resident, gather statements from any other staff involved. They had the witness demonstrate what they saw, and they reported they saw a raised hand that connected to the resident's face. Staff were educated to call Administration about any abuse allegations, and it was not their job to say if an allegation happened or did not happen. If staff would have reported it sooner, they would have completed the investigation sooner, but nothing else would have changed. The process did not change, by the time they knew about the allegation, Certified Nurse Aide #1 no longer worked at the facility and had no contact with the residents. The Administrator stated Certified Nurse Aide #1 had contact with other residents before Administration was aware of the allegation as they worked the rest of their shifts on Saturday, Sunday and Monday before they were terminated. They stated the Director of Nursing took over the investigation and they did not know if any other residents were interviewed or assessed as part of their investigation. They would have told the supervisor to get a statement from Certified Nurse Aide #1 and given the nature of the allegation, they would have been put on suspension. The Administrator stated they could have checked with other residents on Certified Nurse Aide #1's assignment, but they did not because they did not know about the allegation. 10NYCRR 415.4(b)(3)

Based on interview and record review conducted during a Complaint investigation (#NY00359145) during a Standard survey completed on 11/6/2024, the facility did not ensure that each resident receives adequate supervision and assistive devices to prevent accidents for one (Resident #106) of five residents reviewed for accidents. Specifically, a gait belt (an assistive device used to help someone move) was not utilized by staff during a transfer as care planned and Resident #106 sustained skin tears to their left forearm. The finding is: The policy and procedure titled Gait Belt Use dated 3/28/2024 documented all patients/residents requiring touching, partial/moderate, substantial/maximal, or dependent times two people assistance will have a gait belt provided to them for use during transfers. The policy and procedure titled Modes of Transfer dated 7/27/2023 documented that all residents will have a safe mode of transfer from all surfaces. Resident #106 had diagnoses of Parkinson's disease, muscle weakness, and difficulty in walking. The Minimum Data Set (a resident assessment tool) dated 10/3/2024 documented Resident #106 was cognitively intact and required touching or steadying assistance for transfers to the toilet. The comprehensive care plan dated 4/6/2024 documented Resident #106 had a loss in functional mobility, required a gait belt and a grab bar for transfers to the toilet. A nursing progress note completed by Registered Nurse Unit Nurse Manager #3 dated 10/30/2024 at 4:02 PM documented that Resident #106 sustained a skin tear to their left forearm when Certified Nurse Aide #2 transferred the resident to the toilet. An occurrence report statement form dated 10/31/24 from Certified Nurse Aide #2 documented they had transferred Resident #106 with the grab bar and not a gait belt. Certified Nurse Aide #2 documented they did not read the care plan before they transferred Resident #106. During an interview on 10/31/24 at 9:24 AM, Resident #106 stated they were transferred hurriedly to the toilet by Certified Nurse Aide #2. Resident #106 stated they fell against their wheelchair and received two skin tears on their left arm. They stated that they were not wearing a gait belt when they were transferred to the toilet. During an interview on 11/5/2024 at 8:48 AM, Registered Nurse Unit Nurse Manager #3 stated Resident #106 had reported that Certified Nurse Aide #2 did not use a gait belt when transferring them to the toilet. Registered Nurse Unit Nurse Manager #3 stated Resident #106 was care planned to have a gait belt on during transfers as they could fall. The incident was reported to the Director of Nursing. During an interview on 11/5/2024 at 9:06 AM, the Director of Social Work stated they spoke with Resident #106 who stated Certified Nurse Aide #2 did not use a gait belt when they were transferred. The Director of Social Work stated that the Certified Nurse Aide #2 violated the resident's care plan. During an interview on 11/5/2024 at 9:16 AM, the Director of Nursing stated they expected staff to follow the resident's care plan and use a gait belt for transfer for a resident who required it. During an interview on 11/5/2024 at 12:21 PM, Certified Nurse Aide #2 stated they didn't use a gait belt when they transferred Resident #106 to the toilet and should have for resident safety. NYCRR 10 415.12(h)(2)

Based on observation, interview, and record review conducted during the Standard survey completed on 11/6/24, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #138) of three residents reviewed for enhanced barrier precautions (interventions designed to reduce transmission of multi-drug resistant organisms including gown and glove use during high contact resident care activities). Specifically, a nurse did not wear proper personal protective equipment during care of the resident's feeding tube (a tube inserted into the stomach to provide nutrition). The finding is: The Centers for Medicare and Medicaid Services Quality Safety and Oversight memoranda QSO-24-08-NH dated 3/20/24, documented enhanced barrier precautions were indicated for residents with indwelling medical devices even if the resident was not known to be infected or colonized with a multidrug-resistant organism. Examples of indwelling medical devices included feeding tubes. The memo documented enhanced barrier precautions were employed for high contact resident care activities including the care or use of a feeding tube. The policy and procedure titled Transmission Based Precautions with an effective 1/10/24, documented that gowns were to be worn if clothes were likely to be soiled with secretions or excretions. Enhanced barrier precautions and tube feedings were not addressed in this policy and procedure. The policy and procedure titled Community Based Care: Nasogastric Tube insertion and Enteral Feedings Guidelines effective 7/27/18, included procedures for gastrostomy tubes with bolus feeds (a method of tube feeding where a large amount of liquid formula is given over a short period of time) and bolus medication administration. The policy and procedure did not include instructions to wear a gown and did not address enhanced barrier precautions. Resident #138 had diagnoses which included dysphagia, oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat), gastro esophageal reflux disease (a condition in which stomach acid repeatedly flows back up into the tube connecting the mouth and the stomach), and congestive heart failure (a condition in which the heart doesn't pump blood as well as it should). The Minimum Data Set (a resident assessment tool) dated 10/4/24 documented Resident #84 had no cognitive impairment, had a feeding tube and received more than 51% of total calories through tube feeding. The comprehensive care plan initiated on 9/27/24 and revised on 10/2/24 documented that Resident #138 required tube feeding related to their inability to swallow and needed maximum assist with tube feeding and water flushes. Interventions included to monitor, document, report any signs and symptoms of aspiration, infections at the tube site, and tube dysfunction or malfunction. During an observation on 11/5/2024 at 11:52 AM, outside of Resident #138's room was an enhanced barrier precautions set up in plastic, portable storage drawers containing disposable surgical gowns, gloves, and face masks. On the side of the doorway was a sign that Resident #138 was on enhanced barrier precautions and staff were to wear a gown and gloves during hands on care. At 11:55 AM, Licensed Practical Nurse #1 entered the room with a towel and Resident #138's tube feed formula. Licensed Practical Nurse #1 washed their hands and applied gloves. Resident #138 sat in a reclining chair and helped Licensed Practical Nurse #1 place the towel underneath their feeding tube opening. Licensed Practical Nurse #1 opened the feeding tube and approximately 20 milliliters of yellowish colored liquid splashed onto the towel and onto Licensed Practical Nurse #1's glove. Licensed Practical Nurse #1 wiped off their glove onto the towel. Licensed Practical Nurse #1 was not wearing a gown during this procedure. During an interview on 11/5/2024 at 12:25 PM, Licensed Practical Nurse #1 stated that they should have worn a surgical gown during the resident's bolus feed because the resident was on enhanced barrier precautions. They stated that they should have worn a gown for a resident with a gastric tube to prevent cross contamination between residents. During an interview on 11/5/2024 at 12:51 PM with Registered Nurse Unit Nurse Manager #2, they stated they expected their staff to wear gowns, gloves, and a mask for direct care for a resident on enhanced barrier precautions. They stated that if the nurse or the aide thought care might be messy they should wear goggles as well to protect themselves from getting contaminated with germs. They stated that enhanced barrier precautions were to prevent germs from being spread from one resident to another. During an interview on 11/5/2024 at 12:58 PM, the Assistant Director of Nursing Infection Preventionist stated that they expected staff to wear personal protection equipment such as a gown, mask, or goggles with a resident who was on enhanced barrier precautions. During an interview on 11/5/2024 at 1:12 PM, the Director of Nursing stated that they expected staff to wear personal protective equipment when providing care to residents on enhanced barrier precautions to prevent cross contamination with other residents. 10NYCRR 415.19(a)(2)

Based on observation, interview, and record review conducted during the Standard survey started on 11/8/22 and completed on 11/15/22 the facility did not ensure that the resident is free from physical restraints for purposes of discipline or convenience, and that are not required to treat the resident's medical symptoms When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. Specifically, for one (Resident #130) of two residents reviewed there was no documented evidence of a medical diagnose for the use of a restraint and there was no evidence the restraint was re-evaluated for safety after repeated falls on 9/18/22 and 9/19/22 with the seatbelt in place. The finding is: The facility policy and procedure (P&P) titled Community Based Care: Restraints dated 11/18/21 documented the purpose was to provide restraint-free care while protecting patient/resident safety, comfort, and well-being. To define types of restraints, identify indications for the rare utilization of patient/resident restraints, outline requirements of alternatives, orders obtained, and to review monitoring and documentation. To ensure compliance with federal and state requirements for assessment and restraint reduction. Restraints will only be used when all other interventions have been exhausted and the patient/resident posed potential harm to self and /or others. Restraints will not be used for the purpose of discipline or convenience. Preventative and alternative strategies to restraint use are of primary consideration. Physical restraints were defined as: Any manual method or physical or mechanical device, material, or equipment attached or adjacent to the patient's/resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. If restraints are used, they must be the least restrictive for the least amount of time, and an ongoing evaluation of need for use will occur. Restraints will be used only well-documented exceptional circumstances, after all reasonable alternatives have been tried for an adequate period of time. Patient /resident will be closely monitored to ensure that the least restrictive but effective type of restraint is utilized. The State Operations Manual issued 10/21/22 defined a physical restraint as any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to the resident's body; Cannot be removed easily by the resident and restricts the resident's freedom of movement or normal access to his/her body. Examples of the facility practices that meet the definition of a physical restraint include but not limited to: Using devices in conjunction with a chair, such as belts, that the resident cannot remove and prevents the resident from rising. 1. Resident #130 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS- a resident assessment tool) dated 8/17/22 documented Resident #130 was severely cognitively impaired, was usually understood and sometimes understands. The MDS documented the use of a trunk restraint during the look back period. The Comprehensive Care Plan (CCP) dated 9/18/22 documented ADL (activities of daily living) self-performance deficit related to [CONDITION(S)] (cerebral vascular accident). The planned interventions included a Broda chair with gel cushion and seatbelt; Tilt/recline for comfort; and pillow when reclined; Offer urinal every two hours while in Broda; Toilet resident every shift; monitor for pain; Thirty minute checks while in bed; Ensure call light was in reach; Encourage back to bed at hour of sleep (HS) with bed in low position; Ensure appropriate footwear; When patient was restless in the recliner place patient in bed, if attempted 2x's to self-transfer out of bed offer use of recliner; Make sure brakes were locked on all sitting chairs. The CCP did not document an intervention to release the seatbelt every two hours. The Visual/Bedside Kardex Report (a guide used by staff to provide care) dated 11/15/22 and identified as current by Registered Nurse (RN) #1 Clinical Nurse Manager, documented the use of a Broda chair with gel cushion and seatbelt. The Visual/Bedside Kardex Report did not reflect releasing the seatbelt every two hours. The Morse Fall Scale Assessments revealed Resident #130 was a high risk for falls on the following dates: 7/30/22, 8/16/22, 9/4/22, 9/18/22, and 9/19/22. During an observation on 11/8/22 at 9:21 AM, Resident #130 was seated in a Broda chair with their legs positioned over the left arm rest of the chair. A black seatbelt with a buckle was secured around Resident #130 waist. Resident #130 was unable to release the seatbelt buckle upon request and attempted to pull at point where the belt was attached to the chair. The Physical Restraint Evaluation dated 8/15/22 documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #130 had five falls without serious injury. The seatbelt was requested by the spouse. The rational documented was that the seatbelt provided safety when out of bed (OOB) in the chair. The Physical Restraint Evaluation was signed by MD #1 on 8/15/22. During observation and interview on 11/8/22 at 11:22 AM, Resident #130 was in the Broda chair with a seatbelt around their waist. Resident #130's spouse stated the seatbelt was a restraint that it prevented falls. The spouse stated that they had a meeting with the team and agreed on 8/15/22 the seatbelt was the safest means. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Release Q (every) 2 hours when engaged. There was medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physical Restraint Form signed by Resident 130's spouse on 8/16/22 documented the seatbelt was implemented to maximize safety. The facility Resident/Patient Occurrence Reports revealed the following: -9/18/22 at 9:45 AM Resident #130 was witnessed putting both legs onto left side of Broda chair and flipped the chair. The bottom of the Broda chair fell off and the top of chair came down. Resident #130 was on their back on top of the Broda chair on the floor. -9/19/22 at 2:45 PM Resident #130 was seated on the floor at the nurses' desk with the Broda chair tipped over onto its front wheels and Resident #130 was resting their back against the chair. Resident #130 had a superficial abrasion to the right calf that measured 0.5 cm (centimeters). The incident was unwitnessed -9/19/22 at 4:45 PM Resident #130 was found seated on the floor with the Broda chair tipped onto the front wheels. The fall was unwitnessed. The Resident/Patient Occurrence Reports documented a fall summary which included safety and environmental factors. The summary did not document if the seatbelt was in place as planned or whether the seatbelt posed a hazardous risk and was contributing factors to the falls that lead to tipping the Broda chair. MD #1 documented on 9/20/22 that Resident #130 was agitated and tipped themselves out of the Broda chair. The MD did not document the use of the restraint while in the Broda chair when the falls occurred on 9/18/22, and 9/19/22 and there was no documented medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Physical Therapy Progress Note dated 9/21/22 documented a fall assessment was completed. Resident #130 had tipped the Broda chair backwards. There was no decline in functional mobility, no physical therapy was recommended, and the current plan of care was appropriate. There was no documented evidence the Physical Therapist and team re-evaluated the use of the seatbelt, was a contributing factor to the falls, or that the seatbelt posed a safety risk. Review of the Nursing Progress Notes from 9/19/22 through 11/8/22 revealed there was no documented evidence the use of the seatbelt was re-evaluated for its effectiveness after repeated falls. During an observation on 11/14/22 at 3:25 PM, Resident #130 was seated in the Broda chair with their legs positioned over the left side of the arm rest. The seatbelt in place and engaged around their waist. Resident #130 attempted to rise from the Broda chair, was agitated and yelled, Help me, Help me. During an interview on 11/14/22 at 3:30 PM, Certified Nurse Aide (CNA) #3 stated the seatbelt prevented falls and was an additional reminder when the resident would self-transfer. During an interview on 11/15/22 at 8:31 AM, Registered Nurse (RN #2) Nurse Supervisor stated they assessed Resident #130 after the fall on 9/18/22 and the Broda chair was not on top of the resident when they arrived on the unit. Staff, may have released the seatbelt prior to arriving on the unit. The seatbelt was not on. RN #2 stated they did know if the seatbelt contributed to the tipping of the Broda chair and, Never thought to question the seatbelt. During an interview on 11/15/22 at 9:15 AM, MD #1 stated Resident #130 had dementia and the seatbelt was a restraint. The restraint was implemented due to falls and impulsive behaviors. The MD could not provide a medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 11/15/22 at 10:29 AM, CNA # 2 stated the seatbelt was requested by Resident #130's spouse and prevented additional falls. During an interview on 11/15/22 at 10:45 AM the Unit Clerk stated the Broda chair had the potential to tip forward when Resident #130 leaned to pick up something from the floor. The seat belt reminded Resident #130 to stay seated and prevented rising and was beneficial as it allowed staff more time to get to the resident. During an interview on 11/15/22 at 10:55 AM, CNA #1 stated on 9/18/22 they witnessed Resident #130's agitated behavior, thrashing back and forth in the Broda chair. CNA #1 stated the Broda chair tipped backwards, with the seatbelt in place and engaged around Resident #130's waist. During an interview on 11/15/22 at 10:57 AM, the Physical Therapist stated an falls assessment was completed on 9/21/22 for the falls that occurred on 9/18/22 and 9/19/22. The Physical Therapist stated the seatbelt was not re-assessed on 9/21/22. Resident #130 flipped the Broda chair and was unaware if the seatbelt was engaged during the three (9/18 and two on 9/19) falls. My concern was functional mobility, not the potential safety risk or if the seatbelt was a contributing factor that led to the falls. I guess I don't know if the seatbelt was safe. The seat belt should have been re -evaluated for safety. During an interview on 11/15/22 at 11:00 AM, RN #1 Clinical Nurse Manager stated the seatbelt was a restraint used for falls and evaluated quarterly. Potential hazards were discussed with the spouse. A toilet schedule, activities, visiting with the spouse, low bed, thirty-minute visual checks were interventions prior to the seat belt. RN #1 stated the seat belt in the Broda chair was beneficial to Resident #130's safety despite the falls that occurred on 9/18/22 and 9/19/22 and remained appropriate. During an interview on 11/15/22 at 12:52 PM, the Director of Nursing (DON) stated the seatbelt was a restraint and used for falls. Nurses were responsible to release the seat belt every two hours and was documented on the TAR, therefore did not expect it on the care plan. There were no attempts to reduce the seatbelt. The Broda chair with the seatbelt was the least restrictive means which provided resident more benefit, then if the restraint wasn't in place. The DON would have expected ongoing documentation to monitor the use of seatbelt in the Broda chair. The seatbelt was the most appropriate intervention. During an interview on 11/15/22 at 2:22 PM, the Administrator stated the restraint prevented falls and that the seatbelt with the Broda chair were appropriate despite the three falls that occurred on 9/18/22 and 9/19/22. 415.4(a) (2) (iii)

Based on interview and record review during a Standard survey started 11/8/22 and completed 11/15/22, the facility did not ensure that all alleged violations including abuse or mistreatment are reported immediately, but not later than 2-hours after the allegation is made, if the events that caused the allegation involve abuse or not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to the appropriate officials (including the State Survey Agency). Specifically, one (Resident #3) of two residents reviewed for abuse were involved in allegations of mistreatment on 7/7/22 and 10/27/22 and were not reported to the Administrator and the New York State (NYS) Department of Health (DOH) as required. The findings are: The policy titled Identification, Prevention, Investigation and Reporting of Victims of Potential Abuse, Neglect or Exploitation effective date 6/30/21 documented it is the policy of the facility to prohibit any form of patient/resident abuse, neglect while the patient/resident is under the supervision/care of the facility. To assure that all patients/residents are treated with dignity and respect. Report any suspected or actual victim abuse, neglect when identified. All cases of suspected or actual abuse, neglect will be reported to the immediate supervisor/manager and an investigation will begin immediately. All alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse or not later than 24 hours if the events that cause the allegation do not involve abuse, to the administrator of the facility and to other officials including to the NYS DOH through established procedures. 1. Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-a resident assessment tool) dated 9/16/22 documented Resident #3 was understood, understands and cognitively intact. Review of Comprehensive Care Plan revised date 7/7/22 revealed Resident #3 will be monitored for mood state related to anxiety disorder and new environment adjustment. Resident #3 has been accusatory toward staff; they have asked for several aides to be removed from their assignment. During an interview on 11/8/22 at 4:26 PM, Resident #3 stated certified nurse aide (CNA) #7 was angry and stated no to everything they needed. Resident #3 stated they asked to wash their hands after using the bathroom, and CNA #7 said no and when they tried to go to sink in their wheelchair, CNA #7 pulled them away from the sink. Additionally, Resident #3 stated a few months ago, CNA #8 came into their room and splashed water in their face and told them to stop using their call device. Resident #3 stated they notified the RN #5 of both allegations. During a further interview on 11/15/22 at 10:10 AM Resident #3 stated CNA #7 and CNA #8 were not nice and made them feel sad. I'm not their adversary, we're supposed to work together. Additionally, Resident #3 stated they feel fearful sometimes because they never know who's going to walk through the door and if they are going to be kind or not. Review of the Nurses Progress Note dated 7/7/22 at 3:19 PM, RN #5 documented Resident #3 reported CNA #8 took their call light from them and splashed water in their face. RN #5 documented there was no water on residents table at that time and was afraid Resident #3 was making false accusations. Additionally, RN #5 documented that this was not the first CNA Resident #3 had requested not to help them because they do not like how they were being cared for. Review of untitled, undated statement signed by RN #5 documented Resident #3 identified CNA #8 was the one who took away the call light and splashed water on their face by pointing to CNA #8 while they were in Resident #3's room. Additionally, RN #5 documented they discussed situation with Resident #3's Health Care Proxy (HCP). Review of the Nurses Progress Note dated 10/27/22 at 10:25 AM, late entry for 10/25/22, RN #5 documented Resident #3 was upset with CNA #7 over a disagreement with care. Resident #3 stated CNA #7 would not let them finish washing their hands and that CNA #7 was mean to them. Resident #3 expressed CNA #7 does not talk to them and they felt CNA #7 did not like them. During an interview on 11/8/22 at 4:46 PM, RN #5 stated they were aware of complaints voiced by Resident #3 and had addressed them by resolving them between both CNA #7 and CNA #8 and the Resident #3. RN #5 stated an investigation was completed by just them and felt Resident #3's complaints were farfetched, and that Resident #3 had made false accusations against CNA #7 and CNA #8. Additionally, RN #5 stated if they felt it was abuse, they would have reported it to the Director of Nursing (DON). During an additional interview on 11/10/22 at 2:07 PM, RN #5 stated they felt it was a conflict of personalities and didn't write anything down, just switched CNA #7 and CNA #8's assignment. During an interview on 11/15/22 at 9:51 AM, CNA #7 stated they used to be Resident #3's CNA and that Resident #3 was argumentative and made accusations about them. CNA #7 recalls 10/25/22 and stated they had assisted Resident #3 off the toilet and while placing foley bag under wheelchair, Resident #3 started scooting and pushing themselves back in wheelchair towards them. CNA #7 stated they held wheelchair in place away from them and Resident #3 started screaming that they were hurting them, calling out help me. CNA #7 stated they told Resident #3 to wait a second but doesn't think Resident #3 heard them. CNA #7 stated they never denied Resident #3 care. Additionally, CNA #7 stated they were never asked to write a statement and unit manager RN #5 removed them from Resident #3's assignment. During an interview on 11/15/22 at 11:47 AM, CNA #8 stated they recalled accusations made by Resident #3 and that it was the first time having had Resident #3 at facility. CNA #8 stated that Resident #3 reported to RN #5 that they had splashed water in their face. CNA #8 stated they absolutely didn't splash water in Resident #3's face and RN #5 removed them from Resident #3's assignment. Additionally, CNA #8 could not recall if they wrote a statement. During an interview on 11/15/22 at 12:26 PM, the DON stated their expectation was that any allegations of abuse would be reported to them immediately and that all staff are responsible to report abuse. The DON stated if there was ever any doubt, an investigation would be opened online within an hour and to their recollection, an investigation was not initiated for allegations made by Resident #3 on 7/7/22 and 10/27/22. In addition, the DON could not recall if they reviewed allegations made by Resident #3 with the Administrator. Additionally, at 2:01 PM, DON stated they are required to report alleged violations of mistreatment and abuse to the state. DON stated if there was an allegation of abuse and thought it was reportable, they would notify the Administrator. During an interview on 11/15/22 at 12:42 PM, the Administrator stated they would expect allegations of abuse to be brought to their attention and would expect it to be reported to the state in 2 hours. They stated the Facility is responsible to initiate an investigation and get statements to keep track of allegations. 415.4 (b)(2)

Based on interview and record review conducted during a Standard survey started 11/8/22 and completed 11/15/22, the facility did not have evidence that all alleged violations of abuse or mistreatment were thoroughly investigated for one (Resident #3) of two residents reviewed. Specifically, there was a lack of evidence an investigation was completed into allegations of abuse and the lack statements/interviews with staff. The finding is: The policy titled Identification, Prevention, Investigation and Reporting of Victims of Potential Abuse, Neglect or Exploitation effective date 6/30/21 documented all cases of suspected or actual abuse, neglect will be reported to the immediate supervisor/manager and an investigation will begin immediately. An 'Occurrence Report' will be completed. Statements will be obtained from the patient/resident, staff, family member, visitor, and/or anyone involved. The facility Administrator/Designee and the Director of Nursing will be notified of the incident immediately. Providers must be able to provide evidence that once an allegation of abuse was made, that the investigation was commenced immediately. The investigation must be complete and thorough. Documents associated with the facility investigation include but are not limited to complete electronic incident form on the HCS (Health Commerce System) and have available: witness statement(s), resident statement(s), accused statement(s), facility investigation report, employee personnel and training records, plan to prevent reoccurrence. 1. Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS-a resident assessment tool) dated 9/16/22 documented Resident #3 was cognitively intact and was understood and understands. The Comprehensive Care Plan with a revised date of 7/7/22 documented Resident #3 would be monitored for mood state related to anxiety disorder and new environment adjustment. Resident #3 had been accusatory toward staff; they have asked for several aides to be removed from their assignment. Review of the Nurses Progress Note dated 7/7/22 at 3:19 PM, Registered Nurse (RN) #5 documented Resident #3 reported certified nurse aide (CNA) #8 took their call light from them and splashed water in their face. RN #5 documented that there was no water on residents table at that time and RN #5 was afraid Resident #3 was making false accusations. Review of untitled, undated statement signed by RN #5 documented Resident #3 identified CNA #8 was the one that took call light from them and splashed water on their face. RN #5 did not see any water on tray table and did not observe water on Resident #3's face or hair at that time. RN #5 documented that upon returning to Resident #3's room after looking for CNA #8 that Resident #3 had water in their hair and drops of water surrounding the cup. RN #5 asked Resident #3 where the cup of water came from, and the resident stated a CNA gave it to them. Review of the Nurses Progress Note dated 10/27/22 at 10:25 AM, late entry for 10/25/22, RN #5 documented Resident #3 was upset with CNA #7 over a disagreement with care. Resident #3 stated CNA #7 would not let them finish washing their hands and that CNA #7 was mean to them. Resident #3 expressed CNA #7 does not talk to them and they felt CNA #7 did not like them. During an interview on 11/8/22 at 4:26 PM, Resident #3 stated CNA #7 was angry and stated no to everything they needed. Resident #3 stated they asked to wash their hands after using the bathroom, and CNA #7 said no and when they tried to go to sink in their wheelchair, CNA #7 pulled them away from the sink. Additionally, Resident #3 stated a few months ago, CNA #8 came into their room and splashed water in their face and told them to stop using their call device. Resident #3 stated they notified the RN #5 of both allegations. During an interview on 11/8/22 at 4:46 PM, RN #5 stated they were aware of complaints voiced by Resident #3 and had addressed them by resolving them between both CNA #7 and CNA #8 and Resident #3. RN #5 stated an investigation was completed by just them and felt Resident #3's complaints were farfetched, and that Resident #3 had made false accusations against CNA #7 and CNA #8. Additionally, RN #5 stated if they felt it was abuse, they would have reported it to the Director of Nursing (DON). During an additional interview on 11/10/22 at 2:07 PM, RN #5 stated they felt it was a conflict of personalities, didn't write anything down, and just switched CNA #7 and CNA #8's assignment. RN #5 was unable to provide investigation reports or statements from staff involved in the incidents. During an interview on 11/15/22 at 9:51 AM, CNA #7 stated they used to be Resident #3's CNA and that Resident #3 was argumentative and made accusations about them. CNA #7 recalled the incident on 10/25/22 and stated they had assisted Resident #3 off the toilet and while placing foley bag under their wheelchair. Resident #3 started scooting and pushing themselves back in wheelchair towards them. CNA #7 stated they held wheelchair in place away from them and Resident #3 started screaming that they were hurting them, calling out help me. CNA #7 stated they told Resident #3 to wait a second but doesn't think Resident #3 heard them. Additionally, CNA #7 stated they were never asked to write a statement and RN #5 removed them from Resident #3's assignment. During an interview on 11/15/22 at 11:47 AM, CNA #8 stated they recalled accusations made by Resident #3. CNA #8 stated that Resident #3 reported to RN #5 that they had splashed water in their face. CNA #8 stated they absolutely didn't splash water in Resident #3's face and RN #5 removed them from Resident #3's assignment. CNA #8 could not recall if they wrote a statement. During an interview on 11/15/22 at 12:10 PM, Licensed Practical Nurse (LPN) #7 stated they recall the situation between Resident #3 and CNA #8, where CNA #8 was being rough or something. LPN #7 stated that no allegations of abuse were brought to their attention, and they have never had to write a statement related to mistreatment or abuse. During an interview on 11/15/22 at 12:26 PM, the DON stated to their recollection an investigation was not initiated for allegations made by Resident #3 on 7/7/22 and 10/27/22. The DON stated they felt Resident #3 was making part of the story up, wasn't accurate and feels a thorough investigation was completed. In addition, the DON could not recall if they reviewed allegations made by Resident #3 with the Administrator. During an interview on 11/15/22 at 12:42 PM, the Administrator stated they would expect allegations of abuse to be brought to their attention. 415.4(b)(3)

Based on observation, interview, and record review conducted during a Standard survey completed on 2/4/20, it was determined that the facility did not ensure that a resident who was unable to carry out activities of daily living receives the necessary services to maintain good grooming, and personal hygiene. Specifically, one (Resident #20) of four residents reviewed for activities of daily living had issues with multiple one- inch long whiskers on her chin, upper lip, and left eye brow. The finding is: The facility policy and procedure titled Activities of Daily Living (ADL) Care dated 7/17/18 documented to ensure a patient/resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal hygiene. The decision to refuse care and treatment must be documented in the medical record. The undated facility policy and procedure titled Dignity documented to promote care for residents in a manner and in an environment that maintains or enhances each residents sense of self and well-being as well as respect and dignity in full recognition of his or her individuality. Examples of treating residents with dignity and respect include but are not limited to: Grooming residents as they wished to be groomed (hair combed and styled, beards shaved and trimmed. 1. Resident #20 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a resident assessment tool) dated 10/25/19 documented the resident had moderate cognitive impairment. The MDS documented the resident is an extensive assist of two staff members for personal hygiene which includes shaving. Review of the Comprehensive Care Plan (CCP) dated 8/8/19 revealed activity of daily living (ADL) self- care deficit related to history of weakness. The CCP documented the resident was an extensive assist of two staff members for personal hygiene. Further review of the CCP revealed showers were scheduled on Tuesday and Saturday on the day shift. During an observation on 1/29/20 at 10:06 AM, the resident had multiple one- inch long chin hairs including on the top of the upper lip and one- inch long hair on the left eyebrow. The resident stated during this observation that they preferred to have them (hair) removed. Intermittent observations revealed the following: - 1/30/20 at 9:35 AM - resident had whiskers on her chin, upper lip, and left eye brow. Resident #20 stated no one had offered to shave her face. - 1/31/20at 10:23 AM - resident had whiskers on her chin, upper lip, and left eye brow. Resident #20 stated no one had offered to shave her face. - 2/3/20 at 11:38 AM - resident had whiskers on her chin, upper lip, and left eye brow. Resident #20 stated no one had offered to shave her face. An undated Certified Nurse Aide (CNA) Bedside Kardex Report (guide used by staff to provide care) documented the resident was an extensive assist of two staff members for personal hygiene. A review of a Documentation Survey Report dated 12/1/19 to 2/3/20 revealed that staff documented the resident received personal hygiene care on those dates. Review of the[NAME]Lane Shower Schedule documented Resident #20 received showers on Tuesday and Saturday on the day shift. Review of the Treatment Administration Record (TAR) from 1/1/20 through 2/3/20 documented showers were given on Tuesdays and Saturdays. During an interview on 2/3/20 at 1:04 PM, CNA#1 stated typically CNA's are to shave residents on their scheduled bath day and daily if they request to be shaved. During an interview on 2/3/20 at 1:08 PM, CNA# 2 stated residents are shaved on shower days. During an interview on 2/3/20 at 1:10 PM, CNA #3 stated she did not offer to shave the resident this morning because her husband normally does it. During an interview on 2/3/20 at 1:19 PM, Registered Nurse (RN) Unit Manager #1 stated that she expected her staff to offer daily and shave a resident if they want to be shaved, on shower days, and as needed. If a resident refuses she would expect the CNA's to re-approach the resident and tell the nurse. During an interview on 2/4/20 at 11:21 AM, the Director of Nursing (DON) stated that she expected her staff to shave residents on their scheduled shower days as long as the resident was agreeable to shaving or document it in the nurses' notes. In this case it was not. 415.12 (a)(3)

Based on interview and record review conducted during an Abbreviated survey (Complaint # NY 882) completed on 11/21/19, the facility did not ensure the resident's right to be free from neglect for two (Residents #1, 2) of four residents reviewed for neglect. Specifically, Resident #1 was administered insulin by a Registered Nurse (RN) that had drawn insulin from Resident #2's personal insulin pen, which is against facility policy & procedure and the manufacturer's instructions. Resident #2 had his personal insulin pen breached by the RN and had insulin removed without his consent. The finding is: Review of the facility policy titled Identification, Prevention, Investigation and reporting of victims of potential abuse, neglect or exploitation last reviewed and revised in (MONTH) 2019 included: It is the policy of the facility to prohibit any form of resident abuse, neglect or exploitation while the resident is under the supervision/ care of the facility. Report any suspected or actual victim of abuse, neglect, exploitation, injury of unknown origin, and/or misappropriation of resident property when identified. -Neglect is defined as: NYS (New York State) -The failure to provide timely, consistent, safe, adequate and appropriate services, treatment or care to a resident of a residential health care facility while the resident is under the supervision of the facility, including but not limited to: nutrition, medication, therapies, sanitary clothing and surroundings and activities of daily living. CMS (Centers for Medicare & Medicaid) -Failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of a facility policy titled Long Term and Sub Acute Insulin Pens with Autoshield Duo Safety Needle last revised on 11/2018 included: Insulin pens deliver multiple doses but are for single resident use. Insulin pens may never be shared between residents. Never draw up insulin out of a pen using a syringe. Review of [MEDICATION NAME] (insulin [MEDICATION NAME] injection) 100 Units/mL (milliliter) Fact sheet last updated on (MONTH) (YEAR), provided by the facility pharmacy, included: Prescription [MEDICATION NAME] is a long acting insulin used to treat adults with type 2 diabetes and adults and pediatric patients with type 1 diabetes for the control of high blood sugar. [MEDICATION NAME] can be administered using the disposable prefilled [MEDICATION NAME]pen or with a vial and syringe. [MEDICATION NAME] allows patients to set doses from 1 to 80 units in one-unit steps, dialed up and down, in one injection. Do not share needles, insulin pens, or syringes with others. Do not reuse needles. 1. Resident #1 was admitted for subacute rehabilitation with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-a resident assessment tool) dated 10/1/19 revealed the resident had no cognitive impairment. Resident #1 was discharged from the facility on 11/7/19 after completing rehabilitation. Resident #2 was admitted for subacute rehabilitation with [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed the resident had no cognitive impairment. Resident #2 was discharged from the facility on 11/6/19 after completing rehabilitation. Review of the facility's internal investigation revealed insulin pens are stored on the locked medication (med) carts and labeled with appropriate resident's names. The incident involved two residents at the facility. Each resident had meds stored on two separate med carts. On 10/31/19 RN #1 (an agency nurse) was preparing to give insulin to Resident #1 when he stated he could not find insulin in the med cart and said there was no insulin in the med cart. RN #1 went to a second med cart and with a new needle and syringe, drew up 25 units of insulin from Resident #2's insulin pen. It is not known if RN #1 cleaned the pen's port with an alcohol swab prior to entry. The pen was not a new pen and had been used previously on Resident #2. RN #1 stated that he injected Resident #1 with 25 units of insulin. It is not known if he used a new needle. The incident was witnessed by RN #2. RN #2 questioned RN #1 as to why he was doing this. RN #2 observed RN #1 draw up the insulin but did not see RN #1 inject the resident. Review of a written statement dated 11/8/19, RN #1 documented that he cleaned the port, drew up [MEDICATION NAME] and gave the scheduled [MEDICATION NAME] (Resident #1) from another pen (Resident #2) due to no insulin here. Never did this occurrence before. This was the first occurrence. Review of a written statement dated 11/8/19, RN #2 documented that on (MONTH) 31 (2019), RN #2 worked with RN #1 that asked if RN #2 had any insulin in her med cart. RN #1 pulled out an insulin [MEDICATION NAME] pen on Team B belonging to another patient (Resident #2). RN #1 indicated that he was going to use it to give to his patient (Resident #1) on Team [NAME] RN #2 told him that he cannot do that, you should never share insulin pens as there could be a risk of blood borne pathogens inside the insulin; they are patient specific and are only for the patient whose name is on the pen. RN #1 shrugged and said, so. RN #2 told RN #1 of an incident at another local facility where insulin pens were shared, and it infected many patients. RN #1 said, Now you got me paranoid about that. RN #1 continued to draw up the insulin with another needle from the [MEDICATION NAME] pen. RN #2 stated that she walked away. Review of the physician Order Summary Report for Resident #1 documented an order dated 10/22/19 for [MEDICATION NAME] solution Pen-Injector 100 unit/ml (milliliters)(Insulin [MEDICATION NAME]) inject 25 units subcutaneously (SQ- beneath the skin) at bedtime for diabetes mellitus. The order summary report documented that the dose of [MEDICATION NAME] was decreased on 11/4/19 to 20 units SQ at bedtime. Review of Resident #1's discharge summary dated 11/7/19 documented the resident was continuing to improve and was recommended for discharge with home care services on 11/7/19. The physician documented that he decreased the resident's [MEDICATION NAME] (insulin) from 25 units at bedtime to 20 units at bedtime since the resident's blood sugars have been relatively well-controlled. Review of the physician Order Summary Report for Resident #2 documented an order dated 10/23/19 for [MEDICATION NAME] Solution 100 unit/ml (Insulin [MEDICATION NAME]) 70 units SQ at bedtime. Scheduled insulin via insulin pen. Review of Resident # 2's discharge summary dated 11/4/19 documented the resident was continuing to improve and will be discharged on [DATE] with home care services. Diabetes appeared stable. Review of documentation provided by the facility pharmacy on 11/18/19 revealed that 2 insulin pens were dispensed to Resident #1 on 10/22/19 and 11/1/19 respectively. During an interview on 11/19/19 at 10:00 AM, the Pharmacy Supervisor stated that each [MEDICATION NAME]pen has 300 units of [MEDICATION NAME]. For Resident #1 this would have been a 12-day supply. On 10/31/19 Resident #1 should have had 3 doses of 25 units of insulin left in the pen dispensed on 10/22/19. During an interview on 11/18/19 at 1:00 PM, the DON stated, that on 10/31/19 RN #1 drew insulin from Resident #2's pen and administered the insulin to Resident #1. Both residents had been discharged from the facility by the time the facility was made aware of the incident. Upon Resident #1's discharge of 11/7/19, 2 insulin pens remained; the pen that was ordered on [DATE] delivered on 11/1/19; and that the other insulin pen that RN #1 apparently could not find on 10/31/19. The DON stated that extra [MEDICATION NAME] was available on anther unit. RN #1 should have informed the RN Supervisor of the lack of insulin. Arrangements could have been made to have the after-hours pharmacy deliver the insulin. If the insulin pen is discontinued while the resident is at the facility, the pen is disposed of in the sharp's container. If upon discharge the resident is still ordered on the insulin pen the remaining pen(s) are given to the resident. During an interview on 11/18/19 at 2:00 PM, RN #2 stated, that on 10/31/19 while working the 6:00 PM to 6:30 AM shift she and RN #1 were working on different med carts. RN #1 asked for insulin and said he did not have any on his cart. RN #2 told him she did not have any insulin except insulin pens. RN #1 went into her cart and removed an insulin pen belonging to another resident. RN #2 told RN #1 that he could not do that, there is no sharing of insulin pens. RN #1 said, let me show you something and withdrew insulin from the insulin pen from the rubber [MEDICATION NAME] using a regular orange topped insulin syringe. RN #2 did not recall if RN #1 cleaned the insulin pen's rubber [MEDICATION NAME] with alcohol prior to withdrawing the insulin. RN #2 stated that she refused to perform the second check of the insulin dose drawn up by RN #1 and walked away. RN #2 did not observe RN #1 administer the insulin to the resident. During an interview on 11/19/19 at 9:00 AM, RN #1 stated, that he is an agency nurse that worked at the facility on 10/31/19 on the 6:00 PM to 6:30 PM shift. While passing medications there was no insulin pen for Resident #1 on the med cart and there was no insulin in the unit refrigerator. He borrowed Resident #2's insulin pen, drew up the appropriate amount of insulin from the pen using a regular insulin syringe. He cleaned the rubber [MEDICATION NAME] of the insulin pen with alcohol prior to withdrawing the insulin. RN #1 administered the insulin to Resident #1. He did not recall receiving education that insulin pens are not to be shared. 415.4(b)(1)(i)

Based on interview and record review conducted during an Abbreviated survey (Complaint #NY 882) completed on 11/21/19, the facility did not report an incident of neglect within 24 hours to the State Survey agency for two (Residents # 1, 2) of four residents reviewed for neglect. Specifically, an incident that involved Resident #1 was administered insulin by a Registered Nurse (RN) that was drawn from Resident #2's insulin pen was not reported to the New York State (NYS) Department of Health (DOH) as required. The finding is: Review of the facility policy titled Identification, Prevention, Investigation and reporting of victims of potential abuse, neglect or exploitation last reviewed and revised in (MONTH) 2019 included: All alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials including the NYS DOH through established procedures. Mandatory reporters are those professionals who care for nursing home residents. This includes health care workers who provide services and those providing services under contract. All incidents of abuse, exploitation and neglect, including injuries of unknown origin, and misappropriation of resident property will be reported immediately to the Facility Administrator/ Designee, the Director of Nursing (DON), and in accordance with New York law to the DOH. Reporting to the DOH is done in accordance with timeframes noted above. Report any incident with reasonable cause to the NYS DOH via the Health Commerce Network (HPN) electronic incident report system. Review of a facility policy titled Long Term and Sub Acute Insulin Pens with Autoshield Duo Safety Needle last revised on 11/2018 included: Insulin pens deliver multiple doses but are for single resident use. Insulin pens may never be shared between residents. Never draw up insulin out of a pen using a syringe. Review of [MEDICATION NAME] (insulin [MEDICATION NAME] injection) 100 Units/mL (milliliter) Fact sheet last updated on (MONTH) (YEAR), provided by the facility pharmacy, included: Prescription [MEDICATION NAME] is a long acting insulin used to treat adults with type 2 diabetes and adults and pediatric patients with type 1 diabetes for the control of high blood sugar. [MEDICATION NAME] can be administered using the disposable prefilled [MEDICATION NAME]pen or with a vial and syringe. [MEDICATION NAME] allows patients to set doses from 1 to 80 units in one-unit steps, dialed up and down, in one injection. Do not share needles, insulin pens, or syringes with others. Do not reuse needles. 1. Resident #1 was admitted for subacute rehabilitation with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS-a resident assessment tool) dated 10/1/19 revealed the resident had no cognitive impairment. Resident #1 was discharged from the facility on 11/7/19 after completing rehabilitation. Resident #2 was admitted for subacute rehabilitation with [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed the resident had no cognitive impairment. Resident #2 was discharged from the facility on 11/6/19 after completing rehabilitation. Review of the facility's internal investigation revealed insulin pens are stored on the locked medication (med) carts and labeled with appropriate resident's names. The incident involved two residents at the facility. Each resident had meds stored on two separate med carts. On 10/31/19 RN #1 (an agency nurse) was preparing to give insulin to Resident #1 when he stated he could not find insulin in the med cart and said there was no insulin in the med cart. RN #1 went to a second med cart and with a new needle and syringe and drew up 25 units of insulin from Resident #2's insulin pen. It is not known if RN #1 cleaned the pen's port with an alcohol swab prior to entry. The pen was not a new pen and had been used previously on Resident #2. RN #1 stated that he injected Resident #1 with 25 units of insulin. It is not known if he used a new needle. The incident was witnessed by RN #2. RN #2 questioned RN #1 as to why he was doing this. RN #2 observed RN #1 draw up the insulin but did not see RN #1 inject the resident. RN #2 reported the incident to the RN Unit Manager on 11/8/19 that immediately reported the incident to the Administrator, Director of Nursing (DON) and the Assistant Director of Nursing (ADON). On 11/8/19 the RN #2 was put on suspension for further investigation; the incident was reported to RN #1's staffing agency and the facility discontinued contact with RN #1; and the facility Administrator reported the incident to the NYS Department of Health (DOH). During an interview on 11/18/19 at 11:30 AM, the facility Administrator stated that the incident of neglect was reported to administration by RN #2 on 11/8/19 and was reported to the DOH shortly after the facility was made aware of it. During an interview on 11/18/19 at 1:00 PM, the DON stated, that on 10/31/19 RN #1 drew insulin from Resident #2's pen and administered the insulin to Resident #1. On 11/8/19 RN #2 reported the incident to her Unit Manager who reported it to her (DON), the Administrator and ADON. The facility met with RN #2 and placed her on administrative suspension pending further investigation. The incident was reported to the agency that employed RN #1 and the facility discontinued the contract with RN #1. On 11/8/19 the facility Administrator reported the incident to the NYS DOH via the Health Commerce Network (HPN). During an interview on 11/18/19 at 2:00 PM, RN #2 stated, that on 10/31/19 while working the 6:00 PM to 6:30 AM shift she and RN #1 were working on different med carts. RN #1 asked for insulin and said he did not have any on his cart. RN #2 told him she did not have any insulin except insulin pens. RN #1 went into her cart and removed an insulin pen belonging to another resident. RN #2 told RN #1 that he could not do that, there is no sharing of insulin pens. RN #1 said, let me show you something and withdrew insulin from the insulin pen from the rubber [MEDICATION NAME] using a regular orange topped insulin syringe. RN #2 did not recall if RN #1 cleaned the insulin pen's rubber [MEDICATION NAME] with alcohol prior to withdrawing the insulin. RN #2 stated that she refused to perform the second check of the insulin dose drawn up by RN #1 and walked away. RN #2 did not observe RN #1 administer the insulin to the resident. RN #2 stated that she did not report the incident to her supervisor on 10/31/19 due to fear of retaliation by RN #1. RN #2 stated that on 11/8/19 while talking with her Unit Manager she saw that she was scheduled to work with RN #1 on that day and told the Unit Manager of the incident that occurred on 10/31/19. The Unit Manager stated that we must report this immediately to the Administrator and DON, which they did. 415.4(b)(4)

Based on interview and record review conducted during the Standard Survey completed on 1/10/19, the facility did not ensure that the Pharmacist report any irregularities to the attending physician and the facilities Medical Director and Director of Nursing (DON). Specifically, one (Resident #97) of five resident's residents reviewed for drug regimen reviews had issues involving the lack of Consultant Pharmacist's identification and recommendation regarding the continued use of [MEDICATION NAME] (antipsychotic medication) without attempts for a gradual dose reduction (GDR). The finding is: The policy and procedure entitled Medication Regimen Review Recommendations and Reports dated 10/18 revealed the licensed pharmacist will report in writing, any irregularities to the attending physician, the facility's Medical Director and the Director of Nursing to be acted on. The pharmacist's review considers factors such as; whether the physician and staff have documented any attempts for gradual dose reductions (GDR) or added any non-pharmacological approaches, in an effort to reduce or discontinue the drug. 1. Resident #97 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- a resident assessment tool) dated 11/11/18 documented the resident was severely cognitively impaired, was sometimes understood and sometimes understands. The MDS documented there were no indicators of [MEDICAL CONDITION] and no there were no behavioral symptoms. Additionally, Section N documented the resident received an antipsychotic medication on a routine basis and that no GDR had been attempted. Review of the comprehensive care plan (CCP) dated 3/28/18 revealed the use of [MEDICATION NAME] due to inconsolable distress related to psychological and behavioral symptoms of dementia. Interventions included explore possible reasons for the resident's distress (environmental/ psychosocial stressor, treatable medical conditions), monitor and report mood and response to medication. Notify MD (medical doctor) of adverse consequences. Pharmacy consultant medication review prn (as needed). In addition, review psych medication use no less than quarterly. Review of the physician's orders [REDACTED]. Review of the Medication Administration Records (MAR) dated (MONTH) (YEAR) through (MONTH) 2019 revealed the resident was administered [MEDICATION NAME] 100 mg three times a day as ordered. Review of the Consultant Pharmacist Medication Review Record (MMR) Signature Log dated 10/2017 through 1/2019 revealed there were no irregularities documented, and there were no recommendations made by the pharmacist to address the continued use of [MEDICATION NAME] without an attempt of a GDR. During an interview on 1/8/19 at 1:52 PM, the Consultant Pharmacist stated she was aware of the Federal Regulations and antipsychotics are to have a GDR two times within the first year with one month in between and then annually thereafter. I do not always recommend a GDR, because the Physician typically is on top of the medications and based on Physician documentation I would have not expected a GDR of the [MEDICATION NAME]. During an interview on 1/8/19 at 2:33 PM, the Director of Nurses (DON) stated she agreed with the Consultant Pharmacist not to GDR the [MEDICATION NAME]. The DON then stated decreasing the medication would cause the resident to rock in her chair more, causing increased anxiety and risk for falling out of the Broda chair and stated a GDR would be detrimental. 415.18 (c)(2)

Based on observation, interview, and record review conducted during the Standard survey completed on 1/10/19 the facility did not ensure that residents who use psychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for two (Resident #30 and 97) of five residents reviewed for [MEDICAL CONDITION] medications. Specifically, Resident #30 was documented to have had a failed GDR (gradual dose reduction) for the antipsychotic medication [MEDICATION NAME] with documented evidence to support the failure. Resident #97 lacked gradual dose reduction (GDR) attempts for the antipsychotic medications [MEDICATION NAME], and the lack of documented evidence of behaviors to support the continued use of the medication. The findings are: The policy and procedure entitled [MEDICAL CONDITION] Drug Review dated 5/1/18 revealed the purpose is to ensure a patient/ resident is not given Psychotherapeutic medications (anti-psychotic, anti-depressant, anti-anxiety, sedative/ hypnotic, and psychopharmacologic drugs) unless a comprehensive assessment identifies clear indications of need necessary to treat a specific condition as diagnosed and documented in the medical records and includes parameters for their use. Patients/ residents who are prescribed these drugs receive a GDR and behavioral interventions, unless clinically contraindicated, in an effort to decrease or discontinue the use of these drugs. Additionally, the rationale for continuing the medication must be documented and include evidence that the following has been evaluated: - All resident's target symptoms and the effect of the medication on the severity, frequency, and other characteristics of the symptoms; - Any changes in the resident's function during the previous quarter assessment; and - Whether the resident experienced any medication related adverse consequences during previous quarter. Documentation should reflect attempts to implement care-planned, non-pharmacological approaches and their on-going effectiveness of these interventions. 1. Resident #30 was admitted into the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a resident assessment tool) dated 12/27/18 revealed that the resident was severely cognitively impaired, usually understood and usually understands. The MDS also documented there were no behaviors and no potential indicators of [MEDICAL CONDITION]. Additionally, the resident received an antipsychotic medication. During observation on 1/8/19 at 11:18 AM, the resident was in the lounge area quietly watching television. There were no behaviors noted at this time. During an observation on 1/9/19 at 12:41 PM, the resident had consumed all her food at lunch and a glass of juice was left untouched. A signed Medication Review Report dated 12/13/18 revealed and order to decrease [MEDICATION NAME] to 25 mg (milligrams) PO (by mouth) Q (every) HS (hour of sleep) for GDR. An MD (medical doctor) Order Form dated 12/28/18 revealed to increase the [MEDICATION NAME] to 50 mg PO QHS for a failed GDR, (patient increase fidgety, needs more instructions, decreased appetite, not doing as well). Review of the Medication Administration Records (MAR) dated 12/1/18 to 12/31/18 revealed the resident received [MEDICATION NAME] 50 mg po at HS on 12/1/18 to 12/12/18 and then again 12/28/18 to 12/31/18. Between 12/13/18 to 12/27/18 the resident received 25 mg po at HS. Review of an untitled form used by nursing to document resident behaviors dated for of (MONTH) (YEAR) revealed there were no documented behaviors for all three shifts. Review of the Nursing Progress Notes from (MONTH) 13, (YEAR) to (MONTH) 27, (YEAR) revealed no behaviors to indicate that the GDR failed for the resident. Review of a Social Work Progress note dated 1/2/19 revealed they were updated by nursing staff that the resident had changes since the GDR of [MEDICATION NAME]. Was noted to have increase focusing issues for taking her medications and increase fidgeting. The MD was made aware and increased [MEDICATION NAME] back to prior dosage. Review of the comprehensive care plan (CCP) with initiated date of 6/20/18 revealed the resident uses [MEDICAL CONDITION] medications, [MEDICATION NAME], related to behavior management with dementia. 12/13/18 GDR continues, 12/28/18 increase [MEDICATION NAME] related to GDR failed. During an interview on 1/9/19 at 10:45 AM CNA #4 (certified nurse aide) stated that the behaviors she witnessed for this resident was that the resident became more aggravated with her and would sometimes try to push her away during care. But when she spoke to her the resident would allow her to continue with the care with no problems. The CNA also stated that she felt the resident may have been acting that way because the CNA had been off on leave for a bit and the resident was not used to her. The CNA stated that the past month the resident has had no behaviors and has been calm and that the resident really dos not talk or say much. During an interview on 1/9/19 at 12:03 PM the Registered Nurse (RN) #2 Unit Manager stated that this resident originally came over from rehab for behaviors associated with dementia. They use stuffed animals and balls of yarn as interventions for the resident. RN #2 stated the resident had a failed GDR because the resident's behaviors included fidgeting, being anxious, and episodes of crying. During an interview on 1/9/19 at 12:41 PM, CNA #3 stated that the resident ate all her lunch. CNA #3 stated the resident can sometimes fidget with her food, but when redirect the resident is fine and will continue eating her meal. CNA #3 stated that the resident really hasn't had any behaviors. During an interview on 1/9/19 at 2:03 PM, the Physician stated, I feel that she needed the dose bumped back up to get rid of the behaviors she was having. These behaviors were fidgeting and needing more instructions. The resident also had decreased appetite and was not doing as well. The Physician stated that nursing called him and told him of these behaviors and requested that the [MEDICATION NAME] be put back to 50 mg. The Physician stated he does not look for any documentation on resident's behaviors and that he relies on the staff to inform him of these behaviors. The Physician stated he did not understand why he was being asked questions about this because the issue is that nursing was not documenting any behaviors. The Physician stated that he never knows when the regulations change and was not sure of what the regulations are for unnecessary medications. During an interview on 1/10/19 at 10:51 AM the DON (Director of Nursing) stated that the provider would be the one to ultimately decide that a resident has had a failed GDR. The staff would contact the provider and let them know what behaviors they were seeing with the resident and then the provider decides whether to increase them back or not. Residents with behaviors are discussed every morning during morning rounds as a team. DON stated she reviewed the medical record and understands that there was a lack of documentation for the [MEDICATION NAME] to have been increased back. She stated the staff felt that the resident was exhibiting the same behaviors that they had in the past, just before she would become more behavioral. The staff did not want her to get to that point, so they asked the physician for the higher dose to be reordered. 2. Resident #97 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident was severely cognitively impaired, was sometimes understood and sometimes understands. Section E documented there were no indicators of [MEDICAL CONDITION] and there were no behavioral symptoms. Section N documented the resident received an antipsychotic medication on a routine basis and that no GDR had been attempted. Review of the comprehensive care plan (CCP) dated 3/28/18 revealed the use of [MEDICATION NAME] due to inconsolable distress related to psychological and behavioral symptoms of dementia. Interventions included explore possible reasons for the resident's distress (environmental/ psychosocial stressor, treatable medical conditions), monitor and report mood and response to medication. Notify MD of adverse consequences. Pharmacy consultant medication review prn (as needed). In addition, review psych medication use, no less than quarterly. Review of a Psychiatric Evaluation dated 10/14/17 documented the resident is fidgety, constantly rocking and trying to stand at supper time with recommendations to consider splitting up the dose of [MEDICATION NAME]. In addition, changing the [MEDICATION NAME] to 100 mg three times a day from 150 mg twice daily. Review of the physician's orders [REDACTED]. Review of the Medication Administration Records (MAR) dated (MONTH) (YEAR) through (MONTH) 2019 revealed the resident was administered [MEDICATION NAME] 100 mg three times a day as ordered. Review of the Psychotherapeutic Drug Reviews dated 2/8/18 through 11/16/18 revealed there were no recommendations to reduce or discontinue the [MEDICATION NAME]. Review of the Social Work Assessments dated for 3/12/2018 through 11/9/2018 revealed the resident tends to have a rocking motion in her wheel chair and is restlessness and anxious at times. Review of the Nursing Progress Notes dated 1/8/2018 through 1/8/2019 revealed there was no documented evidence of behaviors to support the use of an antipsychotic medication. Review of the physician progress notes [REDACTED]. In addition, there was no documentation regarding reducing, or discontinuing the medication. Review of the untitled forms used by nursing to document resident behaviors dated from (MONTH) (YEAR) through (MONTH) 2019 revealed there was no documented evidence of behaviors. During an interview on 1/8/19 at 11:58 AM, Registered Nurse (RN) Unit Manager #2 stated, rocking was a typical behavior; otherwise may call out. The physician addresses the [MEDICAL CONDITION] medication on a routine basis and was on top of it. During an interview on 1/8/19 at 1:52 PM, the Consultant Pharmacist stated she was aware of the Federal Regulations and antipsychotics are to have a GDR two times within the first year with 1 month in between and then annually thereafter. I do not always recommend a GDR, because the physician typically is on top of the medications and based on physician's documentation I would have not expected a GDR of the [MEDICATION NAME]. The Consultant Pharmacist further stated based on interviews with staff the resident displayed increased anxiety, restlessness and grinding teeth. During an interview on 1/8/19 at 2:33 PM, the DON stated that she agreed with the Consultant Pharmacist, not to GDR the [MEDICATION NAME]. Decreasing the medication would cause the resident to rock in her chair more, causing increased anxiety and risk for falling out of the Broda chair, and further stated a GDR would be detrimental. The DON further stated she expects better nursing documentation to support the continued use of the [MEDICATION NAME]. The DON stated as long as the physician documents a reduction would be harmful, there was no reason to discontinue the medication. During an interview on 1/9/19 at 8:40 AM, CNA #5 stated the resident has been real quiet, but typical behaviors are rocking back and forth, grinding her teeth, and may swear occasionally. During an interview on 1/9/19 at 8:48 AM, CNA #7 stated typical behaviors are rocking and occasionally will call out with hands on care. In addition, CNA #7 stated the resident has trouble with vision and stated calling out may be related to not being able to see. During an interview on 1/9/18 at 9:29 AM, Licensed Practical Nurse, LPN #1 stated the nurses are responsible for documenting behaviors and recalled the resident occasionally calling out. During an interview on 1/9/19 at 11:44 AM, the Director of Social Work stated she was aware that dose reductions are required. In the past, about a year ago the resident was inconsolable (weepy) and would not respond to different approaches that were used. The [MEDICATION NAME] was so beneficial. The resident's mood and level of distress have stabilized. During telephone interview on 1/9/19 at 12:28 PM, the Psychiatrist stated the physician is very involved and on top of [MEDICAL CONDITION] medications. The Psychiatrist further stated she was willing to evaluate the resident again because she has not been seen since 10/2017 and was unaware of current behaviors. In addition, the Psychiatrist stated she will make recommendations for annual dose reductions and consults. During interview on 1/9/19 at 1:59 PM, the Physician stated It took a lot of time getting the resident comfortable here. The daughter was demanding and proud of the progress. The Physician stated he does not review the nursing documentation and relies on the staff to update him. The Physician stated he did not understand why he was being asked questions about this because the issue is that nursing was not documenting any behaviors. The Physician stated that he never knows when the regulations change, but stated he does know when someone is admitted on an antipsychotic, the medication should be reduced two times within the first year and then annually thereafter. 415.12(1)(2)(ii)

Based on interview, and record review conducted during the Standard survey completed on 1/10/19, the facility did not ensure that the resident has a right to choose activities, schedules, and health care consistent with his or her interests, assessments, and make choices about aspects of his or her life in the facility that are significant to the resident. Specifically, one (Resident #9) of three residents reviewed for choices was not honored with the preference of a shower three times a week. The policy and procedure (P&P) entitled Resident's Rights dated 4/17 documented resident rights were developed to ensure that each resident's rights were protected and promoted; that each resident be encouraged and assisted in the fullest exercise of these rights and are afforded their right to a dignified existence, self-determination, respect, full recognition of their individuality, consideration and privacy. The P&P entitled Resident Self-Determination dated 3/17 documented the resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choices. The finding is: 1. Resident #9 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- a resident assessment tool) dated 12/14/18 revealed the resident was cognitively intact, understands and was understood. The MDS documented it was very important to the resident to choose between a tub bath, shower, bed bath, or sponge bath. Review of the Activities Interview for Daily Preferences completed with the resident dated 2/7/18 and 4/17/18 revealed it was very important to the resident to choose between a tub bath, shower, bed bath, or sponge bath. The resident preferred a shower. Review of the follow up question, Is a bath/shower 2 x (times) a week acceptable to you? The resident's response was No. Review of the Activities Interview for Daily Preferences completed with the resident dated 12/5/18 revealed it is very important to the resident to choose between a tub bath, shower, bed bath, or sponge bath. The resident preferred a shower. Review of the follow up question, Is a bath/shower 2 x a week acceptable to you? The resident's response was No, 3 x a week. The comprehensive care plan (CCP) revised on 8/9/18 documented the resident received showers on Sunday and Thursdays during the day shift. The Unit Bath/Shower schedule dated 10/18/18 documented showers were scheduled every Sunday and Thursday. During an interview on 1/7/19 at 10:32 AM, the resident stated that she would like showers three times/week. The resident also stated the staff snicker when she asks and think it's a joke. The Kardex (guide used by staff to provide care) dated 1/9/19 documented instructions to provide showers on Sundays and Thursdays during the day shift. The Weekly Skin/Nail Checks forms documented from 9/2/18 through 12/27/18 that showers were received twice weekly. During interview on 1/9/19 at 8:25 AM, Registered Nurse (RN) Unit Manager #2, stated preferences are completed by Activities, are completed upon admission, and then quarterly. RN #2 stated he was responsible to review the Daily Preferences and address any concerns. The form is reviewed and signed by the IDT (interdisciplinary team). RN #2 stated he would accommodate resident's preferences and must have missed it. Typically, the showers are scheduled according to room numbers. So, if changes need to be made, it may interfere with other showers. During interview on 1/9/19 at 9:18 AM, the Activities Aide stated she interviewed the resident on 12/5/18. The interviews are completed and the Daily Preferences forms are given to the Director of Activities. During interview on 1/9/19 at 10:41 AM, the Director of Activities stated Daily Preferences forms are reviewed and signed by the IDT during morning report. The responses are input into the MDS and the RN Unit Manager was responsible to follow up with any changes in preferences. During interview on 1/9/19 at 11:30 AM, the Director of Nurses (DON) stated she recalled discussing preferences with the daughter regarding time changes, but not frequency. The DON stated the expectation was that preferences are updated quarterly and as needed. The RN Unit Manager was responsible to update any changes. 415.5(b)(1,3)

Based on observation, interview, and record review conducted during the Standard survey completed on 1/10/19, the facility did not ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain good grooming and personal hygiene. Specifically, two (Residents #97, 363) of three residents reviewed for Activities of Daily Living (ADL's) had issues with a soiled mechanical lift sling that was not removed prior to providing a shower and resident was not washed after its removal (#97); and incomplete incontinence care after a bowel movement (#363). The findings are: 1. Resident #97 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS- a resident assessment tool) dated 11/11/18 documented the resident was severely cognitively impaired, was sometimes understood and sometimes understands. The resident requires an extensive assist of two staff members for bed mobility and personal hygiene. In addition, totally dependent on staff during bathing, and transfers in and out of tub/shower. The resident is frequently incontinent of bowel and bladder. Review of the Comprehensive Care Plan (CCP) dated 12/24/18 revealed the resident has bladder incontinence related to dementia and history of urinary tract infections (UTI ' s). The interventions were for incontinence care after each incontinent episode. Toilet on rising in morning, one and a half hours of meals, every two hours at hs (hour of sleep) and check for incontinence every four hours during the night. Review of the Kardex (guide used by staff to provide care) report dated 1/8/19 revealed the resident required an extensive assist of one staff member for personal hygiene/bathing. In addition, showers were scheduled on Wednesday and Saturday during the day shift. During a care observation on 1/9/19 at 9:56 AM, certified nurse aides (CNA #6 and #7) transferred the resident from a broad chair (specialty wheel chair) using a mechanical lift to a shower chair. The sling was visibly saturated with urine, from the resident's midback down to underneath the resident. The residents brief was also saturated with a large amount of foul smelling yellow urine. CNA #6 and #7 proceeded to provide the resident with a shower while sitting on the urine soaked sling. After the shower the CNA's transferred the resident back to bed onto two clean incontinent pads using the same soiled sling. CNA#7 instructed the resident to roll over towards CNA #6. CNA #7 proceeded to dry the resident's back. A small amount of fecal material was visible on the resident's rectum. CNA #7 using a damp wash cloth and wiped off the fecal material. Tucked under the wet, saturated soiled sling and instructed the resident to roll in the other direction. CNA #6 removed the soiled saturated sling, incontinent pads, towels and wash cloth from underneath the resident. CNA #6 dried the resident's back and buttocks with a clean dry towel, applied barrier cream and applied a clean incontinence brief. CNA #6 proceeded to apply lotion to the residents torso, arms and legs then dressed the resident. The CNA's did not rewash the resident's back or hips were the soiled sling had contacted the resident's skin. During interview on 1/9/19 at 10:45 AM, CNA #7 stated she was unaware the sling was saturated with urine and stated she would have performed incontinent care prior to the shower. In addition, typically they would remove the soiled sling prior to showering and stated she did not. During interview on 1/9/19 at 10:55 AM, CNA #6 stated the sling and the resident's brief were soiled with urine. CNA #6 then stated removing the soiled sling while the resident was sitting in the shower chair would cause friction and shearing. I leave the sling in place. CNA #6 further stated incontinent care should have been given in bed prior to the shower. During an interview on 1/9/19 at 12:11 PM, the Assistant Director of Nursing (ADON) stated she expects incontinent care be done in bed prior to showering residents. All slings need to be removed prior to the start of showers unless care planned to leave the sling in place. In addition, would expect the resident be rewashed in bed after removal of a soiled sling if the same sling is used. During interview on 1/9/19 at 12:20 PM, the Director of Nursing (DON) stated the expectation was that all incontinent care is given prior to showers, including removing soiled slings. 2. Resident #363 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Additionally, the resident required extensive assist of one person for personal hygiene. The policy and procedure (P&P) entitled Perineal/ Incontinence Care in Subacute/LTC dated 9/28/18 documented that perineal and incontinence care is to be performed as part of a daily bath. Additionally, both outer hips and buttocks are to be washed, rinsed, and dried. An undated Kardex documented the resident was an extensive assist of one person for personal hygiene of their lower body and toileting. During an observation of morning care on 1/9/19 at 6:52 AM, the resident was given a bed bath prior to getting dressed. Certified Nurse Aide (CNA) #1 and CNA #2 assisted the resident with bathing. CNA #2 rolled the resident onto her left side and began to wash her right hip and buttock. As CNA #2 washed her buttock the resident had a small amount of feces that was wiped up with a washcloth. A small amount of feces was smeared on the barrier pad on the bed. CNA #2 changed the soiled barrier pad and placed a clean one under her. CNA #2 then placed a clean brief and dressed the resident. CNA #1 and #2 then placed the resident in her wheelchair. The residents left hip and buttock was not washed by the CNA's. During an interview on 1/9/19 at 7:12 AM, CNA #1 and CNA #2 both stated they should have washed the resident on her left hip and buttock. CNA #1 stated that they should have rolled the resident over to CNA #2 to wash the resident's left side. CNA #2 stated that she should have washed her hip and I can't believe I forgot to wash her left side. During an interview on 1/9/19 at 7:20 AM, Registered Nurse (RN) Unit Manager #1 stated she expects her staff to wash the resident thoroughly after the resident has a bowel movement. I guess I will have to re-educate them on morning care. During an interview on 1/10/19 at 9:30 AM, the Infection Control RN stated that she expects the staff to clean and wash the resident thoroughly. 415.12(a)(3)

Based on observation, interview, and record review conducted during the Standard survey completed on 8/11/17, the facility did not establish and maintain an infection control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Four (Opal, Persimmon Way, Sterling Court, Jade Terrace) of four nursing units reviewed for infection control practices during blood glucose monitoring revealed the facility was not utilizing a manufacturer approved cleansing agent before or after the use of shared blood glucose meters. Residents #44, 71, 95 and 211 and were involved. In addition, one (Resident #244) of two residents observed for infection control practices during resident care had issues with the lack of glove use and proper hand hygiene after the Certified Nurse Aide (CNA) handled the resident's Foley (tube inserted into the bladder to drain urine) drainage bag. The findings are: 1. Resident #71 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS- a resident assessment tool) dated 6/22/17 revealed the resident has moderately impaired cognition, usually understands and is understood. Review of an Order Summary Report dated 8/10/17 revealed physician orders [REDACTED]. Observation on 8/9/17 at approximately 7:24 AM, the Licensed Practical Nurse (LPN #2) removed the Evencare G2 blood glucose monitor and a bottle of blood glucose test strips from the top drawer of the medication cart. LPN #2 immediately inserted a test strip into the blood glucose monitor, without cleansing the monitor. LPN #2 put on gloves and cleansed Resident #71's finger with an alcohol wipe and dried the fingertip with a clean gauze pad. LPN #2 obtained a finger stick blood sample using a single use lancet and then touched the tip of the test strip to a droplet of blood on the resident's fingertip. After reading the blood glucose level on the monitor, LPN #2 removed the test strip from the meter with a gloved hand. LPN #2 gathered the lancet, alcohol wipe and gauze pad in the gloved hand, wrapped the soiled supplies in the glove and disposed of them in the medication cart garbage. LPN #2 immediately returned the blood glucose meter to the drawer of the medication cart without cleansing the meter. LPN #2 then administered Resident #71 oral medications and wheeled the resident down the hall. The LPN returned to the medication cart and stated she was finished with Resident #71 and began another resident's oral medication pass. Interview with the Registered Nurse In-service Coordinator (RN #3) on 8/9/17 at approximately 7:35 AM, revealed the facility does not have single resident use blood glucose monitors. The Nurse Educator further stated that each medication cart on the nursing units has one blood glucose monitor to be used for all residents residing on that hall that require finger stick blood glucose testing. The In-service Coordinator stated that blood glucose monitors should be cleansed with either an alcohol wipe or the PDI Sani-hands Instant Hand Sanitizing Wipes. Interview with the Director of Nursing (DON) on 8/9/17 at approximately 7:45 AM revealed that nursing staff are to cleanse the multiple resident blood glucose monitors with either an alcohol pad or the PDI Sani-hands Instant Hand Sanitizing Wipes on the medication carts. During an interview with LPN #2 on 8/9/17 at 11:26 AM, LPN #2 stated that the blood glucose monitor in the medication cart should be wiped off with either an alcohol wipe or the PDI Sani-hands Instant Hand Sanitizing Wipes. LPN #2 stated that she remembered that she put the blood glucose monitor back into the cart after using it earlier that morning but stated she remembered to clean the monitor later while passing medications. Observation on 8/9/17 at approximately 11:18 AM revealed that LPN #1 used an alcohol wipe to clean the glucose meter prior to completing Resident #95's finger stick. Interview on 8/9/17 at approximately 11:24 AM with LPN #1 revealed that she always used an alcohol wipe to clean the glucose meter. LPN #1 stated, isn't that what we are supposed to use?. Observation on 8/9/17 at 11:19 AM revealed that LPN #3 cleansed the glucose meter for 10-15 seconds with a PDI Sani-hands Instant Hand Sanitizing Wipe and completed a finger stick for Resident #44. After completing the resident's finger stick, LPN #3 cleansed the glucose meter with a PDI handwipe once again for 10-15 seconds and obtained a finger stick on Resident #211. During an interview with LPN #3 on 8/10/17 at approximately 11:19 AM, LPN #3 stated that PDI Sani-hands Instant Hand Sanitizing Wipes are used to clean the glucose meters. LPN #3 further stated that bleach based wipes are used to clean the blood glucose meter only if the resident has Clostridium difficile (C. diff, bacteria in the bowel that may cause diarrhea). During an interview with LPN # 4 on 8/9/17 at 11:42 AM, LPN #4 stated, We use the Clorox wipes when someone has[DIAGNOSES REDACTED]. Otherwise we just use the Sani hand wipes. Review of the PDI Sani-hands Instant Hand Sanitizing Wipes container revealed the Uses listed on the container were: - Antiseptic - For handwashing to decrease bacteria on the skin; after assisting ill persons; and before contact with a person under medical care or treatment. - Apply topically to the skin to help prevent cross-contamination. Review of the manufacturer's instructions for cleaning and disinfection the Evencare G2 Meter revealed the following products are validated for disinfection the Evencare G2 meter and lancing device: - Dispatch Hospital Cleanser Disinfectant Towels with Bleach - Medline Micro-Kill Disinfecting, Deodorizing, Cleaning Wipes with Alcohol - Clorox Healthcare Bleach Germicidal and Disinfectant Wipes - Medline Micro-Kill Bleach Germicidal Bleach Wipes During an interview on 8/9/17 at approximately 12:50 PM, the Assistant Director of Nursing (who is also the Infection Control Nurse) stated that the glucometer should be cleaned between each patient with a bleach wipe. During an interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 8/10/17 at approximately 8:30 AM revealed that they stayed late on 8/9/17 and came in early on 8/10/17 to have an in-service for the nursing staff on the proper cleaner and proper cleaning technique for the glucometer with new guidelines for the staff to follow. Review of an untitled document provided by the DON on 8/11/17 at 9:45 AM revealed that there were 34 residents residing in the facility at the time of the survey who received blood glucose testing using portable multi use glucose monitors. Review of the undated facility document entitled Glucometer Cleaning revealed all glucometers will be cleaned between patients/ residents with the use of Clorox Healthcare Bleach Germicidal Wipes. No exceptions. The document also stated to follow the recommended guidelines on the container. Review of a facility policy and procedure entitled Glucometer, Cleaning and Control Solution Testing dated 1/25/12 revealed the entire surface of the monitor is to be cleaned in between patient/resident use with an EPA (Environmental Protection Agency) registered disinfectant effective against Hepatitis B, Hepatitis C, and HIV (human immunodeficiency virus). 2. Resident #244 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident is cognitively intact, understands and is understood. Additionally, the resident has an indwelling catheter (tube inserted into the bladder to drain urine). Review of an Order Summary report printed on 8/10/17 revealed a physician order [REDACTED]. Review of Nursing progress notes revealed the following: - 7/27/16 Resident tolerating Keflex (an antibiotic) for a urinary tract infection. - 10/25/16 Resident continues to tolerate [MEDICATION NAME] antibiotics well for recurrent urinary tract infections. - 6/20/17 Resident on Keflex for urinary tract infection. - 6/25/17 Resident remains on Keflex for a urinary tract infection and [MEDICATION NAME] antibiotic for recurrent urinary tract infections. - 6/27/17 Urinary analysis positive for [MEDICATION NAME] (indicates a positive urinary tract infection). Many bacteria and Leukocyte esterase (white blood cells found in urine associated with infection). Order received for [MEDICATION NAME] (antibiotic) 500 milligrams (mg) by mouth daily for seven days for urinary tract infection. Review of the August 2017 Medication Administration Record (MAR) revealed the resident is receiving [MEDICATION NAME] 0.5 gm twice a day for urinary tract infection prevention. Observation of care on 8/9/17 at approximately 7:15 AM revealed the resident was laying on his bed; the resident's urinary drainage bag was laying on the mattress and contained yellow colored urine. CNA #2 with ungloved hands picked up the urinary drainage bag from the mattress as they (CNA #2, #3) prepared to transfer the resident from the bed to his wheelchair using a mechanical lift. CNA #2 touched the mechanical lift sling to position the resident onto the lift. Once the resident was lowered into his wheelchair, CNA #2 with ungloved hands placed the urinary drainage bag (containing urine) into a privacy bag underneath the resident's wheelchair. CNA #2 then picked up a pillow and placed it next to the resident's right side and another pillow behind the resident's head. CNA #2 continued to open the window curtain and move the wheelchair. CNA #2 then washed his hands. During an interview on 8/9/17 at approximately 7:30 AM, CNA #2 he stated that he should have washed his hands after touching the urinary drainage bag. During an interview on 8/10/17 at approximately 7:30 AM, the Assistant Director of Nursing stated that she expects staff to wear gloves when touching any part of the Foley bag or tubing. Review of a facility policy and procedure entitled Hand Washing/ Hand Hygiene dated May 2009 revealed that staff are to decontaminate hands before and after handling resident/ patient care devices. 415.19 ( a )(1)(b)(4)

Based on observation, interview and record review conducted during an Abbreviated survey (Complaint #NY 168) completed on 10/20/16, the facility did not ensure that each resident received adequate supervision and assistive devices to prevent accidents. One (Resident #1) of three residents reviewed for accidents was left outside on a covered patio without supervision or a means to communicate with facility staff from approximately 1:30 PM to 5:15 PM and the temperature outside was 87 degrees. The finding is: 1. Resident #1 is [AGE] years old with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS-a resident assessment tool) dated 5/23/16 revealed the resident has moderately impaired cognition. Review of the facility's Resident/ Patient Occurrence Report dated 7/21/16 at 4:45 PM completed by a Registered Nurse (RN) revealed that upon looking for Resident #1 for the unit cookout, she was found sitting outside under the patio. The RN assessment revealed that the resident was brought to her room, toileted, skin was warm to touch and vital signs were stable. The resident refused dinner, and fluids were provided. The resident was re-approached and took cottage cheese and peaches. The resident denied complaints. The report documented the resident's vital signs as: blood pressure (BP) 138/74 (normal), temperature 98.4 (normal 98.6), pulse 80 (average 80) and respirations 18 9 (normal 12-20). The resident's mental status at the time of the occurrence was noted to be alert. The resident's statement was I went out for lunch, didn't want to come back in just yet; then nobody came. Review of the facility's Incident Investigation Report dated 8/3/16 by the Administrator documented that on 7/21/16 at 5:15 PM Resident #1 was found on the outside covered patio. She was last seen by staff at 2:30 PM. The report states that on 7/21/16 when associates began transporting residents to the evening meal, they noticed that the resident was not in her room. Shortly thereafter the resident was located on a covered courtyard patio. Staff reported this to the Nursing Supervisor. The Nursing Supervisor and the Licensed Practical Nurse (LPN) #2 brought the resident back to her room, assessed the resident and reported to the Director of Nursing (DON). Review of the facility's timeline of the 7/21/16 incident revealed the following: -9:47 AM Certified Nurse Aide (CNA) #2 (not the assigned CNA) takes resident to the courtyard after taking her to the bathroom. -12:15 PM CNA #2 serves resident lunch on the courtyard. -12:40 PM CNA #2 brings resident to her room to use the bathroom, verified by camera. -12:55 PM CNA #2 returns resident to the courtyard, verified by camera. -1:30 PM Resident was seen by LPN #1 (day shift LPN) and another staff member (Scheduler) -1:47 PM CNA #2 checks on the resident and tells her that she is leaving for the day. -1:55 PM Resident was seen on the courtyard (through a window by another staff member) with drinks and a snack. -2:30 PM Resident was seen on the courtyard by a Resident Transporter. -5:15 PM Resident was brought back into the facility by the RN and LPN #2 (evening shift LPN). Review of Occurrence Report staff statements (regarding the incident) revealed the following: Review of CNA #2's written statement, dated 7/25/16, revealed Resident #1 wanted to go outside after breakfast as she had done the day before. CNA #2 took her out after breakfast and let the nurse and another aide know. The resident wanted to eat lunch outside instead of going back to her room. When the resident was done with lunch, CNA #2 stated that she took resident to the bathroom. The resident did not want to come back in. After 1:30 PM the resident went back outside with drinks and her crossword puzzles. CNA #2 stated that at around 1:47 PM she told the resident and another resident sitting outside, that she was heading home. CNA #2 stated that she let staff know, when she was leaving, about her team and that they were outside. Review of CNA #1's (the aide assigned to the resident on 7/21/16) statement dated 7/22/16, stated that on 7/21/16 she was not aware that Resident #1 was outside after lunch. She stated that she did not take the resident outside. Review of an interview with LPN #1 (day shift LPN) conducted by the DON on 7/25/16 revealed that Resident #1 told LPN #1 that somebody was coming back to take her to the toilet. The resident wanted to stay outside. LPN #1 stated that the she thought the resident was inside when she left at the end of her shift. LPN #1 stated that the resident can propel herself. LPN #1 stated that if you looked outside the door you would not have been able to see the resident because she was close to the building. Review of the Scheduler's typed statement dated 7/22/16 revealed that she was outside between the Jade and Sterling Units at about 1:30 PM. LPN #1 walked out with her (the Scheduler) and the dogs. The resident was sitting by the door in the shade. The Scheduler asked LPN #1 who the resident was because she had been outside for awhile. LPN #1 told her that it was Resident #1 from the Sterling Unit and the resident wanted to stay outside. The Scheduler stated that LPN #1 talked with the resident and the resident was telling her that it was a beautiful day and she was enjoying sitting outside. Review of the Unit Secretary's written statement dated 7/22/16 revealed that on 7/21/16 at approximately 1:45 PM she was looking out the Unit Manager's office window to see if a certain resident was in the courtyard. She noticed Resident #1 sitting on the patio near the door. She had a bedside table with drinks and a snack in front of her and did not appear to be in any distress. Review of a written statement by the Resident Transporter dated 7/26/16 revealed that he went outside on 7/21/16 at 2:30 PM to get a resident for therapy. While he was wheeling the resident into the building he saw Resident #1 outside who stated that it was hot out there. The Resident Transporter responded yes it is and wheeled the other resident into the building. Review of a written statement by LPN #2 (evening shift LPN) dated 7/21/16 revealed that upon change of shift it was never brought to her attention that Resident #1 was sitting outside. LPN #2 stated that when she entered Resident # 1's room at approximately 3:40 PM to fill the water pitcher, LPN #2 assumed she was at Bingo because she has attended in the past. Review of a written statement by CNA #3 (evening shift CNA) dated 7/21/16 revealed that during change of shift she and the other aides were not notified that Resident #1 was outside. In addition, CNA #3 stated that Resident #1 was not incontinent when she was taken inside to be toileted. Review of a written statement by CNA #4 (evening shift CNA) dated 7/21/16 revealed that she was not informed by the day shift that Resident #1 was outside of the building. Review of a written statement by CNA #5 (evening shift CNA) dated 7/25/16 revealed that there was no mention of Resident #1 being outside at change of shift on 7/21/16. Review of the RN's written statement, dated 7/21/16, revealed that when assisting with transporting of resident's to the unit picnic Resident #1 was not down yet. Staff looked for Resident #1 who is normally in her room and found her under the patio on Jade (unit). She was brought to her room and taken to the bathroom. Resident #1 was upset that they forgot about her. Once back in the chair fluids were offered and vital signs were taken. Resident #1 refused the food from the picnic, other options were offered and the resident took cottage cheese and peaches. Review of Resident #1's Care Plan, last revised on 6/8/16, revealed Resident #1 requires limited assistance of one person for toileting and requires supervision of one person with a wheeled walker for transfers. The resident is at high risk for falls (Fall Care Plan initiated on 4/4/15 and revised on 3/25/16). Interventions include to anticipate and meet the resident's needs, be sure the resident's call bell is within reach and encourage the resident to use it, and do not leave alone in the bathroom. The Care Plan revealed that the resident had a fall on 2/13/16 where the resident was lowered to the floor in the bathroom due to not bearing weight, and on 3/25/16 the resident slid from the wheelchair while obtaining a weight. Review of the July 2016 Medication Administration Record (MAR) revealed that Resident #1 had no medications scheduled to be administered between 8:00 AM and 8:00 PM on 7/21/16. Review of facility Guidelines entitled Shift to Shift reporting standards; Unit to Unit effective 6/30/13 revealed that the Rationale for the guidelines is to provide a process for communication of patient/ resident conditions needs and status changes to appropriate staff. For nurse to nurse communication scenarios to be reported may include but not limited to special needs or observations. The guidelines indicate that nursing staff are to make walking rounds. Review of a Corrective Action Report dated 8/10/16 revealed that LPN #1 was discharged from the facility. The report documented that it was LPN #1's responsibility to know where the residents were on her floor. It was her responsibility to notify the second shift that the resident may still be outside. The report documented that Resident #1 was outside from approximately 1:30 PM to 5:00 PM. The temperature was above 87 degrees on that day the resident could have suffered harm from being left outside for that length of time. Review of a Corrective Action Report dated 8/10/16 revealed that CNA #1 was discharged from the facility. The report documented that CNA #1 was assigned to work the day shift for the group that included Resident #1. The report documented that after an investigation it was discovered that the resident was seated outside on the courtyard from before 10:00 AM until nearly 5:15 PM. The temperature was over 87 degrees on that day. CNA #1 did not know that the resident was still outside at the end of her shift despite seeing her out there earlier in the shift. When asked where she thought the resident was at the change of shift, CNA #1 stated that she thought the resident was in her room. The report documented that it was CNA #1's responsibility to know the whereabouts of the residents on her assignment. During interview on 8/29/16 at approximately 11:00 AM, Resident #1 stated that one day in July staff took her out onto the patio. Resident #1 stated that in the afternoon the staff forgot about her and did not come to get her until dinnertime. Resident #1 stated that she was not in distress but it was hot out and that she had a drink with her outside. Resident #1 stated that she did not have to go to the bathroom while out on the patio and was not wet when staff brought her in at about 5:00 PM. During interview on 10/20/16 at approximately 11:30 AM, the DON stated that it is the responsibility of the out-going shift staff including the LPN Team Leader and the assigned aide to know the whereabouts of all their residents at change of shift time and to report anything out of the ordinary to the on-coming shift staff. The DON stated that it is also the on-coming shifts responsibility including the LPN Team Leader and the assigned CNA to do walking rounds to ensure they know the condition and whereabouts of all residents on their assignment. During interview on 10/20/16 at approximately 12:00 PM, CNA #2 stated that on 7/21/16 she worked the 6:00 AM to 2:00 PM shift. CNA #2 stated that she was not assigned to Resident #1 but was helping out on the unit and talked with the resident often. CNA #2 stated that in the morning, before lunch she took Resident #1 outside to the courtyard at the resident's request. CNA #2 stated that Resident #1 had drinks and her puzzles with her outside. CNA #2 stated that Resident #1 ate lunch outside at the resident's request. CNA #2 stated that she took Resident #1 into the facility after lunch to toilet her. After toileting, the resident requested to go back outside so CNA #2 took her outside. CNA #2 stated that at approximately 1:50 PM she went outside to check on Resident #1 and to tell the resident that she was leaving for the day. CNA #2 stated that Resident #1 was fine at that time and still had drinks on her table. CNA #2 stated that upon leaving her shift she reported to the 2:00 PM to 10:00 PM shift that Resident #1 was outside on the patio. CNA #2 does not remember which aide she reported it to. In summary, Resident #1 was left outside under a covered patio from 1:30 PM until approximately 5:15 PM with no supervision and no means to communicate with staff. The day shift LPN and assigned CNA were not aware of the resident's whereabouts at the end of their shift and the evening shift LPN and CNA were not aware of the resident's whereabouts until 5:15 PM when she was found on the patio. 415.12(h)(2)

Based on observation, interview, and record review conducted during the Standard Survey completed on 6/29/16, the facility did not ensure that each resident's drug regimen is free from unnecessary drugs. One (Resident #8) of four residents observed for medication administration had an issue involving a physician's orders [REDACTED]. The finding is: 1. Resident #8 has [DIAGNOSES REDACTED]. Review of a significant change Minimum Data Set (MDS - a resident assessment tool) dated 3/3/2016 revealed the resident has severely impaired cognition, understands, and is understood. Review of a Medication Review Report (physician's orders [REDACTED]. Observation on 6/22/16 at approximately 9:16 AM revealed a Licensed Practical Nurse (LPN #1) administered Atenelol 25 mg to Resident #8. LPN #1 did not obtain a blood pressure or pulse prior to the administration of the medication. Review of Medication Administration Records (MARs) dated 3/9/16 to 6/22/16 revealed Atenelol 25 mg was transcribed as ordered by the physician with parameters to hold the medication for SBP under 100 or AP under 60. Additional review of the MARs revealed the Atenelol was administered daily and there was no documented evidence that the resident's SBP and AP were checked prior to the administration of Atenelol. Interview with LPN #1 on 6/22/16 at approximately 2:37 PM revealed the (Atenelol) dose was lowered a few months ago and the LPN stated that she thought the Physician did not want the blood pressure and pulse checked due to the low dose of Atenelol. LPN #1 stated the last blood pressure and pulse was done on 6/1/16 and the systolic blood pressure was 120 and the pulse was 57. LPN #1 stated that at times, the resident has a pulse rate in the 50's. LPN #1 reviewed the medication order transcribed on the Medication Administration Record [REDACTED]. LPN #1 stated that a blood pressure and pulse should be completed prior to the administration of Atenelol and documented in the MAR. The LPN stated that this measure is to be done to assure that the resident's blood pressure and pulse are within the stated parameters and it is okay to administer the medication. Interview with the Registered Nurse (RN #1) Clinical Nurse Manager on 6/22/16 at approximately 3:00 PM revealed the physician's orders [REDACTED]. RN #1 stated that it is expected that every day prior to the administration of the [MEDICATION NAME], the resident's blood pressure and pulse will be checked. If the numbers fall below the parameter limits, then the medication is not to be given. RN #1 reviewed the MARS from 3/9/16 to 6/22/16 and stated there were no documented blood pressure or pulse readings prior to the time of the medication administration. Interview with the RN Assistant Director of Nursing (ADON) on 6/27/16 at approximately 11:45 AM revealed that when a medication order has a parameter, the blood pressure and pulse is to be obtained at the time of the med (medication) pass (administration) and the med is held if it is below the parameters. 415.12(l)(1)

Based on observation, interview, and record review conducted during the Standard Survey completed on 6/29/16, the pharmacy consultant did not identify and report drug regimen irregularities to the attending physician and the director of nursing. One (Resident #8) of six residents reviewed for monthly drug regimen reviews had an issue involving the lack of pharmacist identification and reporting of irregularities related to the omission of blood pressure and pulse rate monitoring prior to the administration of Atenolol (a medication used to treat high blood pressure (hypertension) and angina (chest pain). The finding is: 1. Resident #8 has [DIAGNOSES REDACTED]. Review of a significant change Minimum Data Set (MDS - a resident assessment tool) dated 3/3/2016 revealed the resident has severely impaired cognition, understands, and is understood. Review of a Medication Review Report (physician's orders [REDACTED]. Observation on 6/22/16 at approximately 9:16 AM revealed a Licensed Practical Nurse (LPN #1) administered Atenelol 25 mg to Resident #8. LPN #1 did not obtain a blood pressure or pulse prior to the administration of the medication. Review of Medication Administration Records (MARs) dated 3/9/16 to 6/22/16 revealed Atenelol 25 mg was transcribed as ordered by the physician with parameters to hold the medication for SBP under 100 or AP under 60. Additional review of the MARs revealed the Atenelol was administered daily and there was no documented evidence that the resident's SBP and AP were checked prior to the administration of the medication. Review of the Pharmacy Consultant's Medication Regimen Review sheet for Resident #8 revealed the Pharmacist reviewed Resident #8's medication regime on 4/30/16, 5/28/16, and 6/6/16. Additional review of the Medication Regimen Review sheet revealed no documented evidence that the Pharmacy Consultant identified or addressed that the resident's blood pressure and pulse were not checked daily prior to the administration of Atenelol. There was no evidence that the Pharmacist alerted the Physician or Director of Nursing regarding the omissions. Interview with LPN #1 on 6/22/16 at approximately 2:37 PM revealed the (Atenelol) dose was lowered a few months ago and the LPN stated that she thought the Physician did not want the blood pressure and pulse checked due to the low dose of Atenelol. LPN #1 stated the last blood pressure and pulse was done on 6/1/16 and the systolic blood pressure was 120 and the pulse was 57. LPN #1 stated that at times, the resident has a pulse rate in the 50's. LPN #1 reviewed the medication order transcribed on the Medication Administration Record (MAR) dated 6/2016 and stated that the order read to hold the Atenelol if the systolic blood pressure is less than 100 or the pulse is less than 60. LPN #1 stated that a blood pressure and pulse should be completed prior to the administration of Atenelol and documented in the MAR. The LPN stated that this measure is to be done to assure that the resident's blood pressure and pulse are within the stated parameters and it is okay to administer the medication. Interview with the Registered Nurse (RN #1) Clinical Nurse Manager on 6/22/16 at approximately 3:00 PM revealed the physician's orders [REDACTED]. RN #1 stated that it is expected that every day prior to the administration of the Atenolol, the resident's blood pressure and pulse will be checked. If the numbers fall below the parameter limits, then the medication is not to be given. RN #1 reviewed the MARS from 3/9/16 to 6/22/16 and stated there were no documented blood pressure or pulse readings prior to the time of the medication administration. Interview with the Consulting Pharmacist on 6/27/16 at approximately 11:00 AM revealed the Consulting Pharmacist checks each resident's record monthly in regards to medications and physician's orders [REDACTED]. The Consultant Pharmacist stated that If there is a physician's orders [REDACTED]. Interview with the RN Assistant Director of Nursing (ADON) on 6/27/16 at approximately 11:45 AM revealed that when a medication order has a parameter, the blood pressure and pulse is to be obtained at the time of the med (medication) pass (administration) and the med is held if it is below the parameters. Review of a policy and procedure entitled Medication Regime Review Recommendations and Reports dated 2/2008 revealed the medication reviews are completed to ensure that each resident is free from actual or potential negative outcomes. 415.18(c)(1)(2)

Based on observation, interview and record review conducted during the Standard survey completed on 3/20/14, 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 #5) of 16 residents reviewed for quality of care did not have a therapeutic drug level obtained as ordered by the Physician. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy. The finding is: 1. Resident #5 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - an assessment tool) dated 3/4/14 revealed the resident has moderately impaired cognitive skills, is sometimes understood, usually understands, and has short and long term memory problems. Intermittent observations from 3/17/14 to 3/19/14 between the hours of 8:00 AM and 3:00 PM revealed the resident is alert and active, she participated in her daily activities and was able to indicate her personal preferences. Review of physician's orders [REDACTED]. Review of a Therapeutic Drug Monitoring laboratory (Lab) report dated 4/18/13 revealed the resident had a [MEDICATION NAME] Acid ([MEDICATION NAME]) level of 37 (reference range 50 to 100 ug/ml). There was no further documentation available. Interview with the Registered Nurse (RN) Clinical Nurse Manager (CNM) on 3/19/14 at 11:20 AM revealed the physician's orders [REDACTED]. The RN CNM stated "the last test we can find is April, 2013, it should have been done again in October. It looks like we missed it. The resident is not showing any signs of [MEDICATION NAME] toxicity that I am aware of." The RN CNM explained that the nurses are supposed to write the lab orders into a communication book when they are ordered. Interview with the Unit Secretary on 3/19/14 at 11:25 AM revealed she is responsible for scheduling the residents' lab work. The Unit Secretary explained that "Whoever gets the order from the doctor, is supposed to put the order in the communication book. From the communication book, I transfer the scheduled labs to the lab book. For the next month I review the lab book, make a lab requisition sheet and then an individual yellow lab request sheet on a daily basis." The Unit Secretary stated that the request for the routine six month [MEDICATION NAME] level did not make it into the lab book and there is no back up system to check for errors. Interview with the Nurse Practitioner on 3/19/14 at 11:40 AM revealed she would not typically monitor a resident on [MEDICATION NAME] at a low dose for behaviors like Resident #5; the monitoring becomes more important when we are looking for a therapeutic level to address [MEDICAL CONDITION]. Interview with the Pharmacy Consultant on 3/19/14 at 4:05 PM revealed he reviews the labs as part of the Monthly Drug Regimen Review and Resident #5 was being monitored for [MEDICATION NAME] use for behaviors rather then [MEDICAL CONDITION]. Interview with the Director of Nursing (DON) on 3/20/14 at 2:30 PM revealed the facility does not have a policy regarding the scheduling of labs. 415.12

Based on record review and staff interview conducted during an abbreviated survey (complaint # NY 709) completed on 8/6/12, it was determined that the facility did not ensure that residents were free from significant medication errors. One (Resident #1) of four residents reviewed for medication errors revealed that the resident continued to receive 8 doses of [MEDICATION NAME] (medication used as an anticoagulant -blood thinner that prevents the formation of blood clots), after it should have been discontinued. This was actual harm that is not immediate jeopardy. The findings are: 1. Resident #1 has [DIAGNOSES REDACTED]. Review of the hospital Discharge Summary dated 6/22/12 revealed discharge instructions for full dose [MEDICATION NAME] therapy and [MEDICATION NAME] (anticoagulant medication); and daily PT ([MEDICATION NAME] time - blood clotting studies)/INRs (International normalizing ratio - standardized normalized blood coagulating values). The discharge medications revealed orders for [MEDICATION NAME] 60 milligrams (mg) subcutaneously (SQ - beneath the skin) every 12 hours until the patient's INR was therapeutic "which would be 2 to 3". Review of the facility "Sub Acute/ LTC admission orders [REDACTED]. Additional admission orders [REDACTED]. Review of the laboratory log notebook maintained on the unit revealed the resident was entered on 6/22/12 as needing daily PT/INRs. Review of a "Laboratory Services" slip dated 6/23/12 revealed that the resident's INR was 2.0. The lab slip is initialed and dated 6/23/12 with a notation "NNO" (no new orders). Review of a "Nurse's Note" dated 6/23/12, the "FBM Traditional Care Team Daily Report" and the "[MEDICATION NAME] Worksheet" for the resident revealed no evidence that the 6/23/12 INR results were documented. The Senior Registered Nurse (Sr. RN) #1 stated during an interview on 7/17/12 at approximately 1:15 PM that on 6/23/12 she received the resident's INR lab result of 2.0 via a fax. She stated that she left a voice mail for the on-call NP informing her of the INR results. The Sr. RN further stated that the NP later called back and stated that there were no new orders. The Sr. RN stated that she did not change the frequency of the resident's INRs which she stated were to be done daily. She stated that she did not document the INR result on the resident's "[MEDICATION NAME] Worksheet". The Sr. RN stated that she was not aware that the resident was on the medication [MEDICATION NAME] with orders to discontinue the medication when the INR result was therapeutic between 2 to 3. Review of the computerized "admission/ routine" orders signed by the NP on 6/25/12 revealed orders for "Enoxaprin 60 mg/ 0.6 milliliters (mls) Generic for [MEDICATION NAME] 60 mg Inject 0.6 ml (60 mg dose) SQ every 12 hours til if no response therapeutic (2 to 3)". Review of the "History and Physical" Examination signed by the NP on 6/25/12 documented that the resident's problems included TIA ([MEDICAL CONDITION] - stroke that comes and goes quickly)/[MEDICAL CONDITION] "likely secondary to subtherapeutic [MEDICATION NAME]". The note states that the patient "is currently on [MEDICATION NAME] and her [MEDICATION NAME] was restarted. She is on [MEDICATION NAME] until therapeutic". Review of a "MD Order Form" dated 6/25/12 revealed orders to perform a PT/INR in the morning then every Monday and Thursday. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]"Enoxaprin 60 mg/ 0.6 mls Generic for [MEDICATION NAME] 60 mg Inject 0.6 ml (60 mg dose) SQ every 12 hours til if no response therapeutic continued ... (2 to 3)". The medication administration times were 8:00 AM and 9:00 PM. Further review of the MAR indicated [REDACTED]. Review of a "Laboratory Services" report dated 6/26/12 revealed the resident's INR result was 6.1 (therapeutic range for the resident was 2 to 3). The lab sheet was initialed by the RN with a notation that the NP was aware and orders were received. Review of the "MD order form" dated 6/26/12 revealed orders to discontinue the [MEDICATION NAME] and obtain a PT/INR daily until the INR was less than 3.0. Review of a Nurse's Note dated 6/26/12 at 10:30 AM documented by RN #3 revealed the NP was notified of the INR result of 6.1 and [MEDICATION NAME] was to be discontinued until the INR is below 3. The note also documents that the patient complained of slight rust colored blood from the right naris (nostril) for 3 days. The note indicates that the Sr. RN was notified. Review of an "MD Order Form" dated 6/26/12 documented by RN #3 revealed a verbal order from the NP to discontinue the [MEDICATION NAME] and to perform a daily PT/INR until the INR is less than 3.0. RN #3 stated during an interview of 7/11/12 at approximately 1:00 PM that on 6/26/12 when she obtained the INR result of 6.1 she notified the NP and obtained the order to discontinue the [MEDICATION NAME] and get daily PT/INRs until the INR was less the 3.0. She further stated that she did not know the resident was on [MEDICATION NAME]. RN #3 stated that she never passed medications for the resident. Review of a "Nurse's Note" dated 6/27/12 written by RN #1 documented that at 11:00 AM the resident's INR result was 8.5, the NP was notified and the [MEDICATION NAME] remains on hold. Review of a "MD Order Form" dated 6/27/12 at 11:00 AM revealed orders to administer Vitamin K (vitamin that allows blood to clot normally) 5 mg intramuscularly now for the elevated INR of 8.5. Review of the "Nurse's Note" and "Occurrence Report" dated 6/27/12 completed by RN #1 revealed that at approximately 1:00 PM, the resident complained of a right upper extremity (RUE) lump. The note documented that upon exam there was an 8 centimeter (cm) round hematoma (collection of blood under the skin) of purple red firm tissue. The note documented that the brachial and radial pulse were palpable and the NP was notified. RN #1 stated during an interview on 7/11/12 at 11:00 AM that upon completing the occurrence report for the resident's hematoma on 6/27/12, she realized that the resident was still receiving the [MEDICATION NAME] so she obtained an order to discontinue it. Review of "MD Order Forms" dated 6/27/12 revealed orders for the following: - hold therapy today - Monitor the hematoma of the RUE every shift - No labs or blood pressures to the RUE until resolved hematoma - discontinue [MEDICATION NAME] - Neurological checks and vascular checks (radial and brachial) every shift until resolved. Review of a "Physician/ NP/PA Communication and Progress Note" dated 6/27/12 at 6:00 PM revealed that the resident complained of severe pain in the RUE not relieved by Tylenol 650 mg. The NP was called and new orders were received to increase Tylenol to 1,000 mg every 6 hours. The note further documented that at 8:00 PM the family made the decision to send the resident to the emergency room for evaluation. Review of the hospital admission "history and physical" exam dated 6/28/12 revealed the resident was admitted with a "very large 20 x 40 cm right upper extremity hematoma with tension and warmth". Other [DIAGNOSES REDACTED]. Admission laboratory data noted on the history and physical exam included: hemoglobin - 8.1 (normal is 12 to 16), hemotcrit 24.4 (normal is 36 to 47), PT - 93.7 (normal is 9.3 to 13.5), INR - 8.5 (normal is 2 to 3 for anticoagulant therapy). Review of the hospital Discharge Summary dated 6/30/12 revealed the resident had a discharge [DIAGNOSES REDACTED]. The Discharge Summary revealed that the resident required an open incision and evacuation of the right upper extremity hematoma. Further review of the Discharge Summary noted that the resident received vitamin K and required a total of 5 units of packed red blood cells. The resident was discharged back to the facility requiring RUE (right upper extremity) wound care. The RN Assistant Director of Nursing (ADON) stated during an interview on 7/10/12 at approximately 2:00 PM that according to the admission orders [REDACTED]. She stated that the manner in which the [MEDICATION NAME] order was printed on the MAR indicated [REDACTED]. The ADON stated that normally the RNs monitor the INR and [MEDICATION NAME] dose and the Licensed Practical Nurses (LPNs) administer the [MEDICATION NAME]. The ADON further stated that it is the medication nurses' responsibility to initiate a [MEDICATION NAME] flow sheet prior to administering the first dose of [MEDICATION NAME]. She also stated that it is the night shift LPNs' responsibility to review the MARs for accuracy against the physician orders. The RN ADON stated that the facility's investigation shows that the LPNs who administered the [MEDICATION NAME] admitted to not seeking clarification of the [MEDICATION NAME] order. Review of the facility's "Incident Investigation Report" regarding Resident #1 revealed that according to the hospital discharge orders the [MEDICATION NAME] should have been discontinued on 6/23/12 after the INR results of 2.0 were received. The patient continued to receive the [MEDICATION NAME] until the afternoon of 6/27/12. The conclusion of the investigation revealed that when the printed MAR indicated [REDACTED] "Enoxaprin 60MG/0.6 ML S Inject 0.6 ML (60 MG dose) SQ every 12 hours til if No response therapeutic (2-3)" The facility's investigation concluded the following: - The misprint error was not noted and corrected by the Nurse who reviewed the MAR indicated [REDACTED] - Subsequent staff who saw the MAR indicated [REDACTED]. - When subsequent INR results were obtained, the staff did not notify the provider that the resident was on [MEDICATION NAME] and [MEDICATION NAME]. As a result of these oversights, the [MEDICATION NAME] was not discontinued as ordered in the hospital discharge instructions. This resulted in the patient continuing to receive both anticoagulants. The NP stated during an interview on 7/17/12 at 12:00 PM that she does not recall if she was the NP on call on 6/23/12 regarding the resident's INR result of 2.0. She further stated that she initialed the admission orders [REDACTED]. She stated that she performed the history and physical exam on the resident on 6/25/12 and explained that she normally sees residents and does her notes in the morning and usually reviews and initials the lab slips in the afternoon. The NP stated that she probably wrote her note on 6/25/12 before seeing the lab slip of 6/23/12. The NP stated that she would not have automatically known that the resident was on [MEDICATION NAME] and would assume that the nurses would take care of discontinuing the [MEDICATION NAME] when the INR was therapeutic since that was the standing order on admission. The facility Medical Director stated during an interview on 7/11/12 at 11:30 AM that the resident should not have continued to receive the [MEDICATION NAME] after the INR of 6/23/12 was at 2.0. The Physician stated that he does not know if the continued use of [MEDICATION NAME] caused the hematoma. He stated that it could be a combination of the use of [MEDICATION NAME] and [MEDICATION NAME] or it could have just been the [MEDICATION NAME]. He further stated that multiple systems failed at the facility regarding the continuation of the [MEDICATION NAME] past 6/23/12. He stated that the pharmacy MARs came back with an incorrect order, the MARs were not reviewed by the nurse, and the nurses continued giving the [MEDICATION NAME] and [MEDICATION NAME] after the INR was therapeutic. 415.12(m)(2)